Rev. bras. ortop. vol.51 número2

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w w w . r b o . o r g . b r

Original

article

Correlation

between

anthropometric

data

and

length

and

thickness

of

the

tendons

of

the

semitendinosus

and

gracilis

muscles

used

for

grafts

in

reconstruction

of

the

cruciate

ligament

夽

Rafael

Noschang

Pereira

∗

_,

_Francisco

_Consoli

_Karam,

_Roberto

_Luís

_Schwanke,

Rubens

Millman,

Zilmar

Minetto

Foletto,

Carla

Helena

Augustin

Schwanke

PontifíciaUniversidadeCatólicadoRioGrandedoSul(PUC-RS),PortoAlegre,RS,Brazil

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Articlehistory:

Received1September2014 Accepted5May2015

Availableonline9February2016

Keywords:

Anteriorcruciateligament Anthropometry

Transplantationautologous Tendons

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t

Objective:Preoperativeestimationofthelengthanddiameterofthesemitendinosus(ST) andgracilis(G)tendonscanassistsurgeonsandallowthemtohavetheopportunityto choosealternativegrafts.Theaimofthisstudywastoinvestigatewhetheranthropometric measurementssuchasheight,weightandbodymassindex(BMI)orthepatient’sageand sexhaveanycorrelationwiththethicknessandthelengthofSTandGtendons.

Methods:Dataweregatheredfrom64patientswhounderwentthesurgicalprocedureof anteriorcruciateligamentreconstructionusingthetendonsoftheSTandGmusclesas grafts,betweenJune2012andAugust2013.Variablessuchasage,sex,weight,height,body massindex(BMI)andlengthanddiameterofthetendonsoftheSTandGmuscleswere analyzed.

Results:There wasa positivecorrelation betweenthe heightand totaldiameter ofthe quadruplegraft(r=0.254;p=0.043),totallengthoftheSTtendon(r=0.450;p<0.01),diameter ofthedoubleST(r=0.270;p=0.031),tripleST(r=0.347;p=0.005),lengthofGtendon(r=0.249;

p=0.047)anddiameterofthedouble-G(r=0.258;p=0.039).However,age(r=-0.015;p=0.908), weight(r=0.165;p=0.193)andbodymassindex(r=0.012;p=0.926)showednocorrelation.

Conclusion: Ourresultsshowthatage,weightandBMIdidnotcorrelatewiththediameter andlengthofthegraft,whiletheheighthadapositivecorrelationwiththetotallengthof theflexortendonsandthediameterofthegraftfromtheflexors(STandG).

夽

WorkperformedatHospitalSãoLucas,PontifíciaUniversidadeCatólicadoRioGrandedoSul(PUC-RS),HospitalMãedeDeusand HospitalDivinaProvidência,PortoAlegre,RS,Brazil.

∗ _{Corresponding}_author_.

E-mail:[email protected](R.N.Pereira).

http://dx.doi.org/10.1016/j.rboe.2016.01.011

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Correlac¸ão

entre

dados

antropométricos

e

comprimento

e

espessura

dos

tendões

dos

músculos

semitendinoso

e

grácil

usados

como

enxerto

na

reconstruc¸ão

do

ligamento

cruzado

r

e

s

u

m

o

Objetivo:Aestimativapré-operatóriadocomprimentoedodiâmetrodostendões semitendi-noso(ST)egrácil(G)podeauxiliarepermitirqueoscirurgiõestenhamaoportunidadede escolheropc¸õesdeenxerto.Oobjetivodesteestudofoipesquisarseexistecorrelac¸ãoentre asmedidasantropométricas,comoaltura,peso,índicedemassacorpórea(IMC),idadee sexodopaciente,comaespessuraeocomprimentodostendõesSTeG.

