Sports Medicine Research: In the Lab & In the Field: Taking Sides – the Hamstring Autograft Debate (Sports Med Res)


Wednesday, October 2, 2013

Taking Sides – the Hamstring Autograft Debate

Ipsilateral Versus Contralateral Hamstring Grafts in Anterior Cruciate Ligament Reconstruction

McRae S, Leiter J, McCormack R, Old J, & MacDonald P. American Journal of Sports Medicine.  Epub ahead of print; doi:10.1177/0363546513499140

Take Home Message:  An ACL hamstring autograft can be harvested from either the same or opposite leg without compromising quality of life, clinical signs and symptoms, or strength for at least 24 months after surgery.

Increasingly, patients receive anterior cruciate ligament (ACL) reconstructions with a hamstring autograft, specifically the semitendinosus autograft (STG).  When using STG, a question remains whether it is better to take it from the ipsilateral or contralateral hamstring for optimal outcomes.  Therefore, the purpose of this multicenter, single-blind, randomized study was to compare the outcomes (i.e., quality of life, strength, pain, IKDC [clinical assessment of signs and symptoms]) between contralateral and ipsilateral STG ACL reconstructions in 100 participants. The authors assessed participants preoperatively and post-operatively at 3, 6, 12, 18, and 24 months.  There were no group differences for quality of life, strength, IKDC knee assessments, pain, and rerupture rate at 24 months postoperatively.  Among patients that had the graft harvested from the same knee as the ACL reconstruction, the knee with both the reconstruction and graft harvest had less knee flexion strength – and possibly less extension strength – than the contralateral unaffected knee at 3 months.  Both groups had comparable knee strength by the end of the follow-up period (24 months).  

Clinically, it appears that there are no major advantages or disadvantages to STG site selection.  This is a nice finding because it gives surgeons flexibility to consider which site to take the graft from.  If a person has a history of repetitive hamstring issues on the involved side, a decision could be made to take it from the contralateral side with no apparent downside.  While this study did not find any differences with graft re-rupture rates, it would be interesting to compare the incidence of other lower extremity pathologies.  Of note, there were no major differences in pain nor analgesic use between the two groups.  With the contralateral group having “2 surgical sites” one may have expected them to be in more pain, however, this was not the case.  Theoretically, this allows for healthy hamstrings to serve as secondary stabilizers of the newly reconstructed ACL.  It may also be interesting to compare participant-perceived outcome differences based on activity that they were returning back to.  For instance, a participant returning back to sprinting activities compared with someone returning to activities of daily living may have very different perceptions of successful outcomes.

Questions for Discussion: When do you think that you might opt for a contralateral over an ipsilateral STG site?  Has anyone seen a contralateral STG ACL reconstruction done clinically?  What have your experiences been?
Written by: Nicole Cattano
Reviewed by: Jeffrey Driban

Related Posts:
Patellar Tendon versus Hamstring Autografts: 15 Years After Reconstruction

McRae S, Leiter J, McCormack R, Old J, & Macdonald P (2013). Ipsilateral Versus Contralateral Hamstring Grafts in Anterior Cruciate Ligament Reconstruction: A Prospective Randomized Trial. The American Journal of Sports Medicine PMID: 24001575


Sarah De Simone said...

Although the study shows that there are no major advantages or disadvantages to the semitendinosus autograft for anterior cruciate ligament reconstruction, if any, what sports/activities would be the better choice in choosing whether to reconstruct the anterior cruciate ligament (ACL) with an ipsilateral hamstring autograft or a contralateral hamstring autograft?

Nicole Cattano said...

Sarah-I don't know. I think that is a great point. Anecdotally, I am thinking that for a hurdler, it may be important not to take the autograft from the lead leg. There may also be other implications for baseball/softball pitchers, but I am not sure there is any evidence to support this. Does anyone have any other thoughts about this?

Lauren Rao said...

