Novel technique of predicting the dimensions of 5-stranded hamstring grafts for anterior cruciate ligament reconstruction: A descriptive study

Rahul Hemant Shah; Rahul P; Yashavantha K. C; Satish Shervegar; Ashok Kumar P

doi:10.1016/j.jor.2023.12.003

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doi:

10.1016/j.jor.2023.12.003

Novel technique of predicting the dimensions of 5-stranded hamstring grafts for anterior cruciate ligament reconstruction: A descriptive study

Rahul Hemant Shah, Rahul P, Yashavantha K. C, Satish Shervegar, Ashok Kumar P

Department of Orthopaedics, Ramaiah Medical College and Hospitals, Bengaluru, India

∗∗Corresponding author: Rahul Hemant Shah. rahul54shah@gmail.com

Received: 2023-4-10, Accepted: 2023-12-7, Published: 2023-12-12

Professor P K Surendran Memorial Education Foundation

Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Prediction of hamstring tendon autografts is essential when planning a ligament reconstruction surgery. This is especially important in cases of multiple ligament reconstruction surgeries. This study was designed to predict the dimensions of 5-stranded hamstring grafts from anthropometric parameters in patients undergoing anterior cruciate ligament (ACL) reconstruction surgery.

172 patients undergoing ACL reconstruction with hamstring autografts were included in the study. Preoperative parameters included age, gender, height, weight, body mass index (BMI), thigh length, thigh circumference, and tibia length; intraoperative parameters included semitendinosus (ST) and gracilis (G) length and diameter, final 5-stranded graft length and diameter. Pre-operative data was correlated with intra-operative data using tests of significance.

Height, tibia and thigh length were greater in males (p < 0.05) whereas BMI was greater in females (p < 0.05). G and ST length alongwith 5-stranded graft length and diameter were significantly greater in males (p < 0.05). The graft dimensions could be correlated with the pre-operative anthropometric parameters using specific equations. This was applicable to the lengths and diameters of ST, G and 5-stranded grafts. We also noted that an increase in age was associated with a reduction in graft dimensions except for the diameter of G graft in females and length of 5-stranded grafts in males.

5-stranded hamstring graft dimensions can be reliably predicted using anthropometric parameters and this eases surgical planning.

Keywords

Anterior cruciate ligament reconstruction

Anthropometry

Hamstring graft

Knee arthroscopy

Sports medicine

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1 Introduction

Anterior cruciate ligament (ACL) is often injured during contact sports and high-velocity injuries.¹ Surgery is the gold standard treatment in patients with ACL tear presenting with instability. ACL reconstruction involves replacing a graft in place of ruptured ACL using either an autografts or an allograft.² Autografts enhance the quality of reconstructions and have a lesser chance of graft rupture and improved knee stability than allografts.³

Bone patellar tendon bone graft, hamstring tendon graft and allograft are the most commonly used grafts in ACL reconstruction.² Decreased donor site morbidity and less anterior knee pain are some of the advantages of hamstring tendon grafts.⁴ They are stiffer and stronger when used as quadruple strands. ACL reconstructions need specific tendon diameter and length depending on the type of reconstruction, graft preparation technique and fixation method.⁵ Hence, preoperative prediction of hamstring graft dimensions helps the surgeon in anticipating difficulties encountered during surgery and the need for additional grafts. This is especially important in multi-ligament reconstruction surgeries and where allografts are unavailable.⁶

The predictability of hamstring tendon dimensions by anthropometric parameters such as height, thigh diameter and body mass index (BMI) for ACL graft size has been analysed in the past.^7–11 However, there is no study till date which documents the correlation between anthropometric parameters and 5-stranded hamstring graft dimensions. This study was conducted with the aim of finding such a correlation in order to facilitate pre-operative prediction of hamstring graft dimensions and, hence, help to decide the need for additional grafts in case of insufficient dimensions.

2 Materials and methods

This study was conducted between 2016 and 2022 after obtaining institutional ethical committee approval and informed consent from the patients. Our institution protocol involves all ACL reconstruction patients to undergo a 5-stranded hamstring autograft with pre-operative anthropometric measurements unless contraindicated such as those with a previous hamstring injury and those with concurrent medial collateral ligament injury.