Métodos:Entrejunhode2012eagostode2013,foramcoletadososdadosde64pacientesque sesubmeteramaoprocedimentocirúrgicodereconstruc¸ãodoligamentocruzadoanterior emqueseusaramcomoenxertoostendõesdosmúsculosSTeG.Foramanalisadasvariáveis comoidade,sexo,peso,alturaeíndicedemassacorporal(IMC),comprimentoediâmetro dostendõesdosmúsculosSTeG.

Resultados: Houveumacorrelac¸ãopositivaentrealturaediâmetrototaldoenxertode quá-druplo(r=0,254p=0,043),comprimentototaldotendãoST(r=0,450,p<0,01),diâmetrodo STduplo(r=0,270p=0,031),STtriplo(r=0,347p=0,005),comprimentodotendãoG(r=0,249 p=0,047)ediâmetrodoGduplo(r=0,258p=0,039).Noentanto,idade(r=-0,015p=0,908), peso(r=0,165p=0,193)eíndicedemassacorporal(r=0,012p=0,926)nãoapresentaram correlac¸ão.

Conclusão:Nossosresultadosmostramqueidade,pesoeIMCnãosecorrelacionaramcomo diâmetroecomprimentodoenxerto,enquantoaalturatinhaumacorrelac¸ãopositivacom ocomprimentototaldostendõesflexoresecomodiâmetrodoenxertodosflexores(STeG). ©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Todososdireitosreservados.

Introduction

Thegrowing trendtoward practicing sports,together with greatercomplexityofsportsmovementshasincreasinglybeen causingknee jointinjuriestoappear.Theanteriorcruciate ligament(ACL)isamongmostcommonlyaffectedligaments, and surgical treatment is chosen for most patients who presentpainandinstability.1_The_autologous_grafts_most

fre-quentlyusedinACLreconstructionsarethepatellar,gracilis (G),semitendinosus(ST)andquadricepstendons.Each tech-niquehas its adherents and indications,and selecting the graftdependsonmanyfactors,includingthesurgeon’s pref-erenceandthepatient’sageandlevelofactivity.Thesurgical techniqueusingthetendonsoftheSTandGmusclesasgrafts presentsresults thatare similartothose from thepatellar tendontechniqueandenablesmootherandlesspainful reha-bilitation.Themaindisadvantagesofthistechniqueinclude theindividualvariabilityinlengthandthicknessofthegraft fromthetendonsandthepotentialcomplicationsduringgraft harvesting.2–5_After_the_tendons_have_been_removed_from_the

semitendinosusandgracilismuscles,andbeforethegrafthas beenconstructed,surgeonsarefacedwithmanypossibilities forthefinalconfigurationofthegraft.Theseincludeusingthe semitendinosustendonindouble,triple orquadruple form alone,orindoubleforminassociationwiththetendonofthe gracilismuscle,alsoindoubleform(thusmakingaquadruple graft),orevenothercombinations.Preoperativeestimationof thelengthanddiameteroftheSTandGtendonsmayhelpand allowsurgeonstohavetheopportunitytochooseanothergraft

optionifthetendonthatmightbeharvesteddoesnotmeet theneedsofagivenpatient.However,nomethodcapableof preciselydeterminingthelengthanddiameterofSTandG tendonsbeforeACLreconstructionsurgeryisperformedhas yetbeendescribedintheliterature.

The objective of this study was to investigate whether anthropometricmeasurementssuchasthepatient’sheight, weight,bodymassindex(BMI),ageandsexwouldhaveany correlation withthe thicknessandlengthofthehamstring tendons(STandG).

