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Preserved insertions of the semitendinosus and gracilis tendons (STG) in ACL

reconstruction: A new surgical technique with preliminary results

Article  in  Current Orthopaedic Practice · July 2010

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 I N N O V A T I O N S
Preserved insertions of the semitendinosus and gracilis
tendons (STG) in ACL reconstruction: a new surgical
technique with preliminary results
Ravi K. Gupta, Siddharth Aggarwal, Varun Aggarwal, Sudhir K. Garg and Sachin Kumar
ABSTRACT
Background
A torn anterior cruciate ligament leads to loss of proprioception
function normally provided by an intact anterior cruciate
ligament. Relying on the hypothesis that preservation of the
tibial insertions of the semitendinosus and gracilis tendons
(STG), while using a quadrupled STG graft may provide better
proprioception function, we describe a new surgical technique
that uses a quadrupled STG graft with preserved tibial insertions.
Methods
The study was a retrospective follow-up analysis of 45 patients
with anterior cruciate ligament deficient knees that were
reconstructed using a new surgical technique. Functional
evaluation was done based on the Lysholm Knee Score.
Proprioception was tested with active reproduction of passive
position (ARPP) test, single-leg forward-hop (SLHT) test, single-
limb standing test (SLST) and threshold for detection of passive
motion (TDPP) test. The average duration of follow-up was 40.6
months (range, 33--50 months).
Results
The mean Lysholm score improved from a preoperative value of
62.4 to 95.2 at final follow-up. Various tests demonstrated that
there was significant improvement in the quality of propriocep-
tion sensation as compared with the preoperative values.
However, the sensation was still inferior in comparison to the
normal knee. All patients returned to their preinjury functional
levels. There was one rerupture resulting from a second injury in
a football player at 3.5 years after the surgery.
Conclusions
The new surgical technique preserving the tibial insertions of the
STG with satisfactory early to mid-term functional results is
another option for ACL reconstruction that provides significantly
superior proprioception sensation compared with preoperative
values. However, whether the quality of proprioception is
superior to the one provided by a free graft needs to be
established by undertaking further double-blind prospective
comparative studies.
Department of Orthopaedics, Government Medical College Hospital,
Chandigarh, India
Correspondence to: Dr Ravi K Gupta, MBBS, MS, DNB, MNAMS,
Department of Orthopaedics, Government Medical College Hospital,
Chandigarh, India-160047
Tel: þ 91 98765 21592; fax: þ 91 172 2673244;
e-mail: ravikgupta2000@yahoo.com
1940-7041 ß 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Volume 21  Number 4  July/August 2010
I N P R A C T I C E
Keywords
anterior cruciate ligament, knee, medial hamstrings
INTRODUCTION
A
rthroscopy assisted anterior cruciate ligament (ACL)
reconstruction is a widely accepted procedure for
the management of ACL rupture.1--5 The two most
commonly used autogenous grafts are the bone-patellar
tendon-bone (BTB) graft, and the quadrupled semitendino-
sus-gracilis (STG) tendon construct.1,6 Although both grafts
have been successfully used, there have been concerns of
anterior knee pain and weakness of the knee extensor
apparatus with BTB graft7--9 and failure of the STG graft in
achieving rigid fixation to bone.10,11 To partially offset this
problem, Kim et al.12 proposed the preservation of the tibial
insertions of the semitendinosus and gracilis tendons, while
harvesting the graft with an additional fixation of a double
spiked washer on the tibial side.
The normal ACL, in addition to providing mechanical
stability, also contributes to the proprioception sensation
of the knee. Proprioception is the sensory modality that
encompasses the sensation of joint position and joint
motion. Mechanoreceptors, along with muscle spindles for
the joint proprioception, have been found in the cruciate
ligaments.13 Loss of proprioception in a knee with a
deficient ACL is well documented.14,15 Thus, in an ACL
deficient knee, in addition to the mechanical stability, the
restoration of the proprioception should be one of the
important goals of any ACL reconstruction surgery.16 There
are reports in the literature that the mechanosensitive
afferent units contained in the tendon and aponeurotic
insertions of the muscles have the ability to transmit
nociceptive and proprioceptive impulses.17,18
With this background in mind, we started using a new
surgical technique, preserving the insertions of the STG,
with the aim of obtaining better functional results, espe-
cially in terms of improved proprioception of the knee.
