Complications Related to Hamstring Tendon Harvest

Quadriceps tendon autograft for pediatric anterior cruciate ligament reconstruction results in promising postoperative function and rates of return to sports: A systematic review

PURPOSE

To assess the performance of the quadriceps tendon (QT) autograft in pediatric anterior cruciate ligament reconstruction (ACLR).

METHODS

A systematic search of MEDLINE, PubMed, and EMBASE was conducted on March 1, 2021. Studies of all levels of evidence reporting outcomes and/or complications after QT autograft ACLR in pediatric patients (≤ 18 years old) were eligible for inclusion. Study demographics, patient demographics, reported outcomes, and complications were abstracted. Screening and data abstraction were designed in accordance with PRISMA and R-AMSTAR guidelines. Descriptive statistics were presented when applicable, with data for heterogeneous outcomes presented in narrative summary fashion.

RESULTS

A total of 14 studies examining 596 patients (46.3% female), mean age 15.4 years, were included in this systematic review. Mean postoperative Lysholm scores ranged from 94.0 to 99.5. Mean postoperative IKDC subjective scores ranged from 75.9 to 94.0. Limb symmetry index ranged from 96.8 ± 10.4 to 100.4 ± 7.6% across multiple hop tests. Return to sports (RTS) rates ranged from 88.9 to 91.7%. Eleven studies reported postoperative complications, whereby 16 patients (4.8%) experienced contralateral complications and injuries. Forty-six patients (9.4%) experienced ipsilateral complications, including ten graft failures (2.5%) and two growth disturbances (0.6%).

CONCLUSIONS

QT autograft ACLR in the pediatric population retains the potential of regaining a preinjury level of knee stability, and yields promising postoperative function and rates of RTS, yielding comparable outcomes relative to HT autograft and the reference-standard BPTB ACLR that have previously been described in the literature. Moreover, use of the QT autograft is associated with low rates of postoperative complications, including graft failure and growth disturbances in this active and high-risk patient population in observational studies to date. Therefore, clinical equipoise exists to further appraise the influence of QT autograft on postoperative outcomes compared to aforementioned autograft options in a randomized control trial fashion.

LEVEL OF EVIDENCE

IV.

Anatomical study of paratenons and fascia lata connections in the posteromedial knee region

INTRODUCTION

In the last decade, fascia research increased significantly in various aspects such as anatomical and biomechanical features related to epimuscular force transmission.

METHODS

The present anatomic study focuses on macroscopic observations of the potential gracilis and semitendinosus paratenons, as well as fascial surroundings connections in the posteromedial knee region on 17 lower-limbs dissections.

RESULTS

The gracilis and semitendinosus expansions and paratenons were observed in all specimen and further connections with the fascia lata and crural fascia were demonstrated. Contrary to the previously described expansions connected to the tendons, we observed that the expansions were the edges of the paratenon tunnel and that the paratenon structure surrounded the overall muscle. Both paratenons of gracilis and semitendinosus were connected to the crural fascia and, respectively, to the sartorius fascia (part of the fascia lata), to the semimembranosus and the fascia lata. Furthermore, numerous connections between the fascia lata and the neighboring structures in the posteromedial knee region are described.

DISCUSSION-CONCLUSION

The present study describes for the first time gracilis and semitendinosus paratenons and other surrounding fascial connections. Such macroscopic observations may represent a new basis for further characterization of the myofascial pathway of epimuscular force transmission in the knee region.

Premature hamstring graft amputation during harvesting in ACL reconstruction

Introduction

There are some possible complications during or after hamstring graft harvesting such as premature graft amputation, medial collateral ligament injury and infrapatellar branch of the saphenous nerve injury. Premature graft amputation can occur by inadequate removal of the accessory branches of the hamstring tendons, poor surgical technique and/or too sharp tendon stripper. In this study, we report a case of premature hamstring graft amputation due to degeneration caused by osteochondroma at the posteromedial aspect of the proximal tibia.

