CHA P T E R 62

Hamstring Tendon Autograft for Anterior

Cruciate Ligament Reconstruction
Charles H. Brown, Jr., MD
Neal Chen, MD
Nader Darwich, MD

The success of anterior cruciate ligament (ACL) recon-

struction is influenced by many factors, such as the initial
Preoperative Considerations
tensile properties of the graft tissue, the initial fixation of
the graft, the healing at the graft fixation sites, the biologic History and Physical Examination
remodeling of the graft, and the type of postoperative
rehabilitation program used. Owing to its high initial Patients thought to have an ACL tear should provide
tensile strength and stiffness, ability to be rigidly fixed to detailed history of the initial injury and any subsequent
bone, rapid healing of bone to bone at the graft fixation injuries and their treatment. The diagnosis is confirmed by
sites, and outcome studies documenting predictable success the Lachman and pivot shift tests or by magnetic reso-
in restoration of anterior knee laxity and elimination of nance imaging if needed. It is particularly important to
the pivot shift phenomenon, the central-third patellar recognize associated injuries to the posterolateral and pos-
tendon autograft is considered by many surgeons to be the teromedial structures. Failure to recognize and to treat
“gold standard” for ACL reconstruction. However, because associated patholaxity at the time of the ACL reconstruc-
of the well-documented donor site morbidity associated tion may result in continued complaints of instability or
with the harvest of patellar tendon autografts, improve- failure of the ACL reconstruction.
ments in soft tissue graft fixation techniques, and clinical
outcome studies demonstrating no significant difference
between patellar tendon and hamstring tendon ACL Imaging
reconstructions, four-stranded hamstring tendon auto-
grafts have become an increasingly popular graft choice A preoperative anteroposterior radiograph of the involved
for ACL reconstruction.* In this chapter, we describe our knee in full extension and standing anteroposterior and
current surgical technique for performing ACL recon- posteroanterior 45-degree flexion views of both knees are
struction with autogenous doubled gracilis and semitendi- important to rule out associated bone injury or joint space
nosus tendon (DGST) grafts. narrowing and to assess skeletal maturity of the patient. A
true lateral radiograph of the injured knee in maximum
hyperextension allows measurement of the intercondylar
*References 1, 2, 4, 5, 7, 12, 13, 15, 18, 22, 26, 28, 30. roof–femoral angle, which can be useful for preoperative

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 Surgical Techniques of the Anterior Cruciate Ligament

planning of the tibial tunnel in the sagittal plane. A healing at the graft fixation sites has occurred.4 Because of
Merchant view of both knees is helpful in assessment of the longer time required for hamstring tendon grafts to
patellar alignment and tilt. Full-length standing radio- heal to bone, it is important to use graft fixations that
graphs of both lower extremities from hips to ankles are are strong and stiff and that resist slippage under cyclic
indicated in patients with joint space narrowing to allow loading, to prevent the development of progressive laxity
measurement of the mechanical axis. Combined or staged in the postoperative period. However, at present, the
tibial osteotomy and ACL reconstruction may be indicated optimal graft fixation method for hamstring tendon grafts
in patients with malalignment and symptoms of pain and remains controversial, and there is little consensus as
instability. to what fixation methods produce the best clinical
outcomes.

Indications and Contraindications

Hamstring tendon autografts are indicated for any acute Femoral Fixation Options (Fig. 62-1)
or chronic ACL reconstruction. ACL reconstructions per-
Laboratory biomechanical studies have demonstrated that
formed with hamstring tendon grafts have been shown to
the EndoButton CL and cross pins provide strong femoral
result in faster recovery of quadriceps muscle strength,
fixation with minimal slippage during cyclic loading.6,19
lower incidence of donor site pain, and less interference
Although intertunnel fixation with interference screws is
with kneeling and crawling than after ACL reconstruc-
a popular hamstring tendon graft fixation technique, our
tions performed with patellar tendon autografts.12,18,26
laboratory biomechanical studies have demonstrated that
Because of less interference with kneeling and crawling,
this fixation method is the weakest and has the largest
hamstring tendon grafts are the autogenous graft of choice
amount of slippage during cyclic loading.6,19 We prefer
for patients whose occupation, lifestyle, or religion requires
femoral fixation with the EndoButton CL for the following
“knee walking,” crawling, or kneeling. Hamstring tendon
reasons:
grafts are also our preferred autogenous graft for patients
with a history of extensor mechanism surgery or trauma. ● Fixation strength is high.
We also prefer hamstring tendon grafts for patients with ● Slippage during cyclic loading is minimal.
a history of patellofemoral pain or patellar tendinopathy.
● The fit of the tendon in the bone tunnel is tight.
Finally, hamstring tendon grafts are the autogenous graft
of choice when ACL reconstruction is indicated in patients ● The 360 degrees of contact between the bone tunnel
with open growth plates. wall and the hamstring tendon graft enhances healing.
The only absolute contraindication to use of ham- ● The amount of graft inserted into the femoral tunnel
string tendon grafts for ACL reconstruction is previous can be customized.
harvest of the hamstring tendons. In cases in which prior ● Removal of the implant is not required in revision
pes anserine transfer or open surgical procedures on the cases.
medial side of the knee have been performed, the resulting
● Fixation properties are not dependent on the bone
scarring and alteration of normal tissue planes may com-
quality of the distal femur.
plicate harvest of hamstring tendon grafts. In these situa-
tions, the surgeon may elect to use an alternative autograft
or allograft tissue. Studies demonstrating a significant loss
of knee flexor strength at high flexion angles suggest Tibial Fixation Options (Fig. 62-2)
caution in use of hamstring tendon grafts for athletes such
as gymnasts, wrestlers, sprinters, and American football Tibial fixation is the weak link of ACL graft fixation, and
defensive backs and safeties, who require maximum flexor tibial fixation of hamstring tendon grafts remains prob-
strength at high angles of flexion.9,32 lematic.4 Problems with tibial fixation result primarily
from the lower bone mineral density of the proximal tibia
and the fact that tibial fixation devices must resist shear
forces applied parallel to the axis of the tibial bone tunnel.4
Surgical Planning Cortical fixation techniques can address the issue of the
lower bone mineral density of the proximal tibia. However,
Graft Fixation these implants are often prominent and may cause local
skin irritation and pain and require a second operation for
Rigid initial graft fixation is critical to the success of any removal.24 Intratunnel tibial fixation with interference
ACL reconstruction.4 Attainment of rigid initial graft fixa- screws eliminates the problem of prominent hardware;
tion prevents failure and minimizes elongation at the graft however, laboratory biomechanical studies have shown
fixation sites during cyclic loading of the knee before that this fixation method is the weakest and demonstrates

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 Hamstring Tendon Autograft for Anterior Cruciate Ligament Reconstruction

A B C

62

D E F

Figure 62-1 Femoral fixation options. A, EndoButton CL. B, Bone Mulch screw. C, TransFix. D, RigidFix. E, Bioabsorbable screw. F, EZLoc.

the greatest amount of slippage under cyclic loading.20,24 Surgical Technique

On the basis of its ease of use and of biomechanical studies
that demonstrate high initial fixation strength and stiff- Anesthesia and Positioning
ness with minimal slippage under cyclic loading condi-
tions, we prefer intertunnel tibial fixation with the IntraFix The operation is performed as an outpatient procedure
tibial fastener (DePuy-Mitek, Norwood, Mass).7,19 under general or regional anesthesia. A thigh-length TED

