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The rupture of the anterior cruciate, the ligament that plays a leading role in knee stabilization, is one of the most severe and most frequent injuries of the particular joint, often with a long recovery period. A common injury for high-performance athletes and anyone involved in sports; it alters the knee mechanics, and, if not treated promptly and effectively, it increases the chances of injuries to the meniscus or the cartilage, injuries which are in turn associated with premature osteoarthritis.
The most recent data from the American Academy of Orthopaedic surgeons indicate that, each year, about 200,000 americans suffer a rupture of the anterior cruciate ligament, with more than half of them resorting to surgical treatment for the replacement of the torn or injured ligament.


Nowadays, syndesmoplasty of the anterior cruciate ligament is performed arthroscopically, with small incisions, a minimally invasive technique which is a preferred option, as it includes less postoperative pain, fewer hospitalization days, and faster recovery. In fact, it is especially recommended for professional athletes, young and active patients who do not wish to change their lifestyle, those who are over 40 and do heavy manual labour work or practice sports, or in patients with multiple ligament knee instability, or even with a meniscus tear.
The surgeon, after assessing the case of each patient, shall choose the appropriate graft. Nowadays, in most cases, a graft by the patient themselves is used, as it has the advantage of faster integration and fewer immune responses, and, usually, the hamstring autograft is selected. It is all about two tendons (semimembranosous and semitendinosous) which are inserted along the inside of the thigh and knee, and which are “folded” by the surgeon to form four “cords”, namely, a quadruple bundle.
The period of return to sports activities depends on the orthopaedic surgeon’s approval, so as not to pose a risk to the graft, but it usually ranges from 6 to 9 months.


The correct placement of the graft at its anatomical position, in both the tibia and the thigh is of particular importance for the success of the surgery, so that, after it the knee shall not be loose during extension and stiff during flexion. The advantage of the quadruple hamstring autograft is that a smaller surgical incision is required; postoperatively, the patient experiences less pain, while the possibility of anterior pain (especially in the patellar tendon) is reduced to zero. Moreover, the graft’s maximum resistance is of 4,000 newton.


According to the international literature, the disadvantages include the weakness of hamstrings in the donor area (their strength is restored to 85%, one year after surgery), while, regarding the receiving area, the stabilization of the implant performed with a titanium screw or an absorbable material between the tendon and the bone, and, consequently, the stability strength in relation to bone-to-bone stabilisation is lower. However, the evolution of fixation systems has internationally increased the “popularity” of the graft, as it seems to be better accepted by the patients themselves.

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