2.1

2.1 Inclusion criteria

1.Patients with closed physis.2.3 stranded semitendinosus (ST) and 2 stranded gracilis (G) grafts sutured together to give a 5-stranded hamstring graft.

2.2

2.2 Exclusion criteria

1.Patients who had sustained musculoskeletal injury to both lower limbs in the past before presenting to us.2.Patients diagnosed with systemic inflammatory diseases and neuromuscular disorders.3.Bilateral knee ligamentous injury.

Patients with complaints of knee instability were examined and magnetic resonance imaging (MRI) was also done for all patients with clinical signs suggestive of ACL tear. Age and gender of all the patients were documented. Height was measured with a stadiometer and weight with a standard weighing scale. Thigh length was measured from anterior superior iliac spine to medial joint line of the knee on the contralateral thigh. Thigh circumference was the mid-point of the measured thigh length. Contralateral thigh was measured as ipsilateral thigh would have given lesser than normal circumference on account of wasting of the quadriceps muscle seen in ACL injuries. Tibia length was measured from medial joint line of the knee to the tip of medial malleolus. The last three parameters were measured with a standard measuring tape.

2.3

2.3 Surgical technique

4–5 cm straight incision was made medial to tibial tuberosity. Pes anserinus was identified to retrieve ST and G tendons. Tendons were harvested as close to the bone as possible in order to obtain maximum length. ST was folded into 3 and G was folded into 2 strands giving a final graft of 5 strands. The rationale behind a 5-stranded graft was that of a better outcome.¹² Graft length and diameter of ST and G tendons were measured when they were harvested and stripped off their surrounding soft tissues. 5-stranded graft diameter and length were measured after suturing ST and G together using polyethylene terephthalate. The length of the grafts was measured using a sterile ruler and diameter using sterile cylindrical tubes in 5 mm increments. Appropriate sized reamer was used for tibial tunnel preparation under direct arthroscopic visualization after checking 5-stranded graft diameter. A guidewire was inserted using a power drill close to the femoral attachment of the native ACL for the femoral tunnel. The graft was then passed in a retrograde fashion from tibia to femur followed by fixation at the femoral end with an endobutton. The tibial end was fixed with an interference screw. Soft tissue closure was done in layers in an interrupted manner. The anthropometric variables were then correlated with the graft dimensions.

2.4

2.4 Statistical analysis

Data was analysed using SPSS version 18.0, R software version 4.1.1 and Microsoft Excel. Multiple linear regression model was used to predict ST length, ST diameter, G length, G diameter and 5-stranded graft length and diameter. Stepwise regression was used to find best set predictive variables. Mann Whitney and independent t-test were used to find the significant difference between groups and Spearman rank correlation to find the correlation between different variables. Multinomial regression analysis was performed to determine the factors influencing the graft dimensions. P < 0.05 was considered statistically significant.

3 Results

194 patients underwent ACL reconstruction during the 6-year period of the study at our institution. After applying inclusion and exclusion criteria, 172 patients were included in the study (Fig. 1) of which, 132 were males and 40 were females. Mean age of the patients was 30.49 ± 8.39 years, ranging from 18 to 52 years. Table 1 gives a distribution of the patients amongst various age groups.

Table showing the number of patients included in the study after applying the exclusion criteria.

Table 1 Age-wise distribution of patients.

Age (in years)	n (%)
Less than 20	24 (14%)
21 to 30	60 (35%)
31 to 40	72 (42%)
41 to 50	12 (07%)
More than 50	04 (02%)
Total	172 (100%)

Height, BMI, thigh, and tibial length significantly differed between both genders. With respect to graft dimensions, G length (P = 0.01), ST length (P = 0.002) and 5-stranded graft diameter (P = 0.02) and length (P = 0.02) were significantly more in male patients (Table 2).

Table 2 Variation of parameters amongst both the genders.

