Five-Strand Versus Four-Strand Hamstring Autografts in Anterior Cruciate Ligament Reconstruction—A Prospective Randomized Controlled Study


      To compare the clinical outcomes of the routine use of 5-strand hamstring grafts (where possible) with those of 4-strand grafts in primary anterior cruciate ligament (ACL) reconstruction.


      A total of 64 patients were enrolled in a prospective randomized controlled study comparing the use of 5-strand and 4-strand semitendinosus–gracilis autografts in single bundle ACL reconstruction (n = 32 in each group). Four participants in each group were lost to follow-up and were excluded from the outcome analysis. The outcomes of 28 patients in the 5-strand group and 28 patients in the 4-strand group were analyzed. The diameters of all grafts were measured intraoperatively. Patients were assessed postoperatively at 2 years with objective assessments (anterior knee laxity using the KT-2000 arthrometer, Lachman test, pivot-shift test, hop test) and patient-reported outcome scores (Lysholm knee score, Knee Injury and Osteoarthritis Outcome Score, International Knee Documentation Committee subjective knee score, SF-36 physical and mental components, Tegner activity scale). Postoperative graft ruptures were also noted.


      There were improvements in all outcome measures postoperatively regardless of the number of graft strands. When we compared the study and control groups, there were no significant differences in all subjective and objective outcome measures except the Knee Injury and Osteoarthritis Outcome Score symptoms score (5-strand group 93.3 ± 9.2 vs 4-strand group 86.2 ± 14.7, P = .04). The KT-2000 side-to-side difference was 2.79 ± 2.11 mm in the 5-strand group and 2.54 ± 1.75 mm in the 4-strand group (P = .63). The 5-strand study group had 2 graft ruptures at 1 year, whereas the 4-strand control group had one partial graft rupture at 6 months.


      At 2-year follow-up, the routine use of the 5-strand hamstring tendon autograft was not superior to that of the quadrupled or 4-strand graft in primary ACL reconstruction.

      Level of Evidence

      Level I, prospective randomized controlled trial.
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