Materials

and

methods

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consentstatementwereexcludedfromthesample.Thestudy wasconductedamongpatientswhowereevaluatedthrough anamnesis, physical examination and magnetic resonance imaging,andforwhomtherewasanindicationforsurgical reconstruction ofthe ACL inwhich the ST and G tendons wereusedtoconstructthegraft.Thisinvestigationdidnot changetheroutineofstepstobefollowedduringthesurgical procedureindicated.Thedata-gatheringdidnotaddriskto theprocedure.Thisstudywasapprovedbyouruniversityand bytheresearchethicscommitteesoftheinstitutionsinvolved. Thefollowingvariables were analyzed:age, sex,weight, height,bodymassindex(BMI), lengthofthetendonofthe semitendinosusmuscle,lengthofthetendonofthegracilis muscle,diameterofthetendonofthesemitendinosus mus-clewhen folded inthe middle (double) and in threeparts (triple),diameterofthetendonofthegracilismusclewhen foldedinthemiddle(double)andthediameterofthetendons ofthesemitendinosusandgracilismuscleswhenfoldedinthe middleandgrouped(quadruple).

Firstly,demographicdata(ageandsex)and anthropomet-ricinformation(weightand height)reported atthe timeof thesurgerywereobtainedandnotedinthemedicalfile.Soon afterwards,duringthesurgicalprocedure,measurementson thetendonsofthesemitendinosusandgracilismusclesthat wereusedforconstructingthegraftsweremade.

The technique for obtaining the grafts during the ACL reconstructionsurgeryconsistedofanobliqueanteromedial incisionintheproximaltibia,attheleveloftheinsertionof theSTandGmuscles.Following this,thetendonoftheST musclewasdissectedand wasthen deinsertedagainstthe boneandremovedusingagraftextractor.Thesame proce-durewas repeatedin relationtothe tendonofthe gracilis muscle.Afterthetendonshadbeenpreparedthroughremoval ofthe musclelayer, the length(cm)and diameter (MM)of thegraftswereobtainedusingarulerandmeasuring cylin-derthathadpreviouslybeensterilized.Thediametersofthe semitendinosusandgracilisgraftsweremeasuredusingaset ofcylindrical tubesrangingindimensionfrom6to12mm, instepsof0.5mmbetween cylinders.Both ofthe tendons weremeasured.Inthecaseofthetendonderivedfromthe semitendinosusmuscle,its totallengthand diameterwere measured twice. Firstly, it was folded in the middle (dou-ble)andthenitwasfoldedintothreeparts(triple).Thetotal lengthand diameter ofthe graft derived from the gracilis muscleweremeasuredwiththetendonfoldedinthemiddle (double).Lastly,thelengthanddiameterofthetwotendons foldedinthemiddleandgroupedtogether(quadruple)were measured.Themeasurementsweremadewithoutsuturing thread,whichmighthavehinderedobtainingthereal dimen-sionsofthetendons(Figs.1and2).

Thedatagatheredwereanalyzedthroughdescriptiveand analytical statistics. IN the descriptive phase, means and standarddeviationswereused.Inthe analyticalphase,the variableswerecomparedinrelationtothedifferentlengths anddiametersofthetendonsofthesemitendinosusand gra-cilismuscles.Thettestforindependentsampleswasused toidentifydifferencesintheclinicalandintraoperative vari-ables.Pearson’scorrelation coefficient(r)andsimplelinear regressionwereusedtodeterminetherelationshipbetween theresultvariables(diameterofthequadruplegraftandthe

Fig.1–Removalofflexortendons.

lengthsofthesemitendinosusandgracilistendons)andthe predictivevariables(age,sex,height,weightandBMI). Differ-enceswereconsideredtobesignificantwhenPvalueswere lessthan0.05.TheanalysiswasdoneusingtheSPSSsoftware, version17.0.

Results

Among the 64 individuals analyzed between June 2012 and August 2013, 60 (94%) were male and four (6%) were female.Thepatients’meanagewas31.78±8.26years(range: 15–48 years); among the females, it was 32±13.49 years,

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Table1–Resultsfrommeasurementsonanthropometric data.