Parameters	Females, n = 40	Males, n = 132	P-value
Age (years)	33.4 ± 8.75	29.61 ± 8.21	0.24
Height (cm)	155.7 ± 6.63	168.39 ± 6.18	0.001*
Weight (kg)	74.8 ± 12.65	75.27 ± 12.29	0.92
Body mass index (kg/m²)	30.8 ± 4.44	26.42 ± 4.4	0.01*
Thigh length (cm)	46.3 ± 4.39	50.67 ± 2.72	0.01*
Thigh circumference (cm)	56.7 ± 6.96	52.85 ± 5.75	0.08
Tibia length (cm)	38.7 ± 2.7	41.58 ± 2.6	0.01*
ST length (cm)	26.9 ± 1.7	29.24 ± 1.88	0.002*
ST diameter (mm)	3.7 ± 0.48	3.85 ± 0.36	0.29
G length (cm)	23.3 ± 4.001	27.33 ± 1.78	0.01*
5-stranded graft length (cm)	8.3 ± 0.82	9.06 ± 0.78	0.02*
5-stranded graft diameter (mm)	7.7 ± 0.67	8.33 ± 0.64	0.02*

Thigh (P = 0.017) and tibial length (P = 0.004) had a significant correlation with G length in females. Age was significantly correlated in a negative manner with G diameter in males. Height (P < 0.05) and tibia length (P < 0.05) of all the patients were significantly correlated with ST graft length whereas thigh length correlated with ST graft length in females alone. Weight of the patients correlated with ST graft diameter (P = 0.012) in males. Thigh length correlated with 5-stranded graft length only in females whereas BMI correlated only in males. None of the anthropometric variables were found to correlate significantly with the 5-stranded graft diameter in both the genders (Table 3).

Table 3 Graft dimensions compared with anthropometric variables.

Anthropometric variables	G graft length, r		G graft diameter, r		ST length, r		ST diameter, r		5-stranded graft length, r		5-stranded graft diameter, r
Anthropometric variables	Females	Males	Females	Males	Females	Males	Females	Males	Females	Males	Females	Males
Age	−0.220	−0.308	0.074	−0.651	−0.125	−0.019	−0.061	−0.047	−0.062	0.027	−0.099	−0.257
Age	0.219	0.386	0.683	0.041*	0.490	0.958	0.735	0.897	0.730	0.941	0.585	0.474
Height	0.302	0.444	0.080	0.420	0.514	0.651	−0.023	0.623	0.339	0.048	−0.136	0.268
Height	0.087	0.199	0.657	0.227	0.002*	0.042*	0.897	0.054	0.054	0.895	0.451	0.454
Weight	0.034	0.023	0.200	0.498	−0.31	−0.52	0.166	0.753	0.176	−0.562	0.64	0.539
Weight	0.850	0.949	0.264	0.143	0.863	0.887	0.357	0.012*	0.329	0.091	0.724	0.108
BMI	−0.094	−0.201	0.167	0.331	−0.256	−0.407	0.173	0.534	0.017	−0.651	0.121	0.469
BMI	0.605	0.578	0.352	0.350	0.151	0.243	0.335	0.112	0.924	0.042*	0.504	0.172
Thigh length	0.412	−0.151	0.272	0.361	0.715	−0.224	0.146	0.413	0.391	−0.475	0.013	0.308
Thigh length	0.017*	0.677	0.126	0.306	0.000*	0.535	0.416	0.235	0.024*	0.165	0.944	0.386
Thigh circumference	0.053	0.039	0.126	0.532	−0.126	−0.215	0.131	0.631	0.138	−0.522	0.080	0.629
Thigh circumference	0.768	0.914	0.486	0.113	0.485	0.551	0.468	0.05	0.442	0.121	0.656	0.051
Tibia length	0.482	0.593	0.207	0.348	0.526	0.657	−0.055	0.178	0.329	0.332	−0.44	0.043
Tibia length	0.004*	0.071	0.249	0.324	0.002*	0.039*	0.760	0.622	0.061	0.349	0.809	0.906

We applied stepwise linear regression models for predicting graft dimensions and noted certain equations which were found to be reproducible in our study. Table 4 gives the result of stepwise linear regression model for predicting ST length. Application of multiple linear regression model showed that tibia length, thigh length and circumference had a significant effect on ST length. The effect of unit increase in tibia and thigh length and the effect of unit decrease in thigh circumference on ST length is given as follows in the regression equation:ST length = 10.15 + 0.27(Thigh length)-0.08(Thigh circumference) +0.23(Tibia length)R² = 0.5368, p-value<0.001

Table 4 Stepwise linear regression model for predicting ST length.