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 Surgical Techniques of the Anterior Cruciate Ligament

A B antiembolism stocking (Kendall Company, Mansfield,

Mass) and a foam rubber heel pad are applied to the well
leg. A padded pneumatic tourniquet is applied high on the
thigh of the operative leg but is rarely used during the
operation. The patient is positioned supine on the operat-
ing room table and given 1 g of a first-generation cephalo-
sporin intravenously followed by a continuous intravenous
infusion of ketorolac at 4 mg/hr. A lead gonad shield is
applied to protect the patient from radiation exposure
during intraoperative fluoroscopy. Our preferred tech-
nique is to position the lower extremity so that a full, free
range of motion can be performed during the procedure.
C D Full unrestricted flexion of the knee is particularly impor-
tant if the femoral tunnel is drilled by the anteromedial
portal technique. We use a padded thigh post and hip
positioner placed at the level of the tourniquet and a
padded, L-shaped footrest that can be moved along the
side rail of the operating room table, allowing the flexion
angle of the knee to be changed during the procedure. The
padded footrest is typically adjusted to maintain the knee
at 90 degrees of flexion without manual assistance. The
padded hip positioner stabilizes the patient’s pelvis and
the padded thigh post acts as a fulcrum to allow applica-
tion of valgus force to the knee, permitting the medial
compartment to be opened for performance of meniscus
surgery (Fig. 62-3). Use of a standard circumferential
E F
arthroscopic leg holder and dropping the foot of the oper-
ating room table limit knee flexion and may compromise
drilling of the femoral tunnel by the anteromedial portal
technique.
After routine iodine skin preparation and sterile
draping, a solution of 5 mg of morphine sulfate plus
20 mL of 0.25% bupivacaine (Marcaine) with 1 : 100,000
epinephrine is injected into the suprapatellar pouch for
pre-emptive analgesia. With the use of a continuous ketor-
olac intravenous infusion and intra-articular administra-
tion of morphine, we have not found it necessary to use
femoral nerve blocks for postoperative pain management.
Use of an infusion pump improves joint distention and
visualization, allowing the procedure to be performed
G H without inflation of the tourniquet.

Specific Steps (Box 62-1)

1. Hamstring Tendon Graft Harvest

Harvest of the hamstring tendons can be performed
through a vertical or oblique skin incision centered over
the tibial insertion of the pes anserine tendons (Fig. 62-4).
When the transtibial tunnel technique is used to drill the
femoral tunnel, it is important to center the vertical skin
incision midway between the anterior tibial crest and the
Figure 62-2 Tibial fixation options. A, AO ligament washers. B, WasherLoc. posteromedial border of the tibia to allow the tibial tunnel
C, Spiked ligament washer. D, Staples. E, Suture-post fixation. to be positioned along the anterior fibers of the medial
F, Bioabsorbable screw. G, IntraFix tibial fastener. H, GTS sleeve
and tapered screw. collateral ligament (MCL). If the femoral tunnel is to be
drilled by the anteromedial portal technique, the vertical

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 Hamstring Tendon Autograft for Anterior Cruciate Ligament Reconstruction

62

B
Figure 62-3 A, The padded thigh post and L-shaped footrest allow the knee to be positioned at 90 degrees of flexion without manual assistance. B, The thigh
post allows full, unrestricted knee flexion during the procedure.

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 Surgical Techniques of the Anterior Cruciate Ligament

Box 62-1 Surgical Steps lines (resulting in a more cosmetic appearance), provides
1. Hamstring tendon graft harvest
better proximal exposure of the tendons, and requires less
skin retraction during drilling of the tibial tunnel. The
2. Graft preparation anatomic course of the infrapatellar branches of the saphe-
3. Arthroscopic portal placement
nous nerve also makes them less vulnerable to injury when
the oblique skin incision is used.31 However, the saphe-
4. Preparation of the intercondylar notch nous nerve can be injured if the oblique skin incision is
5. Femoral tunnel
positioned too close to the posteromedial corner of the
tibia or sharp dissection is extended back into this region.31
6. Tibial tunnel Should premature amputation of the semitendinosus
7. Calculation of EndoButton CL length and graft preparation
tendon occur, the oblique skin incision is not extensile and
an additional skin incision is required to harvest a patellar
8. Graft passage and femoral fixation tendon autograft. We recommend against use of the
9. Graft tensioning
oblique skin incision until experience is gained with
the harvesting technique and the surgeon is able to con-
10. Tibial fixation sistently harvest hamstring tendon grafts of adequate
11. Closure
length.
In the average-size patient, the superior border of
the sartorius tendon is approximately one finger width
Sartorius below the tibial tubercle or three finger widths below the
Adductor magnus tendon
medial joint line (personal observation: the tendons insert
more proximally in Middle Eastern patients). In revision
Infrapatellar branch cases involving a failed primary patellar tendon recon-
saphenous nerve
struction, the distal portion of the previous patellar tendon
Gracilis tendon harvest incision can be extended distally 2 to 3 cm below
the tibial tubercle, allowing simultaneous harvest of the
hamstring tendon grafts and removal of the tibial fixation
hardware.
The skin incision and subcutaneous tissues are infil-
trated with a solution of 0.25% bupivacaine with 1 : 100,000
epinephrine for hemostasis and pre-emptive analgesia. We
routinely harvest the tendon grafts without inflation of the
tourniquet. The sartorius fascia is exposed by sharp and
Fascial sling blunt dissection. We use an inside-out technique to harvest
Semitendinosus the two tendons because this technique gives an excellent
tendon
view of the internal aspect of the pes anserine and allows
Semimembranosus the surgeon to better visualize and to identify any of the
tendon associated anatomic variations or variable tendon attach-
Saphenous nerve ments to the tibia, which are common.21 In the inside-out
technique, the conjoined tibial insertion of the two tendons
Figure 62-4 Hamstring tendon graft harvest skin incisions and anatomic
is detached from the tibia by making an inverted L-shaped
relationships on the medial side of the knee. A vertical or an oblique skin incision through the sartorius fascia. The sartorius fascia
incision can be used to harvest the hamstring tendons. Important features is grasped with an Allis clamp and lifted away from the
to note are the proximity of the vertical incision to the infrapatellar branches
of the saphenous nerve, the proximity of the oblique incision to the
tibia, thus protecting the underlying MCL. The fascia is
saphenous nerve, the relationship of the saphenous nerve to the gracilis incised parallel to the gracilis tendon and the tibial inser-
tendon, the fascial connection between the medial head of the tion of the two tendons is sharply released from the crest
gastrocnemius, and the fascial sling that suspends the semitendinosus
tendon beneath the semimembranous muscle. (From Brown CH, Sklar JH,
of the tibia, revealing the inner aspects of the two tendons
Darwich N. Endoscopic anterior cruciate ligament reconstruction using (Fig. 62-5).
autogenous doubled gracilis and semitendinosus tendons. Tech Knee Surg A right-angled type clamp is used to separate the two
2004;3:217.)
tendons from the undersurface of the sartorius fascial flap,
which is preserved for later closure. The gracilis tendon
skin incision can be positioned closer to the anterior crest is sharply divided and grasped with wide Allis-Adair
of the tibia. This incision is more extensile and can easily tissue forceps (Codman & Shurtleff, Inc., Raynham, Mass).
be extended to harvest a patellar tendon graft should pre- Blunt scissors dissection is used to free the tendon from
mature amputation of the semitendinosus tendon graft the undersurface of the sartorius fascia. It is important to
occur. The oblique skin incision runs parallel to Langer’s bluntly release the interconnecting fascial bands that run

