Endoscopic-Assisted Hamstring Tendon Harvesting

Abstract

Efficient hamstring tendon harvesting is a crucial part of anterior cruciate ligament reconstruction surgery using autografts. Harvesting of the gracilis and semitendinosus tendons is usually performed using an open approach, exposing the distal tibial attachment of the tendons at the pes anserinus and proceeding using a tendon stripper without direct tendon visualization. The success of the anterior cruciate ligament reconstruction surgery strongly depends, among other factors, on the preservation of the hamstring tendon length and integrity. Inadequate tendon release from their attachments and improper use of the tendon stripper, in addition to poor intraoperative visibility, may lead to premature tendon amputation, endangering the success of the operation. We describe an endoscopic-assisted technique of hamstring tendon harvesting that provides complete visualization of the tendons from the tibia attachment to the musculotendinous junction. The procurement of the tendons is completed under direct vision using any tendon stripper. This surgical technique offers a way to minimize complications that may arise during the standard open tendon harvesting techniques without additional visualization.

Fig 1

The optical dissector used to facilitate tendon harvesting comprises a handling handle at one end and a hollow, slotted retractor at its other end (A). A 30° or, preferably, a 70° arthroscope is placed into the sheath (B). This device supersedes the use of a retractor and is very useful for tendon dissection in tight spaces.

Fig 2

In a left knee, with the head on the left side of the photograph, the optical dissector (OD) is inserted within the pes anserinus following the course of the hamstring tendons. A blunt hook (H) or a cotton tape is passed around each tendon and used to apply longitudinal traction. All fascial and tendon attachments are dissected under direct vision using a pair of Metzenbaum scissors (M). Occasional bleeders can be cauterized using a diathermy.

Fig 3

Endoscopic dissection and harvesting of the gracilis tendon in a left knee. The tendon is dissected from the distal tibial attachment to the proximally located musculotendinous junction under direct vision using a pair of Metzenbaum scissors (A). Palpation around the tendon is accomplished with the scissors and fascial bands are divided under direct vision. In this case, an open tendon stripper is inserted and advanced proximally until the tendon is harvested under direct endoscopic visual control (B).

Fig 4

In a left knee, to facilitate tendon harvesting the tendons, the assistant holds the optical dissector (OD), and the surgeon manipulates the tendon hook (H) and a closed tendon stripper (S) in this case. The tendon stripper should be directed toward the proximal tendon attachment which differs between the gracilis and the semitendinosus tendons. Note that in the photograph, the direction of the stripper is not yet appropriate.

Fig 5

Endoscopic dissection and harvesting of the semitendinosus tendon (ST) are generally more demanding due to the presence of a strong posteromedial fascial band attaching it to the medial head of the gastrocnemius muscle fascia. In this case the ST tendon in a left knee is visualized and the fascial band (fb) is divided with the scissors (Metz) (A). Once liberated from its attachments, the ST tendon is freely movable, and the medial collateral ligament (MCL) is clearly visible (B). The tendon harvester is inserted and the tendon is harvested under endoscopic visual control (C).

Fig 6

Method 2. In this variation, endoscopic-assisted tendon harvesting can be accomplished without the use of dedicated instrumentation. In a right knee, a long Langenbeck retractor (L) is inserted into the pes anserinus, elevating the fascia and the subcutaneous tissue. A 70° arthroscope (A) without its sheath is inserted into the wound parallel to the tendon and longitudinal tendon traction is applied with a blunt hook (H). Tendon dissection is performed with a 20-cm long Metzenbaum scissors (not shown) and harvesting is completed with a tendon stripper.