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Younger age and smaller hamstring graft size linked with higher ACL revision rates

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Robert A. Magnussen

SAN DIEGO — Decreased hamstring autograft size and younger patient age are predictors of early graft failure and revision, according to a presenter here.

Robert A. Magnussen, MD, said that the use of hamstring autografts less than or equal to 8 mm in diameter in patients younger than 20 years old is associated with a high early revision rate.

“Decreased hamstring graft size is significantly correlated with increased short-term revision rates,” Magnussen said during his presentation at the 2011 Annual Meeting of the American Orthopaedic Society for Sports Medicine. “Further work with more patients and a more complete follow-up is necessary to further explore this relationship,” he said.

Revision rates

Magnussen and his team retrospectively evaluated 256 of 338 consecutive patients (75.7%) who underwent primary ACL reconstruction. All patients received quadrupled hamstring grafts performed with standard arthroscopic techniques. Graft size, patient gender and age at the time of ACL reconstruction were recorded from medical records along with whether each patient underwent revision ACL reconstruction during the follow-up period.

The 256 patients included 136 men, and the patients ranged in age from 11 years to 52 years. Average follow-up was 14 months. Revision ACL reconstruction was required in 7% of the patients at a mean of 12 months following surgery. Revision was required in 1 of 58 patients (1.7%) with grafts greater than 8 mm in diameter, 9 of 139 patients (6.5%) with 7.5 mm or 8 mm grafts and 8 of 59 patients (13.6%) with grafts 7 mm or less in diameter.

Most failures occurred in patients younger than 20 years old with grafts 8 mm in diameter or less, and the revision rate in this population was 16.4%. Multiple logistical regression revealed decreased age at reconstruction and decreased graft size to be associated with significantly increased risk of revision.

Impact of gender

Magnussen said female gender was not an independent predictor of graft failure when patient age and graft size were considered.

“This may explain the increased failure rates of hamstring autografts in females that has been reported in some studies,” he said.

Reference:

Magnussen RA, Lawrence JTR, West RL, et al. Graft size and patient age are predictors of early revision following ACL reconstruction with hamstring autograft. Paper #4. Presented at the 2011 Annual Meeting of the American Orthopaedic Society for Sports Medicine. July 7-10. San Diego.

Disclosure: Magnussen has no relevant financial disclosures.

Magnussen et al in "Graft Size and Patient Age are Predictors of Early Revision Following ACL Reconstruction with Hamstrings Autograft" took an important step towards recognizing the effects of graft sizes in ACL reconstructions. Authors conclude that patients under 20 years old and patients and hamstrings graft sizes of 7mm or less are more prone to early ACL graft failure.

In evaluating the effect of age, younger patients tend to be more active and more anxious to return to their previous activities. As such, they often shorten rehabilitation and expose the graft without complete healing.

In Pittsburgh, we utilize pre-operative MRI measurements of the quadriceps and patellar tendons, the ACL insertion site size and length to aid in graft selection based on individual patient anatomy. Those measurements are then confirmed intra-operatively with an arthroscopic ruler.

Kopf et al. found a large variation in tibial insertion site size (Kopf et al., AJSM Jan 2011). This study highlights the importance of individualizing ACL reconstruction. All the efforts should be made to restore at least 60 - 80% of the native insertion site. Therefore, the chosen graft source, weather a quadriceps tendon, patellar tendon, hamstrings or a hybrid source must be able to accomplish this goal. For example, in a 18mm insertion site, a 8mm graft covers 45% of the insertion site.

In cadaveric studies, smaller grafts have a biomechanical lower ultimate failure load than bigger ones. However, graft failure is only one aspect of patient outcome. Objective in vivo outcome measurements must be considered to truly evaluate the role of graft size and insertion site size in knee kinematics.

This paper is important for highlighting the discussion of anatomical approach for ACL reconstruction respecting individualized aspects of patient's anatomy.

— Freddie H. Fu, MD, DSc(Hon), DPs(Hon)
Orthopedics Today Editorial Board member
University of Pittsburgh

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