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 Hamstring Tendon Autograft for Anterior Cruciate Ligament Reconstruction

62
Fascial sling
Semitendinosus
tendon
Semimembranosus
tendon
Tendon stripper

Saphenous nerve

Figure 62-6 Passage of the tendon stripper outside of the fascial sling
beneath the semimembranous muscle may result in the tendon stripper’s
Figure 62-5 The inverted L-shaped fascial flap is reflected distally, exposing taking an aberrant path into the thigh and causing premature amputation of
the deep aspect of the two tendons. the semitendinosus graft. (From Brown CH, Sklar JH. Endoscopic anterior
cruciate ligament reconstruction using quadrupled hamstring tendons and
EndoButton femoral fixation. Tech Orthop 1998;13:285.)

between the two tendons. Sharp or scissors dissection

along the superior border of the gracilis should be avoided
to prevent injury to the saphenous nerve, which leaves per passes outside of the tendon’s normal path (Fig. 62-6).7
Hunter canal and crosses over the superior border of the If excessive resistance is encountered in attempting to
gracilis tendon at the posteromedial corner of the knee.31 advance the tendon stripper through this region, it is
Five throws of a running baseball-style whipstitch are tempting to pull harder on the semitendinosus tendon and
placed in the free end of the gracilis tendon with a No. 2 to apply more force to the tendon stripper to advance it.
nonabsorbable suture (Ti•Cron, United States Surgical, However, this can cause the fascial sling beneath the semi-
Norwalk, Conn; Ethibond special order D-5757, Ethicon, membranosus to constrict, making it more difficult to pass
Inc., Somerville, NJ). the tendon stripper. Decreasing tension on the tendon and
Depending on the surgeon’s preference, the tendons “navigating” the tendon stripper through the fascial sling
can be harvested with a slotted tendon stripper, a closed will often lead to success. In a heavily muscled individual,
Brand-type tendon stripper, or a tendon harvester the tendon stripper will often meet resistance at the mus-
(Linvatec, Largo, Fla). The gracilis tendon is harvested by culotendinous junction; this can be overcome by steady
flexing the knee to 90 degrees and advancing the tendon pressure and rotation of the tendon stripper or by use of
stripper parallel to the tendon by a slow, steady, rotating the larger 7.4-mm diameter stripper (Smith & Nephew
motion. The semitendinosus tendon is harvested in a Endoscopy, Andover, Mass). A successful graft harvest
similar fashion; however, there are more extensive fascial typically results in graft lengths of 20 to 26 cm for the
connections that extend from the inferior border of the gracilis and 24 to 30 cm for the semitendinosus tendon.
semitendinosus tendon to the medial head of the gastroc-
nemius.7,31 These fascial connections must be released to 2. Graft Preparation
prevent premature amputation of the semitendinosus Preparation of the hamstring tendon grafts is facilitated by
tendon. use of a graft preparation board (Graft Master II; Smith &
More proximally in the thigh, the surgeon may Nephew Endoscopy). Residual muscle fibers on the proxi-
encounter a second potential troublesome area at a band mal end of both tendons are removed by blunt dissection
of thickened semimembranosus fascia that courses infe- with a metal ruler, a large curet, or a Cushing-type perios-
rior and medial to the semimembranosus tendon.7 This teal elevator. The two tendons are cut to the same length,
thickened band of fascia forms a sling for the semitendi- and the proximal end of each tendon is tubularized with a
nosus tendon, suspending it from the inferior border of running, baseball-style whipstitch of a No. 2 nonabsorbable
the semimembranosus muscle. Premature amputation of suture. The sutures on each end of the tendon grafts are
the semitendinosus tendon can result if the tendon strip- tensioned with a “cinching” motion to remove excess slack

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 Surgical Techniques of the Anterior Cruciate Ligament

Figure 62-7 Doubled gracilis and semitendinosus tendon (DGST) graft. (From Brown CH, Sklar JH, Darwich N. Endoscopic anterior cruciate ligament
reconstruction using autogenous doubled gracilis and semitendinosus tendons. Tech Knee Surg 2004;3:221.)

from the whipstitches. The two tendon grafts are looped

around a No. 5 suture, making a DGST graft (Fig. 62-7).
The diameter of the DGST graft is measured to the nearest
0.5 mm by use of a 0.5-mm incremental sizing block
or sizing tubes. The whipstitches from the gracilis and
semitendinosus tendons on each end of the graft are tied
together approximately 12 cm from the end of the tendon
grafts. This facilitates use of a graft-tensioning device later
in the procedure. The DGST graft is looped around an
EndoButton tensioning post (Smith & Nephew Endos-
copy), and the DGST graft is covered with a moist laparot-
omy pad and pretensioned on the graft preparation board
with 5 to 10 pounds for the remainder of the procedure.

3. Arthroscopic Portal Placement

As recommended by Cohen and Fu,10 we use three portals
for ACL reconstruction (Fig. 62-8). A high anterolateral
portal at the level of the inferior pole of the patella adja-
cent to the lateral border of the patellar tendon is used for
the routine viewing portal. The height of this portal places
the arthroscope above the fat pad and provides an excel-
lent “look down” view of the ACL tibial attachment site.
This portal gives a frontal view of the femoral attachment
site of the ACL and is most helpful in determining the
clock orientation and high-low placement of the femoral
tunnel. An anteromedial portal at the level of the inferior
pole of the patella adjacent to the medial border of the
patellar tendon is used for instrumentation and viewing of
the medial wall of the lateral femoral condyle. This portal
provides a more orthogonal view of the ACL femoral
Figure 62-8 Portal location (right knee).
attachment site and allows more accurate assessment of
shallow-deep femoral tunnel placement (Fig. 62-9).
An accessory medial portal located directly inferior
to the anteromedial portal at the level of the medial joint
line is used for drilling of the femoral tunnel. routine diagnostic arthroscopy is performed, and associ-
ated meniscal and chondral injuries are treated appropri-
4. Preparation of the Intercondylar Notch ately. The torn fibers of the ACL are removed from the
Preparation of the intercondylar notch is necessary to lateral femoral condyle and the tibial attachment site by a
allow visualization of the ACL femoral attachment site. A motorized shaver, electrocautery pencil, or radiofrequency

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 Hamstring Tendon Autograft for Anterior Cruciate Ligament Reconstruction

