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

Tubularization of Bone-Tendon-Bone Grafts: Effects on Mechanical Strength and Postoperative Knee Stability in Anterior Cruciate Ligament Reconstruction

Background and Objectives: The study addresses a significant limitation in applying bone-patellar tendon-bone (BTB) grafts in anterior cruciate ligament (ACL) surgery. By exploring the tubularization of grafts, the study extends the understanding of this surgical technique. The dual approach of the study-focusing on biomechanical properties using an animal model and postoperative outcomes in humans-offers a comprehensive perspective. Materials and Methods: The experimental cohort encompassed ten pairs of fresh porcine bone-tendon-bone grafts. One graft in each pair underwent modification through sutures that transformed the flat graft into a cylindrical structure. Testing determined the force required for the modified graft to rupture mechanically, expressed as N/mm2, compared to conventionally prepared bone-tendon-bone grafts. The second phase of the research involved a prospective randomized clinical trial comprising 120 patients undergoing operative ACL reconstruction. For half the cases, grafts were tubularized using a random selection process. Clinical evaluations preoperatively and 12 months postoperatively employed the Tegner, Lysholm, and IKDC scoring scales for knee assessment. Results: Experiments showed that ligaments made using the tubularized surgical technique have statistically significantly higher values of measured force and higher maximum elongation values than ligaments made using the classical method. The clinical study concluded that there was no significant difference between the two groups of patients in the average score on the Tegner, Lysholm, and IKDC scales before and after surgery. Conclusions: The study results showed that suturing the graft does not negatively affect its biomechanical properties, and tubularization significantly increases the values of force required to cause rupture and the values of maximum elongation during rupture. Given the possibility of the one-year follow-up period being insufficient, future investigations should extend this period to acquire objective functional insights post-surgery.

Traumatic Isolated Avulsion Rupture of the Distal Semitendinosus Tendon in a Non-athlete

Isolated distal semitendinosus (ST) injuries remain an uncommon hamstring injury, with avulsion ruptures reported even less frequently. These injuries occur due to eccentric overloading seen in sprinting or jumping injuries. Treatment ranges from conservative management to surgical tenotomy or reattachment to the tibial bone. We present a unique case of a 30-year-old male with an isolated avulsion rupture of the distal ST tendon after a fall. To our knowledge, this is the first case reported in the literature of an isolated distal ST injury in a non-athlete due to trauma.

Outside-in technique versus inside-out semitendinosus graft harvest technique in ACLR: a randomised control trial

Background

Paraesthesia after hamstring graft harvest is a ubiquitous complication in the early post-operative period, and its correlation with vertical versus horizontal skin incision are well documented. The purpose of the study is to evaluate the incidence and extent/area of sensory loss of saphenous nerve branches occurring with the outside-in (OI) versus inside-out technique (IO) of semitendinosus graft harvest from the sartorius fascia and to determine a better method of graft harvest.

Methods

Sixty patients who underwent isolated semitendinosus graft harvest during anterior cruciate ligament reconstruction (ACLR) between 2016 and 2017. Patients were randomised into two groups depending on the graft harvest technique: 30 in the OI group and 30 in the IO group. The area of sensory loss was mapped on the patients’ skin using tactile feedback from the patients at each follow-up (10 days, 1 month, 3 months, 6 months and 1 year). Then, the area of sensory changes for the infrapatellar branch (IPBSN) and sartorial branch (SBSN) of the saphenous nerve, incision length, graft harvest duration, and graft length were analysed statistically between the groups.

Results

In groups 1 and 2, 18/30 (60%) and 19/30 (63%) of patients, respectively, developed sensory changes, with no significant difference between the groups (p = 0.79). Isolated SBSN and IPBSN paraesthesia occurred in 2/60 (3%) and 19/60 (32%), respectively. Combined SBSN and IPBSN paraesthesia was present in 16/60 (27%) of patients. There was no significant difference in the area of the sensory deficit between OI and IO groups on the 10th post-operative day or at 1-month, 3-month or 1-year follow-up (p = 0.723, p = 0.308, p = 0.478, p = 0.128, respectively). However, at 6-month follow-up, the area of paraesthesia was significantly higher in the IO group (p = 0.009). The length of incision and duration of graft harvest was higher in the OI group than in the IO group (p = 0.002 and p = 0.007, respectively), and the total length of the graft was greater in the IO group (p = 0.04).

Conclusion

Incidence is equally distributed, area of iatrogenic saphenous nerve injury gradually decreases, and recovery is seen in the majority of the patients in both graft harvest techniques. IO graft harvesting technique is better in terms of graft harvest time and cosmetics and yields longer graft; however, area of paraesthesia, though not significant, was two-fold higher than the OI technique at 1-year follow-up.

Clinical relevance

IO graft harvest technique would enable the surgeon to adopt quicker graft harvest, smaller surgical scar and lengthier graft than the OI technique.

Level of evidence

Therapeutic randomised controlled prospective study, Level II.

Posterior hamstring harvest improves aesthetic satisfaction and decreases sensory complications as compared to the classic anterior approach in anterior cruciate ligament reconstruction surgery

Purpose

The use of the posterior approach for harvesting hamstring grafts has recently become popular thanks to new all-inside techniques and retrograde drills. This study aims to compare the classic anterior approach with the posterior approach in the popliteal fossa.

Methods

Retrospective comparative study of 100 consecutive cases of primary ligamentoplasty performed using ipsilateral semitendinosus autograft with at least one year of follow-up. 50 patients with anterior approach (group A) and 50 patients with posterior approach (P). Ratio men/women: 9/1. Mean age: 32 ± 13 years. Mean operative time: 64.88 ± 12.28 min.

Study variables

Graft harvest time; intraoperative complications (semitendinous [ST] tendon cut); postoperative neurological complications (allodynia, paresthesia, pain) or hematoma in the donor area; atrophy of the operated thigh compared to the contralateral thigh, postoperative VAS score, aesthetic satisfaction and overall satisfaction.

Results

Graft harvest time of 9.5 min in group A versus 5.25 min in group P (p < 0.05). Sensory complications: 16% in group A versus 2% in group P (p < 0.05). Regarding the patient’s evaluation of the aesthetic result of the surgery, 80% in group A and 92% in group P were very satisfied, 16% in group A and 8% in group P were satisfied and 4% in group A and no patients in group P not very satisfied (p < 0.05). No significant differences were found in terms of total operative time, postoperative joint movement, atrophy of the operated thigh, postoperative VAS, or overall patient satisfaction.

Conclusions

The posterior approach to harvesting the ipsilateral hamstring graft obtained better results than the anterior approach in terms of aesthetic satisfaction of the patient, lower rate of neurological complications (allodynia, paresthesias and hypoesthesia in the anterior region of the knee and leg) and shorter hamstring harvest time.

Level of evidence

IV.

Hamstring autograft utilization in reconstructing anterior cruciate ligament: Review of harvesting techniques, graft preparation, and different fixation methods

Rupture of the anterior cruciate ligament (ACL) is a common orthopedic injury. Various graft options are available for the reconstruction of ruptured ACL. Using the hamstring muscle as an autograft was first described in 1934, and it remains a commonly harvested graft for ACL reconstruction. Hamstring autografts can be harvested using the traditional anteromedial approach or the newer posteromedial technique. An isolated semitendinosus tendon can be used or combined with the gracilis tendon. There are numerous methods for graft fixation, such as intra-tunnel or extra-tunnel fixation. This comprehensive review discusses the different hamstring muscle harvesting techniques and graft preparation options and fixation methods. It provides a comprehensive overview for choosing the optimal surgical technique when treating patients.

