1 Orthopedic Research Center, Ghaem Hospital, Mashhad University of Medical Sciences, Ahmad-Abad Street Mashhad, Iran

2 1Orthopedic Research Center, Ghaem Hospital, Mashhad University of Medical Sciences, Ahmad-Abad Street Mashhad, Iran.


Background: Good clinical outcome and return to sport and daily functions after anatomical arthroscopic anterior
cruciate ligament (ACL) reconstruction is goal standard in this surgery. but to date, there are different challenging
issues between orthopedic surgeons regarding graft selection and surgical techniques.
Methods: We retrospectively reviewed the patients who underwent anatomical arthroscopic one bundle ACL
reconstruction with quadruple hamstring tendon autograft from 2010 to 2016 in our orthopedic sport medicine center.
Eighty-two eligible patients (82 knees) who had met our inclusion criteria were examined in terms of knee stability by
clinical examinations and KT 2000 arthrometer and - also were evaluated regarding variables related to their health
and knee status with a mean 48months follow-up.
Results: Seventy-seven patients (93.9%) were male and the other 5 cases (6.1%) were female. The mean age
was 33 ± 8.06 years old at the time of surgery and mean BMI amount was 26.81 ± 3.72. 78 patients (95%) returned
to pre-injury sport activity level after ACL reconstruction and two patients (2.4%) had re-rupture. 63 patients
(76.8%) had negative anterior drawer and 67patients (81.8%) negative lachman tests respectively. 10 patients
(13%) were found to have positive pivot shift tests which was correlated with pain and a less KOOS scores with a
significant difference (P= 0.03). 72 patients (87%) had negative tests in active and 70 (85.4%) had less than 3 mm
side to side difference in manual testing by KT2000. Final KOOS score was 70.87 ± 19.76. Mean Lysholm score
was 90 ± 4.77. Mean International Knee Documentation Committee (IKDC) score of this study was 85 ± 14.11.
Patients who had concomitant partial meniscectomy had significantly lower IKDC scores (P<0.01).Mean kujala
score was 79 ± 3.07.
Conclusion: The use of quadrupled hamstring tendon autograft besides the most important part of the treatment
which is the surgical technique would yield to excellent results in ACL reconstruction both subjectively and objectively.
In addition, patient selection and surgeon’s experience should be considered in determining the treatment plan for the