Variables Meanandstandarddeviation

Age(years) 31.78±8.26(15–48years)

Height(m) 1.77±0.08(1.52–1.96m)

Weight(kg) 82.43±12.89(56–115kg)

BMI{weight(kg)/height2_(m)} _26.14_±_3.74_{(21.60–37.55)}

Lengthofsemitendinosus tendon(cm)

28.75±2.91(23–36cm)

Doublesemitendinosus(mm) 6.24±0.75(4.5–8mm) Triplesemitendinosus(mm) 7.32±0.76(6–9mm) Lengthofgracilistendon(cm) 25.28±3.81(14–34cm) Doublegracilis(mm) 5.16±0.81(4–7mm) Diameterofthequadruple

graftfromtheflexor tendons(mm)

8.03±0.72(7–10mm)

Total=64patients(60malesandfourfemales).

and amongthemales,it was 31.76±7.97 years.Themean heightwas1.77±0.08cm(range:1.52–1.96cm);meanweight 82.43±12.89kg(range:56–115kg);andmeanBMI26.14±3.74 (range: 21.60–37.55). The mean tendon lengths measured duringthe operationwere28.75±2.91cm(range: 23–36cm) forthesemitendinosusand25.28±3.81cm(range:14–34cm) forthe gracilis.Themeans tendon thicknesses(diameters) were6.24±0.75mm(range: 4.5–8mm)forthedouble semi-tendinosus; 7.32±0.76mm (range: 6–9mm) for the triple semitendinosus;and6.24±0.75mm(range:4.5–8mm)forthe doublegracilis.Themeantotaldiameterofthequadruple ten-dongraft (STand G) was 8.03±0.72mm(range: 7–10mm). During the study period, wedid notobtain any quadruple flexorgraftssmallerthan7mmorlargerthan10mm(Table1). Intotal,75% ofthe patientshad quadrupleflexorgrafts ofdiameter7–8mm,while25%ofthegraftswerelargerthan

0

14

2

32

15

1 0

5 10 15 20 25 30 35

10 9

8 7.5 7

6

Number of occurrences

Diameters of quadruple grafts from flexors (mm)

Distribution of the diameters of quadruple grafts from flexors

Fig.3–Distributionofthediametersofquadruplegrafts

fromflexors.

8mm. Thefrequenciesofdifferentdiameters ofquadruple flexorgraftswereasfollows:7mm(22%),7.5mm(3%),8mm (50%),9mm(23.5%)and10mm(1.5%)(Fig.3).

Therewerepositivecorrelationsbetweenheightandthe totaldiameterofthequadruplegraftfromtheflexortendons (r=0.254; p=0.043);totallengthofthe semitendinosus ten-don(r=0.450;p<0.01);diameterofthedoublesemitendinosus (r=0.270; p=0.031); diameter of the triple semitendinosus (r=0.347;p=0.005);totallengthofthegracilistendon(r=0.249;

p=0.047); and diameter of the double gracilis (r=0.258;

p=0.039).However,age(r=−0.015;p=0.908),weight(r=0.165;

p=0.193) and body mass index (r=0.012; p=0.926) did not presentanycorrelationwiththetotaldiameterofthe quadru-plegraftorwiththelengthsofthesemitendinosusandgracilis tendons(Table2).

Table2–Correlationofthedimensionsofthegracilisandsemitendinosustendonswithanthropometricvariablesand age.

Tendons Age(years) Weight(kg) Height(m) BMI(kg/m2₎

r p

Totallengthofgracilis(cm) 0.064 0.221 0.249 0.076

0.613 0.079 0.047a _0.550

Doublegracilis(mm) −0.141 0.233 0.258a _0.101

0.265 0.063 0.039 0.427

Totallengthofsemitendinosus(cm) 0.171 0.214 0.450 −0.063

0.177 0.089 0.000a _0.621

Doublesemitendinosus(mm) −0.054 0.256a _0.270a _0.116

0.671 0.041 0.031 0.361

Triplesemitendinosus(mm) 0.132 0.176 0.347a ₋_0.030

0.300 0.164 0.005 0.812

Thicknessofquadruplegraft(mm) −0.015 0.165 0.254 0.012

0.908 0.193 0.043a _0.926

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Discussion

Useofflexortendongraftshasbecomeanincreasinglypopular choiceamongorthopedicsurgeonsforACLreconstructions.6