MATERIALS AND METHODS
The current study is a retrospective analysis of 45 patients
(39 men and 6 women) who underwent ACL reconstruction
with a new surgical technique at our institute from January
2004 to December 2005. Patients older than 60 years of age,
skeletally immature patients, patients with associated
posterior cruciate ligament (PCL) injury and patients in
Current Orthopaedic Practice 409
410 | www.c-orthopaedicpractice.com Volume 21  Number 4  July/August 2010

low-demand professions were excluded from the study. The

new surgical technique was explained to the patients, and
each patient signed an informed consent.

Surgical Technique
Through a curvilinear incision positioned proximal and
medial to the insertion of the pes anserinus, the insertions
of the semitendinosus and gracilis tendons are identified, and
any associated fascial bands are carefully severed with scissors.
With the tibial insertions of the tendons left intact, an open-
ended tendon stripper is used to harvest the graft. The
proximal free ends of the tendons are sutured together by
wrapping the broader aponeurosis of semitendinosus around
the gracilis tendon using Ethibond No. 2 suture (Ethicon, Inc.
Johnson and Johnson, Somerville, NJ). The tendons are
looped around an Ethibond No. 5 suture placed at their
middle, thus creating a quadrupled graft. The graft is sutured
with vicryl No. 1 suture at the looped end. The proximal free
ends of the harvested tendons are sutured to the intact distal
insertions of the tendons with Ethibond No. 2 suture using a
baseball stitch over a segment of 5--7 cm, depending on the
span of aponeurotic portion of the harvested tendons. The
average length of the quadrupled graft was 118.62 cm (range,
110--130 cm). The graft is sized with a sizer and marked 3 cm
from the looped end with a marker (Figure 1).
Arthroscopy is then performed, and any meniscal problem is
treated. Placing an ACL tibial guide through the anteromedial
portal into the posteromedial aspect of ACL’s footprint, the
tibial tunnel is angled from a medial-to-lateral direction and
posteriorly in the sagittal plane so that the graft does not
impinge on the intercondylar roof in full extension. It is
ensured that the entry of the tunnel into the joint is posterior
to the roof of the intercondylar notch. The angle of the tibial
guide usually is kept at about 501; however, the angle can be
FIGURE 2. Rigidfix jig collar (Johnson and Johnson, Mitek, Mumbai, India)
visible at the femoral opening.
altered if the length of the harvested graft is small. A tibial
reamer with a diameter equivalent to the size of the graft is
used to drill the tunnel. The femoral tunnel is positioned by
using a femoral aimer (offset guide) passed transtibially, so that
there is at least 1--2 mm of the intact posterior wall after
drilling the femoral tunnel of a diameter equal to the diameter
of the graft. The technique of Rigidfix (Johnson and Johnson,
Mitek Mumbai, India) requires the femoral tunnel to be drilled
to a depth of 3 cm. In our technique, however, we used the
depth of the femoral tunnel up to the outer cortex of the
femur. The Rigidfix jig is used to drill the side holes for the
transfixation pins. The tibial and femoral rod assembled on
the jig corresponding with the sized graft is passed through the
tunnel. The collar of the jig entering the femoral tunnel is
stopped at the 3 cm mark (Figure 2) to allow the transfixation
of the graft to be near the articular opening of the femoral
tunnel. Two transfixation holes are drilled using the Rigidfix
trocar and cannulae (Figure 3).

FIGURE 1. Semitendinosus and gracilis graft looped over Ethibond suture

(Ethicon, Inc., Johnson and Johnson, Somerville, NJ) and quadrupled, the
aponeurotic ends sutured with Ethibond suture with the preserved
insertions (arrow A) and looped end sutured with vicryl suture and marked
at 3 cm (arrow B). FIGURE 3. Two cannulae in place in the lateral femoral cortex.