Combined Assessments of Patellar Tendon and Hamstring Tendon Parameters on Preoperative Magnetic Resonance Imaging Can Improve Predictability of Hamstring Tendon Autograft Diameter in the Setting of Anterior Cruciate Ligament Reconstruction

Purpose

To evaluate whether preoperative magnetic resonance imaging (MRI) measurements of multiple tendon autograft sources could be used to improve estimates of intraoperative hamstring tendon autograft (HTA) diameter.

Methods

Patients who underwent anterior cruciate ligament reconstruction with HTA at our institution were identified through electronic health records. Preoperative MRI tendon measurements of the patellar tendon (PT) length, PT width, PT thickness, quadriceps tendon thickness, semitendinosus tendon (ST) cross-sectional area (CSA), and gracilis tendon (GT) CSA were conducted by 2 independent evaluators using digital imaging measurement tools.

Results

A total of 53 patients met the inclusion criteria, with a mean HTA diameter of 7.98 ± 0.7 mm. Height greater than 1.63 m, weight greater than 63.4 kg, PT length greater than 4.2 cm, PT thickness greater than 0.33 cm, ST CSA greater than 10.8 mm², and GT CSA greater than 6.3 mm² were associated with an HTA of 8 mm or greater (P < .005). Female sex was associated with an HTA of less than 8 mm (P < .05). PT length, PT thickness, and GT CSA were the strongest predictors of an HTA of 8 mm or greater and were combined into an additive logistic regression model: Score = -23.24 + (1.68 × PT length) + (20.104 × PT thickness) + (1.48 × GT CSA). If the score was greater than 0.237, the HTA graft diameter was predicted to be 8 mm or greater with 83% specificity, 91% sensitivity, and 87% accuracy.

Conclusions

By combining PT length and PT thickness measurements with GT CSA measurements in a logit function model, we were able to show improved overall specificity, sensitivity, and accuracy of estimated HTA diameters in our data set when compared with assessments of anthropometric, ST CSA, GT CSA, or combined ST-GT CSA measurements in isolation.

Clinical Relevance

Preoperative MRI measurements may be used to screen whether a patient is likely to have an 8-mm graft in the setting of anterior cruciate ligament reconstruction with HTA and thus may help guide graft choice.

Preoperative MRI Assessment of Hamstring Tendons to Predict the Quadruple Hamstring Graft Diameter in Anterior Cruciate Ligament Reconstruction

Introduction

The cross-sectional area (CSA) and length of an individual's hamstring tendons are both variable, making it challenging for the operating surgeon to generate an ideal size graft during arthroscopic anterior cruciate ligament (ACL) reconstruction surgery. If we can predict the hamstring graft diameter using MRI (a routine radiological investigation used to diagnose knee pathology), this information, if obtained before surgery rather than after the harvesting of the hamstring tendons, may influence the graft choice and allow us to successfully perform ACL reconstruction with sufficient graft diameter.

Aims

The aims of this study were to determine the reliability and accuracy of 3T MRI in predicting quadruple hamstring graft diameter for ACL reconstruction, to determine the statistical correlation between the CSA of hamstring tendons on MRI and intraoperative quadruple hamstring graft diameter, and to find out the minimum CSA of hamstring tendons (ST+GR) required for an 8 mm quadruple hamstring graft diameter.

Methods

This prospective diagnostic study included 50 patients diagnosed with complete ACL rupture. On MRI, we assessed the CSA of the semitendinosus and gracilis tendons at two levels: one at the joint line and the other at the level where the anteroposterior (AP) diameter of the medial femoral condyle is longest. The quadruple ST+GR graft was passed through 0.5 mm increments of holes in the block (Biotek (Winooski, Vermont) or Smith & Nephew, London, United Kingdom) intraoperatively, and the diameter of the hole that permitted smooth passage of the whole graft was taken as the quadruple graft diameter. The cutoff CSA required for a graft of sufficient size was calculated using simple logistic regression analysis. The correlation between CSA measurements on MRI and intraoperative quadruple hamstring graft diameter was determined using Pearson's rank correlation coefficient.

Results

The mean ST+GR CSA on MRI was 18.9 mm², the minimum CSA was 14.45 mm², and the maximum CSA was 23.8 mm². Pearson's correlation between the intraoperative quadruple hamstring graft diameter (mm) and ST+GR CSA on MRI was 0.838. The minimum ST+GR CSA required for an 8 mm quadruple hamstring graft diameter is 17.5 mm².

Conclusion

A strong statistical correlation between ST+GR CSA on MRI and intraoperative quadruple hamstring graft diameter was found (Pearson's correlation = 0.838, p-value = 0.000). Thus, MRI is a reliable radiological investigation that can be used to predict the quadruple hamstring graft diameter. This method can help orthopedic surgeons successfully perform ACL reconstruction surgery without any graft complications.  

Finishing stationary cycling too early after anterior cruciate ligament reconstruction is likely to lead to higher failure

Background

Anterior cruciate ligament injury arises when the knee anterior ligament fibers are stretched, partially torn, or completely torn. Operated patients either end up re-injuring their reconstructed anterior cruciate ligament or majority develop early osteoarthritis regardless of the remarkable improvements of surgical techniques and the widely available rehabilitation best practices. New mechanism theories of non-contact anterior cruciate ligament injury and delayed onset muscle soreness could provide a novel perspective how to respond to this clinical challenge.

Main body

A tri-phasic injury model is proposed for these non-contact injuries. Mechano-energetic microdamage of the proprioceptive sensory nerve terminals is suggested to be the first-phase injury that is followed by a harsher tissue damage in the second phase. The longitudinal dimension is the third phase and that is the equivalent of the repeated bout effect of delayed onset muscle soreness. Current paper puts this longitudinal injury phase into perspective as the phase when the long-term memory consolidation and reconsolidation of this learning related neuronal injury evolves and the phase when the extent of the neuronal regeneration is determined. Reinstating the mitochondrial energy supply and ‘breathing capacity’ of the injured proprioceptive sensory neurons during this period is emphasized, as avoiding fatigue, overuse, overload and re-injury.

Conclusions

Extended use, minimum up to a year or even longer, of a current rehabilitation technique, namely moderate intensity low resistance stationary cycling, is recommended preferably at the end of the day. This exercise therapeutic strategy should be a supplementation to the currently used rehabilitation best practices as a knee anti-aging maintenance effort.

Snapping Hamstring Tendons Case Report: Tenotomy and Tendon Transposition

CASE

A 14-year-old girl with a hypermobility syndrome presented with bilateral snapping semimembranosus (SM) and semitendinosus (ST) tendons. After failure of conservative treatment, she was treated with tenotomy of SM and later tendon transposition of her ST to her gracilis.

CONCLUSIONS

Surgical treatment of snapping hamstring tendons has historically consisted of the release of the tendon insertions (tenotomy) or tendon harvest. This new surgical technique describes an alternative technique for definitive management with tenotomy and tendon transposition where the snapping ST is transposed to the gracilis tendon to maintain hamstring muscle length, strength, and function.