Anatomicalstudieshavedemonstratedthatthemean diam-eterofthenormalACLisapproximately11mm,witharange from 6 to 12mm. Although the parameters foracceptable graftsizethat are necessaryinordertoachieve a satisfac-toryresult after ACL reconstruction have not been clearly defined,adiameterofatleast7mmhastraditionallybeen recommended.7–9 _However,_in _a _recent _study, _greater

inci-denceofACLreconstruction failurewasshown withgrafts smallerthan8mm.10_Studies_on_animal_models_that_evaluated

theinfluenceofgraftdiameteron graftstrength and resis-tancehavedemonstratedthatingraftssmallerthan8mm, failuredue totearingofthetendon materialoccurs,while in grafts larger than 10mm, failure occurs at the fixation screws,duetotraction.11_Thus,_a_capacity_to_predict_which

patientspresentgreaterriskofhavinghamstringtendonsof insufficientdiameter,beforetheoperation,maybebeneficial forsurgicalplanning,therebyavoidingdisagreeable intercur-rencesduringtheoperation.7–10

Inourpatients,weusedavarietyofgraft combinations, suchastripleSTalone,quadrupleSTalone,doubleSTwith doubleG,tripleSTwithdoubleGandtripleSTwithtripleG. Theaimwasalwaystoseekgraftsofdiametergreaterthan 8mm,ofadequatelength.

Thecapacitytopredictthediameterandlengthofthegraft maybeusefulforcertainsurgicaltechniquesandmay pro-videoptionsforthesurgeon.Throughabiomechanicalstudy, Hamneretal.12 _demonstrated _that_the _resistance,_stiffness

andbiomechanicalpropertiesofthegrafttendonareaffected byitsdiameter.However,theresultsfromthefewstudiesin theliteraturecorrelatingpatients’anthropometricdatawith thelengthanddiameterofflexorgraftscontinuetobe contra-dictory.

Inourstudy,weinvestigatedthepredictivevalueofsimple anthropometricmeasurementssuchasheight,weight, BMI andageinrelationtothelengthsofthesemitendinosusand gracilisflexortendonsandthediameterofthequadruplegraft fromtheflexors.Ourresultsshowedthatage,weightandBMI didnotcorrelatewiththelengthordiameterofthegraft,while heighthadapositivecorrelationwiththetotallengthofthe graftsfromthesemitendinosus(r=0.450;p<0.01)andgracilis (r=0.249;p=0.047),andalsowiththediameterofthe quadru-plegraftfromtheflexors(r=0.254;p=0.043).Adeeperanalysis using step-by-stepregression revealed that heightwas the clinicalparameterofgreatestimportanceforpredictingthe thicknessofthegraft.

Tumanetal.13_analyzed₁₀₆_patients_who_underwent_ACL

reconstructionandreportedthatamongtheanthropometric dataanalyzedintheirstudy,suchasheight,weight,sexand age,heightwasthebestpredictorforthediameterofgrafts fromthehamstringsinbothsexes,andparticularlyamong women.Fromtheiranalysis,theyconcludedthatwomen pre-sentedgraft diametersthat were significantlysmallerthan thoseofmen,andthatinpatientswhoseheightwaslessthan 147cm,itwaslikelythatthegraftwouldbeinsufficient,with adiameteroflessthan7mm.

Maetal.14 _{retrospectively}_analyzed_preoperative

anthro-pometricdatafrom536patients. Theirresultsshowedthat heightandsexweresignificantpredictorsforthediameterof flexortendongrafts.Malepatientshadgraftsthatwere signif-icantlylargerthanthoseoffemales.Itwasalsodemonstrated thatheightwasaspecificindicatorsolelyforthemen,without anysignificantresultsforthewomen.

