484

C OPYRIGHT 2016

BY

T HE J OURNAL

OF

B ONE

AND J OINT

S URGERY, I NCORPORATED

Change in Size of Hamstring Grafts During

Preparation for ACL Reconstruction
Effect of Tension and Circumferential Compression on Graft Diameter
Aristides I. Cruz Jr., MD, Peter D. Fabricant, MD, MPH, Mark A. Seeley, MD,
Theodore J. Ganley, MD, and J. Todd R. Lawrence, MD, PhD
Investigation performed at the Department of Orthopaedics, Childrens Hospital of Philadelphia, Philadelphia, Pennsylvania

Background: There is good consensus that anterior cruciate ligament (ACL) grafts should be pretensioned to remove
creep prior to implantation, but the literature contains little information on the inuence of graft preparation or circumferential compression on graft size. The purpose of this study was to investigate how the size of hamstring allografts
changes as they are prepared for ACL reconstruction. We hypothesized that grafts decrease in diameter as they are
prepared with both tension and circumferential compression. We also investigated the interrater reliability of graft diameter measurements during each step of graft preparation.
Methods: Twenty pairs of fresh-frozen human hamstring tendons obtained from an allograft supplier were prepared in a
standardized fashion for ACL reconstruction (suturing followed by longitudinal tensioning followed by circumferential
compression followed by relaxation). Four blinded raters measured each graft in a sequential manner after each graft
preparation step. Interrater reliability was assessed using the intraclass correlation coefcient ICC(2,1). The mean
allograft diameter at each time point was calculated and compared across all time points using repeated-measures
analysis of variance (ANOVA).
Results: Subjecting the grafts to both tension and circumferential compression signicantly decreased their mean
diameter (to 7.38 mm compared with 8.28 mm at baseline; p = 0.044). Interrater reliability revealed almost perfect
agreement at each measurement interval, with the ICC ranging from 0.933 to 0.961.
Conclusions: The average diameter of hamstring ACL grafts decreases by almost 1 mm after they are subjected to both
tension and circumferential compression within a standard cylindrical sizing block.
Clinical Relevance: Because ACL bone tunnels are drilled in 0.5-mm increments, preparing soft-tissue grafts with
circumferential compression in addition to tension may allow creation of tunnels that are one to two incremental sizes
smaller. This could permit less bone removal, which may be particularly applicable for certain reconstruction techniques
such as pediatric, double-bundle, or revision ACL reconstruction, in which limited space is available for tunnel drilling.

Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. It was also reviewed
by an expert in methodology and statistics. The Deputy Editor reviewed each revision of the article, and it underwent a nal review by the Editor-in-Chief prior to publication.
Final corrections and clarications occurred during one or more exchanges between the author(s) and copyeditors.

amstring tendon grafts are the most commonly used

grafts for anterior cruciate ligament (ACL) reconstruction1-3. They have been shown to provide outcomes
similar to those following use of other types of grafts4-12. Graft
strength is proportional to graft size and may be an important
predictor of outcome after ACL reconstruction13-15. The method

with which soft-tissue grafts are prepared as it relates to the sizing

of the graft has received little attention in the literature. While there
is good consensus that grafts should be placed under some tension
prior to implantation, to limit tissue creep from the graft, the
literature contains relatively little information concerning the effects of circumferential compression on nal graft diameter. Given

Disclosure: There was no external funding source for this study. The tissue used in the study was donated by LifeNet Health and was reported to the
federal government as in-kind contribution. On the Disclosure of Potential Conicts of Interest forms, which are provided with the online version of the
article, one or more of the authors checked yes to indicate that the author (or the authors institution) had a relevant nancial relationship in
the biomedical arena outside the submitted work.