Iatrogenic common peroneal nerve injury during harvesting of semitendinosus tendon for anterior cruciate ligament reconstruction

We present a case of iatrogenic injury to the common peroneal nerve (CPN) occurring due to harvesting of a hamstring graft, using a posterior mini-incision technique. A twitch of the foot was noted on retraction of the tendon stripper. After clinically diagnosing a CPN palsy proximal to the knee, the patient was referred to a neurosurgeon within 24 hours. An electromyography (EMG) was not obtained since it cannot accurately differentiate between partial and complete nerve injury in the first week after injury. Because the nerve might have been transacted by the tendon stripper, surgical exploration within 72 hours after injury was indicated. An intraneural haematoma was found and neurolysis was performed to decompress the nerve. Functioning of the anterior cruciate ligament was satisfactory during follow-up. Complete return of motor function of the CPN was observed at 1-year follow-up, with some remaining hypoaesthesia.

Assessment of thickness of in vivo autograft tendons around the knee and its correlation with anthropometric data, thickness of patella and anterior cruciate ligament tibial foot print diameter

Inadequate diameters of the autograft tendons are known to be a major cause of graft failure in ligament reconstruction. The purpose of the study was to measure the in-vivo thickness of the available autograft options around the knee and to seek a correlation between the thickness of the tendons and the anthropometric data, patellar thickness and anterior cruciate ligament (ACL) footprint sagittal diameter. Magnetic resonance imaging of 104 consecutive patients with suspected knee injuries were utilized for measurement of the in vivo thickness of pes anserinus tendon (diameter and cross-sectional area [CSA]), patellar tendon (PT) and quadriceps tendon (QT). Pearson’s coefficient was used to find out the relationship between the tendon thickness and anthropometric data, thickness of patella and ACL tibial foot print sagittal diameter. The mean diameters and CSA of the semitendinosus tendon (ST) and gracilis tendon (GT) were 3.77±0.49 mm, 11.62±1.62 mm² and 2.87±0.27 mm, 6.64±1.18 mm² respectively. QT and PT thicknesses were 7.36±0.87 mm and 4.50±0.62 mm respectively. Height and the patellar thickness were seen to have moderate correlation with ST and PT thickness. Weak correlation was seen between the other anthropometric variables and tendon thickness. Magnetic resonance imaging (MRI) assessment of tendon sizes is a reliable method with good inter and intra-rater agreement. Assessment of these anatomical structures with help of MRI would be helpful in preoperative planning and can help in identifying those patients at risk of having smaller tendons.

A modified oblique incision in hamstring tendon graft harvesting during ACL reconstruction

BACKGROUND

During anterior cruciate ligament (ACL) reconstruction, different methods of harvesting hamstring tendon may lead to different degrees of injury to the inferior patellar branch of the saphenous nerve (IPBSN). Most of recent studies in the literature suggest that the classic oblique incision (COI) can reduce the incidence of IPBSN injury. We proposed a modified oblique incision (MOI) and compared it with the COI in terms of the resulting levels of injury and sensory loss and the clinical outcome.

METHODS

Patients with ACL injury admitted to our hospital from April 2015 to July 2019 were randomly selected and included in our study. Thirty patients underwent the COI to harvest hamstring tendons, and the other 32 patients underwent the MOI. The pin prick test was performed to detect the sensation loss at 2 weeks, 6 months, and 1 year after the operation. Digital photos of the region of hypoesthesia area were taken, and then, a computer software (Adobe Photoshop CS6, 13.0.1) was used to calculate the area of the hypoesthesia. The length of the incision and knee joint functional score were also recorded.

RESULTS

At the final follow-up, the incidence of IPBSN injury in COI and MOI were 33.3% and 9.4%, and the areas of paresthesia were 26.4±2.4 cm² and 9.8±3.4 cm² respectively. There was no significant difference in the incision length or knee functional score between the two groups.

CONCLUSION

The MOI can significantly reduce the risk of injury to the IPBSN, reduce the area of hypoesthesia, and lead to high subjective satisfaction. Therefore, compared with the COI, the MOI is a better method of harvesting hamstring tendons in ACL reconstruction.

Influence of hamstring autograft diameter on graft failure rate in Chinese population after anterior cruciate ligament reconstruction

Background

There has been limited literature regarding the influence of hamstring autograft diameter on the outcome of anterior cruciate ligament (ACL) reconstruction in Asian population. This study was undertaken to investigate the failure rate after ACL reconstruction among Chinese patients treated with hamstring tendon autografts of different diameters. Our hypothesis was that an increase in hamstring tendon autograft diameter would reduce the risk of graft failure.

Methods

A retrospective review of 394 consecutive patients who underwent ACL reconstruction using quadrupled semitendinous and gracillis autografts from 2009 to 2018 at our centre was performed. Logistic regression analysis was used to determine the relationship between graft failure rate and predictor variables, including hamstring graft diameter, gender and age.

Results

Hamstring graft diameter of 8.0 mm or more was found to be associated with significant reduction of risk in graft failure rate (P = 0.001, Relative Risk 0.19). No significant association was found between graft failure rate and gender or age.

Conclusion

Hamstring graft diameter 8.0 mm or greater is associated with decreased graft failure rate and revision rate in our local Chinese population.

Lower donor-site morbidity using QT autografts for ACL reconstruction

PURPOSE

Comparing scar cosmesis and regional hypoesthesia at the incision site between quadriceps tendon (QT), bone-patellar tendon-bone (BPTB), and hamstring tendon (HT) for anterior cruciate ligament (ACL) reconstruction.

METHODS

Ninety patients undergoing ACL reconstruction with QT, HT or BPTB were evaluated at 1-year post-op. Scar cosmesis was assessed using the patient and observer scar assessment scale (POSAS) and length of the incision. Sensory outcome was analyzed by calculating the area of hypoesthesia around the scar. The classical ACL reconstruction functional follow-up was measured using the Lysholm score and KOOS.

RESULTS

Concerning QT versus BPTB group, QT patients have a significantly lower mean POSAS (24.8 ± 6.3 vs. 39.6 ± 5.8; p < 0.0001), shorter mean incision (2.8 ± 0.4 cm vs. 6.4 ± 1.3 cm; p < 0.0001), lower extent of hypoesthesia (8.7 ± 5.1 cm² vs. 88.2 ± 57 cm²; p < 0.0001), and better Lysholm score (90.1 ± 10.1 vs. 82.6 ± 13.5; n.s.). No significant difference was seen in KOOS (90.7 ± 7.2 vs. 88.4 ± 7.0; n.s.). Concerning QT versus HT group, no significant difference was found regarding mean POSAS score (24.8 ± 6.3 vs. 31.8 ± 6.2; n.s.), mean length of the incision (2.8 ± 0.4 cm vs. 2.5 ± 0.6 cm; n.s.), KOOS (90.7 ± 7.2 vs. 89.8 ± 8.2; n.s.) and mean Lysholm score (90.1 ± 10.1 vs. 87.8 ± 0.6; n.s.). The mean measured area of hypoesthesia was significantly higher in the HT group (70.3 ± 77.1 cm² vs. 8.7 ± 5.1 cm²; p < 0.0001).

CONCLUSION

Quadriceps tendon harvesting technique has the safest incision by causing less sensory loss compared to BPTB and HT. It also has the advantage of a short incision with more cosmetic scar compared to BPTB, with no difference compared to HT. However, no significant difference in terms of functional outcome was shown between the three autografts. These findings provide surgeons evidence about their clinical practice and help with graft choice decisions.

LEVEL OF EVIDENCE

III.

Gracilis tendon harvest may lead to both incisional and non-incisional saphenous nerve injuries

PURPOSE

The purpose of this study was to map saphenous nerve injuries after gracilis tendon harvest, with the aim of contributing knowledge that makes it possible to prevent these injuries.

METHODS

Twenty-two cadaver limbs were used. Three were dissected to examine fascial structures between the saphenous nerve and the gracilis tendon. In 19 limbs, the gracilis tendon was harvested according to standard operative routine. The saphenous nerve was subsequently exposed by dissection and injuries were recorded.