Transtibial Tunnel Technique Versus Anteromedial

Portal Technique
Hamstring ACL reconstruction can be performed by the
transtibial tunnel or anteromedial portal technique.7,22,25,26,29
Regardless of the surgical technique used, the following
goals must be achieved to optimize the outcome of the
procedure:
● An anatomically positioned, impingement-free tibial
tunnel
● A tibial tunnel with a minimum length of 40 mm
● An orientation of the femoral tunnel at a 9:30- to 10- 62
o’clock position along the sidewall of the lateral
femoral condyle
● A femoral tunnel with a minimum length of 40 mm
Achievement of these goals will eliminate roof im-
A pingement, optimize graft fixation with the EndoButton
CL and IntraFix tibial fastener, and maximize the ability
of a single-tunnel hamstring ACL reconstruction to control
tibial rotation.23
Advantages of the transtibial tunnel technique are
that it is familiar to most surgeons and does not require
the knee to be flexed to 120 degrees during drilling of the
femoral tunnel. Joint distention and the field of view in the
intercondylar notch are compromised when the knee is
flexed to 120 degrees or more, as required with the antero-
medial technique. The transtibial tunnel technique also
tends to produce longer femoral tunnels in the range of 40
to 50 mm. Femoral tunnel lengths in this range are advan-
tageous for the EndoButton CL fixation technique because
they allow a minimum of 25 mm of DGST graft to be
inserted into the femoral socket. Another advantage of
the transtibial tunnel technique is that the length of the
femoral tunnel typically results in the EndoButton
B implant’s resting on the stronger cortical bone of the distal
Figure 62-9 Arthroscopic view of femoral attachment site of the ACL from femur. The major disadvantage of the transtibial tunnel
the anterolateral portal (A) and the anteromedial portal (B). technique is that free positioning of the femoral tunnel in
the intercondylar notch is not possible because the femoral
tunnel location is determined by the axis of the tibial
tunnel.
In the transtibial tunnel technique, the angle of the
probe. We have found that use of a radiofrequency probe tibial tunnel in the coronal plane determines femoral
is faster, allows hemostasis to be achieved, and more com- tunnel length and the position of the ACL graft in the
pletely removes the soft tissue along the lateral wall of the intercondylar notch (Fig. 62-10).7 Laboratory biomechan-
intercondylar notch, providing better visualization of the ical studies have demonstrated that single-tunnel ACL
bone anatomy. Use of the anteromedial portal technique grafts placed at the 10-o’clock position provide better rota-
allows the femoral tunnel to be positioned lower down the tional control as compared with ACL grafts at the 11-
sidewall of the lateral femoral condyle, resulting in a more o’clock position.23 For the femoral tunnel to be positioned
horizontal orientation of the ACL graft. A more horizon- at the 10-o’clock location, the tibial guide pin must be
tal ACL graft avoids posterior cruciate ligament impinge- started adjacent to the anterior fibers of the MCL7 (Fig.
ment and in most cases eliminates the need for notchplasty. 62-11). However, in some cases, even when these recom-
However, a selective notchplasty may be required in the mendations are followed, it may not be possible to place
case of congenitally narrowed notches or in chronic cases the femoral tunnel at the desired position. When faced
with notch stenosis due to the development of notch with this situation, we recommend switching to the antero-
osteophytes. medial portal technique to avoid malpositioning of the

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 Surgical Techniques of the Anterior Cruciate Ligament

Advantages of the anteromedial portal technique include

the following:
● The ability to position the femoral tunnel in a more
anatomic position lower down the sidewall of the
lateral femoral condyle
● The freedom to locate the starting position of the
tibial tunnel anywhere along the medial surface of the
tibia
● The freedom to drill a steeper and therefore longer
tibial tunnel
● The possibility of drilling the femoral tunnel before
drilling the tibial tunnel, which helps maintain joint
distention, improving joint visualization during the
remainder of the procedure
However, the anteromedial portal technique requires
the knee to be flexed 120 degrees or more during the
drilling of the femoral tunnel, which limits joint distention
and provides a more unconventional field of view in
the notch that can result in spatial disorientation.23,29
The anteromedial portal technique also tends to produce
a more horizontal femoral tunnel that results in the
EndoButton implant’s lying on the weaker metaphyseal
bone of the distal femur.8 In our opinion, the ability
of the anteromedial portal technique to allow a more
anatomic placement of the femoral tunnel far outweighs
its few disadvantages. For this reason, the anteromedial
C
portal technique for femoral tunnel drilling has become
B our preferred surgical technique for performing ACL
A reconstruction.

5. Femoral Tunnel
Use of the low accessory medial portal for drilling of the
femoral tunnel allows a longer femoral tunnel to be
achieved than does drilling through the anteromedial
Figure 62-10 Effect of tibial tunnel starting position on femoral tunnel portal. The resulting longer femoral tunnel is more advan-
length. Tibial tunnel starting position close to the tibial tubercle (A) results
in a long, vertically oriented femoral tunnel that requires a long continuous-
tageous for femoral fixation with the EndoButton CL. The
loop length. A long continuous loop decreases stiffness of the femur– location for the accessory medial portal is made by an 18-
EndoButton CL–hamstring tendon complex. Tibial tunnel starting position gauge spinal needle. This portal is located as low as possi-
midway between the tibial tubercle and the anterior fibers of the MCL (B)
typically results in a femoral tunnel length of 50 to 60 mm. Tibial tunnel
ble just above the medial joint line. Placement of the portal
starting position at the anterior fibers of the MCL (C) typically results in a too medially produces a shorter femoral tunnel and risks
femoral tunnel length of 40 to 50 mm. (From Brown CH, Sklar JH. injury to the medial femoral condyle by the endos-
Endoscopic anterior cruciate ligament reconstruction using quadrupled
hamstring tendons and EndoButton femoral fixation. Tech Orthop
copic drill bit during drilling of the femoral tunnel. The
1998;13:288.) accessory medial portal is established under direct vision
with a No. 11 knife blade, with care taken to avoid
injury to the medial meniscus. Dilation of the portal
ACL graft. For a detailed description of hamstring ACL with the blunt arthroscope obturator followed by the tips
reconstruction performed by the transtibial tunnel techni- of the Metzenbaum scissors helps ease future passage of
que, we refer the reader to our previously published instrumentation.
technique.7 A microfracture awl is passed through the accessory
In the anteromedial portal technique, the femoral medial portal and used to mark the starting point for the
tunnel is drilled through the anteromedial portal or an femoral tunnel under arthroscopic guidance. Correct
accessory anteromedial portal.23,29 Because the femoral placement of the awl along the lateral wall of the intercon-
tunnel is made independently of the tibial tunnel, free dylar notch can be verified by intraoperative fluoroscopy
placement in the intercondylar notch is always possible. with the radiographic quadrant method.3 Fine tuning of

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 Hamstring Tendon Autograft for Anterior Cruciate Ligament Reconstruction

A B C

62

Figure 62-11 A, Tibial tunnel starting position at the anterior fibers of the MCL results in a femoral starting point at the 10-o’clock position (central portion of
the ACL footprint). B, Tibial tunnel starting position midway between the anterior fibers of the MCL and the tibial tubercle results in a femoral starting point at
the 11-o’clock position (attachment site of the anteromedial fibers). C, Tibial tunnel starting position close to the tibial tubercle results in a femoral starting
point high in the intercondylar notch outside of the ACL footprint. (Redrawn from Brown CH, Sklar JH, Darwich N. Endoscopic anterior cruciate ligament
reconstruction using autogenous doubled gracilis and semitendinosus tendons. Tech Knee Surg 2004;3:222.)

