Which hamstring tendons for acl reconstruction

Anterior cruciate ligament reconstruction is surgery to reconstruct the torn ligament of your knee with a tissue graft. An ACL injury most commonly occurs during sports that involve twisting or overextending your knee. An ACL can be injured in several ways:. When you injure your ACL, you might hear a loud "pop" sound and you may feel the knee buckle. Within a few hours after an ACL injury, your knee may swell due to bleeding from vessels within the torn ligament. You may notice that the knee feels unstable or seems to give way, especially when trying to change direction on the knee.

An ACL injury can be diagnosed with a thorough physical examination of the knee and diagnostic tests such as X-rays, MRI scans and arthroscopy. X-rays may be needed to rule out any fractures. During a Lachman test, knees with a torn ACL may show increased forward movement of the tibia and a soft or mushy endpoint compared to a healthy knee.

Pivot shift test is another test to assess ACL tear. The Hamstring is the muscle located on the back of your thigh. In recent years, most studies have reported that oblique incisions are less likely to damage the IPBSN than are vertical and horizontal incisions because according to autopsy studies, oblique incisions are more parallel and farther away from the IPBSN, so they are located in a safer area [ 20 , 26 , 27 , 28 , 29 , 30 , 32 ].

However, horizontal incisions easily lead to injury of the sartorius branch [ 24 , 25 ]. Haviv et al. Papastergiou et al. In recent studies, the risk of IPBSN injury was lower for oblique incisions than for two other types of incisions [ 9 , 28 ]. Henry et al. We found that part of the COI was not located within the safe area, especially when the incision was long.

Regarding the rate of IPBSN injury or the area of hypesthesia, there was significant difference between groups. Moreover, the type of incision that we proposed is more accurate and easier to perform than that is the COI. Therefore, we think it is a more appropriate method of harvesting hamstring tendons. According to the literature, blunt injury by a tendon-harvesting device is also a cause of saphenous nerve injury [ 23 ].

However, it has been reported that there are fewer nerve injuries associated with tendon harvesting than there are nerve injuries associated with incisions [ 2 , 29 ].

Sanders et al. Almost all the authors of previous studies believe that it is possible to avoid saphenous nerve injury caused by the tendon-harvesting device by keeping the knee flexed and thigh rotated during hamstring tendon harvesting because the saphenous nerve moves backward and is located far away from the incision [ 6 , 23 ]. In this study, two kinds of oblique incisions were made in this position to harvest hamstring tendons.

In our study results, none of the patients experienced injury to the suture branch, which can cause an abnormal sensation in the medial and distal tibial ridge, as well as sensory abnormalities in the anteromedial skin of the knee joint. Therefore, he believed that the length and direction of the incision were important, and that the length of the incision should be minimized. We also found that the COI is not contained completely within the safe area that was proposed by Kerver et al. However, a shorter incision makes it difficult to expose the tendon.

To expose the tendon, an excessive stretching incision may lead to blunt nerve traction injury. Some authors suggest that surgeons used the blunt separation technique to avoid overstretching and close the wound carefully.

In this study, in patients whose level of sensation returned to normal within 3—6 months after surgery, the recovery of sensation was considered to be related to avoid overstretching and close the wound carefully. This study was completed by a single surgeon, and thus, inter-surgeon variability can be excluded. The average length of the incisions was 3. We found that all 6 patients with skin sensory loss were obese patients with sensory loss in the lower limbs.

The causes of skin sensory loss may be due to the surface markers being placed incorrectly due to difficulty palpating the locations on the body, excessive stretching, and a relatively long incision for tendon exposure. Although Kerver et al.

They proposed the concept of a safe area on the basis of a limited number of autopsy studies, which is also a limitation of their work. Therefore, we think that the saphenous nerve injury in patients who undergo the MOI may be related to variations in the location of the saphenous nerve.

In recent years, most of the related studies that have been conducted have reported that regardless of the type incision that was selected, there were no statistically significant differences in postoperative functional scores. Most patients with abnormal sensation around the knee thought that their work and life would not be affected [ 20 , 26 , 27 , 28 , 29 , 30 , 32 ].

In this study, there was no significant difference in knee joint function or subjective feeling between the two incision groups. Posterior thigh pain is another complication after hamstring autograft harvesting. Laakso et al. They demonstrated that an early trauma during rehabilitation could commence more retraction to the harvested muscle itself and affect the regeneration of the neotendon.