J Bone Joint Surg Am. 2016;98:484-9

http://dx.doi.org/10.2106/JBJS.15.00802

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TABLE I Characteristics of Donors of Human Tissue

Age (yr)

Sex

Side

38

Social history: substance abuse

64

Liver biopsy: steatohepatitis

58

Liver biopsy: lobular inammation

49

Social history: substance abuse

57

Unknown cause of death

21

Cause of death (per autopsy): pneumonia

60

Liver disease of unknown etiology

45

Could not rule out sepsis/bacteremia

50

Cause of death: septic shock

52

Giant cell aortitis

44

Culture results

53

Culture results

59

Liver biopsy: steatohepatitis

58

Technical error at recovery

56

Paraplegia for 7 yr

66

Nodule on chest radiograph; could not rule out cancer

66

Culture results

59

Invasive carcinoma of thyroid

59

Jaundiced on physical assessment and liver biopsy not done

48

Streptococcus group B identied in all recovery cultures

the importance of properly sizing a soft-tissue graft to determine

the correct bone tunnel diameter during ACL reconstruction, it is
vital to understand how graft diameter might be affected during
various steps of graft preparation.
The purpose of this study was to investigate how the
diameter of hamstring allografts changes as they are prepared
in a standardized stepwise fashion. We hypothesized that hamstring tendon allografts decrease in diameter as they are prepared
for ACL reconstruction, specically after the addition of circumferential compression within a standard graft-sizing block.
We secondarily hypothesized that the interrater reliability of
graft diameter measurements by multiple raters during each step
of graft preparation would be excellent.

Fig. 1

Experimental protocol.

Reason for Disqualication for Human Use

Materials and Methods

he study protocol was reviewed by our institutional review board and was
determined to not meet the criteria for human subjects research and therefore
to not require institutional review board oversight. Twenty non-irradiated pairs of
fresh-frozen human hamstring (semitendinosus and gracilis) tendons were obtained from an allograft supplier. The mean donor age was 53.1 years (range,
twenty-one to sixty-six years), and nine donors were female. There were ten right
leg specimens and ten left leg specimens (Table I). Each pair of hamstring tendons
remained paired throughout the investigation.

Experimental Protocol
Four study investigators (one attending surgeon and three fellows) performed the
experimental protocol (Fig. 1). Each investigator prepared ve grafts and, after
graft preparation, measured each of the twenty grafts in a sequential manner and

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TABLE II Mean Graft Diameter and Change in Graft Diameter at Each Time Point
Time Point*

Mean Stand. Dev. (mm)

Mean Change from T0 (95% CI) (mm)

Dunnett-Adjusted P Value (Compared with T0)

T0

8.28 1.21

T1

7.76 1.15

20.53 (20.9, 20.16)

0.350

T2

7.38 1.15

20.90 (21.27, 20.53)

0.044

T3

7.43 1.13

20.85 (21.22, 20.48)

0.061

*T0 = after suture, T1 = after tension, T2 = after compression, and T3 = after relaxation. The value at each time point was compared with the value at
T0 with use of repeated-measures ANOVA and a Dunnett correction for multiple comparisons. A signicant difference (p < 0.05).

recorded the diameter on an individual data collection sheet. Each investigator

was blinded to the others measurements throughout the experimental protocol.
Gracilis and semitendinosus tendon pairs were stripped from their
muscle bellies, cleaned, and sutured with number-2 FiberWire (Arthrex) with a
locking whipstitch over the terminal 2 cm of each tendon. The paired tendons
were then looped over a number-5 Ethibond (Ethicon) suture mounted on a
standard graft preparation board (DePuy Synthes Mitek Sports Medicine) to
fashion a four-strand, double-looped hamstring graft (Fig. 2-A). The grafts
were sized using proprietarily available plastic, slotted, cylindrical sizers (DePuy
Synthes Mitek Sports Medicine) in 0.5-mm increments. The smallest-diameter
sizer that would accommodate the graftwhich would be the diameter of the
tunnel that the clinician would drill to accommodate the graftwas noted.
Immediately before the start of tensioning, each rater measured the diameter of
each of the twenty grafts, and this measurement was designated as T0 (after
suture). Each graft was then held in 20 lb (89 N) of tension for ve minutes,
after which the graft was again measured by the rater (T1 [after tension]). An
independent observer quickly determined the mode graft diameter from the
groups T1 measurements, and the raters (blinded to the mode graft diameter)
then placed the corresponding cylindrical sizer over the looped end of each of
the grafts (Fig. 2-B). After ve minutes within the cylindrical sizer, each graft
was again measured by the rater (T2 [after compression]). The sizer was then
removed and the tension was released from each graft. After ve minutes, each
rater again measured each graft (T3 [after relaxation]). Saline-solution-soaked

sponges were draped over the grafts during all phases of the protocol to help
prevent graft desiccation.

