Anatomic considerations in harvesting the semitendinosus and gracilis tendons and a technique of harvest

"Cigar Wrap" technique for gracilis augmentation in hamstring anterior cruciate ligament reconstruction

The use of Hamstring grafts for anterior cruciate ligament reconstruction is becoming increasingly popular. Most surgeons use a four-stranded graft consisting of double-stranded semitendinosus and gracilis tendons. The gracilis tendon, in addition to being smaller in diameter, is often shorter and more diminutive at its muscular end. We developed a technique for supplementing this tendon using excess semitendinosus tendon. This allows enhanced tibial tunnel fit and improved graft fixation.

Arthroscopic anterior cruciate ligament reconstruction

Significant advances in arthroscopic techniques have led to wide-spread performance of arthroscopically assisted ACL reconstruction. Properly performed reconstruction has proved to be successful clinically. The surgeon who undertakes ACL reconstruction must be familiar with techniques for both autograft hamstring augmentation and bone-patellar tendon-bone ACL reconstruction for the ACL-deficient knee. The arthroscopic techniques discussed in this article will allow successful treatment of most acute and chronic ACL injuries. Arthroscopic ACL reconstruction is a highly demanding procedure, with the possible risk of significant knee disability if the ACL graft is placed improperly. Proper patient selection, surgical technique, and postoperative rehabilitation remain the foundations for successful ACL reconstruction.

Arthroscopically assisted semitendinosus and gracilis tendon graft in reconstruction for acute anterior cruciate ligament injuries in athletes

We evaluated 69 arthroscopically assisted anterior cruciate ligament reconstructions for acute tears at an average followup of 60 months. We used a distally based single semitendinosus and gracilis tendon graft passed over the top and fixed to the femur. Combined medial collateral ligament lesions were seen in 30 knees, and they were repaired when found in the distal third (18 knees). The patients were instructed to recover motion preoperatively, and an early range of motion program was used postoperatively. At followup, symptoms of giving way were seen in five knees (7%). Graft failure was seen in seven knees (10%); failure was defined as a positive pivot shift (clunk or gross) or a side-to-side difference in anterior tibial displacement greater than 5 mm, as measured with a KT-1000 arthrometer. Permanent extension loss (3 degrees to 5 degrees) was found in two knees (3%). Patellofemoral crepitation was seen in eight knees (12%), but the condition was symptomatic in only one knee. Forty-six patients (67%) were active in pivoting sports before surgery and 37 (54%) remained active in these sports at followup. We concluded that this operation is simple, effective, and has a low complication rate. Further studies are necessary to elucidate if a stronger graft (e.g., a patellar tendon) would decrease the rate of graft failure without increasing complications.

Anterior cruciate ligament reconstruction with multistranded autogenous semitendinosus tendon

We evaluated 41 knees 24 to 48 months after anterior cruciate ligament reconstruction was performed using multiple autogenous semitendinosus tendons. The ipsilateral free semitendinosus tendon was tripled or quadrupled to make a graft 7 to 10 mm in diameter and more than 60 mm long. When the diameter of the graft was less than 7 mm, an ipsilateral doubled gracilis tendon was also used (in seven cases). Twenty-three patients (56%) returned to their preinjury activity levels. According to the patients' subjective assessment, 34 (83%) graded themselves as normal or nearly normal. No patient reported giving way of the knee or limitation of knee motion. The average anterior laxity difference between the involved knee and contralateral uninjured knee was 1.5 mm at 200 N. Twenty-nine patients (71%) demonstrated an anterior laxity difference of 3 mm or less when the involved knee was compared with the contralateral uninjured knee. Quadriceps muscle strength was 90% compared with the contralateral healthy limb, and hamstring muscle strength was equivalent to the contralateral limb. In our study, tripled or quadrupled semitendinosus free tendons were excellent anterior cruciate ligament grafts for restoring knee stability, recovering thigh muscle power, and preserving knee motion.