S P E C I A L F O C U S

Sports Medicine
Outcome analysis following arthroscopic augmentation
with autologous hamstring graft in partial tear of the
anterior cruciate ligament with preservation of an
intact bundle: A case series
Narendra Joshi, MSa, Kamaldeep Singh, MSb, Lalit K. Modi, MS, DNBc, Rakesh K. Dhukia, MSd,
Bharatlal Meena, MSe and Rajendra K. Gora, MSf

a
Senior Professor, Department of Orthopaedics and Traumatology, SMS Medical College and Hospital, Jaipur, Rajasthan, India
b
Fellow in Trauma and Arthroplasty, PD Hinduja National Hospital and Medical Research Centre, Mumbai, India
c
Senior Consultant Orthopaedics, CK Birla Hospital, Jaipur, Rajasthan, India
d
Assistant Professor, Department of Orthopaedics and Traumatology, SMS Medical College and Hospital, Jaipur, Rajasthan, India
e
Junior Surgeon Orthopaedics, Government General Hospital, Sawai Madhopur, Rajasthan, India
f
Senior Resident, Department of Orthopaedics and Traumatology, SMS Medical College and Hospital, Jaipur, Rajasthan, India

(35.3%), while preoperatively most were classified as group C

ABSTRACT
Background:
The anatomic approach to anterior cruciate ligament (ACL) recon-
struction has shifted management focus of the commonly encoun-
tered partial tear from resection and complete reconstruction to
augmentation (i.e. selective bundle reconstruction with preservation of
intact remnant bundle). The purpose of this study was to prospectively
evaluate functional outcome after augmentation of partial ACL tears.
Methods:
Thirty-four patients with a partial ACL tear in whom a conservative
trial failed were treated with either anteromedial or posteromedial
single-bundle reconstruction, using an isolated semitendinosus
graft and conserving the remnant bundle. Outcomes were
evaluated clinically using the 2000 International Knee Documenta-
tion Committee [IKDC] knee examination forms, and manual laxity
tests. Subjective evaluation was done using the 2000 IKDC
subjective knee evaluation, Lysholm knee score, and 2000 IKDC
functional score. Patient activity level was determined using the
Tegner activity score. IKDC knee grades were assigned based on
final evaluation on the 2000 IKDC knee examination forms.
(76.5%). Similarly, IKDC subjective and Lysholm scores were
significantly better after follow-up. The difference between mean
Tegner activity level preinjury (6.029 ± 0.9040) and at follow-up
(5.67 ± 1.006) was not significant.
Conclusions:
Selective bundle reconstruction with preservation of remnants
restores knee stability and function. The results are encouraging,
with excellent improvement in functional scores.
Level of Evidence:
Level IV.
Key Words
partial tear, anterior cruciate ligament, augmentation, remnant
preservation
INTRODUCTION

Results:
At final follow-up 2000 IKDC knee examination grades signifi-
cantly improved, with 21 in group B (61.8%) and 12 in group A
Financial Disclosure: The authors report no conflicts of
interest.
Correspondence to Kamaldeep Singh, MS, 9/20, vidhyadhar nagar, Jaipur,
Rajasthan 302039, India
Tel: +919460504008; fax: +0141-2232706;
e-mail: kamaldeep04sms@gmail.com.
1941-7551 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
D
escribed as among the most common causes of knee
instability,1 anterior cruciate ligament (ACL) injury
has an estimated annual incidence of 68.6 per
100,000 person-years in the United States and 78 per
100,000 in Sweden. It is usually encountered in the second
to fourth decades of life (economically the most productive
age group).2,3 Although no official study is available,
extrapolating similar incidence rates to our population in
India may lead us to an epidemic proportion of ACL tears
because of the low average age of our population compared
to the western world.
Partial tears of the ACL constitute around 10% to 40% of ACL
injuries in various study series,4–6 with associated symptoms in

