I'd like to thank Tony Zacharias, he's my fellow that contributed the video for this. We also have this video in Video Journal of Sports Medicine, so it can be seen there. So no conflict of interest relevant to this talk. So go through the objections of this talk. So why I use hamstring autograft for ACL reconstruction, which patients do I prefer to use it in, and then we're going to do a review with a video of sort of harvest prep and then reconstruction tips for that. Using a clinical case, we'll use a hamstring tendon with a five-strand graft, looking at ACL tunnel placement using intramedial tunnel positioning, and then graft passage and fixation. So why hamstring? Well, the hamstring graft is shown to have similar rupture rates to BTB as well as quadriceps and MOON studies have shown us that. Limited donor site mobility, decreased anterior kneeling pain, early progression off of crutches in a high tensile graft. Graft size is not predictable when you use a hamstring, that's one of the disadvantages using that. When we do use, when we have looked at small hamstrings, so less than eight millimeters, those have shown a significantly higher failure rate than grafts over eight millimeters in size. Augmentation with allograft is not shown to be effective with failure rates that are higher than using just a smaller graft on its own and equal to allograft in a lot of cases. Five-strand grafts increase graft size predictably. Using our technique, we tripled the semitendinosus graft, the gracilis tendon is doubled. We're able to increase the average size of the grafts at least a millimeter when going from a four-strand graft to a five-strand graft. When we did have four-strand grafts less than eight millimeters in size, 83% of those we could get greater than eight millimeters when we converted it to a five-strand graft. Larger graft, lower re-tear rates. So which patients do we like to use this in? Well, one's an easy group, the skeletally immature patient. No soft tissue, no length issues, you have plenty of length of your graft. You can do a fiseal sparing approach, you can do a trans-fiseal approach, you can do over the top without any issues. So which patients? Well, which sports do I like it in? My wrestlers I like it in, especially the small guys, they're down on their knees a lot. Volleyball, especially my defensive players are really good for that, your libero is a good option for that. Softball, baseball, I have three catchers of my own. I think a hamstring graft in those groups is a perfect graft. Hockey players are always in a flexed posture, good position for that. My throwers in track and field, crew kids, they're always in that flexed posture. Skiers, especially the older skiers are a really good graft, and my runners are a good group there. Anyone that has a history of anterior knee pain, I think it's a good graft choice. Older patients, now that I'm older, I think older is younger, but those groups are good. And then somebody who has a job that requires a lot of kneeling or squatting. Which patients to be careful with? Well, women's soccer, we've seen that from the MOON studies that the women's soccer players don't do well with hamstring grafts. I think the skill and speed position guys in football, your NFL level players, Dr. Bradley would tell us, use patellar tendons in that group. Sprinters, I worry about that hamstring for that initial burst of speed, so my elite level sprinters, I do avoid a hamstring graft. Somebody with ligamentous laxity, somebody who's short, harder to harvest a graft, they're gonna have a shorter hamstring in that group. Somebody who has a history of a significant hamstring injury or significant medial side knee injury is somebody I'd probably stay away from a hamstring graft. So this is a 25-year-old, she's a recreational soccer player, not playing elite level. She had non-contact injury about three months ago, planted, twisted, felt a pop in her knee, had immediate pain and swelling. On her exam, she had normal alignment, she had a mild effusion, range of motion, a little bit short of full extension, grade one Lachman, and then she had medial joint line tenderness. Her x-rays otherwise looked normal, MRI, complete ACL tear, and she had a bucket handle medial meniscus tear. Can you move it back one, please? Let's go through the video. So standard incision coming off the tibial tubercle just on the inside. We made this incision a little bit longer to help with visualization for this. I dissect down to the sartorial fascia. At that point, you can palpate along that medial aspect of the joint. You can feel the hamstring tendons. The easiest place to feel them is coming around that posterior corner of the tibia. I make an L incision through the sartorial fascia just above the gracilis, take that over to the tibial crest and distally. And as I elevate that up, you have to be careful of not getting into your superficial MCL. At that point here, we're on the deep side of the sartorial fascia, identifying both the semitendinosus and gracilis. Here's the gracilis tendon right here being identified, semitendinosus just below it. Once I get that freed, I'll free it off using the right angle clamps, free it and then it'll be whip stitch. You have to look for any adhesions that are attached to that. This is where a lot of people get in trouble with hamstring grafts. And then free that up. Usually with good retraction with the Army-Navy there, you can get good visualization back. Whip stitch with number two suture. And once I have the gracilis isolated, I will go ahead and do the same thing with the semitendinosus graft. Here's isolating the semitendinosus in a similar way. Semitendinosus graft can have multiple more adhesions down to the gastroc. And this is where you really have to be careful when you're looking down to make sure you're not going to catch any of those bands. Here in a second in the video, once we get this graft whip stitched, you'll be able to see one of these bands right here. My hand gets out of the way. You'll be able to see the fold right there. There's one of the bands. Tell my residents that's the widow maker. That's the one that you'll harvest a short graft. Harvesting, I like to push rather than pull. First get the gracilis graft, take it to the back table, then do the same thing with the semitendinosus graft. Again using, I just use a closed-ended tendon stripper to do that. I do use a quarter percent bupivacaine up the hamstring and harvest site for pain relief afterwards and that seems to work fairly well. And here's that being injected. As far as we move into graft preparation for this, cleaning off the muscle off the tendon length of the graft. Once that's cleaned off, I'll double the grafts over, measure the size. In this case, we went ahead and doubled it, measured this is a seven and a half millimeter sizing tube. Went through that easily. So we have a small graft, small female working on getting that bigger. In her case, her semitendinosus measured about 27 centimeters to a good length of the graft. Thought that was good tissue. I went ahead and whip stitched it at 27. Here I use a suture tape type suture to give me a little bit bigger graft, or bigger suture to tie that in. The gracilis graft I'll cut down to 18 centimeters. So it's gonna give me about nine, nine and a half centimeter graft in total and it's prepared in the same way. Then once the grafts are prepared, I use just a fixed length loop. I think it is predictable. I don't have to worry about it pulling into the soft tissues. 