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Duke Orthopaedics
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Wheeless' Textbook of Orthopaedics

Hamstring Harvest for ACL Reconstruction


- Technique:
    - place the leg in a figure of 4 position;
    - make a small longitudinal incision opposite the tibial tuberlce, midway between the tubercle and the the posterior edge of the tibia;
    - palpate the pes anserinus;
           - generally only the gracilis and semitendinosus will be felt, since the sartorius thins out well proximal to its insertion;
    - attempt to identify the saphenous nerve;
    - make an incision directly over and in line with the gracilis tendon;
    - open the tendon sheath and release adhesions and fibrous extensions that attach to the sheath;
    - pes anserinus is exposed through a short verticel incision;
    - semitendinosus and gracilis tendons are harvested proximally w/ appropriately sized tendon stripper; (Brand type tendon stripper);
          - residual muscle is removed;
          - semiT should be placed in a moistened sponge, but is not be submerged in saline, since this may cause tendon swelling;
          - paratenon surrounding the semitendinosus should be preserved;
    - careful to avoid saphenous nerve damage;
          - references: 
                - Prevalence of saphenous nerve injury after autogenous hamstring harvest: an anatomic and clinical study of sartorial branch injury.
                - A prospective randomised study of the effect of skin incision angle on infrapatellar neuritis and alaterd skin sensation in anterior cruciate ligament reconstruction with semitenindous/gracilis grafts.

    - preparation of the graft:
          - Twisting and Braiding Reduces the Tensile Strength and Stiffness of Human Hamstring Tendon Grafts Used for ACL Reconstruction.
          - Histological and biomechanical studies of inter-strand healing in four-strand autograft anterior cruciate ligament reconstruction in a rabbit model.

    - fate of the harverst site:
          - in report by Eriksson K, et al, authors evaluated fate of the semiT muscle, after ACL reconstruction;
                 - the study included were 16 consecutive patients;
                 - ACL reconstruction was performed with a quadruple semitendinosus tendon graft using the EndoButton technique;
                 - of the patients, 75% showed regeneration of their semitendinosus tendons;
                 - neotendons all inserted below knee joint where they had fused with gracilis tendon to a conjoined tendon inserting in the pes anserinus;
                 - semitendinosus muscle had a smaller cross-sectional area on the operated side but none showed total atrophy;
                 - isokinetic strength of the hamstrings and quadriceps was significantly lower in the operated leg than in the nonoperated leg.
         - in the report by Ferretti A, et al, the authors describe the histologic course of regenerated tissue simulating the semitendinosus tendon in three patients after anterior cruciate ligament reconstruction with doubled semitendinosus and gracilis tendons;
                 - specimens were retrieved during revision surgery for removal of tibial hardware at 6, 24, and 27 months, respectively;
                 - resisted flexion during physical examination in all patients revealed a "string" on the posteromedial aspect of the knee that was quite evident, suggesting the presence of a regenerated semitendinosus tendon;
                 - well-defined fibrous band was identified about 3 cm proximal and medial to the pes anserinus, reproducing the pathway of the native semitendinosus tendon;
                 - in both of the specimens retrieved 2 years postoperatively, all of the central, thicker portion of each specimen was occupied by well-oriented tendon-like fibers together with uniformly distributed spindle-shaped cells that had appearance of mature tenocytes arranged in orderly rows;
         - references:
               - Regeneration of the Semitendinosus Tendon after Its Use in Anterior Cruciate Ligament Reconstruction. A Histologic Study of 3 Cases
               - Semitendinosus muscle in anterior cruciate ligament surgery. Morphology and function.   
               - Semitendinosus Regrowth. Biochemical, Ultrastructural, and Physiological Characterization of the Regenerate Tendon.

