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ACL reconstruction with hamstring tendon autograft and accelerated brace-free rehabilitation: a systematic review of clinical outcomes
  1. Rob P A Janssen1,
  2. Nicky van Melick2,
  3. Jan B A van Mourik1,
  4. Max Reijman1,3,
  5. Lodewijk W van Rhijn4
  1. 1 Orthopaedic Center Máxima, Máxima Medical Center, Eindhoven, The Netherlands
  2. 2 Knee Expert Center Eindhoven, Eindhoven, The Netherlands
  3. 3 Department of Orthopaedic Surgery, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
  4. 4 Orthopaedic Surgery & Traumatology, Maastricht University Medical Center, Maastricht, The Netherlands
  1. Correspondence to Dr Rob P A Janssen; r.janssen{at}


Objective To investigate the clinical outcomes after hamstring tendon autograft ACL reconstruction (ACLR) with accelerated, brace-free rehabilitation.

Design Systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.

Data sources Embase, MEDLINE Ovid, Web of Science, Cochrane CENTRAL and Google scholar from 1 January 1974 to 31 January 2017.

Eligibility criteria for selecting studies Study designs reporting outcomes in adults after arthroscopic, primary ACLR with hamstring autograft and accelerated, brace-free rehabilitation.

Results Twenty-four studies were included in the review. The clinical outcomes after hamstring tendon autograft ACLR with accelerated brace-free rehabilitation were the following: (1) early start of open kinetic exercises at 4 weeks in a limited range of motion (ROM, 90°−45°) and progressive concentric and eccentric exercises from 12 weeks did not alter outcomes, (2) gender and age did not influence clinical outcomes, (3) anatomical reconstructions showed better results than non-anatomical reconstructions, (4) there was no difference between single-bundle and double-bundle reconstructions, (5) femoral and tibial tunnel widening occurred, (6) hamstring tendons regenerated after harvest and (7) biological knowledge did not support return to sports at 4–6 months.

Conclusions After hamstring tendon autograft ACLR with accelerated brace-free rehabilitation, clinical outcome is similar after single-bundle and double-bundle ACLR. Early start of open kinetic exercises at 4 weeks in a limited ROM (90°−45°) and progressive concentric and eccentric exercises from 12 weeks postsurgery do not alter clinical outcome. Further research should focus on achievement of best balance between graft loading and graft healing in the various rehabilitation phases after ACLR as well as on validated, criterion-based assessments for safe return to sports.

Level of evidence Level 2b; therapeutic outcome studies.

  • hamstring autograft
  • ACL reconstruction
  • accelerated rehabilitation
  • clinical outcomes
  • graft remodelling

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

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  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Parts of the abstract of this paper have been presented at the 17th ESSKA Congress (4–7 May 2016) in Barcelona, Spain, as a poster presentation with interim findings. The poster’s abstract was published in ‘Poster Abstracts’ in Knee Surgery Sports Traumatology Arthroscopy.

  • Patient consent Not required.

  • Contributors All authors contributed to the search, screening, data collection, bias assessment and final writing of the manuscript.

  • Data sharing statement We are willing to share any further details of this PRISMA systematic review.

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