RESULTS

A well-defined sub-sartorial fascial layer separated the saphenous nerve from the gracilis tendon. Incisional injuries involving either a medial cutaneous crural branch or the infrapatellar branch were found in 14 of the 19 cases. Non-incisional injuries affecting the sartorial branch of the saphenous nerve (to conform to most surgical literature, we use the term 'sartorial branch' to denote the continuation of the saphenous nerve after departure of the infrapatellar branch) were found in six cases located 5-8 cm proximal and posterior to the gracilis tendon insertion on tibia. The fascia separating the saphenous nerve from the gracilis tendon had been perforated in relation to all non-incisional injuries.

CONCLUSIONS

Small subcutaneous branches of the saphenous nerve are at risk of injury from the incision, while the sartorial branch is at risk outside the incision area. Descriptions of the location of non-incisional injuries have not been published before and are of clinical relevance, as they can contribute to the prevention of saphenous nerve injuries during gracilis tendon harvest.

The rule of twos: Technical note on consistent anatomical landmarks for hamstring graft harvesting

We describe a novel hamstring harvesting technique using the "Rule of Twos" as an aide-memoire to dissect the conjoint tendon in an Asian population undergoing anterior cruciate ligament reconstruction. In a prospective study performed on 17 patients to validate this technique, a 2cm incision is placed 2cm distal and medial to the tip of the tibial tubercle. The surgeon then measured the following variables and calculated their means: 1) Distance from the tip of the tibial tuberosity to the proximal edge of the conjoint tendon (19.4 ± 1.4mm), 2) Width of the conjoint tendon insertion (18.8 ± 1.0mm), 3) Conjoint tendon length (20.1 ± 1.0mm).

A Comparison between Oblique and Vertical Incisions on the Hamstring Tendon Harvesting in Anterior Cruciate Ligament Reconstruction and Infrapatellar Branch Injury of the Saphenous Nerve

Objective  The present study aimed to compare the oblique and vertical incisions in hamstring tendon harvesting in anterior cruciate ligament (ACL) reconstruction and in infrapatellar branch injury of the saphenous nerve. Methods  The present study was conducted at a tertiary referral center for 12 months. Patients with an indication of reconstruction of ACL tear were included in the study, who were then randomized into two groups (vertical [VG] and oblique [OG] groups). After excluding a few cases, 92 patients were eligible for further analysis (VG: n= 44; OG: n =  48). They were followed-up for 9 months after the surgery, and loss of sensation over the knee and over the proximal aspect of the operated leg was recorded. Results  The mean lengths of the incisions were 27 mm and 38 mm for the OG and VG groups, respectively. The total rate of hypoesthesia was 40% (27 patients). A total of 12 (25%) and 25 patients (56.8%) on the OG and VG groups, respectively, reported hypoesthesia symptoms. The presence of hypoesthesia in patients in the VG group was two times higher than in the OG group. No statistical correlation was observed between the nerve injury and age, gender, education, and delay from injury to reconstruction. Conclusion  Oblique incision, which showed lower risk of nerve damage, might be more recommended for graft harvesting. Patients who underwent reconstruction of the ACL in the OG group had a lower incidence of peri-incisional hypoesthesia when compared to those in the VG group.

The 'sentinel' vessel: an anatomical landmark to identify the pes anserinus during hamstrings harvest for ACL reconstruction

Hamstrings identification and subsequent graft harvest can be made difficult by body habitus and variability in tendon anatomy. We describe a 'sentinel' blood vessel near the insertions of gracilis and semitendinosus to facilitate identification. A prospective study of 100 patients (100 knees) undergoing primary arthroscopic ACL reconstruction (via the anterior approach) with hamstrings graft was conducted. We searched for a 'sentinel' vessel and studied its position, orientation and perpendicular distance from the pes tendons. The 'sentinel' vessel was present in 98/100 knees. It passed from the superficial fascia to the periosteum at the pes insertion at a mean perpendicular distance of 8 mm from the upper border of the pes tendons. The 'sentinel' vessel was a consistent anatomical finding and served as a reliable guide in determining the pes insertion. Identifying this anatomical landmark allowed a small skin incision with limited wound dissection minimising risk of injury to the infra-patellar branch of the saphenous nerve.

Preoperative sonographic measurement can accurately predict quadrupled hamstring tendon graft diameter for ACL reconstruction

PURPOSE

Previous studies reported sonography was inferior to MRI to predict hamstring tendon graft diameter for ACL reconstruction. This study aimed to investigate the correlation between intraoperative hamstring tendon graft diameter and its preoperative measurement using different sonographic scanning protocol from previous studies.

METHODS

Two cadaveric knees were utilized for validation. Sonographically guided gracilis tendon (G) and semitendinosus tendon (ST) injections were performed at myotendinous junction of sartorius using colored latex and then dissection was performed. In the clinical studies, 28 patients underwent primary ACL reconstruction were enrolled. Cross-sectional area (CSA) of G and ST were measured at myotendinous junction of Sartorius. The diameter of doubled G (2G), doubled ST (2ST) and quadrupled ST + G (4STG) were intraoperatively measured using graft sizing devices with 0.5-mm increments.

RESULTS

Cadaveric dissection showed the presence of latex on the surface of G and ST at myotendinous junction of Sartorius in all specimens. In the clinical studies, CSA of G, ST, and ST + G significantly correlated with diameter of 2G (r = 0.464, p = 0.039), 2ST (r = 0.712, p < 0.001), and 4STG (r = 0.792, p < 0.001), respectively. As a result of the simple linear regression analysis, 4STG diameter could be predicted by the following formula: 4.345 + 0.210 × CSA. The differences between calculated diameter by this formula and intraoperative 4STG diameter were within ± 0.5 mm in 89.3% (25/28) of subjects.

CONCLUSIONS

The diameter of 2ST and 4STG can be reliably predicted based on sonographic CSA measurement preoperatively. Sonography is a cost-effective alternate to repeat MRI to predict hamstring graft diameter preoperatively.

LEVEL OF EVIDENCE

Diagnostic study; Level II.

No difference in sensory outcome between vertical and oblique incisions for hamstring graft harvest during ACL reconstruction

PURPOSE

To compare the incidence, extent of sensory loss, its clinical effect and natural course caused by sensory nerve injury, during two different skin incisions used for autogenous hamstring graft harvest during ACL reconstruction.

METHODS

This randomized prospective study was carried out on 84 patients, divided into two groups, all of them underwent arthroscopic ACL reconstruction using hamstring tendon graft with two incisions; a vertical incision used in 43 patients, and an oblique incision in 41 patients. The location and area of sensory loss were evaluated during follow-up as well as the degree of improvement and patient satisfaction.

RESULTS

The average age in this study was 29.8 ± 7.2 in the vertical group and 29.9 ± 6.3 in the oblique group. Both semitendinosus and gracilles were harvested in 34 patients, semitendinosus in 49 patients and gracilles in one patient. In the vertical group, a higher incidence of sensory loss was recorded with 21 patients (51.2%), relative to the oblique group with 18 patients (41.9%). However, there was no statistically significant difference (p = n.s). Most of the sensory loss affected the distribution of the IPBSN (infrapatellar branch of saphenous nerve) in 27 patients (69.2%) in both groups, and to a lesser extent in the lower medial area [distribution of SBSN (sartorial branch of saphenous nerve)] in 12 patients (30.8%).

