Anterior Cruciate Ligament Reconstruction With a Quadrupled Hamstring Autograft Does Not Restore Tibial Rotation

As a result of the morbidity associated with anterior cruciate ligament (ACL) reconstruction with a bone-patellar-tendon-bone graft, many orthopaedic surgeons prefer hamstrings as the graft for ACL reconstruction. However, this selection is not based on solid scientific evidence. In vitro research shows that this graft cannot restore control of tibial rotation. Our recent in vivo research work has also demonstrated the same result. In particular, patients undergoing ACL repair who were reconstructed with a quadrupled hamstring tendon graft showed excessive tibial rotation during a dynamic activity when compared with healthy control subjects. Although the hamstring tendon graft has a more advantageous biomechanical profile than other grafts, it seems that it could not replicate the normal ACL regarding its actual anatomy and functional rotational abilities. The improvement and development of new surgical procedures and grafts seems to be the only way to address this problem of excessive tibial rotation. We also propose that the inability of current operative techniques to restore tibial rotation to normal preinjury levels can be the cause of future pathology and osteoarthritis found in ACL-reconstructed patients in the long-term. Abnormal rotational movements could result in loading of the knee cartilage in areas that are not commonly loaded in a healthy knee. These areas resulting from insufficient cartilage thickness may not be able to withstand the newly introduced loading and, over time, knee osteoarthritis is developed.