the awl’s position is performed under fluoroscopic guid- procedure to pass the hamstring tendon graft. Because
ance. Additional confirmation of the correct starting point cylindric hamstring tendon grafts contact the entire edge
can be made by viewing the tip of the awl through the of the femoral tunnel during cyclic motion of the knee, it
anteromedial portal (Fig. 62-12). is extremely important to bevel or chamfer the tunnel
A 4- or 5-mm offset femoral aimer is passed through edges with a rasp to minimize graft abrasion.
the accessory medial portal, and the knee is slowly flexed
to 120 degrees. The blade of the femoral offset aimer is 6. Tibial Tunnel
placed in the over-the-top position, and a 2.7-mm drill- In our surgical technique, a tibial tunnel length of 40 to
tipped guide pin is positioned at the site of the microfrac- 50 mm is optimal; this range will allow the 30-mm-long
ture awl penetration mark. Fluoroscopy can be used to IntraFix sheath to be inserted flush with the tibial cortex,
check the guide pin placement. The knee is slowly brought with no risk that the sheath will protrude into the intra-
into full flexion, and line of sight is used to verify that the articular portion of the knee joint. Setting the adjustable
guide pin will exit the lateral thigh above the intermuscular tibial aimer between 50 and 55 degrees will usually allow
septum. The 2.7-mm drill-tipped guide wire is drilled out these tunnel lengths to be achieved. The starting location
through the soft tissues of the lateral thigh (Fig. 62-13). of the tibial guide pin along the medial surface of the tibia
Inadequate knee flexion can result in the guide pin’s coming is not critical when the anteromedial portal technique is
to lie inferior to the intermuscular septum, placing the used. The anterior horn of the lateral meniscus, the medial
peroneal nerve at risk. A 4.5-mm EndoButton drill bit and lateral tibial spines, and the posterior cruciate liga-
(Smith & Nephew Endoscopy) is used to drill a channel ment are used as landmarks to locate the intra-articular
through the lateral femoral cortex. A closed-end femoral position of the tibial guide pin (Fig. 62-15). It is extremely
socket is drilled with the appropriately sized, calibrated helpful to use fluoroscopy to ensure correct placement of
endoscopic 0.5-mm drill bit (Fig. 62-14). The femoral the tibial guide pin. With the knee in maximum extension,
socket depth must allow for the length of the DGST graft a true lateral fluoroscopic view of the knee with the femoral
to be inserted into the femur (usually 25 to 30 mm) plus condyles overlapping is obtained. The tip of the guide pin
an extra 6 mm to allow the EndoButton to clear the lateral should be parallel to and 2 mm posterior to Blumensaat’s
femoral cortex and to flip. An EndoButton depth gauge line (Fig. 62-16). An offset parallel drill guide can be used
(Smith & Nephew Endoscopy) inserted through the acces- to reposition the guide pin if necessary. To prevent anterior
sory medial portal is used to measure the femoral tunnel drift of the tibial tunnel, a cannulated, rear-entry–style,
length. A loop of No. 5 nonabsorbable suture is inserted 0.5-mm drill bit is used to drill the tibial tunnel. Half-
into the eyelet of the passing pin, and the ends of the suture round or angled ACL chamfering rasps are used to smooth
are passed out of the lateral thigh. The loop of No. 5 suture the intra-articular edges of the tibial tunnel to minimize
is passed into the joint and positioned at the entrance to graft abrasion. Soft tissue around the superior edge of the
the femoral tunnel. This suture will be used later in the Text continued on p. 633.

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 A

C
Figure 62-12 A, Microfracture awl introduced through the accessory medial portal is used to establish a starting point for the femoral tunnel (view through the
anterolateral portal). B, Fluoroscopy is used to orient the starting point for the femoral tunnel. C, Digital fluoroscopic images can be captured with an Image
Capture System. The radiographic quadrant of Bernard et al3 can be used to determine the optimal starting point for the femoral tunnel. According to this
630 method, the starting point for the femoral guide pin should be in the distal corner of the posterior superior quadrant. D, Fine adjustments of the starting point
can be made by viewing the awl through the anteromedial portal. Viewing through this portal gives better shallow-deep spatial orientation in the notch.

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 Hamstring Tendon Autograft for Anterior Cruciate Ligament Reconstruction

62

A B

C
D
Figure 62-13 A, Femoral offset aimer is introduced through the accessory medial portal; the tip of the aimer is positioned at the previously marked starting
point. B, Fluoroscopy can be used to confirm the starting point for the femoral guide pin. C and D, The femoral guide pin is drilled out through the lateral soft
tissues with the knee in full flexion.

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 Surgical Techniques of the Anterior Cruciate Ligament

B
Figure 62-14 A, Femoral tunnel viewed through the anterolateral portal with
the knee at 90 degrees of flexion. B, Femoral tunnel viewed through the
anteromedial portal with the knee at 90 degrees of flexion.

B
Figure 62-16 A, To ensure correct placement of the tibial guide pin,
fluoroscopy is used to obtain a true lateral view with the knee in maximum
hyperextension. B, The guide pin should lie 2 mm posterior to and parallel to
Blumensaat’s line.

Figure 62-15 The tibial guide pin should be positioned halfway between the
medial and lateral tibial spines along a line connecting the anterior horn of
the lateral meniscus and the medial tibial spine.

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 Hamstring Tendon Autograft for Anterior Cruciate Ligament Reconstruction