15 millimeter loop almost all the time works appropriately. Here we're just tying the tape end of the suture into the loop and I bring the graft around. This will give me that three-stranded semitendinosus graft of a length of around nine centimeters. Equal those two ends up and then we'll go ahead and whip stitch the doubled end of the graft. So we basically convert this five-strand graft into a four-strand graft so you can do your normal fixation how you like to do it. So once that's whip stitched, I bring the gracilis graft in with it. It's already been measured so we should be at the same length. You can see that here. I bring it in and then we sort of finish off the graft by just doing a vicral suture to bring all four strands or five strands together into one and then our graft is ready to go. And we keep it with a moistened vancomycin-soaked Raytec at the back table and use later in the case. And here's the size. This is using an eight and a half millimeter sizer here. It's tied over the tibial end of the graft but moved pretty easily over the femoral end so at that point we switched to an eight on that side. So two different size grafts. Here's her knee. This is her ACL tear, femoral sided injury. Her bucketed meniscus has always been reduced and fixed. So we're cleaning up the notch region, clear out the back so I can see for my placement of my tunnels, identifying my tibial tunnel position here, coming off the anterior horno-lateral meniscus in the ACL footprint. I'll mark that, get it set in its position. And then we'll go ahead and establish our accessory medial portal. I want to check where that's coming in full extension. With accessory medial portal drilling, a lot of times I'll bring my drill guide through that especially on a hamstring graft it gets me a little bit lower for my tunnel length. I want to have a tunnel length of about 40 millimeters. Place the 2.4 millimeter guide wire in position, check the knee through extension, make sure I'm looking at an appropriate position. And then once I feel like I'm in a good position arthroscopically, then I'll go ahead and get a lateral fluoroscopic view, just use a mini C-arm at that point. Check its position just behind Blumensot's line, especially with a hamstring tendon graft or a quad tendon graft, you need to make sure you're behind that, it's so anatomic. Drilling the tunnel and then just sort of protecting the back of the tunnel, clearing out some of the soft tissue there, allow the graft to pass easily and smoothing that back edge. And then on the femoral side, I use an over-the-top guide, I'm aiming for about a one millimeter back wall. I'll place it through the accessory medial portal, knee in hyperflexion. And once I've done that, to make sure I get the right spot, I come through that medial portal, check where that guide pin's at. Here I thought it was a little bit high, so when we came in, I came a little bit lower. Again, knee in hyperflexion, drill through my guide pin, and then once I reamed through with a half fluted reamer, doing a hamstring graft, I want to ream to about 20-25 millimeters, make sure I do not blow out the lateral wall at first, using a little cannula to clear out bone debris works great, then breaching that lateral cortex here. Measuring for our tunnel, in this case our tunnel measured about 34 millimeters, you can see it here. We had a good lateral wall, so we felt comfortable with that. You can finish off the drilling, use a fully fluted. So the graft is in part marked, we have a 34 millimeter tunnel, so I mark it at 34 millimeter mark. Then I'll mark it at about the 41 millimeter mark, which tells me my flip distance so I know where I'm at. Here's your final construct of the graft there on a fixed link button. Passing the graft up, passing your passing sutures up, up through the tibial tunnel. As the graft pulled in, if you have your button appropriately placed, the button will go, be able to flip easily on that back cortex. And as you pull the graft in, you want to get to that second line, tells you you're fully seated and the button should flip. Here on the side, you can see my resident, Becca, pulling on that, flipping the graft. And then once the graft's secured, you back pull, you'll feel the toggle go away and you'll see the line come back down to that first line, telling you you have your graft appropriately positioned. And then tibial fixation can be done how you want it. So potential complications and how to avoid those, well the one that we hate the most is the amputation of the tendon. You want to make sure there are no adhesions on the graft, verify, especially on a semi-tendonosis, if you pull on it that you don't have any adhesions back to the gastroc, you'll see the gastroc pull in that situation. You want to make sure you don't disrupt the lateral cortex, be conservative, 20-25 millimeters of drilling initially, all that. If you do blow out the lateral wall, use alternative fixation. You can interference screw, you can use a large button, you can use a screw and washer as a post. And finally tunnel placement, you want to make sure your tibial tunnel's in the appropriate position and then you also want to, and you can get that lateral fluoroscopic view gives a good side. The femoral side, if you look through that accessory medial portal, through your medial portal will give you a good idea where that tunnel is going to be. Again, similar graft failure rate to BTB, improved outcomes with hamstring graft greater than eight millimeters. And there's been no difference in failure with a four-strand versus a five-strand graft when you get greater than an eight millimeter size. You want to decrease anterior knee pain in that group as well and fast regression off crutches and brace. Here are our references, thank you.

hamstring autograft

ACL reconstruction

graft types

donor site mobility

complications