- Complications of Harvest:

     - hamstring weakness issues:
           -
Hamstring strength recovery after hamstring tendon harvest for anterior cruciate ligament reconstruction: a comparison between graft types
           - Treatment of anterior cruciate ligament injuries with special reference to graft type and surgical technique: an assessment of randomized controlled trials.
           - The effects of semitendinosus and gracilis harvest in anterior cruciate ligament reconstruction
           - Isokinetic evaluation of internal/external tibial rotation strength after the use of hamstring tendons for anterior cruciate ligament reconstruction.
           - Assessment of morbidity of semitendinosus and gracilis tendon harvest for ACL reconstruction.
           - Decrease of knee flexion torque in patients with ACL reconstruction: combined analysis of the architecture and function of the knee flexor muscles.
           - Hamstring muscle function after tendon harvest for anterior cruciate ligament reconstruction: evaluation with T2 relaxation time of MRI.
           - Influence of medial hamstring tendon harvest on knee flexor strength after anterior cruciate ligament reconstruction
           - Isokinetic assessment with two years follow-up of anterior cruciate ligament reconstruction with patellar tendon or hamstring tendons
           - A comparison of bone-patellar tendon-bone and bone-hamstring tendon-bone autografts for anterior cruciate ligament reconstruction.

     - hamstring harvest in the older patient:
           - Four-strand hamstring tendon autograft for ACL reconstruction in patients aged 50 years or older
           - Autologous hamstring anterior cruciate ligament reconstruction in patients older than 40
           - Anterior cruciate ligament reconstruction in patients over 40 years using hamstring autograft.

     - cutaneous sensory loss
           - Sensibility loss after ACL reconstruction with hamstring graft.
           - Injury to the infrapatellar branch of the saphenous nerve in anterior cruciate ligament reconstruction: comparison of horizontal versus vertical harvest site incisions
           - Prevalence of saphenous nerve injury after autogenous hamstring harvest: an anatomic and clinical study of sartorial branch injury.

- Indications and Uses for Hamstring Harvest in Orthopaedics
    
     - Foot and Ankle:
           - Free gracilis interposition arthroplasty for severe hallux rigidus
           - Failed first metatarsophalangeal arthroplasty salvaged by hamstring interposition arthroplasty: metallic debris from grommets
           - Autogenous graft repair using semitendinous tendon for a chronic multifocal rupture of the extensor hallucis longus tendon: a case report.  
           - Soft-tissue arthroplasty for hallux rigidus 
           - Delayed rupture of the extensor hallucis longus and and extensor digitorum communis tendons after breaching anterior capsule with a radiofrequency probe during ankle arthroscopy
           - Reconstruction of a chronic extensor hallucis longus tendon laceration with a gracilis tendon autograft
           - Chronic isolated distal tibiofibular syndesmotic disruption: diagnosis and management
           - Ipsilateral free semitendinosus tendon graft transfer for reconstruction of chronic tears of the Achilles tendon 
           - Free hamstrings tendon transfer and interference screw fixation for less invasive reconstruction of chronic avulsions of the Achilles tendon.

     - Shoulder:
           - Semitendinosus tendon graft versus a modified Weaver-Dunn procedure for acromioclavicular joint reconstruction in chronic cases: a prospective comparative study.
           - Acromioclavicular reconstruction using autogenous semitendinosus tendon graft: results of revision surgery in chronic cases.
           - Clinical results of single-tunnel coracoclavicular ligament reconstruction using autogenous semitendinosus tendon
           - A salvage procedure for failed weaver-dunn reconstruction
           - Coracoclavicular ligament reconstruction using a semitendinosus graft for failed acromioclavicular separation surgery.
           - Clinical outcomes of coracoclavicular ligament reconstructions using tendon grafts

     - Elbow:
           - Reconstruction of a chronic distal biceps tendon rupture 4 years after initial injury.
           - Triceps reconstruction using hamstring graft for triceps insufficiency or recurrent rupture.
           - Repair of chronic distal biceps tendon ruptures using autologous hamstring graft and the Endobutton
           - Repair of chronic distal biceps brachii tendon rupture using free autogenous semitendinosus tendon

 - Knee:

       - medial patellofemoral ligament reconstruction:
               -
Anatomical transverse patella double tunnel reconstruction of medial patellofemoral ligament with a hamstring tendon autograft for recurrent patellar dislocation
               - Clinical and radiological outcome of medial patellofemoral ligament reconstruction with a semitendinosus autograft for patella instability.
               - A long-term follow-up study after medial patellofemoral ligament reconstruction using the transferred semitendinosus tendon for patellar dislocation.
               - Hybrid medial patellofemoral ligament reconstruction using the semitendinous tendon for recurrent patellar dislocation: minimum 3 years follow-up.
               - Clinical results of isolated reconstruction of the medial patellofemoral ligament for recurrent dislocation and subluxation of the patella
               - Medial patellofemoral ligament reconstruction for subluxating patellofemoral arthroplasty 
               - Visual analog scale assessment after medial patellofemoral ligament reconstruction: with or without tibial tubercle transfer
               - Dual tunnel medial patellofemoral ligament reconstruction for patients with patellar dislocation using a semitendinosus tendon autograft
               - Hamstring graft fixation in MPFL reconstruction at the patella using a transosseous suture technique
               - Anatomical reconstruction of the medial patellofemoral ligament using a free gracilis autograft
               - Technical note: anatomical reconstruction of the medial patellofemoral ligament using a free gracilis autograft
               - Reconstruction of the medial patellofemoral ligament with gracilis tendon autograft in transverse patellar drill holes


- References:

Combined anterior cruciate-ligament reconstruction using semitendinosus tendon and iliotibial tract.

The use of hamstring tendons for anterior cruciate ligament reconstruction. Technique and results.

An anterior cruciate ligament (ACL) evaluation format for assessment of artificial or autologous anterior cruciate reconstruction results.

Reconstruction of the anterior cruciate ligament of the knee using a doubled tendon graft.

Arthroscopically Assisted Reconstruction of the Anterior Cruciate Ligament. A prospective randomized analysis of three techniques

Brace Free Rehabilitation with Early Return to Activity for Knees Reconstructed with a Double Looped Semitendinosus and Gracilis Graft.

Biomechanical analysis of human ligament grafts used in knee-ligament repairs and reconstructions.

Functional anatomy of the anterior cruciate ligament and a rationale for reconstruction.

The Outcome of a Free Autogenous Semitendinosus Tendon Graft in Human Anterior Cruciate Reconstructive Surgery: A Histologic Study.

Joint infection unique to hamstring tendon harvester used during anterior cruciate ligament reconstruction surgery.

A 10-year comparison of anterior cruciate ligament reconstructions with hamstring tendon and patellar tendon autograft: a controlled, prospective trial.

A prospective, randomized comparison of semitendinosus and gracilis tendon versus patellar tendon autografts for anterior cruciate ligament reconstruction: five-year follow-up

Quality of life and clinical outcome after anterior cruciate ligament reconstruction using patellar tendon graft or quadrupled semitendinosus graft: an 8-year follow-up of a randomized controlled trial.

Patellar tendon or semitendinosus tendon autografts for anterior cruciate ligament reconstruction? A prospective randomized study with a two-year follow-up

Clinical Trials 
Comparison of BioCart™II With Microfracture for Treatment of Cartilage Defects of the Femoral Condyle
A Comparison Between the Performance of Chondrocytes Versus Microfracture Technique on Knee Symptoms (SUMMIT)
Comparison of Microfracture Treatment and CARTIPATCH® Chondrocyte Graft Treatment in Femoral Condyle Lesions
Trial Comparing BST-CarGel and Microfracture in Repair of Articular Cartilage Lesions in the Knee
RCT of ChondroCelect® (in an ACI Procedure) vs Microfracture in the Repair of Cartilage Defects of the Knee (TIGACT01)
Study to Compare the Efficacy and Safety of Cartistem® and Microfracture in Patients With Knee Articular Cartilage Injury or Defect
NeoCart Phase 2 Clinical Trial
Peripheral Blood-drived Stem Cell Trial on Damaged Knee Cartilage (PBSC)
Confirmatory Study of NeoCart in Knee Cartilage Repair
Cartilage Autograft Implantation System (CAIS) for the Repair of Knee Cartilage Through Cartilage Regeneration
Evaluation of an Acellular Osteochondral Graft for Cartilage LEsions Pilot Trial (EAGLE Pilot)
ChonDux for Filling Full Thickness Cartilage Defects in the Femoral Condyle of the Knee




Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Tuesday, January 29, 2013 11:55 am