	Estimate	p-value
(Intercept)	10.15	0.015*
Thigh length	0.27	0.0018*
Thigh circumference	−0.08	0.0397*
Tibia length	0.23	0.0262*

Table 5 gives the result of stepwise linear regression for predicting ST diameter. We observed that gender had a significant effect on ST diameter. ST diameter of males is 0.3 times more than that of females. The regression equation is as follows.ST diameter = 2.79 + 0.30(Gender)+0.01(Weight)R² = 0.1207, p-value = 0.0288

Table 5 Stepwise linear regression for predicting ST diameter.

	Estimate	p-value
(Intercept)	2.79	<0.001*
Gender Male (Ref: Female)	0.30	0.0305*
Weight	0.01	0.1140

Table 6 gives the result of stepwise linear regression for predicting G length. Gender and tibia length have a significant effect on G length. G length of males is 2.79 times more than that of females. With unit increase in tibia length, G length will increase by factor 0.45. The regression equation is as follows.G length = 5.73 + 2.79(Gender)+0.45(Tibia length)R² = 0.4766, p-value<0.001.

Table 6 Stepwise linear regression for predicting G length.

	Estimate	p-value
(Intercept)	5.73	0.2573
Gender Male (Ref: Female)	2.79	0.0024*
Tibia length	0.45	0.001*

Table 7 depicts the linear regression between thigh length and G diameter. Thigh length was shown to have a significant effect on G diameter. With unit increase in thigh length, G diameter increased by factor 0.04. The regression equation is as follows.G diameter = 0.57 + 0.04 (Thigh Length)R² = 0.1148, p-value = 0.015

Table 7 Stepwise linear regression for predicting G diameter.

	Estimate	p-value
(Intercept)	0.57	0.475
Thigh length	0.04	0.015*

Table 8 gives the result of stepwise linear regression for predicting 5-stranded graft length. Weight and BMI have significant effect on 5-stranded graft length. With unit increase in weight, 5-stranded graft length will increase by factor 0.22. With unit increase in BMI, 5-stranded graft length will decrease by factor 0.62. The regression equation is as follows.5-stranded graft length = 36.13–0.16(Height)+0.22(Weight)-0.62(BMI)R² = 0.2601, p-value = 0.002

Table 8 Stepwise linear regression for predicting 5-stranded graft length.

	Estimate	p-value
(Intercept)	36.13	0.0135*
Height	−0.16	0.0626
Weight	0.22	0.0240*
BMI	−0.62	0.0203*

Table 9 gives the result of stepwise linear regression for predicting 5-stranded graft diameter. Gender has significant effect on 5-stranded graft diameter. 5-stranded graft diameter of males is 0.74 times more than that of females. The regression equation is as follows.5-stranded graft diameter = 7.06–0.02(Age)+0.74 (Gender)+0.04(BMI)R² = 0.1814, p-value = 0.0127.

Table 9 Stepwise linear regression for predicting 5-stranded graft diameter.

	Estimate	p-value
(Intercept)	7.06	<0.001*
Age	−0.02	0.1382
Gender Male (Ref:Female)	0.74	0.0038*
BMI	0.04	0.0753

4 Discussion

Ligament reconstruction with graft replacement technique requires thorough planning, especially in multi-ligament injuries. An alternative graft may be required when the harvested hamstring graft is of inadequate dimensions. Hence, this study was done to envisage whether graft dimensions can be predicted with anthropometric variables.

