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BACKGROUND: Anterior cruciate ligament (ACL) reconstruction is one of the most frequent orthopaedic surgeries in young, active people. Secondary graft rupture is common and there is insufficient long-term evidence supporting the application of different surgical techniques to reduce its risk. OBJECTIVE: To investigate and compare outcomes of three primary ACL hamstring graft reconstruction surgeries. METHODS: Retrospective analysis of primary ACL reconstructions undertaken by one surgeon between 2006 and 2012 using three techniques of different graft placements and anchors were compared: (1) Single bundle graft at the site of the antero-medial bundle (SB), (2) a double-bundle graft with proximal and distal endobutton fixation, (EB), and (3) a double-bundle graft attached in a continuous loop with minimal fixation (MF). The primary measure was ACL graft rupture post-operatively. Secondary outcomes included recurrent rotatory instability, return to sport incidence and time-frame, and patient reported outcome measures (PROMs). RESULTS: A total of 216 participants were included (51, 77 and 88 in SB, EB and MF, respectively), 145 (67.1%) male, and aged 30.38 ± 11.63 (mean ± SD). Patient gender between the three groups was significantly different: 37 (72.5%) for SB, 58 (75.3%) for EB and 50 (56.8%) for MF (p = 0.026). There were 151 (69.9%) cases of concomitant injuries (meniscal or chondral), with meniscal injuries making up 65.7% of these injuries. The rates of meniscal injuries were significantly different between the three surgical groups (72.5%, 67.5% and 53.4% for SB, EB and MF, respectively (p = 0.046). Graft failure occurred in 17 (7.9%) surgeries and did not differ statistically between the three surgical groups (p = 0.284) at 8.4 years (SD ± 2.2) follow-up. At a follow up of 9 years (IQR = 7 – 10), 79.3% of participants felt stable with pivoting movements, with no significant difference between groups (p = 0.353). Levels of pre- and post-injury activity were not significantly different between groups when using Marx and Tegner scores (p=0.055, p=0.481), with 56.6% of all participants returning to their previous level of sport at median time of 26.00 (IQR = 12.00-42.50) weeks. CONCLUSION: There were no differences in ACL graft rupture rates or patient-perceived stability after more than 8 years follow-up between three primary ACL reconstruction hamstring graft techniques.

Injuries to the anterior cruciate ligament (ACL) are one of the most common knee injuries, with the majority occurring during non-contact manoeuvers such as side-stepping and single leg landing. Surgical intervention is generally required to restore stability to the tibiofemoral joint, unfortunately no perfect graft choice exists for reconstruction of the ACL, with all graft choices having potential advantages and disadvantages. The quadrupled hamstring autograft taken from the semitendinosus (ST) and gracilis (GR) muscles is a common choice for orthopaedic surgeons. However, harvest of the ST and GR tendons leads to post-operative donor muscle atrophy, as well as proximal retraction of the musculotendinous junction. This could in turn, have implications for tibiofemoral joint function, stability and loading. Thus, the overarching purpose of this thesis was to explore the morphological changes that occur to the donor muscles following tendon harvest and their biomechanical consequences.