AJSM - 2026-06-17 - Journal Article
ACL Reconstruction With Attachment-Sparing Hamstring Autograft Results in Earlier Graft Maturation and Better Short-Term Clinical Outcome in Comparison to Free Graft: A Randomized Controlled Trial.
Sinha S, Arumugham KC, Singh DK, Kumar N, Bera AP, Uppal H, Vakharia KS
Topics
Key Takeaway
Attachment-sparing hamstring autograft achieved complete MRI graft maturation (Figueroa score 5) in 100% of patients at 9 months versus only 10% in free graft controls, with earlier ligamentization detectable as early as 3 months.
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Summary
This RCT compared tibial attachment-sparing hamstring autograft (AS) versus free hamstring graft (FG) ACLR in 50 patients, using sequential MRI Figueroa scoring at 3, 6, and 9 months alongside Lysholm, IKDC, Tegner, and KT-2000 assessments at 3, 6, 9, and 12 months. The AS group demonstrated significantly higher Figueroa scores at all MRI timepoints, with 26.3% reaching score 4 at 3 months versus none in the FG group, and 100% reaching score 5 at 9 months versus 10% of FG patients. Both groups showed significant clinical improvement in Lysholm, IKDC, and ATT, though the AS group showed greater tibial tunnel widening despite superior graft maturation.
Key Limitation
The 12-month maximum follow-up cannot determine whether the early MRI maturation advantage in the AS group translates into reduced graft failure rates or superior long-term functional outcomes.
Original Abstract
BACKGROUND
Attachment-sparing anterior cruciate ligament reconstruction (ACLR) is gaining acceptance over the use of free grafts because of reported early graft ligamentization in both animals and humans. However, the literature regarding clinical outcomes and the correlation of early graft healing is unclear.
HYPOTHESIS
Tibial attachment-sparing hamstring graft (AS) results in earlier graft maturation, which correlates with a better clinical outcome than a free hamstring graft (FG).
STUDY DESIGN
Randomized controlled trial; Level of evidence, 1.
METHODS
A total of 56 patients were randomly assigned to 2 groups at the commencement of the study. Of these patients, 25 (AS group) underwent ACLR using the attachment-sparing technique, while 25 patients (FG group) underwent ACLR using the free hamstring graft technique. Prospective sequential magnetic resonance imaging (MRI) evaluations were performed at 3, 6, and 9 months to document graft maturation, characteristics, orientation, and tunnel dilation. Clinical evaluation was done at 3, 6, 9, and 12 months to document Lysholm, International Knee Documentation Committee (IKDC), and Tegner scores and anterior tibial translation (ATT) by KT-2000 arthrometer, by independent observers.
RESULTS
The overall follow-up rate was 78% (19 cases and 20 controls of 25 in each group). MRI Figueroa scores demonstrated significant differences between the AS and FG groups, with the AS group showing consistently higher scores at all timelines. The earliest noticed graft maturation in the case group was at 3 months (26.3% had Figueroa score 4), compared to 6 months for the controls. In the AS group, all participants attained a Figueroa score of 5 at the final assessment, whereas only 10% of the FG group achieved that. The AS group maintained nearly the same graft diameters, but the FG group showed increased diameter (graft swelling) at all follow-up time points. A significant increase in tibial tunnel diameter over time was observed in both groups, with a greater increase in the AS group. A significant improvement was observed in Lysholm score, IKDC score, and ATT in both groups.
CONCLUSION
Tibial attachment-sparing hamstring grafts result in earlier and complete graft maturation on MRI as compared to free hamstring grafts for ACLR.
REGISTRATION
Clinical Trials Registry - India (CTRI/2022/10/046620).