tibial tunnel is cleared with an electrocautery pencil and a Tension is applied to the hamstring tendon graft,
Cobb periosteal elevator in preparation for insertion of the and the previously placed mark at the insertion length will
IntraFix tibial fastener. be seen to slide back down the femoral tunnel. If the mea-
surements are correct, this mark should lie at the entrance
7. Calculation of EndoButton CL Length and of the femoral tunnel. If it should become necessary to
Graft Preparation remove the graft, the No. 5 passing suture on the Endo-
The required continuous-loop length is calculated by sub- Button can be pulled proximally, tipping the EndoButton
tracting the amount of graft to be inserted into the femoral away from the femoral cortex. The No. 5 safety suture that
socket from the directly measured femoral tunnel length. exited the tibial tunnel is pulled, tipping the opposite end
For example, assuming the femoral tunnel length measures of the EndoButton into the 4.5-mm tunnel. The EndoBut-
48 mm, and 30 mm of DGST graft has been chosen to ton will then disengage from the femoral cortex, and the
be inserted into the femoral tunnel, the required conti- graft can be removed by applying tension to the whip- 62
nuous-loop length is calculated as follows: 48 mm − stitches on the tibial end of the graft.
30 mm = 18 mm. Because the continuous-loop lengths
come in 5-mm increments, a 15- or 20-mm-loop comes 9. Graft Tensioning
closest to the calculated length. In general, we prefer to use The opposite ends of the hamstring tendon graft are
the shortest possible continuous loop because this increases applied to a graft-tensioning device (Smith & Nephew
the stiffness of the femur–EndoButton CL–DGST graft Endoscopy), and a preload of 80 to 100 N is applied to the
complex. In the example cited before, we would choose graft. The tensioning device is designed to apply equal
a 15-mm length of loop. The appropriate length of tension to each end of the four-stranded hamstring tendon
EndoButton CL is selected and placed in the EndoButton graft and to spread the tendons apart, allowing easier
holder (Smith & Nephew Endoscopy), and the axilla of the insertion of the IntraFix tibial fastener. Application of
DGST graft is passed through the continuous loop. The equal tension to all four limbs of the hamstring tendon
two ends of the DGST graft are equalized in length and graft optimizes initial fixation strength and stiffness.16 The
pretensioned to 10 pounds on the graft preparation board. knee is cycled from 0 to 90 degrees for a minimum of 30
The graft is marked with a surgical marking pen at the cycles, with a preload of 80 to 100 N applied to the graft
measured femoral tunnel length. A full-length No. 2 flip- by the tensioning device. Application of a preload and
ping suture and a No. 5 passing suture are passed through cycling of the knee are important steps as they allow the
the end holes of the EndoButton. A second No. 5 suture EndoButton CL to settle on the femoral cortex and remove
can be inserted into the same hole as the No. 2 flipping creep from the polyester continuous loop, the tendon
suture and passed alongside the graft and out of the tibial whipstitches, and the hamstring graft. At present, the
tunnel. If necessary, this “safety suture” can be used to dis- optimal graft tension and knee flexion angle during tibial
engage the EndoButton from the distal femur, allowing the fixation are unknown. Depending on the graft excursion
hamstring tendon graft to be removed from the knee. pattern detected in cycling of the knee, we tend to fix the
graft with the knee positioned between 0 and 20 degrees
8. Graft Passage and Femoral Fixation of flexion. The usual graft excursion pattern detected with
The loop of No. 5 suture is retrieved from the femoral our bone tunnel placements results in pulling of the DGST
tunnel and pulled out of the tibial tunnel. The No. 2 flip- graft into the tibial tunnel (tightening) during the last 20
ping suture and No. 5 passing suture are passed through degrees of terminal extension. When there is minimal graft
the loop of the No. 5 suture and pulled out the lateral excursion detected, we tend to fix the graft with the knee
thigh. Under arthroscopic visualization, the EndoButton at 20 degrees of flexion and near full extension with greater
and the attached hamstring tendon graft are passed across excursions. Because of the high fixation strength and stiff-
the joint and into the femoral socket by use of the No. 5 ness and the resistance to slippage of the IntraFix tibial
passing suture. The DGST graft must be advanced until fastener, we caution against applying excessive tension
the previously placed insertion mark is seen to pass up into (>80 N) to the graft or fixing the knee at a flexion angle of
the femoral socket a distance of a few millimeters. This more than 20 degrees. A high graft tension force in com-
extra distance allows the EndoButton to pass outside the bination with the knee flexed more than 20 degrees may
lateral femoral cortex and to flip. The No. 2 flipping suture result in a permanent flexion contracture.
is pulled in a proximal direction, parallel to the femoral
tunnel, and the EndoButton will be felt to flip against the 10. Tibial Fixation
lateral femoral cortex. Correct deployment can be verified Although the IntraFix tibial fastener is available as a bioab-
by pulling on the No. 2 sutures and feeling the EndoBut- sorbable implant, we continue to prefer the original Delrin
ton “teeter-totter” against the lateral femoral cortex. If any plastic version. The bioabsorbable version requires more
doubts exist about secure deployment of the EndoButton, precise sizing and a larger number of implants, increasing
fluoroscopy can be used to check the position of the inventory. In addition, the bioabsorbable screw can break,
EndoButton. leaving the surgeon with a difficult salvage situation.

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 Surgical Techniques of the Anterior Cruciate Ligament

Concentric placement of the IntraFix tibial fastener

is critical to the success of the technique and starts with
the identification of the central axis of the tibial tunnel.
The central axis of the tibial tunnel is identified by passing
a 1.1-mm guide wire up the center of the tensioning device
and down the center of the four graft strands into the knee
joint. Once the central axis of the tibial tunnel is identified,
the tensioner should be held in this orientation during the
subsequent steps to avoid divergent placement of the
implant. The four-quadrant trial dilator is inserted down
the center of the four hamstring tendon strands and ori-
ented so that each graft strand sits in its own channel.
While the desired tension is maintained on the hamstring
graft, the four-quadrant trial dilator is tapped into the
tibial tunnel for a distance of 30 to 35 mm. This step com-
presses and separates the four tendon strands and notches
the bone tunnel wall to receive the 30-mm IntraFix
sheath.
The 30-mm IntraFix sheath is placed on the sheath
inserter with the derotational tab on the sheath oriented
to match the tab on the sheath inserter. The knee is posi-
tioned at the chosen flexion angle, and a final tension of
60 to 80 N is applied to the DGST graft by use of the
tensioning device. It is important to maintain the chosen
Figure 62-17 Insertion of the 30-mm IntraFix sheath. The 30-mm IntraFix
flexion angle and desired graft tension during the subse- sheath is inserted down the center of the DGST graft, parallel to the axis of
quent steps. The IntraFix sheath is inserted between the the tibial tunnel, with each tendon graft strand positioned in its own
channel.
four graft strands, making sure that each graft strand is
positioned into a separate channel of the sheath with the
derotational tab on the sheath oriented at the 3-o’clock or
9-o’clock position. Orientation of the derotational tab at
these positions allows the IntraFix sheath to be inserted
more deeply into the tibia, avoiding prominence. The
IntraFix sheath is tapped into the bone until the derota-
tional tab is inserted flush with the cortex (Fig. 62-17).
The sheath inserter is removed, and the 0.042-inch
guide wire for the tapered screw is inserted through the
center of the sheath until a loss of resistance is felt as the
tip of the guide wire enters the knee joint.
An IntraFix tapered screw size of 1 mm larger than
the tibial tunnel diameter is chosen. For example, we use
a 7- to 9-mm tapered screw for an 8-mm tibial tunnel.
Given the typical size of most DGST grafts, the 7- to 9-
mm tapered screw is most commonly used. While tension
is maintained on the DGST graft, the IntraFix tapered Figure 62-18 Insertion of the IntraFix tapered screw. With the knee at the
chosen flexion angle, tension is maintained on the graft strands by the graft-
screw is inserted into the sheath until the superior aspect tensioning device, and the IntraFix tapered screw is inserted along the guide
of the screw head is flush with or buried just below the wire into the IntraFix sheath.
tibial cortex (Fig. 62-18). The best bone quality is at or
next to the tibial cortex, and overly deep insertion of the
screw may decrease fixation strength.5 Protruding or
prominent areas of the polyethylene sheath are trimmed has soft bone, we recommend that supplemental tibial
flush with the tibial cortex with a No. 15 blade and a small fixation be used. Depending on the length of the DGST
bone rongeur. graft, the protruding tendons can be stapled below the
The fixation strength of any intratunnel tibial fixa- tibial tunnel with a small barbed staple (Smith & Nephew
tion device depends on the local bone mineral density.4,20,24 Orthopaedics, Memphis, Tenn), or the tendon whip-
If the surgeon thinks that there was inadequate torque stitches can be tied around an extra-small nonbarbed
during the insertion of the tapered screw or if the patient staple or tibial fixation post.

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 Hamstring Tendon Autograft for Anterior Cruciate Ligament Reconstruction

62

Figure 62-19 Arthroscopic appearance of the DGST graft. The femoral

attachment site of the graft is located along the side wall of the lateral
femoral condyle, and the graft is oriented at a 10-o’clock position in the
notch.

