Difficulties with harvest of the Semitendinosus (ST) and, if necessary, Gracilis are vexing for many Orthopaedic Surgeons. It is the primary force that drives many surgeons to use allografts despite the fact the results of allografts are clearly substantially inferior to autografts. I used hamstrings from the beginning of my career in 1985 for open ACL reconstruction. I used large incisions and harvest was easy. When I transitioned from open to arthroscopic ACL reconstruction around 1989 I realized that harvesting the ST from a small anterior incision entailed significant risk of cutting the tendons short at their cross connection with the gastrocnemius. For that reason, after some preliminary cadaver work, in 1991 I developed the posterior mini-incision ST/Gr harvest which utilized a small posterior transverse incision in Langer’s lines to identify the ST and Gr and cut the cross connections where they are easy to see. I then used the small anterior incision to harvest them with a tendon stripper. Almost 30 years and thousands of harvests later I have never cut one short. I wrote up the technique years later and it was published in 2005 in the Arthroscopy Journal as Posterior mini-incision technique for hamstring anterior cruciate ligament reconstruction graft harvest. I also created an AAOS video of the entire technique in a live patient which can be viewed online at ACL.info. This technique and subsequent variants of it are now routinely used by Orthopaedic Surgeons everywhere.
I revisit the topic now because of a just published paper entitled, Use of Posterior Hamstring Harvest During Anterior Cruciate Ligament Reconstruction in the Pediatric and Adolescent Population, which evaluated this harvest technique for the first time in the pediatric population. The authors found that the approach was equally effective and safe in this population as it is in adults.
For surgeons who wish to use a hamstring graft this harvest approach is the ultimate safety net to allow them to do so. There is also no worry about a graft that is too small or too short. A four-strand hamstring graft, either quadruple ST if the ST is over 31cm in length or more often double ST/double Gr graft is always strong enough. Indeed, this graft is far stronger than the native ACL. This is shown in our published series of 150 ACLRs, Stability results of hamstring anterior cruciate ligament reconstruction at 2- to 8-year follow-up, in which none of the implanted ACL grafts failed, but 5 patients tore the ACL in the other knee.
In a lean patient both incisions can be made quite small, and the use of the posterior mini-incision allows the more visible anterior incision to be much smaller than it would otherwise need to be.
Chadwick Prodromos, MD is Medical Director, Illinois Orthoapedics and Sports Medicine Centers and Associate Professor of Orthopaedic Surgery at Rush University College of Medicine in Chicago. He is the author of The Anterior Cruciate Ligament, 2nd Edition. Click here to download a free chapter.
Its a good article.
Its unfortunate, we don’t make use of our colleagues who are trained in microsurgery or reconstruction microvascular to harvest a better graft, when an autologous graft is required when performing reconstruction or repair or augment the repair, whether ACL or Achilles tendon repair, as the concept of performing such a repair than a cadaveric graft or frail tendons, may have superior outcome. My humble thoughts