Volume 31  Number 1  January/February 2020 Current Orthopaedic Practice 1

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2 | www.c-orthopaedicpractice.com
5% to 10%.7 Conventionally, partial tears were treated with
resection of an intact bundle and reconstruction to avoid
overstuffing and impingement, which could lead to decreased
range of motion.8 However, with considerably increased under-
standing of ACL anatomy and biomechanics, the anatomic
double-bundle concept became popular,9–11 and selective bundle
reconstruction came to light. Hence, modern anatomic ACL
reconstruction presently focuses on recreating the native
ligamentous insertion and preserving the remnants.12–14
Preserved fibers have been shown to enhance graft
integration by enhancing vascularization, collagen produc-
tion, and proprioception.15–17 The clinical results of previ-
ously published series of selective-bundle ACL reconstruction
and remnant preservation are good and show the biological
importance of preserving fibers.18–22 Although most studies
discuss remnant preservation, there is a paucity of literature
on augmentation of partial tears of the ACL.21–26
Although most series show objective improvement after
augmentation, data on outcomes related to patients’ per-
spectives (subjective, objective, and activity levels) are scarce.
The purpose of study was to prospectively analyze functional
outcomes after augmentation (single-bundle reconstruction
with a hamstring graft) for treatment of symptomatic partial
tears of the ACL with preservation of an intact bundle. Our
hypothesis was that ACL augmentation, which preserves
residual fibers, will restore stability and function of knee.
MATERIALS AND METHODS
Ethical Review and Study Design
This prospective therapeutic case series study, was approved by
the Ethics Committee of SMS Medical College and Attached
Hospital, Jaipur, India (approval no. 3025/MC/EC/2017). The
study protocol was explained to the patients and informed
consent was obtained from each.
Patient Inclusion and Exclusion Criteria
The study was carried out at a tertiary care and referral center
medical college. Patients seeking consultation for laxity
episodes and/or recurrent pain and swelling in the knee at
the Institute of Orthopaedics and Traumatology between
January, 2015 and November, 2016 were included. A detailed
history was then obtained and thorough physical examination
performed. A Lachman test (LT), anterior drawer test (ADT),
and pivot shift test (PST) were used for laxity assessment.
Radiographs and MRI were obtained in patients who had signs
indicative of ACL injury. MRI analysis and reporting were done
in consensus by a group of radiologists unaware of the clinical
details. Patients with persistent symptoms after conservative
treatment27 with equivocal clinical findings (i.e. none of three
clinical tests [ADT, PST, LT] grade III positive but at least one of
the tests grade I/II positive with a definite end point) and/or
patients with MRI aspects compatible with partial tear were
chosen for the study, with final inclusion after diagnostic
arthroscopic confirmation. Patients with additional ligamen-
tous injuries greater than grade II, arthritic or malaligned knees,
and those with a history of previous knee surgery were
excluded. Patients who sustained iatrogenic injury to an intact
bundle during augmentation also were excluded.
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Volume 31  Number 1  January/February 2020
The sample size was calculated at 80% study power, α error
of 0.05 and expected standard deviation of 2. In our study
group of 37 patients, we were able to collect data for 34
patients, and three patients were lost to follow-up.
Outcome Measurements
Necessary preoperative and postoperative evaluation using a
specially designed form that included the 2000 International
Knee Documentation Committee (IKDC) knee form, Ly-
sholm knee score, Tegner activity score was completed. The
IKDC knee grades were assigned according to final evaluation
as per the 2000 IKDC knee examination forms. Outcomes
were evaluated in terms of clinical evaluation (2000 IKDC
knee examination forms, manual laxity tests), subjective
evaluation (2000 IKDC subjective knee evaluation, Lysholm
knee score, 2000 IKDC functional score), and patient activity
level (Tegner activity score).
Surgical Specifications
Clinical reassessment with the patient under anesthesia was
performed prior to surgery to confirm earlier findings followed
by a diagnostic arthroscopy. The decision to augment was
made when the ACL remnant was thick, with good quality
tissue on probing and was attached at the anatomic footprint.
Otherwise, a standard single-bundle or double-bundle recon-
struction was performed, and the patient was excluded from
the study. For augmentation, an isolated semitendinosus graft