Current Orthopaedic Practice
FIGURE 4. Central placement of lateral holes into femoral tunnel.
The jig is removed. An arthroscope is passed from the
opening of tibial tunnel into the femoral tunnel. A long pin
is passed into both the Rigidfix trocars, one by one, to
confirm the central placement of the transfixation holes
(Figure 4). The graft is pulled through the tibial and femoral
tunnels with the help of a Beath pin (Figure 5) and pulled to
the maximum from the femoral side. With maximal stretch
on the graft, the joint is moved through full range of motion
at least 20 times to remove any kinks in the graft. The
tightness of the ACL graft is checked arthroscopically with a
probe. With maximal tension on the graft maintained from
thigh, the knee is stopped at 301 flexion with posterior
drawer force on tibia. The bioabsorbable transfixation pins
are passed through the pre-drilled holes (Figure 6).
The sutures placed in the looped end of the graft are
removed from the thigh. A knot is tied on the Ethibond
suture on tibial side before severing the redundant sutures.
FIGURE 5. Graft pulled into tunnels with maximal pull applied from the exit
at thigh.
www.c-orthopaedicpractice.com | 411
Postoperative Care
The patients undergo intensive physiotherapy protocols,
with full weight-bearing walking in an extension brace,
active knee flexion in closed chain and static quadriceps
strengthening exercises started from the first postoperative
day.
Each patient was evaluated preoperatively labeled as 0 and
postoperatively at 3 weeks, 6 weeks, 3 months and 6
monthly intervals thereafter. Final functional evaluation
was performed with the Lysholm Knee Score.19 Propriocep-
tion was measured by using various reported clinical tests
(active reproduction of passive positioning test, single-leg
forward-hop test, threshold for detection of passive move-
ment, single-limb standing test: reproduction of standing
position, and single-limb standing test: postural sways and
compensatory movements).20--25 The differences in the
mean values of the injured and uninjured leg were measured
FIGURE 6. Biotransfixation pins being passed into the femoral tunnel in
301 flexion at the knee.
412 | www.c-orthopaedicpractice.com
preoperatively and at final follow-up for all the tests. The
values were compared by applying the Student t-test, and a
P-value was obtained. Similarly, at final follow-up, the values
of the injured leg and uninjured leg of various tests were
compared and the P-values obtained.
RESULTS
There were 39 men and 6 women. Average age was 25.4 years
(range 18--44 years). The mode of injury was a road-side
accident in 37 patients, sports injury in five and fall from
stairs in three. Twenty-one patients had an injury on the left
side. No patient had bilateral involvement. The average
duration of follow-up was 40.6 months (range, 34--50
months). The mean Lysholm score, at the final follow-up
was 95.22 in comparison to the preoperative score of 62.4.
Table 1 shows the comparison of the preoperative defect
(difference between the mean values of the injured and
uninjured leg) and the final follow-up defect, demonstrating
that the improvement in proprioception with all the tests
individually was highly significant (P < 0.01).
Table 2 shows the comparison of the mean values of
individual proprioception tests obtained at final follow-up
with the mean values obtained preoperatively. Only two
tests (single-leg standing tests [SLST] with eyes open
performed for measuring the number of balancing acts
and SLST with eyes open for measuring the number of
sways) showed that the difference between proprioception
of the operated leg and the normal leg was not significant.
The remaining seven tests showed that the proprioception
sensation of the operated leg was significantly inferior to the
normal leg.
Two patients had mild superficial infection, and there was
one rerupture resulting from a second injury at 3.5 years
after surgery during a game in a football player. At final
follow-up, all the other patients went back to their preinjury
functional levels.
DISCUSSION
Anterior cruciate ligament reconstructions using free grafts
from various biological tissues (quadriceps tendon, patella
and patellar tendon, hamstrings tendon, iliotibial band or
tensor fascia lata) have been reported.26 Kim et al.12
TABLE 1. Comparison of values of the defect between the injured and uninjured leg measured preoperatively and
at final follow-up
Name of test
ARPP (degrees)
SLHT single-leg hop test (cm)
SLST eyes closed (cm)
SLST eyes open(cm)
Balance acts in SLST eyes closed (No.)