CONCLUSION

This study clearly revealed the high incidence of nerve injury particularly the IPBSN during hamstring graft harvest, but did not prove a difference between oblique and vertical incisions, with regard to postoperative sensory loss. It was clear that harvesting the semitendinosus alone is not a factor that can diminish nerve injury.

LEVEL OF EVIDENCE

II.

A proposal for a new classification of pes anserinus morphology

PURPOSE

The pes anserinus (PA) is characterized by high morphological diversity. As the semitendinosus and gracilis muscle tendons are routinely harvested for the reconstruction of other tendons, especially the anterior cruciate ligament (ACL), it is of clinical importance. The presence of accessory bands within PA tendons can handicap the harvesting process. Therefore, the purpose of the study was to suggest a new morphological classification of the PA morphology.

METHODS

Classical anatomical dissection was performed on 102 lower limbs (56 right, 46 left) fixed in 10% formalin solution. The morphology and insertion of the PA (including accessory bands) were assessed, and morphometric measurements were taken.

RESULTS

In all cases, the PA was present and composed of the sartorius, gracilis and semitendinosus tendons. Six types of PA were distinguished based on the presence of accessory bands. The most common composed of monotendinous sartorius, gracilis and semitendinosus-54 limbs (52.9%). Additionally, three types of insertion were noted (short, band-shaped and fan-shaped). The mean length between the insertion and the origin of the accessory bands to the fascia of the gastrocnemius muscle was 63.5 mm.

CONCLUSION

The morphology of the PA was highly variable. The gracilis and semitendinosus tendons often had accessory bands that would complicate the harvesting process. The planning of surgical procedures may be improved by our proposed classification.

Endoscopic Harvest of Autogenous Gracilis and Semitendinosus Tendons

The hamstring autograft is one of the most popular grafts for anterior cruciate ligament (ACL) reconstruction. Although many techniques for arthroscopic ACL reconstruction using hamstring autografts have been invented, hamstring harvest techniques have not been focused. Hamstrings are harvested using an open technique that requires a 2- to 5-cm skin incision. In this Technical Note, we describe an endoscopic harvest technique of autogenous gracilis and semitendinosus tendon. This technique needs only a 1- to 1.5-cm skin incision and provides surgeons a sufficient view to safely harvest the hamstrings.

Bone-patellar tendon-bone autograft could be recommended as a superior graft to hamstring autograft for ACL reconstruction in patients with generalized joint laxity: 2- and 5-year follow-up study

PURPOSE

The present study aimed to compare 2- and 5-year outcomes of ACL reconstruction between patients with and without generalized joint laxity and to perform comparative evaluation between two types of grafts used for ACL reconstruction in patients with generalized joint laxity.

METHODS

Two hundred and thirty-seven patients who underwent ACL reconstruction from 2001 to 2008 were included. Patients were classified into two groups according to the presence or the absence of generalized joint laxity, and further subdivided into two subgroups based on the type of graft used: bone-patellar tendon-bone (BPTB) or hamstring. Generalized joint laxity was assessed with the Beighton and Horan criteria using a point scoring system. Stability reflected by the Lachman test, pivot-shift test, and anterior translation measured with KT-2000, and functional outcomes reflected by Lysholm knee score, and International Knee Documentation Committee (IKDC) subjective score were investigated. IKDC objective grade and radiographic grade were also assessed. Clinical assessments were conducted preoperatively and at 2 and 5 years after operation.

RESULTS

Two-year follow-up results showed that patients with generalized joint laxity receiving hamstring grafts had poorer outcomes than those without generalized joint laxity. Five-year follow-up results showed that patients with generalized joint laxity experienced poorer outcomes than patients without generalized joint laxity, irrespective of the type of graft. Comparison of grafts used showed that, in patients with generalized joint laxity, BPTB graft provided significantly better stability and functional outcomes than hamstring graft at both 2- and 5-year follow-ups. Comparisons between serial outcomes measured at 2 and 5 years demonstrated that stability and functional outcomes deteriorated over time in patients with generalized joint laxity.

CONCLUSIONS

Less satisfactory stability and functional outcomes were noted in patients with generalized joint laxity, compared to patients without generalized joint laxity. Comparisons of stability and functional outcomes after ACL reconstruction in patients with generalized joint laxity between two different grafts demonstrated that BPTB graft achieves better results than hamstring graft.

LEVEL OF EVIDENCE

III, a retrospective cohort study.

Additional Attachment of the Semitendinosus and Gracilis Muscles to the Crural Fascia: A Review and Case Illustration

The semitendinosus and gracilis muscles insert primarily onto the superior medial aspect of the tibia. These tendons can be harvested for anterior cruciate ligament reconstruction, and knowledge of their accessory attachments is important for the success of such harvesting procedures. Here, we present a case illustration and review of the attachment of these muscles into the crural fascia (deep fascia of the leg), which is often an underappreciated insertion site.

Association between incision technique for hamstring tendon harvest in anterior cruciate ligament reconstruction and the risk of injury to the infra-patellar branch of the saphenous nerve: a meta-analysis

PURPOSE

To determine how the incision technique for hamstring tendon (HT) harvest in anterior cruciate ligament (ACL) reconstruction affects the risk of injury to the IPBSN and clinical outcome.

METHODS

A systematic literature search of the MEDLINE/Pubmed, Cochrane Central Register of Controlled Trials (CENTRAL) and EBSCOhost electronic databases and clinicaltrials.gov for unpublished studies was performed to identify comparative studies investigating injury to the IPBSN after HT ACL reconstruction by comparing at least two different incision techniques. Data were extracted for the number of patients with evidence of any neurologic deficit corresponding to injury to the IPBSN, area of sensory deficit, the Lysholm score and patient satisfaction. The mean difference (MD) in study outcome between incision groups was assessed. The relative risk (RR) and the number needed to treat (NNT) were calculated. The Chi-square and Higgins' I² tests were applied to test heterogeneity. Data were pooled using a Mantel-Haenszel random-effects model if the statistical heterogeneity was > 50% and a fixed-effects model if the statistical heterogeneity was < 50%. The risk of bias was evaluated according to the Cochrane Database questionnaire and the quality of evidence was graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines.

RESULTS

A total of eight studies (three randomized controlled trials (RCTs) and five comparative studies) were included, of which six compared vertical and oblique incisions, one horizontal and vertical incisions, and one compared all three techniques. HT harvest was performed through a vertical incision in 329 patients, through an oblique incision in 195 patients and through a horizontal incision in 151 patients. Considering the meta-analysis of the RCTs, the performance of a vertical incision significantly increased the risk of causing IPBSN deficiency compared with both oblique and horizontal incision [RR 1.65 (CI 1.10-2.49, p = 0.02) and RR 2.45 (CI 1.73-3.47, p < 0.0001), respectively]. A significantly larger area of sensory deficit was found with vertical incisions compared with oblique ones, with an MD of 22.91 cm² (95% CI 7.73-38.08; p = 0.04). No significant differences were found between the incision techniques in relation to patient-reported outcomes. The same trend was obtained after the performing a meta-analysis of all eight included studies. The quality of evidence in this meta-analysis was determined as "low" to "moderate", mostly due to inadequate methods of randomization and high heterogeneity among the included studies.

CONCLUSION

The performance of a vertical incision to harvest HTs for ACL reconstruction significantly increased the risk of iatrogenic injury to the IPBSN compared with both oblique and horizontal incisions.

LEVEL OF EVIDENCE

Level I-III, meta-analysis of comparative studies.