In our study, we found no posterior thigh pain at final follow-up. This may be because none of our patients are athletes. MOI incision can easily recognize and expose the accessory tendon insertions for hamstring tendon and reduce the incidence of tendon amputation. In a review study, Charalambous and Kwaees [ 5 ] overview the hamstring tendon anatomy and found that the reason of premature tendon amputation and short graft is accessory tendon insertions and fascial bands which site proximal to the insertion of pes anserinus.

Our incision is closer to the proximal tendon than COI. So MOI incision is easier to expose the accessory tendon insertions and fascial bands and reduce the incidence of premature tendon amputation and short graft. This study had some limitations. The first limitation is that observer bias may have affected the results. All the data were collected and measured by a staff member. Due to the busy working conditions in our general hospital, no other observers could assist with the study.

Second, the sample size is small, limiting the generalizability of the results, and studies with larger sample sizes need to be conducted to confirm the results. Moreover, when the skin incision position was located, we relied on the palpable anatomical structures on the body surface, so there may have been errors in locating the position for each incision, thereby affecting the results.

The third is that due to the small sample size, the results may be biased. Finally, blunt needle acupuncture is not accurate enough to be used to measure the extent of sensory nerve injury. In the future, electrophysiological studies may be used to assess nerve injury more accurately.

All the previous studies have demonstrated that the IPBSN always exists regardless of the type of surgical incision selected and that the incision needs to be performed carefully.

Although the MOI performed in this study can significantly reduce the risk of injury, injuries cannot be completely avoided.

The area of hypesthesia gradually decreases with time and even recovers completely. Therefore, the risk of postoperative nerve injury should be explained to patients before surgery, but generally, this injury will not affect function.

Arthornthurasook A, Gaew-Im K. Study of the infrapatellar nerve. Am J Sports Med. Saphenous neuralgia after arthroscopically assisted anterior cruciate ligament reconstruction with a semitendinosus and gracilis tendon graft.

A safe area and angle for harvesting autogenous tendons for anterior cruciate ligament reconstruction. Surg Radiol Anat. The use of hamstring tendons for anterior cruciate ligament reconstruction. Technique and results. Clin Sports Med. Anatomical considerations in hamstring tendon harvesting for anterior cruciate ligament reconstruction. Muscles Ligaments Tendons J. PubMed Google Scholar. Regeneration of the semitendinosus and gracilis tendons following their transection for repair of the anterior cruciate ligament.

A comparison of clinical outcome of augmentation and standard reconstruction techniques for partial anterior cruciate ligament tears.

Eklem Hastalik Cerrahisi. Injury to the infrapatellar branch of the saphenous nerve in ACL reconstruction with the hamstrings technique: clinical and electrophysiological study. 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.

Knee Surg Sports Traumatol Arthrosc. Article PubMed Google Scholar. Nerve injury during anterior cruciate ligament reconstruction: a comparison between patellar and hamstring tendon grafts harvest.

The variable emergence of the infrapatellar branch of the saphenous nerve. J Knee Surg. Oblique incisions in hamstring tendon harvesting reduce iatrogenic injuries to the infrapatellar branch of the saphenous nerve. Use of the International Knee Documentation Committee guidelines to assess outcome following anterior cruciate ligament reconstruction. Anatomic study of infrapatellar branch of saphenous nerve in male cadavers. Ir J Med Sci. A growing body of evidence indicates that there are large deficits in the internal rotation strength, a significant weakness of hamstring muscle strength at high knee-flexion angles, and a significantly lower standing knee-flexion angle after STGR harvest, which has led some authors to recommend the harvest of only the ST tendon whenever possible [ 8 , 9 , 10 ].

Biomechanical studies using animal tendons to determine the effect of braiding or twisting on initial graft strength and stiffness have not yielded clear conclusions. A study done by Kim et al. However, no study is available regarding the impact of the weave technique on strength and stiffness of the hamstring tendon graft used for ACL reconstruction with proper pretensioning of the graft. The purpose of this study was to determine the effect of the weave technique for hamstring graft preparation on the diameter of the prepared graft, the need for harvesting of ST and G or ST alone, and functional outcome.

Our hypothesis is that the weave technique and parallel-graft technique do not affect the final graft diameter and the need for harvesting of the G tendon. After obtaining Ethical Committee approval, we retrospectively evaluated patients who underwent arthroscopic ACL reconstruction from January to December Out of these, patients were treated using the parallel-graft technique and patients using the weave technique.