Balance acts in SLST eyes open (No.)
TDPM (degrees)
Sways in SLST eyes open (No.)
Sways in SLST eyes closed (No.)
ARPP, active reproduction of passive position; cm, centimeters; No., number; SLHT, single-leg forward hop test; SLST, single-limb standing test; TDPP, threshold for
detection of passive motion.
Volume 21  Number 4  July/August 2010
proposed the preservation of the tibial insertions of the STG
graft with the primary aim of providing better distal fixation
at the tibial end. They supplemented the preserved insertion
of the STG with two spiked staples, while femoral fixation
was achieved using an endobutton. Using the same
principle of preserving the STG insertions, we used a
modified surgical technique to provide better propriocep-
tion sensation. In our technique, the femoral fixation is
achieved by using two bioabsorbable Rigidfix pins (Johnson
and Johnson, Mitek India, Mumbai), while tibial fixation
relies on the preserved STG insertion. Our technique,
however, has some unique features that are discussed in
the following text.
Our procedure is only possible by using an open-ended
tendon harvester. Tibial fixation is provided by the pre-
served insertions of the graft, so the procedure relies on
maximally pulling the graft towards the femoral side before
femoral fixation. Thus, the femoral tunnel has to be drilled
through the outer femoral cortex. In the rare event that the
graft is longer than the combined length of the intra-
articular graft and the tibiofemoral tunnels, the graft will
remain lax if the intact outer femoral cortex limits the exit
of the graft proximally. In the traditional free graft
reconstruction, the femoral side is fixed and then tensioning
of the graft is accomplished by pulling it distally from the
tibial tunnel. In the present technique, tensioning is done
by pulling the graft from the proximal femoral side; tibial
side fixation is provided by the intact tibial STG insertions.
For Rigidfix pins, a minimum of 30 mm of graft must
occupy the femoral tunnel. In a theoretical event of a short
graft, the procedure would have to be changed to a free
graft. However, none of our patients included in the present
study or subsequently ever had a graft of less than 30 mm in
the femoral tunnel. The average length of the graft in our
series was 118.62 cm (range, 110--130 cm).
As mentioned, for distal fixation of the graft, we solely
relied on the preserved STG insertions on the tibia. Our
results show that the intact tibial insertions of STG are
sufficiently strong to allow an active rehabilitation program.
One of the main drawbacks of tibial graft fixation after
femoral fixation with an antegrade screw is that some
tension in the graft may be lost. This led to the concept
of a retrograde screw fixation, in which the direction of
the screw facilitates the tension in the intra-articular
Preoperative defect Final follow-up defect Statistical
(uninjured-injured) (uninjured-injured) significance
3.008 0.272 r0.01
58.096 20.119 r0.01
0.839 0.052 r0.01
0.732 0.068 r0.01
1.4 0.168 r0.01
0.192 0 r0
1.128 0.112 r0.01
0.56 0.032 r0.01
2.139 0.272 r0.01
Current Orthopaedic Practice
TABLE 2. Comparison of values of proprioception obtained by individual tests in the injured and the uninjured
(normal leg) at final follow-up
Name of test Value of normal leg
ARPP (degrees)
SLHT single-leg hop test (cm)
SLST eyes closed (cm)
SLST eyes open (cm)
Balance acts in SLST eyes closed (No.)
Balance acts in SLST eyes open (No.)
TDPM (degrees)
Sways in SLST eyes open (No.)
Sways in SLST eyes closed (No.)
