“Caminante no hay camino, se hace camino al andar.” Antonio Machado (1). (“Wayfarer, there is no way, make your way by going farther.”)
The anterior cruciate ligament (ACL) injury and the complications that entail its reconstruction has been a source of interest for many years. The first reported reconstruction with ACL graft was dated in 1913 and performed by Grekov, published in 1919 (2). The first English-written publication regarding ACL reconstruction with a graft was of Hey Groves in 1917 (3).
There are mainly two types of grafts for ACL reconstruction. First, grafts with tendon and bone, such as bone-tendon-bone or Achilles tendon with a calcaneal bone block. On the other hand, graft with only soft tissue (hamstring, fascia lata, anterior or posterior tibialis).
Despite the patellar tendon has been the preferred graft for many years (6), and is still considered as gold standard in ACL reconstruction (7,8), the use of hamstring graft has increased recently (9). The ease in its surgical technique and the good outcomes observed has been crucial elements in favoring its worldwide expansion (8).
Several complications have to be considered with both techniques. The patellar tendon graft may present anterior knee pain within the donor site (10). The use of biological therapies can accelerate regeneration of the donor site as well as decrease pain in this area (11).
Regarding hamstring graft, its decreased diameter can determine an increase rate of rupture (12).
The study by Cruz et al. (12) brings up a very interesting issue. Despite it is well known the need to tension the graft tendons once prepared, for a period of time, the thickness was not considered as a variable during this period. Measuring the diameter of the hamstring graft once measured to obtain the tendons, it does not arise different depending on the time of tension.
In preparing the tunnels, the use of drill bits or dilators increasing medium and one progressive millimeter is common. The variation of the graft can condition us an excessively thick tunnel and can leave us with a too wide space that produces a bell effect and favors the graft failure.
The same study shows us this variable that can certainly improve the surgical technique in case of using this type of graft (12).
Undoubtedly, the small steps in improving surgery are contributing to a long-term knowledge. One of the greatest poets of our country told us in his poems that you “make your way by going farther” (1).
Conflicts of Interest: The authors have no conflicts of interest to declare.
- Machado A. Caminante no hay camino. Proverbios y cantares. Campos de Castilla. 1912.
- Grekov JJ. Scientific work. Jubilee Book for the honour of 25 years of practical scientific work 1894-1919 of professor J.J. Grekov. 1919.
- Hey Groves EW. Operation for the repair of the crucial ligaments. Lancet 1917;3:674-5. [Crossref]
- Jones KG. Reconstruction of the anterior cruciate ligament. a technique using the central one-third of the patellar ligament. J Bone Joint Surg Am 1963;45:925-32. [Crossref] [PubMed]
- Clancy WG Jr, Nelson DA, Reider B, et al. Anterior cruciate ligament reconstruction using one-third of the patellar ligament, augmented by extra-articular tendon transfers. J Bone Joint Surg Am 1982;64:352-9. [Crossref] [PubMed]
- Goldblatt JP, Fitzsimmons SE, Balk E, et al. Reconstruction of the anterior cruciate ligament: meta-analysis of patellar tendon versus hamstring tendon autograft. Arthroscopy 2005;21:791-803. [Crossref] [PubMed]
- Lewis PB, Parameswaran AD, Rue JP, et al. Systematic review of single-bundle anterior cruciate ligament reconstruction outcomes: a baseline assessment for consideration of double-bundle techniques. Am J Sports Med 2008;36:2028-36. [Crossref] [PubMed]
- Freedman KB, D'Amato MJ, Nedeff DD, et al. Arthroscopic anterior cruciate ligament reconstruction: a metaanalysis comparing patellar tendon and hamstring tendon autografts. Am J Sports Med 2003;31:2-11. [PubMed]
- Lipscomb AB, Johnston RK, Snyder RB. The technique of cruciate ligament reconstruction. Am J Sports Med 1981;9:77-81. [Crossref] [PubMed]
- Seijas R, Cuscó X, Sallent A, et al. Pain in donor site after BTB-ACL reconstruction with PRGF: a randomized trial. Arch Orthop Trauma Surg 2016;136:829-35. [Crossref] [PubMed]
- Seijas R, Rius M, Ares O, et al. Healing of donor site in bone-tendon-bone ACL reconstruction accelerated with plasma rich in growth factors: a randomized clinical trial. Knee Surg Sports Traumatol Arthrosc 2015;23:991-7. [Crossref] [PubMed]
- Cruz AI Jr, Fabricant PD, Seeley MA, et al. Change in Size of Hamstring Grafts During Preparation for ACL Reconstruction: Effect of Tension and Circumferential Compression on Graft Diameter. J Bone Joint Surg Am 2016;98:484-9. [Crossref] [PubMed]