ACL reconstructions before October were done using the parallel-graft preparation technique and thereafter the weave-graft preparation method was used. We excluded patients who had a partial ACL tear or a meniscal tear grade 3 , underwent double-bundle ACL reconstruction, in whom an allograft was used or any method of fixation used other than aperture fixation, and who had multi-ligamentous injury.

After applying a tourniquet, the operated part was cleaned and draped. A diagnostic arthroscopy was performed using standard anterolateral and anteromedial portals. A longitudinal incision over the anteromedial tibia is made, and dissection is carried through the subcutaneous tissue till the sartorius fascia is reached.

The fascia is palpated to identify the underlying ST and G tendons. The tendons are blend together at their insertion site on the tibia and the interval between them is more distinct proximally and posteriorly. The sartorius fascia is then incised over this interval in the line of tendons. A right-angle clamp is used to isolate the tendons.

After the vincular attachments are cut under visual control, the ST and G tendons are harvested with a closed-type tendon stripper. So if it is required to increase the diameter, the G tendon is also harvested and prepared over the earlier graft in a similar manner.

This forms the quadrupled or pentavalent hamstring tendon graft. In the weave technique, the initial part of graft preparation is the same. The two thirds of the graft are bent in a similar fashion and clamped to the two respective clamps as stated earlier. These are parallel. Graft preparation in the weave technique. Ankle and foot movements, static quadriceps exercises, knee range of motion, and straight leg raising were started as soon as the patients recovered from anesthesia.

Mobilization walking with walker support was started the next day with priority focussed on the recovery of full extension. Patients who were lost to follow-up were excluded from the study. Only those patients who completed full rehabilitation were included in the study. Anterior tibial translation was then measured in millimeters on these radiographs.

Flexor strength was checked clinically preoperatively and periodically postoperatively by asking the patient to perform prone knee bending with a strap weight attached just proximal to the ankle maximum load and standard set of 30 repetitions.

Group comparisons were done using a t test and a p value of less than 0. In the parallel-graft preparation group, the male and female patient number was and 24, respectively Fig. Their mean age was This group had seven revision ACL reconstructions. Out of the 24 female patients, 20 In the weave-graft preparation group, the male and female patient number was and 15, respectively Fig.

This group had four revision ACL reconstructions. Out of the 15 female patients, eight patients Subjectively, at 2-year follow-up, there was no difference between the two groups in terms of functional outcome that was measured using IKDC parallel-graft group mean: The rerupture rate of the reconstructed ACL was higher in the parallel-strand graft five cases, 2. Bar diagram representing the decreased use of the gracilis tendon in the weave-graft preparation technique.

Our results indicate that with the weave technique for graft preparation, similar diameter and functional outcome can be achieved compared to the parallel-strand technique and the frequency of G tendon harvest is reduced. Interstrand healing was studied by Yan Xu in a rabbit model.

This study showed that the four- strand hamstring tendon needs to pass through the necrosis, revascularization, and ligamentization stages, but the different strands are not involved in a synchronous process.

The interstrand gap may be completely fused, partially fused, fused but connected with connective tissue, or still separated. By braiding the strand, the fusing percentage of the graft could be elevated and biomechanical properties could be improved [ 12 ]. This suggests that in the parallel-strand technique, the strands work as individual strands whereas in the woven strand configuration, all strands work together [ 12 ]. But weaving differs from braiding as it does not involve twisting and two strands remain parallel and only one strand is woven over the others, which helps all three strands to bind to each other strongly.

Spragg et al. Therefore, we made a protocol at our institute to achieve a 7—mm graft diameter. This diameter can be achieved without using the G in most cases if the weave technique is used.

In our study, we also found that the rerupture rate was lower in the weave-technique group compared to the parallel-strand group; however, a longer follow-up is required because of the statistical insignificance. As per the study by Waly, ACL reconstruction using a triple ST tendon is a viable alternative, preserving the G tendon and decreasing hamstring morbidity [ 15 ].

In a study by Tashiro et al. Therefore, if the G is preserved, it helps in early rehabilitation. Stengel et al. Goradia et al. Many authors suggest that good results can be obtained with a triple-strand hamstring graft by not using the G tendon to prevent flexion weakness of the knee.

We used the triple-strand ST tendon with a different graft preparation technique weave technique , which resulted in preservation of the G in majority of cases.