Inastudyon119patientswhounderwentACL reconstruc-tion,Schwartzberget al.15_reported_that_there_was_a_strong

correlation betweenleglengthand thelengthoftheflexor tendonsusedasgrafts(r=0.73;p<0.001).Inthesamestudy, weight(r=0.51;p<0.001)andleglength(r=0.42;p<0.001)only showed moderate correlations withgraft diameter.All the other correlationswere weakin relationto height.Weight measurementsandagedidnotshowanyrelationshipwiththe lengthanddiameteroftheflexortendons,andthesefindings were concordantwiththeresultsreportedbySchwartzberg etal.15

InanalysesbyTremeetal.16_on_the_length_and_diameter_of

thesemitendinosusandgracilistendonsof50patientswho underwentACLreconstruction,astrongcorrelationwasfound betweenthelengthofthegraftandthepatient’sheightand lower-limblength.Thediameterofthegraft wascorrelated withthepatient’sweightandthighcircumference.

Althoughourstudy didnotconfirmall thepositive cor-relationsofotherstudies,12–17 _our_results_favored_the_notion

thatindividualanthropometricvariablessuchasheightmay bepredictorsforthelengthanddiameteroftheflexortendons (STandG)thatareusedinACLreconstruction.Ourresultsalso showedthatheighthadapositivecorrelationwiththetotal lengthofthesemitendinosusandgracilistendonsandwith thediametersofdoubleST,tripleST,doubleGand quadru-plegrafts,andtheywerealsoconcordantwiththefindingsof Tumanetal.13_Moreover,_our_results_demonstrated_that_height

wasthemostimportantvariable,especiallyamongwomen, whereasSchwatzberg etal.15 _found_that_height_had_a_weak

correlationwiththighdiameterand thatweightand lower-limbdiameterhadamoderatecorrelationwithgraftdiameter. Thereislimitedevidenceintheliteraturecorrelatingthe patient’sfitnessandphysicalactivitylevelwiththelengthand diameteroftheflexortendons.Tremeetal.16_reported_that

theyhadnotfoundanycorrelationbetweenthediameterof theflexorgraftsandthepatient’ssportsandactivitylevels. SimilarresultswererecordedbyPichleretal.17_in_their_study

oncadavers.

Other studies in the literature have used radiological imaging examinations such as computed tomography and magneticresonanceimaging(MRI)inanattempttopredict thelengthanddiameterofflexorgraftsbeforetheoperation. Althoughsomestudieshaveshowngoodcorrelationsbetween measurementsofcross-sectionalareaandtendonthickness, othershavenotshownanycorrelation.18–20_{Nevertheless,}_the

lackofstandardizationinrelationtothelevelatwhich mea-surementsaremadeandregardingthetrustworthinessand precisionofthe examinationsgivesrisetolimitations that make the results obtainedquestionable. Yasumoto et al.19

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Hamadaetal.20_showed_that_MRI_was_impractical_for

evalu-atingthesizesofthetendons,giventhatalongsweeptime wouldbeneededandthecostishigh.

Conclusion

Thecapacitytopreciselypredictthelengthanddiameterof thehamstringtendons(STandG)usedinACLreconstructions continuestobeanimportantfactorindecision-makingandin choosingthebestsurgicaltechniqueandtheappropriategraft. Ourresultsshowedthatage,weightandBMIdidnotcorrelate withthediameterandlengthofthegraft,whileheightshowed apositivecorrelationwiththetotallengthoftheflexor ten-donsandwiththediameterofthegraftfromtheflexors(ST andG).

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

Acknowledgements

SpecialthankstothephysiciansLuizAntonioSilveiraSimões PiresandGuilhermeIslerPereira,whocontributedequallyto data-gatheringandconductingthisstudy.

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