We noted that height, thigh and tibia length were significantly higher in males. A Japanese study showed that men had greater pre-operative anthropometric parameters with women having shorter and thinner tendons.¹³ G length, ST length and 5-stranded graft length and diameter in our study were higher in males which is in line with the study published by Milano et al.¹⁴ in which females had shorter ST and G graft lengths. However, Schwartzberg et al. found no significant difference in the ST graft diameter between either genders.⁷

ACL reconstruction using both, ST and G grafts, has shown to have good results.¹⁵^,¹⁶ Hence, we used both the grafts to construct 5-standed hamstring autograft. In our study, the mean age was 30.49 years with a male predominance. This was quite similar to other published studies.⁸^,¹⁷ We noted that the age of male patients showed an inverse and significant correlation with the G graft diameter. Stergios et al. reported that patient’s height and weight showed a significant correlation with G length.¹⁵ Magnussen et al. reported that age is a potential factor for re-intervention in ACL reconstruction.¹² They also concluded that age <20 years had increased revision rates.¹² We noted that graft dimensions reduced in our patients as their age increased. Although this wasn’t statistically significant for majority of the parameters, such a negative correlation has not been reported in the Indian scenario before.

Height, thigh and tibial length were found to correlate with ST length in females and with height and tibia length in males in our study, whereas, weight was found to correlate with ST diameter only in males. Stergios et al. reported that patient’s height and weight showed a significant correlation with ST length.¹⁵ Sundararajan et al. found both ST diameter and length to be significantly correlated with height, weight, thigh segment length and total limb length indicating the anthropometric variables are better at differentiating adequate and inadequate graft dimension in patients.¹⁸ This suggests that a model to forecast graft dimensions should incorporate height of the patient. A retrospective study found the diameter of the final graft to be correlated with height and concluded patients with height <140 cm have a higher risk of a graft <7 mm in diameter.¹⁹ Boisvert et al. found a correlation between height and graft diameter in females.²⁰ However, age and height did not show correlation with graft diameter amongst males in their study.

It has been reported that the 5-stranded hamstring autograft attains better clinical outcomes than 4-stranded autograft with a graft diameter of ≥8 mm.²¹ This was the rationale behind using 5-stranded grafts in our surgical technique. We could not find a correlation between pre-operative parameters and the failure to achieve 3-stranded ST graft in 17 patients who were excluded from the study. Poor graft lengths would preclude the surgeon’s ability to offer double-bundle ACL reconstruction without the use of allografts. Studies have stated graft diameter of >8 mm did not fail the ACL reconstruction while a graft size of <8 mm have a revision risk of 5.2%. Hence, increased graft diameter improves the patient-reported outcome scores.⁵^,²²

Literature has reported that regression analysis has a predictive value of 36% in predicting the hamstring graft diameter.⁸ Pereira et al. revealed that height is the only influential parameter that predicts the graft thickness.¹⁰ One study reported height and thigh circumference as significant predictors of graft diameter²³ whereas another study reported age as the independently significant predictor of the final hamstring graft diameter.²⁴ We noted that none of the anthropometric parameters had a bearing on the 5-stranded graft diameter, however, ST thickness correlated positively with weight in males and G thickness correlated negatively with age in males. Female patients had no significant correlating factors for graft diameters.

We noted that there was a decrease in graft dimensions with an increase in age in both the genders (except for gracilis diameter in females and 5-stranded graft length in males). This has yet to be reported in Indian population. Therefore, we recommend a larger sample size across various races to ascertain whether the negative correlation between age and hamstring graft dimensions truly exists or not in order to come to a robust conclusion. The exact cause of this reduction in graft dimensions needs to be studied in greater detail.

To the best of our knowledge, this is the only study which mentions equations for predicting the dimensions of 5-stranded hamstring graft which is reproducible after considering specific pre-operative anthropometric parameters. We believe that it is imperative to carry out an anthropometric analysis of all patients prior to ligament reconstruction as a pre-operative protocol. This is especially important in multi-ligament injuries as this may affect surgical planning with regards to the decision of donor sites on acquiring the grafts. This study has feasible clinical application in routine practice as it does not require any additional investigations or surgical technique to come to a conclusion. It can be performed across various ethnicities and regions of the world if basic principles of graft harvesting and measurement are followed.