Statistical Analysis
Interrater reliability was assessed using the intraclass correlation coefcient
ICC(2,1) for the four independent raters at each time point and evaluated
16
according to the Landis and Koch criteria . Because of the almost perfect
agreement among investigators, the mean diameters of all twenty prepared grafts
at each corresponding time point were calculated and used for subsequent
comparative analyses. After ensuring data normality, we compared the mean
graft diameters across all time points using repeated-measures analysis of variance (ANOVA). Dunnett-adjusted pairwise comparisons of each time point (T1,
T2, and T3) with T0 were then performed to determine which scenarios resulted
in a graft diameter that differed from the baseline diameter. All comparisons
were two-tailed with p < 0.05 used as the threshold for signicance. Because
twenty specimen pairs were provided for use in the current study, an a priori
power calculation could not be performed.

Results
he interrater reliability of the blinded measurements obtained at each time point as assessed with the intraclass
correlation coefcient ICC(2,1) ranged from 0.933 to 0.961.

Fig. 2

Fig. 2-A Double-looped, four-strand hamstring graft on a graft preparation board. Fig. 2-B Hamstring tendon graft compressed within a sizer block.

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Fig. 3

Mean graft diameter after each step of graft preparation. The graft
diameter was signicantly decreased after longitudinal tension and
circumferential compression when compared with the baseline state
(p = 0.044). The error bars represent 95% condence intervals.

According to the Landis and Koch criteria, this represents almost perfect interrater reliability16.
The mean graft diameters after each step of graft preparation and the changes from baseline (T0) are shown in Table
II. Following ve minutes under tension, the mean graft diameter decreased 0.53 mm (95% condence interval [CI] = 20.9
to 20.16 mm) compared with baseline (p = 0.35). Following
circumferential compression under tension, the mean graft
diameter decreased 0.90 mm (95% CI = 21.27 to 20.53 mm)
compared with baseline (p = 0.044). Following relaxation, the
grafts remained smaller (by a mean of 0.85 mm [95% CI = 21.22
to 20.48 mm]) than they were at baseline, but this difference
did not reach signicance (p = 0.061). Thus, although the graft
diameters were smaller than baseline at all subsequent steps of
graft preparation, only tensioning the graft with the addition of
circumferential compression within a cylindrical sizer signicantly decreased the graft diameter (Fig. 3).
Discussion
oft-tissue grafts are commonly used for ACL reconstruction, and the hamstring tendons (semitendinosus and gracilis
tendons) are often used for these grafts1-3. Biomechanical and
clinical studies have conrmed that hamstring autografts are effective for ACL reconstruction. The biomechanical properties of
hamstring tendon grafts have been extensively studied with in
vitro testing17-19, which has shown looped hamstring grafts to have
greater tensile strength than the native ACL17,20. The clinical outcomes of ACL reconstructions done with hamstring autografts
have been reported to be comparable with those of ACL reconstructions done with other graft sources4-12. Because the diameter
of the hamstring autograft has been shown to inuence ACL
rerupture rates13,14 as well as patient-reported outcomes after ACL
reconstruction15, accurate recording and reporting of hamstring
autograft size is of primary importance when evaluating clinical
studies of ACL reconstruction.

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A secondary goal of our study was to assess the interrater