Use of Posterior Hamstring Harvest During Anterior Cruciate Ligament Reconstruction in the Pediatric and Adolescent Population

Background:

Posterior hamstring harvest has been described in the adult population in a limited fashion, but no study is available describing the use of posterior hamstring harvest in an active pediatric and adolescent cohort. At times, surgeons may be faced with a challenging anterior harvest due to patient anatomic characteristics, particularly the anatomic features and size of the pes tendons. Clinicians need to have multiple harvest approaches at their disposal. Complications with hamstring harvest such as premature graft transection are more problematic in this population due to higher failure rates with allograft tissue. The posterior harvest via its more proximal location may allow for easier tendon identification, visualization of the accessory attachments, and longer preserved tendon length if transection error occurs when the anterior approach is avoided based on surgical technique, patient anatomic characteristics, and surgeon and patient preference.

Purpose:

To describe the technique of a posterior hamstring harvest in pediatric and adolescent patients and to analyze complications.

Study Design:

Case series; Level of evidence, 4.

Methods:

This study was a retrospective review of a consecutive series of pediatric and adolescent patients who underwent posterior hamstring harvest. During surgery, the patient’s leg was abducted and externally rotated to expose the posteromedial aspect of the knee. A 2-cm incision was made overlying the palpable medial hamstring at the popliteal crease. The posterior hamstring tendons were first harvested proximally with an open tendon stripper and distally with a closed stripper. Preoperative, intraoperative, and postoperative findings and complications were analyzed.

Results:

A total of 214 patients (mean ± SD age, 15.7 ± 4.1 years; range, 8.0-19.8 years) underwent posterior harvest, with a mean ± SD follow-up of 1.83 ± 1.05 years. No complications occurred in our series related to graft harvest—no graft transections, neurovascular injuries, secondary procedures for wound healing or closure, cosmetic concerns, or limitations in return to activity due to the posterior incision.

Conclusion:

The posterior hamstring harvest is a safe and reliable technique to harvest autograft tendon in pediatric and adolescent anterior cruciate ligament reconstructions. The posterior technique entailed no complications related to harvest. No patients expressed any cosmetic concerns about their incision or had limitations in return to sport due to the posterior harvest.

Hamstring autograft size importance in anterior cruciate ligament repair surgery

Graft size in hamstring autograft anterior cruciate ligament (ACL) surgery is an important factor directly related to failure. Most of the evidence in the field suggests that the size of the graft in hamstring autograft ACL reconstruction matters when the surgeon is trying to avoid failures.

The exact graft diameter needed to avoid failures is not absolutely clear and could depend on other factors, but newer studies suggest than even increases of 0.5 mm up to a graft size of 10 mm are beneficial for the patient. There is still no evidence to recommend the use of grafts > 10 mm.

Several methods – e.g. folding the graft in more strands – that are simple and reproducible have been published lately to address the problem of having an insufficient graft size when performing an ACL reconstruction. Due to the evidence presented, we think it is necessary for the surgeon to have them in his or her arsenal before performing an ACL reconstruction.

There are obviously other factors that should be considered, especially age. Therefore, a larger graft size should not be taken as the only goal in ACL reconstruction.

Cite this article: EFORT Open Rev 2018;3:93-97. DOI: 10.1302/2058-5241.3.170038

Oblique incisions in hamstring tendon harvesting reduce iatrogenic injuries to the infrapatellar branch of the saphenous nerve

PURPOSE

Iatrogenic injury to the infrapatellar branch of the saphenous nerve (IPBSN) is associated with many surgical interventions to the medial aspect of the knee, such as anterior cruciate ligament (ACL) reconstruction. Different types of surgical incisions during hamstring tendon harvesting for ACL reconstruction are related to a variable risk of IPBSN injury. This study aimed to evaluate the risk of iatrogenic IPBSN injury during hamstring tendon harvesting for ACL reconstruction with different incision techniques over the pes anserinus.

METHODS

This study was performed on 100 cadavers. Vertical, horizontal, or oblique incisions were simulated on each cadaveric limb to determine the incidence of iatrogenic IPBSN injury.

RESULTS

The vertical incision caused the IPBSN injury during hamstring tendon harvesting in 101 (64.7%), the horizontal incision in 78 (50.0%), and the oblique incision in 43 (27.6%) examined lower limbs. The calculated odds ratios (OR) for risk of injury in vertical versus horizontal and horizontal versus oblique incisions were 2.4 (95% CI 1.5-3.6) and 1.8 (95% 1.2-2.8), respectively.

CONCLUSIONS

The vertical incision technique over the pes anserinus should be avoided during hamstring tendon harvesting for ACL reconstruction. The adoption of an oblique incision, with the shortest possible length, will allow for the safest procedure possible, thus minimizing the risk of iatrogenic IPBSN injury, and improving patient outcomes and postoperative quality-of-life.

Indirect transfer of the sternal head of the pectoralis major with autogenous semitendinosus augmentation to treat scapular winging secondary to long thoracic nerve palsy

BACKGROUND

Scapular winging resulting from long thoracic nerve palsy is uncommon but debilitating, and the choice of surgical treatment is inconsistent. The autogenous semitendinosus tendon plays a key role as an interposed tendon graft, although its use in the indirect transfer of the sternal head of the pectoralis major during the treatment of scapular winging has rarely been reported.

MATERIALS AND METHODS

A retrospective review was performed during a 9-year period from the clinical data of 26 cases (28 shoulders) with indirect transfer of the sternal head of the pectoralis major with the interposition of an autogenous semitendinosus tendon graft for dynamic stabilization of the scapula. The range of active movement (forward elevation, abduction, and external rotation), American Shoulder and Elbow Surgeons score, visual analog scale score, and complications were evaluated with a mean of 47 months of clinical follow-up.

RESULTS

Patients' active shoulder movements (forward elevation, abduction, and external rotation), American Shoulder and Elbow Surgeons score, and visual analog scale score showed significant improvements (P < .01). One seroma developed and resolved with extraction. Four shoulders had adhesive capsulitis and recovered after physiotherapy. There was no recurrence of scapular winging in any patient.

CONCLUSION

Timely treatment, often surgical, is vital to the recovery of scapular winging secondary to long thoracic nerve palsy. Our results suggest that indirect transfer of the sternal head of the pectoralis major with interposition of the autogenous semitendinosus tendon can effectively treat scapular winging due to long thoracic nerve palsy with limited sequelae. Widespread use of this technique is recommended.

A Comparative Outcome Study of Hamstring Versus Tibialis Anterior and Synthetic Grafts for Deltoid to Triceps Transfers

PURPOSE

To assess elbow extension strength and complications after deltoid-triceps transfers using hamstring tendon graft compared with tibialis anterior and synthetic tendon grafts.

METHODS

A retrospective review of deltoid-triceps transfers in patients with tetraplegia performed between 1983 and 2014.

RESULTS

Seventy-five people (136 arms) had surgery performed, with the majority undergoing simultaneous bilateral surgery (n = 61; 81%). Tibialis anterior tendon grafts were used in 68 arms, synthetic grafts in 23 arms, and hamstring tendon grafts in 45 arms. The average age at surgery was 31 years. Sixty-three arms (46%) were assessed between 12 and 24 months after surgery. Seventy percent of the group (n = 54) were able to extend their elbow against gravity (grade 3 of 5 or greater) following surgery. Seventy-nine percent of those with hamstring grafts achieved grade 3 of 5 or more compared with 77% with tibialis anterior and 33% with synthetic grafts. There was a statistically significant difference in postsurgery elbow extension between the tibialis anterior group and the synthetic graft group and the hamstring and the synthetic graft group but not between the tibialis anterior and the hamstring group. Complications occurred in 19 arms (14%), the majority occurring immediately after surgery and associated with the wounds. The remaining complications were with the synthetic graft group in which dehiscence of the proximal attachment occurred in 30% of the arms.