was used in double or triple folds (size ≤ 7 to 8 mm) and fixed
with a cortical suspensory fixation button device on the
femoral side and bioresorbable interference screw on the tibial
side (Figure 1).
Postoperative Care
A rehabilitation program similar to standard ACL reconstruc-
tion was followed.28 Reevaluation was done at 3, 6, and 12
mo postoperatively.
Statistical Analysis
Statistical analysis was performed using the SPSS, trial version
23 for Windows statistical software package (SPSS Inc.,
Chicago, IL) and Primer. The categorical data were presented
as numbers (percent) and were compared among groups
using a chi square test. Groups compared for quantitative
data were presented as mean and standard deviation and
were compared using a Student t-test. A P value less than 0.05
was considered statistically significant.
RESULTS
Patient Characteristics
Out of a total of 37 patients initially treated, 21 had
anteromedial and 16 had posterolateral-bundle tears, for
which respective bundle reconstructions were done.
The mean age of patients was was 30.2 yr (range, 20-43 yr),
with only one patient being female. The mean duration of
interval between injury and surgery was 4.88 ± 1.3 mo. Most
injuries were sustained during recreational sports. The
second most common cause was a road traffic accident.
Current Orthopaedic Practice
FIGURE 1. A, Partial tear of the anterior cruciate ligament involving the posterolateral bundle. B, Intact anteromedial bundle after careful debridement. C,
Isolated semitendinosus graft used in double or triple fold. D, Anteromedial-bundle augmentation (posterolateral bundle reconstruction).
Twelve patients had a concomitant meniscal injury, with
seven involving the medial meniscus and and five the lateral
meniscus. Two patient with medial meniscal tears underwent
repair; for the remaining patients partial meniscectomies were
done. Traumatic chondral injuries were noted in six patients,
but none was so severe that warranted treatment. The articular
cartilages were intact for the remaining patients.
Outcome Measures
An MRI diagnosis of a partial tear could be correctly made in
only 47.06%. At 12-month follow-up, 2000 IKDC knee
examination grades significantly improved (21 grade B, 12
grade A) while preoperatively most were classified as grade C
(Table 1). Preoperatively and at 1-year postoperatively,
subjective IKDC scores were 66.25 and 91.20, respectively
(P < 0.001). The Lysholm knee scores preoperatively (70.82)
compared to after follow-up (91.15) were also significantly
better (P < 0.001) (Table 2). The difference in mean Tegner
activity level preinjury (6.029) and at final follow-up (5.67)
was not significant (P = 0.133) (Table 3).
Noticeable improvement (P < 0.05) was seen on manual
laxity tests (LT, ADT, PST) at follow-up. Although preoper-
atively all posterolateral-bundle tears and 71.42% of ante-
romedial-bundle tears demonstrated grade 1 or 2 laxity on
LT, postoperatively only two of the posterolateral-bundle and
three of anteromedial-bundle tears had persistent grade 1
laxity, and the rest all were bilaterally comparable. Only four
patients (19%) with anteromedial-bundle tear had grade 1
laxity postoperatively, while preoperatively 57.41% had
grade 2 laxity on ADT (P < 0.001). Similarly, stability after
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www.c-orthopaedicpractice.com | 3
augmentation in posterolateral-bundle tears improved sig-
nificantly. Grade 2 (53.85%) or grade 1 (46.15%) laxity as
assessed on PST preoperatively had improved to equal
(76.93%) or grade 1 (23.07%) at 12-month follow-up
(P < 0.001; Table 1). Significant functional improvement, as
measured by the IKDC functional score from a preoperative
mean of 5.5 to a postoperative mean score of 8.91 also
supported augmentation (P < 0.001; Table 2).
Exclusions and Complications
Four patients had a flexion deficit of more than 20 degrees
when compared with other side (110 to 140 degrees), whereas
none had extension deficit. Three had superficial infection that
resolved with antibiotics. Two patients who had partial tears
could not be included because of iatrogenic injury to the intact
bundle during arthroscopic augmentation and required stand-
ard reconstruction. No graft failure was noted at last follow-up.
DISCUSSION
In the present study, we found statistically significant
subjective and objective improvements in patient outcome
and activity level after selective-bundle reconstruction.
Although these results are similar to those in previously
published series of augmentation,21–26 use of different grafts
and fixation techniques in previous series has precluded
development of a standard method of treatment. Hence, the
effect of graft choice and fixation on outcome measures
cannot be ruled out. With this study we tried to evaluate the
4 | www.c-orthopaedicpractice.com Volume 31  Number 1  January/February 2020