reliability of the four investigators who measured the diameter of
the hamstring allografts. We found this interrater reliability to be
almost perfect, an observation similar to that of Dwyer et al.21,
who reported excellent interrater and intrarater reliability of
measurements of hamstring graft size. Thus, we conclude that
the hamstring graft sizes reported in the literature are reliable.
Additionally, comparisons of reported sizes across studies can be
meaningful if the authors are consistent in reporting when
during the graft preparation process these measurements were
made and how the graft was prepared prior to measurement.
The primary goal of our study was to evaluate the change
in diameter of a soft-tissue graft as it was prepared for implantation. Dwyer et al. measured prepared hamstring grafts at a
single time point 21. For several years at our institution, we have
routinely prepared soft-tissue grafts with both tension and circumferential compression (applied to both the femoral and the
tibial side of the graft with two separate cylindrical sizers), and we
have found that the measured graft diameter changes (i.e., becomes smaller) as the graft is prepared. In this investigation, the
mean allograft diameter decreased by 0.90 mm, from 8.28 mm at
baseline to 7.38 mm after the grafts were both tensioned and held
within a slotted, cylindrical sizing block (p = 0.044). This result is
not only statistically signicant but also clinically relevant since
ACL bone tunnels are commonly drilled in 0.5-mm increments.
A decrease in graft diameter of almost 1 mm represents a prepared tunnel diameter that is nearly two sizes smaller. It has also
been our experience that this method of graft preparation helps
to ease nal graft passage, a nding that has been recognized by
manufacturers, who have made proprietarily available products
to address it (http://www.arthrex.com/knee/graft-tubes-set; accessed September 24, 2015).
We know of only one prior study that examined how softtissue grafts adapt to external compression22. In a laboratory-based
study of bovine tendon grafts tested with a custom-adapted material
testing machine, Meyer et al. found that compression with 6000 N of
pressure could produce a 75% reduction in the volume of an 8-mm
tendon graft. The authors thought that their ndings likely represented a temporary volumetric reduction due to extrusion of water
from the grafts. They concluded that the viscoelastic behavior of
tendon grafts under pressure allows preconditioning of the grafts to
reduce their volume and diameter. They postulated that because the
total collagen content of the tendon graft is not altered, this effect
may allow for a tighter t of the graft within a bone tunnel.
However, they used supraphysiologic loads to compress the tendon
grafts, which led to deformation of the grafts. This would not be
possible and probably would not be desirable in the clinical setting.
Nevertheless, our study shows that compressing grafts within standard sizing blocks also has a signicant effect on graft diameter and
thus may have clinical implications.
Altbuch et al.23 examined graft tissue swelling as a function
of graft size by measuring the pull-through force (through a
modied sizing guide) of fresh-frozen tibialis anterior allografts
kept in saline-solution-soaked sponges for twenty, forty, or sixty
minutes. After twenty minutes of soaking, the force required
to pull a graft through a certain-diameter aperture signicantly

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increased compared with baseline, suggesting that a soft-tissue

allograft swells while kept in a saline-solution-soaked sponge ex
vivo. They did not precondition the grafts by tensioning, but
nevertheless this effect may be extrapolated to the behavior of a
graft over time after it has been implanted because of the
synovial uid environment of the knee.
Bone tunnel enlargement has been observed after both aperture xation and suspensory xation of soft-tissue ACL grafts24-26.
Although clinical outcomes are similar despite the amount of
tunnel enlargement27,28, bone loss as a result of bone tunnel enlargement may have an effect on future procedures29,30. Because of
this, bone preservation and a graft-tunnel diameter match are
important considerations during primary ACL reconstruction. It
has been suggested that a graft-tunnel diameter mismatch may
allow imbibition of joint uid into the bone tunnel, leading to
enlargement. If we surmise that the bone tunnel functions similarly
to a sizer placed on the graft and creates circumferential compression, then, on the basis of our data, an uncompressed graft
may become signicantly smaller in diameter after implantation,
potentially contributing to this mismatch. Thus, just as all grafts are
pretensioned prior to implantation to account for and remove
creep in the graft, circumferential compression within cylindrical
graft sizers may account for any possible deformation of the graft in
the implanted state and improve the overall t of the graft.
Because it has been suggested that using smaller soft-tissue
grafts for ACL reconstruction is associated with an increased risk of
failure13,14, surgeons have employed strategies to implant larger grafts.
The relationship of graft size to failure rates may be multifactorial.
Perhaps larger grafts provide a larger surface area for tendon-tobone healing as well as restoration of a larger area of the native ACL
footprint. The relationship of graft size to failure rates may also have
its root in the total amount of collagen within the graft, with smaller
grafts having less collagen and therefore less strength31. Since compressing a larger graft to a smaller size should not affect collagen
content, the method of graft preparation described in our study may
be an acceptable way to reconcile the desire to place a greater
amount of graft collagen with the wish to not remove additional
bone. This is of particular importance during certain reconstruction
techniques such as pediatric, double-bundle, or revision ACL reconstruction, in which limited space is available for tunnel drilling.
We propose that tensioning and circumferentially compressing an
adequately sized soft-tissue graft within a cylindrical sizer allows a
smaller bone tunnel to accommodate a larger graft.
There are inherent limitations to our laboratory-based
study. The donor tissue was received from a certied tissue bank
because each donors tissue had been disqualied for clinical use
for various reasons (Table I); however, these reasons were unrelated to the gross appearance and macroscopic structure of the
hamstring tendon grafts. The average age of the tissue donors
ranged from twenty-one to sixty-six years (mean, 53.1 years). This
may also have inuenced our measured graft diameters since allograft donor age may affect certain tissue biomechanical properties32-34. We chose to include all donated allograft tissue regardless of
donor age because of the limited availability of human tissue for
research. We did not specically control for donor age in our
experimental protocol since this was not our primary research

