Anterior cruciate ligament reconstruction with 4-strand hamstring autograft and accelerated rehabilitation: a 10-year prospective study on clinical results, knee osteoarthritis and its predictors

Knee Surg Sports Traumatol Arthrosc. 2013 Sep;21(9):1977-88. doi: 10.1007/s00167-012-2234-9. Epub 2012 Oct 19.


Purpose: Analysis of long-term clinical and radiological outcomes after anterior cruciate ligament (ACL) reconstruction with special attention to knee osteoarthritis and its predictors.

Methods: A prospective, consecutive case series of 100 patients. Arthroscopic transtibial ACL reconstruction was performed using 4-strand hamstring tendon autografts with a standardized accelerated rehabilitation protocol. Analysis was performed preoperatively and 10 years postoperatively. Clinical examination included Lysholm and Tegner scores, IKDC, KT-1000 testing (MEDmetric Co., San Diego, CA, USA) and leg circumference measurements. Radiological evaluation included AP weight bearing, lateral knee, Rosenberg and sky view X-rays. Radiological classifications were according to Ahlbäck and Kellgren & Lawrence. Statistical analysis included univariate and multivariate logistic regressions. RESULTS CLINICAL OUTCOME: A significant improvement (p < 0.001) between preoperative and postoperative measurements could be demonstrated for the Lysholm and Tegner scores, IKDC patient subjective assessment, KT-1000 measurements, pivot shift test, IKDC score and one-leg hop test. A pivot shift phenomenon (glide) was still present in 43 (50%) patients and correlated with lower levels of activity (p < 0.022). Radiological outcome: At follow-up, 46 (53.5%) patients had signs of osteoarthritis (OA). In this group, 33 patients (72%) had chondral lesions (≥grade 2) at the time of ACL reconstruction. A history of medial meniscectomy before or at the time of ACL reconstruction increased the risk of knee OA 4 times (95% CI 1.41-11.5). An ICRS grade 3 at the time of ACL reconstruction increased the risk of knee OA by 5.2 times (95% CI 1.09-24.8). There was no correlation between OA and activity level (Tegner score ≥6) nor between OA and a positive pivot shift test.

Conclusion: Transtibial ACL reconstruction with 4-strand hamstring autograft and accelerated rehabilitation restored anteroposterior knee stability. Clinical parameters and patient satisfaction improved significantly. At 10-year follow-up, radiological signs of OA were present in 53.5 % of the subjects. Risk factors for OA were meniscectomy prior to or at the time of ACL reconstruction and chondral lesions at the time of ACL reconstruction.

Level of evidence: II.

MeSH terms

  • Adult
  • Anterior Cruciate Ligament Injuries
  • Anterior Cruciate Ligament Reconstruction / methods*
  • Anterior Cruciate Ligament Reconstruction / rehabilitation*
  • Arthroscopy
  • Autografts
  • Female
  • Humans
  • Knee Injuries / complications
  • Knee Injuries / rehabilitation
  • Knee Injuries / surgery*
  • Male
  • Osteoarthritis, Knee / epidemiology
  • Osteoarthritis, Knee / etiology
  • Osteoarthritis, Knee / prevention & control
  • Prospective Studies
  • Tendons / transplantation*
  • Treatment Outcome