TABLE 1. Objective evaluation parameters

Anteromedial bundle Posterolateral bundle

Objective evaluation Preoperative Follow-up Preoperative Follow-up

parameters N (%) N (%) P N (%) N (%) P
Objective IKDC grades < 0.001S < 0.001S
A 0 10 (47.62) 0 2 (15.38)
B 5 (23.81) 10 (47.62) 1 (7.69) 11 (84.62)
C 15 (71.43) 1 (4.76) 11 (84.62) 0
D 1 (4.76) 0 1 (7.69) 0
Anterior drawer test < 0.001S < 0.001S
Equal 2 17 0 11
Grade I 7 4 8 2
Grade II 12 0 5 0
Grade III 0 0 0 0
Pivot shift test < 0.001S < 0.001S
Equal 8 20 0 10
Grade I (glide) 11 1 6 3
Grade II (clunk) 2 0 7 0
Grade III (gross) 0 0 0 0
IKDC, International Knee Documentation Committee.

functional outcome after anatomical augmentation with
hamstring graft in our population group.
Clinical diagnosis of partial tears is difficult. With the patient
under anesthesia, we observed that laxity was more evident on
ADT for anteromedial-bundle tears and PS test for posterolateral-
bundle injury. The Lachman test was more commonly positive
in posterolateral-bundle tears, which may be attributed to the
contribution of the posterolateral bundle to knee stability at low
flexion angles.29–35 Siebold and Fu,7 clarified the difference
between anteromedial-bundle and posterolateral-bundle tears.26
An MRI diagnosis of partial ACL tears is difficult, with low
levels of accuracy.26,36,37 Only 16 of 34 tears could be
accurately labeled as partial tears by our radiologists. The
routine use of standard orthogonal views (sagittal and
coronal) to assess ACL injury might have contributed to
the low accuracy. Additional parasagittal and paracoronal
(oblique) planes can be used to improve visualization.38,39
Moreover, many features of partial tears are indistinguishable
from those of a complete tear, mucoid degeneration, or even
a normal ACL.37,40
Except for routine complications of surgery, disadvantages
of arthroscopic augmentation can include overstuffing of the
notch and impingement that causes loss of motion as
reported by Sonnery-Cottet et al.,25 although this was not
seen in this study. They demonstrated that the size of the
graft requires special attention to avoid these complications.
In our study, the minimal debridement of the remnant and
use of isolated semitendinosus graft (size <7-8 mm) may have
avoided this complication.
The superiority of augmentation techniques over standard
ACL reconstruction has not been demonstrated. Four recent
prospective, randomized controlled trials comparing ACL
reconstruction, with or without remnant preservation,
showed similar clinical outcomes at final follow-up. Hong
et al.41 in their comparative study using a four-strand
allograft, found no evident advantage of the remnant
preservation technique over the standard techniques in
terms of stability, synovial coverage, and proprioception
recovery. Zhang et al.42 showed that remnant preservation
prevented tibial tunnel enlargement. Park et al.43 found
identical clinical results when compared with a double-
bundle reconstruction. In a preliminary French prospective
randomized study,44 the authors found comparable clinical
results with improved anterior laxity using preservation
techniques. Only the study by Adachi et al.45 showed better
outcomes in the augmentation group. In a study by Demirağ
et al.,46 tunnel enlargement was found to be less in the
augmentation group, especially on tibial side.
Based on the available literature, preservation of ACL
remnants is beneficial in at least four ways: (1) it provides
mechanical strength and support in early postoperative period,
protecting the graft and allowing faster rehabilitation; (2) the
ACL remnants have the capacity to improve the ligamentiza-
tion of the graft, and preservation of the synovial sheet seems

TABLE 2. Subjective evaluation parameters

Anteromedial bundle Posterolateral bundle

Subjective evaluation Preoperative Follow-up Preoperative Follow-up

parameters scores scores P scores scores P
2000 IKDC subjective 65.11 89.99 < 0.001S 65.01 88.81 < 0.001S
Lysholm score 71.00 91.67 < 0.001S 70.54 90.31 < 0.001S
2000 IKDC functional score 5.57 9.00 < 0.001S 5.38 8.77 < 0.001S
IKDC, International Knee Documentation Committee.

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Current Orthopaedic Practice
TABLE 3. Patient activity level
Anteromedial bundle
Patient activity level Preinjury Follow-up
Tegner activity level 5.952 5.619
to play an important role in its vascularization;15,47 (3) the
preservation technique keeps mechanoreceptors within the
tibial stump;16,17,48 and (4) the intact bundle serves as a point of
reference and improves accuracy of tunnel placement.7
There are several weakness in our study. Our sample size was
small, and the results are preliminary given the short follow-up.
Long-term studies are definitely needed to validate this
procedure. Laxity measurements were subjective only; no
instrumented measurement of laxity could be done. The
decision to perform selective-bundle reconstruction was based
purely on subjective arthroscopic assessment by the surgeon
through probing, hence this could be criticized because even if
the fibers are intact upon probing, this does not necessarily
correlate with functionality, and a dysfunctional bundle may
be preserved. The mechanical or histological properties of the
intact bundle were not analyzed. Moreover, we did not evaluate
the postoperative MRI of our grafts or compare them.
CONCLUSIONS
Success after ACL reconstruction may depend not only on an
anatomical reconstruction by grafting but also on preserva-
tion of the intact fibers. Our study supports that selective-
bundle reconstruction with preservation of remnants restores
knee stability and function.
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