Main Subjects

1. Voigt C, Schönaich M, Lill H. Anterior cruciate ligament
reconstruction: state of the art. Eur J Trauma. 2006;
2. Lohmander LS, Englund PM, Dahl LL, Roos EM. The
long-term consequence of anterior cruciate ligament
and meniscus injuries: osteoarthritis. Am J Sports
Med. 2007; 35(10):1756-69.
3. Arnold JA, Coker TP, Heaton LM, Park JP, Harris WD.
Natural history of anterior cruciate tears. Am J Sports
Med. 1979; 7(6):305-13.
4. Feagin JA Jr, Curl WW. Isolated tear of the anterior
cruciate ligament: 5-year follow-up study. Am J Sports
Med. 1976; 4(3):95-100.
5. Noyes FR, Matthews DS, Mooar PA, Grood ES. The
symptomatic anterior cruciate-deficient knee. Part II:
the results of rehabilitation, activity modification, and
counseling on functional disability. J Bone Joint Surg
Am. 1983; 65(2):163-74.
6. Caborn DN, Johnson BM. The natural history of the
anterior cruciate ligament-deficient knee. A review.
Clin Sports Med. 1993; 12(4):625-36.
7. Liden M, Ejerhed L, Sernert N, Laxdal G, Kartus J.
Patellar tendon or semitendinosus tendon autografts
for anterior cruciate ligament reconstruction: a
prospective, randomized study with a 7-Year followup.
Am J Sports Med. 2007; 35(5):740-8.
8. Fetto JF, Marshall JL. The natural history and diagnosis
of anterior cruciate ligament insufficiency. Clin Orthop
Relat Res. 1980; 147(1):29-38.
9. Sherman MF, Warren RF, Marshall JL, Savatsky GJ. A
clinical and radiographical analysis of 127 anterior
cruciate insufficient knees. Clin Orthop Related Res.
1988; 227:229-37.
10. Myklebust G, Maehlum S, Holm I, Bahr R. A prospective
cohort study of anterior cruciate ligament injuries
in elite Norwegian team handball. Scand J Med Sci
Sports. 1998; 8(3):149-53.
11. Fu FH, Bennett CH, Ma CB, Menetrey J, Lattermann
C. Current trends in anterior cruciate ligament
reconstruction. Part II. Operative procedures
and clinical correlations. Am J Sports Med. 2000;
12. Harilainen A, Sandelin J. A prospective comparison of
3 hamstring ACL fixation devices--Rigidfix, BioScrew,
and Intrafix--randomized into 4 groups with 2 years
of follow-up. Am J Sports Med. 2009; 37(4):699-706.
13. Liu ZT, Zhang XL, Jiang Y, Zeng BF. Four-strand
hamstring tendon autograft versus LARS artificial
ligament for anterior cruciate ligament reconstruction.
Int Orthop. 2010; 34(1):45-9.
14. Noyes FR, Butler DL, Grood ES, Zernicke RF, Hefzy
MS. Biomechanical analysis of human ligament grafts
used in knee-ligament repairs and reconstructions. J
Bone Joint Surg Am. 1984; 66(3):344-52.
15. Wallace MP, Howell SM, Hull ML. In vivo tensile
behavior of a four-bundle hamstring graft as a
replacement for the anterior cruciate ligament. J
Orthop Res. 1997; 15(4):539-45.
16. Freedman KB, D’Amato MJ, Nedeff DD, Kaz A, Bach
BR Jr. Arthroscopic anterior cruciate ligament
reconstruction: a metaanalysis comparing patellar
tendon and hamstring tendon autografts. Am J Sports
Med. 2003; 31(1):2-11.
17. Goldblatt JP, Fitzsimmons SE, Balk E, Richmond JC.
Reconstruction of the anterior cruciate ligament:
meta-analysis of patellar tendon versus hamstring
tendon autograft. Arthroscopy. 2005; 21(7):791-803.
18. Xie X, Liu X, Chen Z, Yu Y, Peng S, Li Q. A meta-analysis
of bone-patellar tendon-bone autograft versus fourstrand
hamstring tendon autograft for anterior
cruciate ligament reconstruction. Knee. 2015;
19. Amis AA, Scammell BE. Biomechanics of intraarticular
and extra-articular reconstruction of the
anterior cruciate ligament. J Bone Joint Surg Br. 1993;
20. Canale ST, Beaty JH. Campbell’s operative
orthopaedics: adult spine surgery e-book. 12th ed.
Canada: Elsevier Health Sciences; 2013. P. 2138-42.
21. Li S, Su W, Zhao J, Xu Y, Bo Z, Ding X, et al. A metaanalysis
of hamstring autografts versus bone-patellar
tendon-bone autografts for reconstruction of the
anterior cruciate ligament. Knee. 2011; 18(5):287-93.
22. Rahnemai-Azar AA, Sabzevari S, Irarrázaval S, Chao T,
Fu FH. Anatomical individualized ACL reconstruction.
Arch Bone Joint Surg. 2016; 4(4):291.
23. Montazeri A, Goshtasebi A, Vahdaninia M, Gandek B.
The short form health survey (SF-36): translation and
validation study of the Iranian version. Qual Life Res.
2005; 14(3):875-82.
24. Salavati M, Mazaheri M, Negahban H, Sohani SM,
Ebrahimian MR, Ebrahimi I, et al. Validation of a
persian-version of knee injury and osteoarthritis
outcome score (KOOS) in Iranians with knee injuries.
Osteoarthritis Cartilage. 2008; 16(10):1178-82.
25. Rahimi A, Norouzi A, Sohani SM. The validity and
reliability of the persian version of the international
knee documentation committee (IKDC) questionnaire
in Iranian patients after acl and meniscal surgeries. J
Rehabilit. 2013; 14(2):116-24.
26. Negahban H, Pouretezad M, Yazdi MJ, Sohani SM,
Mazaheri M, Salavati M, et al. Persian translation
and validation of the Kujala Patellofemoral Scale in
patients with patellofemoral pain syndrome. Disabil
Rehabil. 2012; 34(26):2259-63.
27. Kazemi SM, Abbasian MR, Esmailijah AA, Zafari A,
Shahrbabaki ZS, Keshavarz AH, et al. Comparison
of clinical outcomes between different femoral
tunnel positions after anterior cruciate ligament
reconstruction surgery. Arch Bone Joint Surg. 2017;5(6):419.