Case presentation

We reported the case of a 28-year-old Thai male who had an ACL injury was scheduled for ACL reconstruction. In this case, we had planned to use a hamstring graft for double-bundle ACL reconstruction. During the gracilis tendon harvesting, the graft was prematurely amputated by a tendon stripper at the level of the osteochondroma. The premature graft amputation was sent for pathology, which showed degenerated tissue.

Conclusion

In cases of osteochondroma at the posteromedial aspect of the proximal tibia, it is a chance of premature hamstring graft amputation. We suggest removing the osteochondroma before harvesting the tendon grafts to avoid the risk of premature graft transection.

•

The incidence of premature graft amputation is rare.

•

In this patient, premature graft amputation caused by osteochondroma at the posteromedial aspect of the proximal tibia.

•

In cases of osteochondroma at the medial proximal tibia, we suggest removing the osteochondroma before harvesting the tendon grafts.

Open Full-Thickness Quadriceps Tendon Autograft Harvest With Repair for Anterior Cruciate Ligament Reconstruction

Historically, one of the most common graft choices for anterior cruciate ligament (ACL) reconstruction in the pediatric population has been the hamstring autograft. Although pediatric ACL reconstructions with a hamstring autograft have allowed a majority of children and adolescents to return to athletics, it has been reported that anywhere between 6% and 38% of these patients will go on to experience subsequent graft rupture. The quadriceps tendon autograft is an alternative to the hamstring tendon autograft that demonstrates superior preliminary outcomes, and we currently recommend it for skeletally immature patients undergoing primary and revision ACL reconstruction. This paper aims to describe our technique for an open full-thickness quadriceps tendon harvest with repair.

Arthroscopic primary repair of the anterior cruciate ligament: what the radiologist needs to know

Recently, there has been a renewed interest in primary repair of proximal anterior cruciate ligament (ACL) tears. Magnetic resonance imaging (MRI) plays an important role in preoperative patient selection and in postoperative ligament assessment. Knowledge of the imaging factors that make patients candidates for primary ACL repair, namely proximal tear location and good tissue quality, can help radiologists provide information that is meaningful for surgical decision making. Furthermore, an understanding of the surgical techniques can prevent misinterpretation of the postoperative MRI. This article reviews preoperative MRI characterization of ACL injuries, techniques of arthroscopic primary ACL repair surgery and examples of postoperative MRI findings.

Pes Anserinus Structural Framework and Constituting Tendons Are Grossly Aberrant in Nigerian Population

We evaluated the morphological framework of the pes anserinus in both knees of ten Nigerian cadavers and we observed high degree of variability in its morphology and location. The pes anserinus inserted specifically on the superior half of the media border of the tibia, as far inferiorly as 124.44 mm to the tibial tuberosity (prolonged insertion). The insertion was also joined to the part of tibia close to the tibia tuberosity (90%) and to the fascia cruris (10%). The initial insertion point of the pes anserinus was always found at the level of the tibia tuberosity. We found out that accessory bands of sartorius, gracilis, or semitendinosus were part of the pes anserinus in 95% of all occasions studied whereas the combined occurrence of monotendinosus sartorius, gracilis, and semitendinosus tendons was found in only 5% of all occasions. The pes anserinus did not conform to the layered pattern and the tendons of sartorius, gracilis, or semitendinosus were short. The inferior prolongation of the pes anserinus connotes extended surface area of attachment to support the mechanical pull from the hamstring muscles. This information will be useful in precise location and grafting of the pes anserinus.

Minimally invasive posterior approach in the popliteal fossa for semitendinosus and gracilis tendon harvesting: an anatomic study

INTRODUCTION

Harvesting the semitendinosus (ST) and gracilis (GR) tendons at the anteromedial side of the knee may be hampered by a conjoint tendon insertion on the tibial metaphysis and an accessory bundle between the ST and the medial gastrocnemius. Locating and sparing the terminal branches of the saphenous nerve are difficult on an anteromedial approach. The principal objective of the present anatomic study was to assess the feasibility of ST and GR harvesting from a minimally invasive posterior approach in the popliteal fossa. The secondary objective was to analyze the risk of saphenous nerve branch lesion during harvesting.