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question and our sample size (n = 20) precluded any meaningful

stratication based on donor age. Rather, we accounted for any
variation that may have existed among specimens by utilizing a
repeated-measures study design in which each specimen served as
its own internal baseline control. Additionally, we did not perform
an a priori power analysis as the study specimens represented all
available donated grafts. A post hoc power analysis was not performed because the main hypothesis of the current study was
found to be signicant, so a type-II error could not have occurred.
The measurements of the diameters of the prepared hamstring tendon grafts were based on four investigators best judgment of the appropriately sized cylinder of the standard tissue
sizing block. No other means (e.g., calipers) were used for measurement. The goal of this study, however, was to investigate a
clinically relevant, real-world scenario during ACL reconstruction
surgery.
In our experimental protocol, we utilized one sequence of
graft preparation (i.e., tension followed by compression) and
measured the difference in graft diameter after each step. We
chose this experimental protocol because it is similar to how we
prepare grafts in clinical practice. We did not control for how
different sequences (i.e., compression followed by tension) or
methods of graft preparation could affect graft diameter or include a negative control because our limited supply of donor
tissue made it impractical to do so. To account for the lack of a
negative control, we used repeated-measures analysis and compared each measurement with the baseline condition. Each
specimen therefore served as its own internal control, a method
that could arguably be more rigorous than using a separate group
of tendons as a control. We also did not directly study the effect (if
any) of circumferential compression within bone tunnels in vivo
or study whether our results apply to autograft tissue.
Finally, whether our described method of graft preparation
and sizing inuences clinical or radiographic outcomes of ACL reconstruction is unknown. On the basis of our clinical experience,
however, we believe that tensioning and compressing soft-tissue
ACL grafts (including autografts) within cylindrical sizers prior to
implantation allows drilling of smaller-diameter bone tunnels. This
method is simple and does not add time to graft preparation because
grafts can be held compressed with standard cylindrical sizers during
standard pretensioning on a graft board while the surgeon prepares
the bone tunnels arthroscopically. The smaller diameter of the graft
also seems to ease graft passage while theoretically not sacricing any
inherent strength related to collagen content. We suppose that this
also allows for a closer graft-tunnel diameter match.
In conclusion, the average diameter of hamstring ACL grafts
decreases by almost 1 mm compared with baseline after application of both tension and circumferential compression within a
standard cylindrical sizing block. This is clinically relevant because
ACL bone tunnels are drilled in 0.5-mm increments and preparing
soft-tissue grafts in this manner may allow creation of tunnels that
are one to two incremental sizes smaller. This could permit less
bone removal, which may be particularly applicable for certain
reconstruction techniques such as pediatric, double-bundle, or
revision ACL reconstruction, in which limited space is available for
tunnel drilling. This study adds to existing knowledge because the

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literature contains little information on the effect of circumferential compression on soft-tissue grafts. n

1Department

NOTE: The authors acknowledge Ms. Marcy Dull for her work in the preparation and execution of
this investigation.

2Division

FOR

of Orthopaedic Surgery,
Brown University, Providence, Rhode Island
of Orthopaedics,
Childrens Hospital of Philadelphia,
Philadelphia, Pennsylvania

3Department

of Orthopaedic Surgery,
Geisinger Medical Center,
Danville, Pennsylvania

Aristides I. Cruz Jr., MD1

Peter D. Fabricant, MD, MPH2
Mark A. Seeley, MD3
Theodore J. Ganley, MD2
J. Todd R. Lawrence, MD, PhD2

E-mail address for A.I. Cruz Jr.:

[email protected]

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