This study does have certain limitations. First, the measurements and correlations presented here are based on chronological age and not physiological age. This might play an imperative role in analysis as two patients of the same age may have different physiological states. This may mandate different reconstruction techniques and different graft diameters may be required. Another limitation is the lack of comparison with another prediction method such as an ultrasound or MRI. The body weight assessments only acquire the total weight while the percent of body fat and lean body mass were not looked in the patients which could have a better method of assessment. The number of females in this study was quite small and this could have affected the predictive outcomes. The last limitation is that this study included only a single ethnicity. We do recommend a larger sample size across various ethnicities to test the reliability of this study.

5 Conclusions

Hamstring graft dimensions can be predicted by formulae based on specific anthropometric parameters. This facilitates pre-operative planning and may alleviate the need for additional autografts or allografts. Caution is needed especially in older patients as the graft dimensions seem to decrease as age increases. The cause for this decrease needs to be investigated in further detail.

Funding/sponsorship

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

Institutional ethical committee approval

Obtained.

Data availability

With the corresponding author.

Use of AI tool

No.

Guardian/patient’s consent

This study was conducted between 2016 and 2022 after obtaining institutional ethical committee approval and informed consent from the patients.

CRediT authorship contribution statement

Rahul Hemant Shah: Data curation, investigation, methodology, writing. Rahul P: Conceptualization. Yashavantha K. C: Project administration. Satish Shervegar: Supervision. Ashok Kumar P: Validation, visualization.