This study is great. I really would have thought that the graft site made a difference. I agree with both Sarah and Nicole, however, that more needs to be looked at in specific sports as well as in general populations as well. I think the patient-perceived outcomes idea stated in the article is also a great idea. Perhaps patients with a graft taken from one side or the other may expect their rehabilitation to be better or worse than other patients. I am thinking that for jumping sports like basketball, diving, trampolinists, gymnastics, etc. may want the graft to be taken from the leg that isn't considered their "jumping" leg or dominant leg. I would think that the decision for surgeons to take from one side or the other should be very patient to patient specific.

Nicole Cattano said...

Lauren-Great point about patient centered decisions! Maybe some sort of strength assessment PRE-surgery could be informative. For instance, if one hamstring is significantly weaker than the other.

Although I wonder how my orthopedists would be comfortable with changing procedures that they may be comfortable with. Does anyone know any physicians that are currently doing this?

Catherine LeBlanc said...

Out of personal experience, I had an ACL with the ipsilateral side (which was also my dominant side). A great point that everyone has made is perhaps taking the hamstring graft from the non-dominant side, as to prevent further injury on the leading leg. If I had had a choice, perhaps I would have wanted my graft from my non-dominant leg.
Though I am curious as to if taking from the contralateral side is beneficial due to the typical hamstring/quad ratio associated with ACL tears. Would it expose the "unaffected side" side more to an ACL tear because the hamstring is weaker than the quadriceps more than what caused an ACL tear on the "affected side"? I definitely agree with Nicole about perhaps doing a pre-surgical assessment about strength for that possible reason.

Sam Korolev said...

If I was an elite athlete, or even a Weekend Warrior type of athlete, I would choose to get a ACL STG contralateral to the previous injured knee. Mentally I would always feel as if that taking a graft from my "injured" leg would not be a strong selection in graft material for already weak knee. I

Nicole Cattano said...

Catherine-great points about predisposition based on quad dominance. Out of curiosity, you said you would have liked your non-dominant side possibly as the site for the autograft...what sport did you play?

Sam-I understand your situation. I think as an ex-athlete I would say a similar thing. However, now that I have wondered into weekend warrior status myself...I'm more thinking I would opt for NO SURGERY and just rehabilitation.

Any thoughts on this?

Matt Johnson said...

If I was an athlete dealing with this situation and I had no preexisting hamstring condition, I think I would opt to have an ipsilateral ACL STG. The thought process behind this decision being that I would not want to put a healthy knee at risk first during surgery, and then having to rehab that knee in addition to the affected knee with the ACL STG. Being that there are no remarkable differences between ipsilateral and contralateral ACL STG's then in my mind ipsilateral would make more sense. During the ACL rehabilitation process I would also be strengthening the hamstring muscle that was involved in taking the STG, without potentially putting the opposite joint at risk.

Nicole Cattano said...

Matt-I think that is a great point-why have a surgical procedure done on an apparently "healthy" side?

I think my interest lies more in it being an OPTION in the event that it is not healthy or in the event of a sport-specific demand causing undue demand on a specific graft site.

Anonymous said...

Ryan Tonucci.
It is benefitial thing for no major advantages or disadvantages in regaurds to the which semitendinosus autograft the leg is taken from. This allows the option of taking the ipsilateral or the contralateral semitendinosus autograph providing if one side is compromised.

Michael Burke said...

Even though there is no difference between using a semitendinosis autograph in the reconstructed anterior cruciate ligament leg versus using a semitendinosis autograph from the contralateral leg 24 months post-op, I would think taking the autograph from the same knee would benefit the athlete more in the short term. Two surgeries mean the athlete needs to rehabilitate both knees. While infection has a very small risk of occuring, having two surgeries will double that persons risk. Also having one completely healthy knee will give a better idea of strength, range of motion, swelling, etc when comparing the athletes progress bilaterally in the short term (3months post-op where knee flexion is limited, and possibly knee extension in the leg opposite of the reconstruction where the semitendinosis autograph was taken)

Nicole Cattano said...

Ryan and Michael-you both bring up very good points.

I wonder what the infection rate is like? Furthermore, I am very curious as to what the rehabilitation process would look like after a contralateral graft was harvested. For example, are they back to normal 3 months post-op? I understand the concerns for a "healthy" comparison...but how long do we speculate it will take for that side to become healthy again?

Has anyone previously dealt with a contralateral graft site help clarify?

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