There are different reconstruction graft options that can be used to reconstruct the native anterior cruciate ligament, with autograft hamstring tendons being one of the most commonly used.
Preparation of a hamstring autograft varies depending on patient characteristics and physician preference.
There are several methods to identify hamstring tendons, graft harvest and graft preparation techniques…to obtain an individualized graft according to patients anatomy and physical activity.
Please share your own tips and tricks!
The standard method by identifying semiT or gracilis on flexed knee is followed by a mini incision followed by use of tendon stripper to obtain desired tendon part. The muscles and attached soft tissue is removed manually and desired bundles are created with use of ethibond as suture material over a tendon board.
Thank you for your contribution dear Ganesh.
Can you please explain which measurements you make for the configuration of the graft (two-strand, three strand...) in order to estimate appropriate graft length and diameter...?You always use semiT and gracilis for your ACLR?
Mostly double bundle is used and that is reflected in most researches from here as well.. but BPTB or quadriceps tendon one are also gaining preferences.
I usually harvest Semi T first and if i m getting sugficent length 30cm or more i qudrupled it and use it alone .
oblique incision after identifying identify gracilis, below it is
Semi T.UseTendon stripper in standard way. complete removal of muscle fibers. Qudrupled graft
I usually harvest 18-22cm - I use the Linvatec stripper which allows one to cut at a measured depth, Peter Annear published less pain than with a stripper that obligates full length. I use 25ml LIA mixture along the tendon injected with a mixing cannula before stripping. After harvesting both, I clean semiT of any (rarely much) muscle, and hand to my assistant to whip stitch. Meanwhile, I clean gracilis of muscle (more work) and whip stitch. I then take both tendons, pulling them laterally & superiorly from the tibia & find band of semiT to gastrocnemius & divide. I then take the two hamstrings off the tibia with a periosteal patch. Then I clean and whipstitch that end. If doubled graft is
Thank you so much for sharing with all of us your technique to harvest and prepare Hamstring tendon autografts.
So do you inject LIA mix in Hamstring tendons before stripping? Don´t you think that injecting dexamethasone along tendons could weaken the graft? The periosteal patch on the tibia is an amazing technique since you can get an "extra" length on final tendon!
Your final diameter size target is 7 mm? According to these 2 studies (Mariscalco et al. The influence of hamstring autograft size on patient-reported outcomes and risk of revision after anterior cruciate ligament reconstruction: A Multicenter Orthopaedic Outcomes Network (MOON) Cohort Study. Arthroscopy 2013;29:1948-1953 and Conte et al. Hamstring autograft size can be predicted and is a potential risk factor for anterior cruciate ligament reconstruction failure: A systematic review and analysis. Arthroscopy 2014;30:882-890) the "magic" target number (in adults) should be a graft diameter higher than 8 mm (to decrease the risk of re-rupture).
Once again thank you for your wonderful description; )
I don't worry that the graft will be weakened with the dexamethasone - compared with a cortisone injection for rotator cuff impingement or ITB friction - it is a small dose over a large area. I might add I push close scissors up next to the tendon, and using the mixing cannula up the defect just created. I expect it anaesthetises the surrounding muscle.
I am aware of graft size might add to re-rupture rate. Age of patient is a MUCH greater factor - patients under 20 I am inclined to us a 5x graft where possible (notch size & graft length). There is art to medicine, no magic!
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