The stability and range of motion of the knee are

checked. It is important to verify that the patient has full
range of motion before leaving the operating room. The
arthroscope is inserted into the knee, and graft tension and
impingement are assessed. Our usual graft placement and
tensioning technique result in the four strands of the
DGST graft being maximally tight between 0 and 20 A
degrees, with the graft tension decreasing slightly as the
knee is flexed to 90 degrees (Fig. 62-19). After confirma- Figure 62-20 Postoperataive radiographs. A, Proper tibial tunnel placement
results in placement of the EndoButton at the flare of the distal femur. A
tion that the patient has a full range of motion and nega- small staple was used for supplemental tibial fixation in this case.
tive Lachman and pivot shift test results, the passing and
flipping sutures are pulled out of the lateral thigh.

11. Closure
A closed suction drain is inserted under the sartorius removed when the patient is discharged from the day-
fascia up into the hamstring harvest site and is helpful surgery unit.
in preventing postoperative hematoma formation and
decreasing ecchymosis along the medial side of the knee.
The sartorius fascia that was preserved during the graft
harvest is repaired back to the tibia with a 0 absorbable Postoperative Management
suture. The subcutaneous tissue is closed in layers with
fine absorbable sutures. A running 3-0 Prolene subcuticu-
Follow-up
lar pullout suture produces a cosmetic closure. A second
solution of 5 mg of morphine sulfate plus 20 mL of 0.25%
The patient is seen at 7 to 10 days for suture removal and
bupivacaine with 1 : 100,000 epinephrine is injected into
postoperative radiographs (Fig. 62-20).
the suprapatellar pouch, and a 30-mg bolus of ketorolac is
given for postoperative pain control. The continuous intra-
venous ketorolac infusion is continued until the patient is
discharged from the day-surgery unit. A light dressing is Rehabilitation
applied over the wound, followed by a thigh-length TED
antiembolism stocking, Cryo/Cuff (DJ Orthopedics, Vista, Our postoperative rehabilitation protocol is described in
Calif ), and knee immobilizer. The Hemovac drain is Table 62-1. The weight-bearing schedule is modified if a

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 Surgical Techniques of the Anterior Cruciate Ligament

B
C
Figure 62-20, cont’d B, Lateral radiograph in maximum hyperextension. The
tibial tunnel is parallel and posterior to Blumensaat’s line.

meniscus repair, microfracture, or other associated liga-

mentous surgery has been performed.

Complications

The risks of complications such as infection, deep venous

thrombosis, and loss of motion are the same as for ACL D
reconstructions performed with other graft sources.
However, we are unaware of reports of extensor mecha- Figure 62-21 Technique for preparation of a triple-stranded semitendinosus
graft. A, Semitendinosus graft with No. 2 nonabsorbable whipstitches placed
nism rupture or patellar fracture after ACL reconstruction at each end. B, The appropriate-length EndoButton CL is tied to one end of
performed with hamstring tendon grafts. Complications the semitendinosus graft, and the other end of the semitendinosus tendon
unique to hamstring tendon grafts include premature is tied to EndoButton tape (Smith & Nephew Endoscopy). C, The end of the
semitendinosus graft with the EndoButton tape is looped through the
amputation of the hamstring tendons, saphenous nerve EndoButton CL and the EndoButton tape is passed through the resulting
injury, bleeding at the hamstring tendon harvest site, and loop of semitendinosus graft, making a three-stranded semitendinosus graft.
hamstring muscle “pulls.” D, Final appearance of a triple-stranded semitendinosus graft. (From Brown
CH, Sklar JH, Darwich N. Endoscopic anterior cruciate ligament
The risk of premature amputation of the tendons reconstruction using autogenous doubled gracilis and semitendinosus
can be minimized by following the recommendations out- tendons. Tech Knee Surg 2004;3:233.)
lined in the section on graft harvest. If the gracilis tendon
is amputated but the semitendinosus is successfully har-
vested, it is possible in most cases either to triple or to around a fixation post or an extra-small nonbarbed staple.
quadruple the semitendinosus tendon, depending on its If necessary, the tibial fixation can be augmented with a
length (Fig. 62-21). In these situations, the EndoButton 25- to 30-mm bioabsorbable screw with a diameter 1 mm
CL can still be used for femoral fixation; however, because greater than that of the tibial tunnel. If the semiten-
of the shorter length of the graft construct, alternative dinosus tendon is amputated, it will be necessary to use
tibial fixation is obtained by tying the EndoButton tape an alternative autograft, such as the patellar tendon or

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 Hamstring Tendon Autograft for Anterior Cruciate Ligament Reconstruction

Table 62-1 Postoperative Rehabilitation Protocol for Hamstring ACL Reconstruction

Goals Exercises

Phase I: Days 0-7

Control pain, inflammation, joint effusion, swelling Knee Cryo/Cuff, thigh-length TED stocking, elevation

Full passive extension equal to that of the opposite Heel props, pull knee into hyperextension with elastic band
knee

Achieve 90-degree flexion Wall slides, gravity-assisted flexion sitting on the edge of a table

Prevent quadriceps shutdown Electrical muscle stimulation, quad isometrics, straight-leg raises, active
assisted extension 90-0 degrees 62
Prevent heel cord contracture Ankle pumps, calf stretches with elastic bands

Gait training Weight bearing as tolerated with knee immobilizer and crutches; meniscus
repair, revisions: ↑25% body weight/week, wean off crutches at end of
week 4

Phase II: Weeks 1-2

Control inflammation, pain, joint effusion, swelling Continue phase I exercises

Maintain full symmetric extension Continue phase I exercises

Achieve 100-125 degrees of flexion Assisted flexion with use of opposite leg, wall slides, heel drags, rolling stool

Develop muscle control to be safely weaned off Continue phase I exercises, mini-squats, toe raises, active extension 90-30
knee immobilizer and crutches degrees

Protect hamstring donor site Prevent sudden, forceful hamstring stretching with the knee and hip in
extension, such as attempting to lean forward to put on socks and shoes or
leaning forward to pick up an object off the floor

Phase III: Weeks 2-4

Maintain symmetric extension Heel props, prone heel hangs, lock knee out, “stand at attention”
Patients who fail to obtain symmetric extension should be considered for
extension splinting or a “drop-out” cast

Wean off knee immobilizer Discard immobilizer when straight-leg raises are performed without a quad lag

Wean off crutches One crutch with ability to bear 75% of body weight; discard crutches with full
weight bearing and ability to walk with normal heel-toe gait

Achieve 125-135 degrees of flexion Heel slides, sitting back on heels

Hamstring strengthening Hamstring isometrics 0-90 degrees, pull rolling stool backward

Quadriceps strengthening Continue phase II exercises, mini-squats with elastic band for resistance

Hip strengthening Side-lying hip abduction, adjustable-angle hip machine

Proprioceptive training Balance board double-leg stance

Aerobic conditioning Elliptical machine

Phase IV: Weeks 4-6

Obtain full flexion Heel slides, sitting back on heels

Continue quadriceps, hamstring, and hip Mini-squats, leg press 50-0 degrees, front step-ups (control hip valgus),
strengthening StairMaster backward, proprioceptive neuromuscular facilitation, toe raises,
seated leg-curl machine 0-90 degrees

Proprioceptive training Balance board double- and single-leg stance, add ball throws and catches