ARPP, active reproduction of passive position; cm, centimeters; No, number; SLHT, single-leg forward hop test; SLST, single-limb standing test; TDPP, threshold for
detection of passive motion.
reconstructed ACL.27,28 Tibial fixation with staples or a
screw post outside the tibial tunnel has a mechanical
disadvantage of being far away from the normal insertion
of ACL.29
In the present study, femoral fixation was achieved with
rigidfix transfixation pins in 301 of knee flexion and with
maximal pull on the looped end of the tendon from the
thigh; to have reliable femoral fixation it is important to
ensure central placement of the transfixation pins in the
femoral tunnel (Figure 4). Although ultimate long-term
success of an ACL reconstruction depends on healing of the
graft fixation sites and biological incorporation of the graft
material, initial graft fixation is important in the immediate
postoperative period.30 Femoral fixation with transfixation
pins, being closer to the femoral insertion of ACL, gives
superior mechanical fixation compared with endobuttons
and interference screws.30,31 On the tibial side, the intact
tibial insertions of the STG have some mechanical dis-
advantage of being away from the tibial ACL footprint
compared with interference screw fixation in the tibial
tunnel. However, relying on the intact STG insertions, we
believe, has no risk of late slackening of the graft.
Our procedure is not possible with the types of femoral
fixations requiring hyperflexion at the knee joint to see the
femoral tunnel because this will likely result in the slackness
of the intra-articular tendon when the knee is restored back
to extension. We believe that the procedure may be
successfully performed with an outside-in interference screw
in the femoral tunnel because this does not require
hyperflexion of the knee during the screw insertion. It is
possible to insert an outside-in screw into the femoral
tunnel with the knee in 301 of flexion while continuous pull
is maintained on the femoral side of the graft during the
screw insertion. This requires an additional small incision
on the anterolateral thigh at the site of screw insertion;
however, we have no experience with using this. Further,
our technique also is not possible with implants that are
fixed on the femoral side (e.g. endobutton, and the
transfixation pin passing through the center of the quad-
rupled loop) because to provide a tight graft, one end of the
graft must be pulled for maximal tension. There is a
technical possibility of looping the double graft over a
transfixation pin in the femoral tunnel, pulling it back and
tensioning it distally. We have no experience with this
technique, and we believe that it may be technically difficult
www.c-orthopaedicpractice.com | 413
Value of injured leg Statistical significance
1.73 2.002 P r0.01
133.619 113.5 P r0.01
0.962 1.014 P r0.05
0.640 0.708 P r0.01
1.219 1.387 P r0.01
0 0 No difference
1.247 1.359 P r0.01
0.0624 0.0944 P ¼ 0.108 (Not significant)
2.365 2.637 Pr0.01
to tension the graft in this manner because of the friction
provided by the rough tunnel walls having a diameter equal
to that of the graft.
The afferent units in tendons and aponeurotic insertions
of the muscles are capable of transmitting proprioceptive
impulses.17,18 It is a fact that the capability to transmit
proprioceptive impulses is based on an intact musculoten-
dinous unit under physiologic tension and not on a
sectioned unit. However, we think that the afferent units
that are preserved in the intact insertions of STG, in
comparison to a free graft, may be able to provide better
function of proprioception when the physiologic loads are
transmitted to the intact insertions through the tensioned
graft placed in the tibiofemoral tunnels.
For assessment of results, we relied on the Lysholm score
and various tests of proprioception mentioned in the
literature, which have been successfully reported to assess
the status of ACL-reconstructed knees in the absence of KT
1000 testing.19--25,32
The results of our preliminary study showed that the
quality of proprioception sensation significantly improved
from preoperative values (determined by comparing the
injured with the uninjured knees preoperatively; Table 1).
However, only two of the nine tests at final follow-up
demonstrated comparable proprioceptive sensation of the
operated leg with the normal leg (Table 2). Thus, we believe
that although our new technique does provide significant
improvement in proprioceptive sensation of the leg from
preoperative values, the sensation of proprioception is
probably less than normal. Whether the quality of proprio-
ceptive sensation obtained by using a STG graft with preserved
insertions is superior to the one obtained by using a free graft
needs further evaluation with well-controlled, randomized
comparative studies. The functional evaluation of our patients
with the Lysholm score showing satisfactory results without
significant failure and all our patients being able to return to
the preinjury levels of activity demonstrate the success of the
technique in treating the instability. Moreover, the technique
is more cost effective because it does not involve additional
tibial fixation with a screw or a staple.
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