References

Bisciotti G.N., Chamari K., Cena E., Bisciotti A., Corsini A., Volpi P., . Anterior cruciate ligament injury risk factors in football. J Sports Med Phys Fit. 2019 Apr 30;59(10):1724-1738.
[Google Scholar]
Macaulay A.A., Perfetti D.C., Levine W.N., . Anterior cruciate ligament graft choices. Sport Health. 2012 Jan;4(1):63-68.
[Google Scholar]
Nagda S.H., Altobelli G.G., Bowdry K.A., Brewster C.E., Lombardo S.J., . Cost analysis of outpatient anterior cruciate ligament reconstruction: autograft versus allograft. Clin Orthop Relat Res. 2010 May;468:1418-1422.
[Google Scholar]
Ranjan R., Asif N., . Choices of graft for anterior cruciate ligament reconstruction. Saudi J Sport Med. 2016 Jan 1;16(1):7.
[Google Scholar]
Mariscalco M.W., Flanigan D.C., Mitchell J., et al . The influence of hamstring autograft size on patient-reported outcomes and risk of revision after anterior cruciate ligament reconstruction: a Multicenter Orthopaedic Outcomes Network (MOON) cohort study. Arthrosc J Arthrosc Relat Surg. 2013 Dec 1;29(12):1948-1953.
[Google Scholar]
Janssen R.P., van der Velden M.J., van Den Besselaar M., Reijman M., . Prediction of length and diameter of hamstring tendon autografts for knee ligament surgery in Caucasians. Knee Surg Sports Traumatol Arthrosc. 2017 Apr;25:1199-1204.
[Google Scholar]
Schwartzberg R., Burkhart B., Lariviere C., . Prediction of hamstring tendon autograft diameter and length for anterior cruciate ligament reconstruction. Am J Orthoped (Belle Mead, NJ). 2008 Mar 1;37(3):157-159.
[Google Scholar]
Mardani-Kivi M., Karimi-Mobarakeh M., Mirbolook A., et al . Predicting the hamstring tendon diameter using anthropometric parameters. Arch Bone Jnt Surg. 2016 Oct;4(4):314.
[Google Scholar]
Aljuhani W.S., Alamri S.G., Alsharif S.A., Annaim M.M., . Correlation between body mass index and quadruple hamstring autograft size. J Musculoskel Surg Res. 2019 Apr 1;3:200.
[Google Scholar]
Pereira R.N., Karam F.C., Schwanke R.L., Millman R., Foletto Z.M., Schwanke C.H., . Correlation between anthropometric data and length and thickness of the tendons of the semitendinosus and gracilis muscles used for grafts in reconstruction of the anterior cruciate ligament. Rev Bras de Ortop. 2016 Mar;51:175-180.
[Google Scholar]
Leiter J.R., Elkurbo M., McRae S., MacDonald P.B., . Determining ACL hamstring graft diameter from anthropometric and radiology measurements. . 2012 Sep;vol. 94:103.
[Google Scholar]
Magnussen R.A., Lawrence J.T., West R.L., Toth A.P., Taylor D.C., Garrett W.E., . Graft size and patient age are predictors of early revision after anterior cruciate ligament reconstruction with hamstring autograft. Arthrosc J Arthrosc Relat Surg. 2012 Apr 1;28(4):526-531.
[Google Scholar]
Chiba D., Tsuda E., Sasaki S., Liu X., Ishibashi Y., . Anthropometric and skeletal parameters predict 2-strand semitendinosus tendon size in double-bundle anterior cruciate ligament reconstruction. Orthop J Sport Med. 2017 Jul 25;5(8)
[Google Scholar]
Milano G., Mulas P.D., Ziranu F., Piras S., Manunta A., Fabbriciani C., . Comparison between different femoral fixation devices for ACL reconstruction with doubled hamstring tendon graft: a biomechanical analysis. Arthrosc J Arthrosc Relat Surg. 2006 Jun 1;22(6):660-668.
[Google Scholar]
Stergios P.G., Georgios K.A., Konstantinos N., Efthymia P., Nikolaos K., Alexandros P.G., . Adequacy of semitendinosus tendon alone for anterior cruciate ligament reconstruction graft and prediction of hamstring graft size by evaluating simple anthropometric parameters. Anat Res Int. 2012;2012
[Google Scholar]
Beynnon B.D., Johnson R.J., Fleming B.C., et al . Anterior cruciate ligament replacement: comparison of bone-patellar tendon-bone grafts with two-strand hamstring grafts: a prospective, randomized study. JBJS. 2002 Sep 1;84(9):1503-1513.
[Google Scholar]
Thomas S., Bhattacharya R., Saltikov J.B., Kramer D.J., . Influence of anthropometric features on graft diameter in ACL reconstruction. Arch Orthop Trauma Surg. 2013 Feb;133:215-218.
[Google Scholar]
Sundararajan S.R., Rajagopalakrishnan R., Rajasekaran S., . Is height the best predictor for adequacy of semitendinosus-alone anterior cruciate ligament reconstruction? A study of hamstring graft dimensions and anthropometric measurements. Int Orthop. 2016 May;40:1025-1031.
[Google Scholar]
Tuman J.M., Diduch D.R., Rubino L.J., Baumfeld J.A., Nguyen H.S., Hart J.M., . Predictors for hamstring graft diameter in anterior cruciate ligament reconstruction. Am J Sports Med. 2007 Nov;35(11):1945-1949.
[Google Scholar]
Boisvert C.B., Aubin M.E., DeAngelis N., . Relationship between anthropometric measurements and hamstring autograft diameter in anterior cruciate ligament reconstruction. Am J Orthoped. 2011 Jun 1;40(6):293-295.
[Google Scholar]
Krishna L., Tan X.Y., Wong F.K., Toh S.J., . A 5-strand hamstring autograft achieves outcomes comparable to those of a 4-strand hamstring autograft with a graft diameter of 8 mm or more in anterior cruciate ligament reconstruction. Orthop J Sport Med. 2018 Mar 15;6(3)
[Google Scholar]
Park S.Y., Oh H., Park S., Lee J.H., Lee S.H., Yoon K.H., . Factors predicting hamstring tendon autograft diameters and resulting failure rates after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2013 May;21:1111-1118.
[Google Scholar]
Asif N., Ranjan R., Ahmed S., Sabir A.B., Jilani L.Z., Qureshi O.A., . Prediction of quadruple hamstring graft diameter for anterior cruciate ligament reconstruction by anthropometric measurements. Indian J Orthop. 2016 Feb;50:49-54.
[Google Scholar]
Moghamis I., Abuodeh Y., Darwiche A., Ibrahim T., Al Ateeq Al Dosari M., Ahmed G., . Anthropometric correlation with hamstring graft size in anterior cruciate ligament reconstruction among males. Int Orthop. 2020 Mar;44:577-584.
[Google Scholar]