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Tomasz Poboży

Attachment-sparing ACL reconstruction: earlier graft maturation on MRI

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Tomasz Poboży

Polish version: Rekonstrukcja ACL z zachowaniem przyczepu piszczelowego — szybsze dojrzewanie przeszczepu w MRI

Can preserving the native tibial attachment of the hamstring tendons improve graft maturation after ACL reconstruction? A randomized trial in the August issue of The American Journal of Sports Medicine found clearly earlier maturation on MRI with attachment preservation. This is an interesting biological finding, but should not yet be treated as proof of clinical superiority.

Why this study matters

Hamstring grafts are usually detached from their native insertion and fixed within bone tunnels. An attachment-sparing technique retains the distal tibial insertion, potentially preserving some blood supply and the biological connection to bone. Earlier revascularisation and ligamentisation might shorten the period of biological vulnerability.

Earlier MRI maturation does not necessarily mean better function, fewer reruptures or a safe basis for accelerated rehabilitation. A randomized comparison is therefore particularly useful.

Study design

This Level I randomized trial compared attachment-sparing (AS) hamstring autografts with conventional free grafts (FG). Initially, 56 patients were randomized. The methods describe 25 undergoing AS reconstruction and 25 receiving FG reconstruction.

MRI at 3, 6 and 9 months assessed Figueroa maturation scores, graft characteristics, orientation and tunnel widening. Independent clinical assessments at 3, 6, 9 and 12 months included Lysholm, IKDC and Tegner scores and KT-2000 anterior tibial translation. Final follow-up was completed by 78% of participants: 19 in the AS group and 20 in the FG group. The final imaging comparisons therefore involved a small sample.

Main results

  • Figueroa MRI scores were significantly better with attachment preservation at successive assessments.
  • The earliest signs of maturity appeared at 3 months in the AS group, when 26.3% of grafts reached Figueroa grade 4. A comparable stage first appeared at 6 months in the FG group.
  • At final assessment, all AS patients remaining in the analysis reached Figueroa grade 5, compared with 10% in the FG group.
  • Graft diameter was more stable with AS, while FG grafts showed greater swelling on serial MRI.
  • Tibial tunnel widening progressed in both groups and was greater with attachment preservation.
  • Lysholm, IKDC and anterior tibial translation improved significantly in both groups.

Clinical interpretation for an orthopaedic surgeon

The clearest finding concerns MRI evidence of graft maturation. Preserving the tibial attachment appears to influence early graft biology, consistent with the technique’s proposed mechanism and relevant to further research on remodelling.

Functional implications require more caution. The abstract reports improvements in both groups, but provides insufficient detail to establish a clinically important advantage for AS. Although the paper’s title refers to better short-term clinical outcomes, the abstract does not quantify that difference sufficiently.

Limitations

  • The sample was small, with only 39 patients completing final follow-up.
  • The reported 78% completion rate raises the possibility of attrition bias.
  • The strongest signal concerned a surrogate endpoint, MRI appearance, rather than rerupture, return to sport or long-term function.
  • Clinical follow-up extended to 12 months, too short to establish durability or late failure rates.
  • Greater tibial tunnel widening with AS shows that not every assessed parameter favoured attachment preservation.
  • The full text has restricted access. This summary is limited to the public abstract and publisher/PubMed metadata.

Implications for practice

The study strengthens the biological rationale for preserving the tibial hamstring attachment and supports larger, longer comparative trials. For surgeons using this technique, it suggests a real effect on early graft remodelling.

It does not establish fewer ACL reruptures, earlier safe return to sport or grounds for shortening a standard rehabilitation protocol. A more mature MRI appearance also does not by itself demonstrate greater mechanical strength in humans. Those conclusions require larger studies, longer follow-up and clinical endpoints.

References

Sinha S, Arumugham KC, Singh DK, Kumar N, Bera AP, Uppal H, Vakharia KS. ACL Reconstruction With Attachment-Sparing Hamstring Autograft Results in Earlier Graft Maturation and Better Short-Term Clinical Outcome in Comparison to Free Graft: A Randomized Controlled Trial. The American Journal of Sports Medicine. 2026;54(10):2399–2406. First published online: 17 June 2026; journal issue: August 2026. DOI: 10.1177/03635465261455046. PubMed: PMID 42310826.

The publisher labels the article as restricted access; this summary therefore relies solely on the public abstract and metadata.

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For Doctors and Physiotherapists · Research Updates, Literature and Evidence-Based Medicine

Content prepared by: Tomasz Poboży - orthopaedic surgeon.

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