Aerobic conditioning Stationary bike (adjust to protect patellofemoral joint), elliptical machine, pool
exercises
Continued on overleaf.
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 Surgical Techniques of the Anterior Cruciate Ligament

Table 62-1 Postoperative Rehabilitation Protocol for Hamstring ACL Reconstruction—cont’d

Goals Exercises

Phase V: Weeks 6-12

Increase lower extremity strength and endurance Increase intensity of phase IV exercises, high-speed (300-360 degrees/sec)
isokinetics, extension (90-30 degrees), flexion (0-90 degrees), elliptical
machine, StairMaster backward and forward, treadmill walking, pool exercises

Advance proprioceptive and perturbation training Increase intensity of phase IV exercises

Phase VI: Weeks 12-16

Increase quad and hamstring strength Increase intensity of phase IV exercises, midrange (180-240 degrees/sec)
isokinetics, extension (90-30 degrees), flexion (0-90 degrees)

Increase hamstring strength at high flexion angles Prone leg curls with elastic tubing and leg-curl machine (90-120 degrees)

Jogging and running Treadmill jogging and running, outdoor running on low-impact surface

Crossover drills Lateral step-over, carioca drills

Phase VI: Weeks 16-24

Hard cutting and sports-specific drills Figure-of-eight, circle run, plyometrics, hopping, jumping, sprinting

Return to noncontact sports at 4-5 months Golf, tennis, biking, hiking

Return to full sports at 6 months (revisions, 9

months)

quadriceps tendon, or allograft tissue if preoperative informed consent process, and the patient and surgeon
consent has been obtained. The possibility of premature should agree on a course of action should this complica-
amputation of the tendons should be discussed during the tion occur.

PEARLS AND PITFALLS ● Drilling the femoral tunnel first minimizes fluid extravasation, maintains
joint distention to improve visualization, and minimizes use of the
● Before detaching the conjoined tibial insertion of the two tendons and tourniquet.
their dissection off the tibia, it is important to clearly identify and to ● Use fluoroscopy to confirm the femoral tunnel starting point.
bluntly separate the tendons from the underlying MCL. Failure to do so
● Make adjustments to the femoral tunnel starting position by viewing
may result in the mistaken dissection of the MCL off the tibia.
through the anteromedial portal.
● Leaving the distal 5 mm of each tendon attached to the fascial
● The knee must be flexed 120 degrees or more when the anteromedial
flap makes reattachment of the flap easier at the end of the
portal technique is used.
procedure.
● The femoral tunnel length can be increased by drilling the femoral guide
● Apply firm traction to the tendon whipstitches to release any of
pin into the lateral femoral condyle a distance of 2 to 3 mm, then
the remaining fascial connections before harvest of the tendon
angulating the femoral offset aimer toward the midline of the knee.
grafts.
● Increasing the infusion pump pressure when the knee is fully flexed can
● Complete release of the fascial connections to the medial head of the
improve visualization in the notch.
gastrocnemius can be verified by the absence of tethering of the
muscle and bowing of the tendon when traction is applied to the ● Visualization can be improved during drilling of the femoral tunnel by

whipstitch. suctioning debris out of the joint with use of a shaver placed through
the anteromedial portal.

Results stability and result in higher postoperative activity levels.

However, these studies included some series in which older
Historical perceptions of hamstring ACL reconstructions hamstring fixation methods and two-stranded hamstring
are that they produce unpredictable objective stability, tendon grafts were used. Prospective randomized controlled
tend to stretch out with time, and are not as good as recon- studies comparing quadrupled hamstrings with bone–
struction with a patellar tendon graft. patellar tendon–bone reconstructions have demonstrated
Meta-analyses of Yunes et al33 and Freedman et al14 no significant differences in laxity or in clinical outcome
concluded that patellar tendon autografts produce greater measures at early follow-up.1,2,13,15,22,26,30 A meta-analysis

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 Hamstring Tendon Autograft for Anterior Cruciate Ligament Reconstruction

performed by Prodromos et al,28 in which the results were tion resulted in higher stability rates than did all other
stratified by graft and fixation type, demonstrated that four- graft-fixation combinations. When the literature is carefully
stranded hamstring tendon grafts had overall stability rates analyzed, four-stranded hamstring ACL reconstruction
equal to or higher than those of patellar tendon grafts. This with second-generation fixation is comparable to patellar
study also demonstrated that the four-stranded hamstring tendon autograft reconstruction, and current preconcep-
stability rates were fixation dependent; series using Endo- tions regarding four-stranded hamstring ACL reconstruc-
Button femoral fixation and second-generation tibial fixa- tions may be a historical artifact (Table 62-2).

Table 62-2 Outcomes for Four-Stranded Hamstring ACL Reconstructions

Author Year Average Manual Clinical Outcome Donor Site Morbidity

Follow-up Max KT
£ 2 mm
62
EndoButton Femoral Fixation with Second-Generation Tibial Fixation

Cooley et al11 2001 5.7 years 100% 85% IKDC score normal or nearly normal 24% increased PF
crepitus

Eriksson et al12 2001 33 months STG, 43% Lysholm score increased from 61 to 86 STG and PT PF pain
Prospective PT, 48% 58% IKDC score normal or nearly normal scores NS
randomized NS Lysholm and Tegner scores, range of motion, Kneeling pain:
STG vs. PT laxity NS from PT PT > STG

Feller and 2003 3 years 85% 93% IKDC score normal or nearly normal Kneeling pain: STG,
Webster13 PT greater extension deficit; quad strength, 26%; PT, 67%
Prospective activity levels NS from PT
randomized
STG vs. PT

Gobbi et al15 2003 3 years 90% Lysholm score, 91 Kneeling pain, 7%

72% IKDC score normal or nearly normal 10% mild PF crepitus

Gobbi 2005 3 years ST, 88% Lysholm score: ST, 92; STG, 94 Kneeling pain, 3%
ST vs. STG STG, 89% 94% IKDC score normal or nearly normal 10% mild PF crepitus
8% required hardware removal

Prodromos et al27 2005 4.5 years 86% Lysholm score, 95 PF crepitus: mild,
72% IKDC normal or nearly normal 20%; moderate,
No difference between males and females in 3%
Lysholm score or KT laxity scores
No patient required hardware removal

Cross-Pin Femoral Fixation

Aglietti et al1 2004 2 years STG, 57% IKDC score normal: STG, 57%; PT, 63% (NS) PF symptoms: NS
Prospective PT, 65% Range of motion, quad and hamstring Kneeling pain: STG,
randomized NS strength, postoperative activity levels NS 15%; PT, 62%
STG vs. PT

Harilainen et al17 2005 2 years STG, 72% 88% negative pivot shift Not reported
Prospective PT, 62% Lysholm score, 96
randomized NS 85% IKDC score normal or nearly normal
STG vs. PT Knee scores, range of motion, quad and
hamstring strength NS
STG: 58% required removal of tibial fixation
hardware

Fabbriciani 2005 2 years 61% 90% IKDC score normal or nearly normal Not reported

IKDC, International Knee Documentation Committee; PF, patellofemoral; PT, patellar tendon; NS, not significant; ST, semitendinosus tendon; STG,
semitendinosus tendon and gracilis construct.

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 Surgical Techniques of the Anterior Cruciate Ligament

References

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