CONCLUSIONS

Autologous tendon grafting is associated with achievement of antigravity elbow extension in a greater proportion of individuals than with prosthetic grafting.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

ACL Reconstruction Basics: Quadruple (4-Strand) Hamstring Autograft Harvest

Hamstring tendon autograft remains a popular graft choice for anterior cruciate ligament (ACL) reconstruction. Although there are a variety of autograft and allograft options available for ACL reconstruction, advantages of hamstring tendon autografts include decreased postoperative knee pain and an overall easier surgical recovery compared with bone patellar tendon bone autograft. In addition, 4-stranded (quadruple) hamstring grafts are among the strongest grafts biomechanically (at time equals zero). Although the technique of hamstring autograft harvest is relatively straightforward, it is critical to pay attention to several technical steps to avoid iatrogenic neurovascular damage as well as to avoid premature amputation of the graft while using a tendon stripper. In this Technical Note, we describe a technique of hamstring autograft harvest for ACL reconstruction for a quadruple (4-strand) hamstring graft using the gracilis and semitendinosus tendons.

Should the Ipsilateral Hamstrings Be Used for Anterior Cruciate Ligament Reconstruction in the Case of Medial Collateral Ligament Insufficiency? Biomechanical Investigation Regarding Dynamic Stabilization of the Medial Compartment by the Hamstring Muscles

BACKGROUND

Semitendinosus and gracilis muscles are frequently harvested for autologous tendon grafts for cruciate ligament reconstruction. This study investigated the joint-stabilizing effects of these hamstring muscles in cases of insufficiency of the medial collateral ligament (MCL).

HYPOTHESES

First, both the semitendinosus and gracilis muscles can actively stabilize the joint against valgus moments in the MCL-deficient knee. Second, the stabilizing influence of these muscles decreases with an increasing knee flexion angle.

STUDY DESIGN

Controlled laboratory study.

METHODS

The kinematics was examined in 10 fresh-frozen human cadaveric knees using a robotic/universal force moment sensor system and an optical tracking system. The knee kinematics under 5- and 10-N·m valgus moments were determined in the different flexion angles of the (1) MCL-intact and (2) MCL-deficient knee using the following simulated muscle loads: (1) 0-N (idle) load, (2) 200-N semitendinosus (ST) load, and (3) 280-N (200/80-N) combined semitendinosus/gracilis (STGT) load.

RESULTS

Cutting the MCL increased the valgus angle under all tested conditions and angles compared with the MCL-intact knee by 4.3° to 8.1° for the 5-N·m valgus moment and 6.5° to 11.9° for the 10-N·m valgus moment ( P < .01). The applied 200-N simulated ST load reduced the valgus angle significantly at 0°, 10°, 20°, and 30° of flexion under 5- and 10-N·m valgus moments ( P < .05). At 0°, 10°, and 20° of flexion, these values were close to those for the MCL-intact joint under the respective moments (both P > .05). The combined 280-N simulated STGT load significantly reduced the valgus angle in 0°, 10°, and 20° of flexion under 5- and 10-N·m valgus moments ( P < .05) to values near those for the intact joint (5 N·m: 0°, 10°; 10 N·m: 0°, 10°, 20°; P > .05). In 60° and 90° of flexion, ST and STGT loads did not decrease the resulting valgus angle of the MCL-deficient knee without hamstring loads ( P > .05 vs deficient; P = .0001 vs intact).

CONCLUSION

In this human cadaveric study, semitendinosus and gracilis muscles successfully stabilize valgus moments applied to the MCL-insufficient knee when the knee is near extension.

CLINICAL RELEVANCE

In the valgus-unstable knee, these data suggest that the hamstring muscles should be preserved in (multi-) ligament surgery when possible.

Injury of the infrapatellar branch of the saphenous nerve due to hamstring graft harvest

PURPOSE

Sensory disturbance around the surgical incision due to injury of the infrapatellar branch of the saphenous nerve can be seen in the anterior cruciate ligament reconstruction. In this research, we aimed to compare the incidence, extent of sensory loss, its clinical effect, and natural course caused by two different skin incisions used for hamstring graft harvest.

METHODS

Vertical incision for 36 patients and oblique incision for 42 patients used for graft harvest were included in this study. Sensory loss areas were documented at 6th week, 3rd month and 6th month. Pin prick examination is used to detect the change in sensation. Digital photographs of hypaesthesia were taken and analysed by computer for area detection. The length of incision and subjective complain of sensory loss were also noted.

RESULTS

At 6th month, 77% (28/36) of the vertical incisions were associated with persistent sensory loss when compared to the oblique incision (45%, 19/42). The measured area of hypaesthesia was significantly higher in vertical incision (42.4 ± 22.3 cm²) than that in oblique incision (9.3 ± 15.3 cm²) at 6th month. The area of hypaesthesia gradually shrunk in size from distal to proximal in direction. Also, subjective cutaneous anaesthesia was higher in vertical incision (15/36, 41%) than oblique incision (6/41, 14%) at 6th month.

CONCLUSION

Oblique incision with less risk of nerve damage is better for graft harvesting. Area of hypaesthesia gradually reduces with time and even recover totally. As a possible complication, nerve injury and its benign prognosis should be explained to the patient before surgery.

The Effect of Autologous Hamstring Graft Diameter on the Likelihood for Revision of Anterior Cruciate Ligament Reconstruction

BACKGROUND

Hamstring autografts for anterior cruciate ligament (ACL) reconstruction (ACLR) have become popular in the past 2 decades; however, it is difficult to predict the diameter of the harvested tendons before surgery. Previous biomechanical studies have suggested that a smaller graft diameter leads to a lower load to failure, but clinical studies looking at various predictors for failure, including graft size, have been inconclusive.

PURPOSE

To evaluate the relationship of hamstring graft diameter to ACL revision within a large cohort of patients, while controlling for sex, age, body mass index (BMI), and femoral and tibial fixation type.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

A case-control study using patients registered in an ACLR registry was conducted. Revision was used as a marker for graft failure. A case was defined as a patient who underwent primary ACLR with a hamstring autograft that was revised during the study period (April 2006 to September 2012). Three controls, defined as patients who underwent primary ACLR with a hamstring autograft that was not revised, were matched to each of the cases according to age, sex, BMI, and femoral and tibial fixation type. Descriptive characteristics were employed, and conditional logistic regression was conducted to produce estimates of odds ratios and 95% CIs.

RESULTS

A total of 124 cases and 367 controls were identified. There were no significant differences between cases and controls in the distribution of sex (52.4% male vs 52.9% male, respectively; P = .932), median age (17.6 years [interquartile range (IQR), 15.9-20.4] vs 17.6 years [IQR, 15.9-20.4], respectively; P = .999), median BMI (23.4 kg/m(2) [IQR, 21.5-26.4] vs 23.4 kg/m(2) [IQR, 21.6-25.8], respectively; P = .954), femoral fixation (P = .459), and tibial fixation (P = .766). The mean (±SD) graft diameter was 7.9 ± 0.75 mm in the cases and 8.1 ± 0.73 mm in the controls. The likelihood of a patient needing revision ACLR in the study cohort was 0.82 times lower (95% CI, 0.68-0.98) for every 0.5-mm increase in the graft diameter from 7.0 to 9.0 mm.