METHOD

Ten cadaver knees, free of scarring, were used. The whole body was positioned supine. The tendons were located in the popliteal fossa with the knee in 30° flexion. A mini-incision was performed in the fossa. The ST and GR tendons were located, and retrograde followed by anterograde stripping was performed. Tendon lengths and diameters were measured. The knees were then dissected to check for saphenous nerve branch lesions (anterior, infrapatellar and posterior branches).

RESULTS

The GR and ST tendons were respectively located at 14.4 and 24 mm from the medial edge of the knee. In 90% of cases, there was an accessory ST bundle toward the medial gastrocnemius muscle, 26 mm below the posterior edge. Tendons could be harvested without deviation of the stripper. Knee dissection did not find any saphenous nerve branches, these being protected by the sartorius fascia.

DISCUSSION

Posterior ST and GR tendon harvesting in the popliteal fossa is reliable and reproducible. It allows easy sectioning of the accessory ST bundle, without deviation during retrograde stripping. Unlike anterior harvesting, which leads to a rate of saphenous branch lesion of 50-78%, posterior harvesting protects the nerve branches by keeping away from the sartorius.

LEVEL OF EVIDENCE

Level 4.

Horizontal posterior hamstring harvest

Harvesting of the gracilis and semi-tendinosus (ST) hamstring tendons is usually performed by anteromedial approach. Harvesting by a horizontal posterior approach is possible. Based on a series of 90 patients, this technical note describes the perioperative difficulties and the characteristics of the harvested tendon(s) as well as any complications. Only one unsuccessful harvest was reported. Posterior harvesting of the gracilis and ST hamstring tendons is a reliable, reproducible surgical technique with a low rate of complications.

A prospective randomized comparison of irradiated and non-irradiated hamstring tendon allograft for ACL reconstruction

PURPOSE

To analyze the outcome of arthroscopic anterior cruciate ligament reconstruction with irradiated versus non-irradiated hamstring tendon allograft.

METHODS

All hamstring tendon allografts were obtained from a single certified tissue bank, and the irradiated allografts were sterilized with 2.5 Mrad of irradiation prior to distribution. A total of 78 patients who met the inclusion and exclusion criteria of the study were prospectively randomized consecutively into two groups (Non-ir-Allo vs. Ir-Allo). All the operations were done by the same senior surgeon. Before surgery and at follow-up, patients were evaluated by the same observer according to clinical evaluations including the Lachman test, ADT, pivot shift test, varus/valgus stress test, the instrumented KT-2000 arthrometer testing, vertical jump test, one-leg hop test, ROM of knee, Cincinnati knee score, IKDC Subjective Knee Form, Tegner activity score, modified Lysholm knee scoring scale, and the standard knee ligament evaluation form of the IKDC.

RESULTS

Of these patients, 69 (Non-ir-Allo 38, Ir-Allo 31) were available for full evaluation. When compared the Ir-Allo group with Non-ir-Allo group at the final follow-up by Lachman test, ADT, pivot shift test, and KT-2000 arthrometer testing, statistically significant differences were found (P < 0.05). Most importantly, 84% of patients in the Non-ir-Auto group and just only 32% in the Ir-Allo group had a side-to-side difference of less than 3 mm according to KT-2000. The anterior and rotational stability decreased significantly in the Ir-Allo group. According to the overall IKDC, functional, subjective evaluations, and activity level testing, no statistically significant differences were found between the two groups (n.s.). As to the osteoarthritis (OA) rate, for the Non-ir-Allo group, there was no significant difference (n.s.) in development of OA between the operated knee and contralateral knee at the final follow-up. While for the Ir-Allo group, significant difference (P < 0.05) was found in development of OA between the operated knee and contralateral knee. There was statistical difference (P < 0.05) between the Non-ir-Allo and Ir-Allo groups when comparing the development of OA of the operated knees at the final follow-up.

CONCLUSION

There was a significant difference in knee stability between the two groups (in favor of Non-ir-Allo), but no differences in functional scores should be pointed out clearly.

LEVEL OF EVIDENCE

I.