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Peer-reviewedCC BY 4.0Journal of Clinical Medicine

Biomechanical Study of the Quadrupled Gracilis Tendon Graft for the Anterior Cruciate Ligament Reconstruction

  • Ivan Levaj1
  • Ivan Bojanić1,2
  • Ana Pilipović3
  • Jan Homolak4
  • Dinko Nizić5
  • Marko Šimunović6
  • Josip Vlaić7
  • Mislav Jelić1,2
  • Mario Josipović1,2
7 affiliations
  1. 1Department of Orthopedic Surgery, University Hospital Centre Zagreb, Šalata 7, 10000 Zagreb, Croatia
  2. 2Department of Orthopedic Surgery, School of Medicine, University of Zagreb, Šalata 7, 10000 Zagreb, Croatia
  3. 3Faculty of Mechanical Engineering and Naval Architecture, University of Zagreb, Ulica Ivana Lučića 5, 10000 Zagreb, Croatia
  4. 4Department of Pharmacology, School of Medicine, University of Zagreb, Šalata 11, 10000 Zagreb, Croatia
  5. 5Special Hospital Agram, Trnjanska Cesta 108, 10000 Zagreb, Croatia
  6. 6Special Hospital Medikol, Ulica Dragutina Mandla 7, 10000 Zagreb, Croatia
  7. 7Division of Paediatric Orthopaedic Surgery, Children’s Hospital Zagreb, Ulica Vjekoslava Klaića 16, 10000 Zagreb, Croatia
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Abstract

Background/Objectives: To compare the morphological and biomechanical properties of a quadrupled gracilis (4GR) graft with two standard hamstring grafts for anterior cruciate ligament (ACL) reconstruction: a quadrupled semitendinosus (4ST) graft and a doubled semitendinosus–gracilis (2ST2GR) graft. Methods: Tendon specimens were obtained from 30 cadaveric donors (mean age, 42.6 years; range, 21–56 years). Tendon and graft dimensions were measured before biomechanical testing. Grafts underwent standardized preconditioning followed by load-to-failure testing at a displacement rate of 20 mm/min. Differences between graft types were analyzed using a generalized linear mixed-effects model, with results expressed as estimated marginal means with 95% confidence intervals (CI). Results: The mean 4GR graft length was 64.7 (95% CI, 61.6–67.8) mm, with 80% exceeding 60 mm. Graft diameter was greatest in the 4ST group, intermediate in the 2ST2GR group, and smallest in the 4GR group (7.98 [95% CI, 7.67–8.29], 7.41 [95% CI, 7.12–7.70], and 6.12 [95% CI, 5.89–6.36] mm, respectively). The 4ST graft demonstrated significantly greater maximum force than both the 4GR and 2ST2GR grafts, whereas no significant difference was observed between the 4GR and 2ST2GR grafts. In contrast, tensile strength was significantly higher in the 4GR grafts than in both the 4ST and 2ST2GR grafts. Stiffness was significantly higher in the 4ST grafts than in the 4GR grafts, whereas Young’s modulus was significantly higher in the 4GR grafts than in the 4ST grafts. Conclusions: The 4GR graft provided sufficient length for all-inside ACL reconstruction in most specimens. Despite its smaller diameter and lower absolute load-bearing capacity than 4ST, the 4GR graft demonstrated higher tensile strength and Young’s modulus, indicating favorable intrinsic mechanical properties. These findings may help inform graft selection in selected reconstructive procedures.

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Cite

BibTeXRIS
BibTeX
@article{levaj2026biomechanical,
  title = {{Biomechanical Study of the Quadrupled Gracilis Tendon Graft for the Anterior Cruciate Ligament Reconstruction}},
  author = {Ivan Levaj and Ivan Bojanić and Ana Pilipović and Jan Homolak and Dinko Nizić and Marko Šimunović and Josip Vlaić and Mislav Jelić and Mario Josipović},
  journal = {Journal of Clinical Medicine},
  year = {2026},
  month = nov,
  doi = {10.3390/jcm15218609},
  url = {https://www.mdpi.com/2077-0383/15/21/8609},
  note = {CC BY 4.0},
}
RIS
TY  - JOUR
TI  - Biomechanical Study of the Quadrupled Gracilis Tendon Graft for the Anterior Cruciate Ligament Reconstruction
AU  - Ivan Levaj
AU  - Ivan Bojanić
AU  - Ana Pilipović
AU  - Jan Homolak
AU  - Dinko Nizić
AU  - Marko Šimunović
AU  - Josip Vlaić
AU  - Mislav Jelić
AU  - Mario Josipović
PY  - 2026
DA  - 2026/11/05
JO  - Journal of Clinical Medicine
DO  - 10.3390/jcm15218609
UR  - https://www.mdpi.com/2077-0383/15/21/8609
AB  - Background/Objectives: To compare the morphological and biomechanical properties of a quadrupled gracilis (4GR) graft with two standard hamstring grafts for anterior cruciate ligament (ACL) reconstruction: a quadrupled semitendinosus (4ST) graft and a doubled semitendinosus–gracilis (2ST2GR) graft. Methods: Tendon specimens were obtained from 30 cadaveric donors (mean age, 42.6 years; range, 21–56 years). Tendon and graft dimensions were measured before biomechanical testing. Grafts underwent standardized preconditioning followed by load-to-failure testing at a displacement rate of 20 mm/min. Differences between graft types were analyzed using a generalized linear mixed-effects model, with results expressed as estimated marginal means with 95% confidence intervals (CI). Results: The mean 4GR graft length was 64.7 (95% CI, 61.6–67.8) mm, with 80% exceeding 60 mm. Graft diameter was greatest in the 4ST group, intermediate in the 2ST2GR group, and smallest in the 4GR group (7.98 [95% CI, 7.67–8.29], 7.41 [95% CI, 7.12–7.70], and 6.12 [95% CI, 5.89–6.36] mm, respectively). The 4ST graft demonstrated significantly greater maximum force than both the 4GR and 2ST2GR grafts, whereas no significant difference was observed between the 4GR and 2ST2GR grafts. In contrast, tensile strength was significantly higher in the 4GR grafts than in both the 4ST and 2ST2GR grafts. Stiffness was significantly higher in the 4ST grafts than in the 4GR grafts, whereas Young’s modulus was significantly higher in the 4GR grafts than in the 4ST grafts. Conclusions: The 4GR graft provided sufficient length for all-inside ACL reconstruction in most specimens. Despite its smaller diameter and lower absolute load-bearing capacity than 4ST, the 4GR graft demonstrated higher tensile strength and Young’s modulus, indicating favorable intrinsic mechanical properties. These findings may help inform graft selection in selected reconstructive procedures.
SN  - 2077-0383
ER  -