CONCLUSION

In this study, within the range of 7.0 to 9.0 mm, there was a 0.82 times lower likelihood of being a revision case with every 0.5-mm incremental increase in graft diameter.

Minimally invasive semitendinosus tendon harvesting from the popliteal fossa versus conventional hamstring tendon harvesting for ACL reconstruction: A prospective, randomised controlled trial in 100 patients

BACKGROUND

This study aims to compare a technique for hamstring tendon harvesting from a postero-medial incision in the popliteal fossa with the conventional method.

METHODS

One hundred patients who underwent anterior cruciate ligament (ACL)-reconstruction were randomised to either have their tendon graft harvested from postero-medial (group 1) or via an antero-medial approach (group 2). Time for tendon harvest, length of skin incision and duration of tendon harvest were recorded as well as complications and sensory disturbances in the lower leg. Pain scores were documented on the VAS scale.

RESULTS

Time for tendon harvesting averaged one minute 23 s in group 1 versus five minutes 20 s in group 2 (p<0.01). The skin incision measured 21 mm (group 1) versus 49 mm in group 2 (p<0.01). The length of the harvested tendon averaged 272 mm (group 1) and 292 mm in group 2 (p<0.01). There was one superficial wound infection in group 2 and none in group 1. Postoperative pain scores were similar in both groups. None of the patients in group 1 reported sensory disturbance in the lower leg, whilst seven patients in group 2 were found to have reduced sensation in the distribution of the saphenous nerve postoperatively (p<0.01).

CONCLUSION

This study confirms that harvesting the semitendinosus tendon from postero-medial is quicker, results in a shorter scar and reduces the risk of injury to branches of the saphenous nerve. However, harvesting the tendon from postero-medial resulted in a shorter tendon graft.

LEVEL OF EVIDENCE

Level I (Randomised, controlled trial).

Saphenous nerve injury during harvesting of one or two hamstring tendons for anterior cruciate ligament reconstruction

OBJECTIVE

The aim of this study was to assess whether harvesting of two hamstring tendons (semitendinosus and gracilis) has the same rate of nerve injury as harvesting of the semitendinosus tendon alone, used as a triple graft.

METHODS

Changes in sensitivity relating to injury of the infrapatellar branch of the saphenous nerve were evaluated in 110 patients six months after they underwent anterior cruciate ligament (ACL) reconstruction using hamstring tendons. They were divided into two groups: one in which only the semitendinosus was used and the other, the semitendinosus and gracilis.

RESULTS

The group in which only the semitendinosus was used as a graft presented a nerve injury rate of 36.1%. In the group in which the semitendinosus and gracilis tendons were used, 58.1% of the patients presented altered sensitivity. In the general assessment on all the patients, the nerve injury rate was 50.9%.

CONCLUSION

Harvesting the semitendinosus alone and using it in triple form is a viable option for ACL reconstruction and may give rise to fewer nerve injuries relating to branches of the saphenous nerve.

Anatomical reference point for harvesting a flexor graft during arthroscopic reconstruction of the anterior cruciate ligament

Objectives

To evaluate the prevalence of a vascular network adjacent to the insertion of the pes anserinus, so that it could be used as an anatomical reference point to facilitate harvesting flexor grafts for arthroscopic reconstruction of the anterior cruciate ligament (ACL).

Methods

Thirty patients with ACL tears who were going to undergo ACL reconstruction using the tendons of the semitendinosus and gracilis muscles as grafts were selected randomly. During the harvesting of these tendons, the presence or absence of this anatomical reference point was noted.

Results

All the patients presented a vascular network of greater or lesser diameter.

Conclusion

The vascular network seems to be a good reference point during harvesting of the tendons of the semitendinosus and gracilis muscles, for facilitating graft harvesting.

Importance of anatomically locating the infrapatellar branch of the saphenous nerve in reconstructing the anterior cruciate ligament using flexor tendons

Objective

To describe the path of the infrapatellar branch of the saphenous nerve (IBSN) using the medial joint line, anterior tibial tuberosity (ATT), tibial collateral ligament and a horizontal line parallel to the medial joint line that passes over the ATT, as reference points, in order to help surgeons to diminish the likelihood of injuring this nerve branch during reconstruction of the anterior cruciate ligament (ACL) using flexor tendons.

Methods

Ten frozen knees that originated from amputations were examined. Through anatomical dissection performed with the specimens flexed, we sought to find the IBSN, from its most medial and proximal portion to its most lateral and distal portion. Following this, the anatomical specimens were photographed and, using the ImageJ software, we determined the distance from the IBSN to the medial joint line and to a lower horizontal line going through the ATT and parallel to the first line. We also measured the angle of the direction of the path of the nerve branch in relation to this lower line.

Results

The mean angle of the path of the nerve branch in relation to the lower horizontal line was 17.50 ± 6.17°. The mean distance from the IBSN to the medial joint line was 2.61 ± 0.59 cm and from the IBSN to the lower horizontal line, 1.44 ± 0.51 cm.

Conclusion

The IBSN was found in all the knees studied. In three knees, we found a second branch proximal to the first one. The direction of its path was always from proximal and medial to distal and lateral. The IBSN was always proximal and medial to the ATT and distal to the medial joint line. The medial angle between its direction and a horizontal line going through the ATT was 17.50 ± 6.17°.

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.

Partial semitendinosus tendon tear in a young athlete: a case report and review of the distal semitendinosus anatomy

Distal semitendinosus tears have been infrequently reported in the radiology literature, and a detailed description of the anatomy and imaging features of these injuries is lacking. The semitendinosus tendon is clinically relevant, as it is frequently grafted in knee ligament reconstructions and plays an important role in performing competitive activities. We present a case of a 31-year-old man who developed a partial semitendinosus tear during competitive training. This case highlights the common clinical and imaging findings found with distal semitendinosus tears, and explores the various modalities available to treat this injury. We also review the clinically pertinent anatomy of the distal semitendinosus tendon and discuss the pitfalls that musculoskeletal radiologists may encounter, to avoid misdiagnosing these rare injuries.

Posterior single-incision semitendinosus harvest for a quadrupled anterior cruciate ligament graft construct: determination of graft length and diameter based on patient sex, height, weight, and body mass index

PURPOSE

This study aimed to determine final graft length and diameter for a quadrupled semitendinosus anterior cruciate ligament (ACL) construct harvested from a single-incision posterior approach with correlation to preoperative patient variables of sex, height, weight, and body mass index (BMI).

METHODS

This was a retrospective review of data collected prospectively on 60 patients undergoing all-inside quadrupled semitendinosus autograft ACL reconstruction.

RESULTS

The mean values of the final quadrupled constructs were a length of 70.3 mm and a diameter of 9.0 mm. Separated based on sex, female versus male final mean graft length was 68.1 mm versus 71.7 mm, and final mean graft diameter was 8.6 mm and 9.3 mm, respectively. In both sexes, patient height and weight were strongly correlated to final construct diameter (r = 0.60 and r = 0.56) and length (r = 0.47 and r = 0.44), respectively.

CONCLUSIONS

A single-incision posterior harvest approach allowed for retrieval of semitendinosis tendon autografts of sufficient dimension to allow for construction of quadrupled ACL grafts of a diameter of 8 mm or more in 95% of cases. In addition, desired graft length was achieved in all cases. Graft dimensions had moderately strong direct correlations to patient height and weight, with significant size differences noted between the sexes. We believe this to be helpful data for surgeons who might consider performing a quadrupled semitendinosus autograft ACL reconstruction.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.