Anatomic Considerations in Hamstring Tendon Harvesting for Ligament Reconstruction

Abstract

Hamstring tendon autograft remains a popular graft choice for anterior cruciate ligament reconstruction. Although the technique of hamstring autograft harvest is relatively straightforward, it is critical to pay attention to several technical steps to avoid iatrogenic anatomic or neurovascular damage as well as to reduce the risk of premature amputation of the graft when using a tendon stripper. We describe a technique of hamstring autograft harvesting using only 2 anatomic references that makes it a simple and reproducible technique for surgeons, especially those in training.

Fig 1

Anatomic landmarks for arthroscopy and graft harvesting on a left knee. From a lateral view, (A) left knee at 90° of flexion. (B) Contour of patella and tibial tuberosity are marked. (C) The patellar tendon (PT) is identified, and the access points for arthroscopic standard portals are marked. From a medial view, (D) the medial border of the tibia is identified. (E, F) The posterior border of the tibia is marked in a hockey-stick shape.

Fig 2

Crucial landmarks for hamstring tendon harvesting on a left knee. Medial view, (A) medial posterior border of tibia (TPB). (B) Horizontal line from tip of tibial tuberosity to marked tibial border. (C) The horizontal line is divided into thirds.

Fig 3

Skin incision. (A) An incision is made in the second third. (B) The skin is separated with 2 retractors, and a subcutaneous tissue incision is extended subcutaneously proximally and distally. (TPB, tibial posterior border.)

Fig 4

Sartorial fascia (SF) identification on a left knee from medial view. (A) Blunt dissection of the subcutaneous tissue is performed with 2 retractors over the SF; it is observed as a pearly white layer. (B) The knee should be kept in 90° of flexion to maintain the tendon’s tension and the formation of a horizontal step. (C) A Kelly forceps is introduced behind the step and is opened to allow dissection of the SF, eliminating the risk of medial collateral ligament injury. (TPB, tibial posterior border.)

Fig 5

Inverted L–shaped incision in sartorial fascia. (A) A horizontal incision is completed with a scalpel in the junction with the tibial tuberosity. (B) After the horizontal incision is made, a vertical incision is made close to the tibial tuberosity to form an inverted L–shaped incision.

Fig 6

Avoiding iatrogenic damage to medial collateral ligament (MCL). (A) Blunt dissection of horizontal incision of sartorial fascia with Kelly forceps. (B) The use of a scalpel too deep can produce iatrogenic damage to the MCL.

Fig 7

Sartorial fascia identification from a frontal view of a left knee. (A, B) Elevation and detachment of superolateral vertex (arrow) of sartorial fascia in vertical incision adjacent to tibial tubercle. (C) Medial extension of the horizontal incision of the sartorial fascia allows this layer’s eversion in the shape of an open wallet, immediately exposing the hamstring tendons (arrow) through the incision.

Fig 8

Semitendinosus (ST) graft release. (A) A Kelly forceps is used to detach the ST from the sartorial fascia (SF) by inserting the tip. (B) The forceps is pulled between the fascia and tendon toward the vertical cut to release it. (C) The tendon is grasped from the tip, and its attachment is cut.

Fig 9

Release of semitendinosus (ST) bands. (A) The bands are identified with the index finger rotated 360°, hooked with a forceps to expose them, and cut. (B) The tendon is grasped with the forceps and rolled into a clamp to prevent loosening and retraction.

Fig 10

Hamstring tendon harvesting. Once the bands are released, the semitendinosus (ST) and gracilis can be identified and harvested with a tendon stripper.

Fig 11

Semitendinosus (ST) tendon harvesting. (A) An arthroscopic forceps is inserted into the closed tendon stripper. (B) The tendon is held with the tip of the forceps and then exchanged with a strong forceps. (C) The tendon is rolled up. (D) The knuckles of the surgeon should rest on the patient's knee.