28. Charlton WP, Randolph DA Jr, Lemos S, Shields CL
Jr. Clinical outcome of anterior cruciate ligament
reconstruction with quadrupled hamstring tendon
graft and bioabsorbable interference screw fixation.
Am J Sports Med. 2003; 31(4):518-21.
29. Anderson AF, Snyder RB, Lipscomb AB Jr. Anterior
cruciate ligament reconstruction. A prospective
randomized study of three surgical methods. Am J
Sports Med. 2001; 29(3):272-9.
30. Cerulli G, Placella G, Sebastiani E, Tei MM, Speziali A,
Manfreda F. ACL reconstruction: Choosing the graft.
Joints. 2013; 1(1):18-24.
31. Genuario JW, Faucett SC, Boublik M, Schlegel TF. A
cost-effectiveness analysis comparing 3 anterior
cruciate ligament graft types: bone-patellar tendonbone
autograft, hamstring autograft, and allograft.
Am J Sports Med. 2012; 40(2):307-14.
32. Williams RJ 3rd, Hyman J, Petrigliano F, Rozental
T, Wickiewicz TL. Anterior cruciate ligament
reconstruction with a four-strand hamstring
tendon autograft. J Bone Joint Surg Am. 2004; 86-
33. Gifstad T, Sole A, Strand T, Uppheim G, Grontvedt T,
Drogset JO. Long-term follow-up of patellar tendon
grafts or hamstring tendon grafts in endoscopic
ACL reconstructions. Knee Surg Sports Traumatol
Arthrosc. 2013; 21(3):576-83.
34. Beynnon BD, Johnson RJ, Fleming BC, Kannus P,
Kaplan M, Samani J, et al. Anterior cruciate ligament
replacement: comparison of bone-patellar tendonbone
grafts with two-strand hamstring grafts. A
prospective, randomized study. J Bone Joint Surg Am.
2002; 84-A(9):1503-13.
35. Aglietti P, Buzzi R, D’Andria S, Zaccherotti G.
Patellofemoral problems after intraarticular anterior
cruciate ligament reconstruction. Clin Orthop Relat
Res. 1993; 288(1):195-204.
36. Marder RA, Raskind JR, Carroll M. Prospective
evaluation of arthroscopically assisted anterior
cruciate ligament reconstruction. Patellar tendon
versus semitendinosus and gracilis tendons. Am J
Sports Med. 1991; 19(5):478-84.
37. Kocher MS, Steadman JR, Briggs KK, Sterett WI,
Hawkins RJ. Relationships between objective
assessment of ligament stability and subjective
assessment of symptoms and function after anterior
cruciate ligament reconstruction. Am J Sports Med.
2004; 32(3):629-34.
38. Peterson RK, Shelton WR, Bomboy AL. Allograft versus
autograft patellar tendon anterior cruciate ligament
reconstruction: a 5-year follow-up. Arthroscopy.
2001; 17(1):9-13.
39. Graf B, Uhr F. Complications of intra-articular anterior
cruciate reconstruction. Clin Sports Med. 1988;
40. Robertson GA, Coleman SG, Keating JF. Knee stiffness
following anterior cruciate ligament reconstruction:
the incidence and associated factors of knee stiffness
following anterior cruciate ligament reconstruction.
Knee. 2009; 16(4):245-7.
41. Rispoli DM, Sanders TG, Miller MD, Morrison WB.
Magnetic resonance imaging at different time periods
following hamstring harvest for anterior cruciate
ligament reconstruction. Arthroscopy. 2001; 17(1):2-8.
42. Wright RW, Fetzer GB. Bracing after ACL
reconstruction: a systematic review. Clin Orthop Relat
Res. 2007; 455(1):162-8.
43. Mascarenhas R, Tranovich MJ, Kropf EJ, Fu FH, Harner
CD. Bone-patellar tendon-bone autograft versus
hamstring autograft anterior cruciate ligament
reconstruction in the young athlete: a retrospective
matched analysis with 2-10 year follow-up. Knee Surg
Sports Traumatol Arthrosc. 2012; 20(8):1520-7.
44. Sajovic M, Strahovnik A, Dernovsek MZ, Skaza K.
Quality of life and clinical outcome comparison
of semitendinosus and gracilis tendon versus
patellar tendon autografts for anterior cruciate
ligament reconstruction: an 11-year follow-up of a
randomized controlled trial. Am J Sports Med. 2011;
45. Bourke HE, Salmon LJ, Waller A, Patterson V,
Pinczewski LA. Survival of the anterior cruciate
ligament graft and the contralateral ACL at a minimum
of 15 years. Am J Sports Med. 2012; 40(9):1985-92.
46. Spindler KP, Kuhn JE, Freedman KB, Matthews CE,
Dittus RS, Harrell FE Jr. Anterior cruciate ligament
reconstruction autograft choice: bone-tendon-bone
versus hamstring: does it really matter? A systematic
review. Am J Sports Med. 2004; 32(8):1986-95.