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COPYRIGHT © 2005 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED

Anterior Cruciate Ligament

Reconstruction with a
Four-Strand Hamstring
Tendon Autograft
Surgical Technique
By Riley J. Williams III, MD, Jon Hyman, MD, Frank Petrigliano, MD, Tamara Rozental, MD,
and Thomas L. Wickiewicz, MD
Investigation performed by the Sports Medicine and Shoulder Service at The Hospital for Special Surgery,
Weill Cornell Medical College, New York, NY
The original scientific article in which the surgical technique was presented was published in JBJS Vol. 86-A, pp. 225-232, February 2004

INTRODUCTION ABSTRACT
Anterior knee instability associated with rupture
of the anterior cruciate ligament is a disabling BACKGROUND:
clinical problem, especially in the athletic
In this study, we analyzed the clinical outcomes at a
individual1. The anterior cruciate ligament has a minimum of two years following reconstruction of
poor capacity for intrinsic repair. Thus, patients the anterior cruciate ligament with use of a four-
who have knee symptoms related to an anterior strand hamstring tendon autograft in patients who
cruciate ligament deficiency may consider liga- had presented with a symptomatic torn anterior cru-
ment reconstruction as a means of stabilizing the ciate ligament.
tibiofemoral joint and restoring high-level func-
tion of the knee joint. Numerous authors have de- METHODS:
scribed successful reconstruction of the anterior One hundred and twenty-two consecutive patients who
cruciate ligament with use of a myriad of donor had an isolated, symptomatic anterior tibial sublux-
autograft (patellar, hamstring, or quadriceps) and ation associated with rupture of the anterior cruciate
allograft (Achilles, patellar, hamstring, or tibialis ligament were treated with reconstruction of the ante-
anterior) tendons2-6. In the United States, the rior cruciate ligament with a four-strand autologous
bone-patellar tendon-bone autograft is the most semitendinosus-gracilis tendon graft. One surgeon per-
commonly used graft in anterior cruciate ligament formed all of the operations. Prior to surgery and at
reconstruction. However, concerns regarding the follow-up examination, physical findings and func-
problems with the extensor mechanism of the tional scores were recorded and knee radiographs
knee, loss of motion, patella infera, patellar frac- were analyzed. Following surgery, a six-month rehabili-
tation regimen was implemented.
ture, and the development of chronic anterior
knee pain have prompted surgeons to seek other continued
graft materials for use in anterior cruciate liga-
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ABSTRACT | continued
is administered, and the patient is then positioned
supine on the operating room table. Prior to the
RESULTS: surgical preparation, the surgeon examines both
Eighty-five patients (70%) were available for follow-up, knees to assess the following parameters: range of
which included physical examination, scoring of func- motion, pivot shift test, Lachman test, varus and
tion, KT-1000 arthrometric testing, and radiographs, valgus stability (at 30° and 0° of knee flexion), and
at a mean of twenty-eight months. Seventy-six (89%) rotational stability. Prophylactic antibiotics are
of the patients had negative Lachman and pivot shift
tests. The mean Lysholm score improved from 55
points preoperatively to 91 points at the time of
follow-up (p < 0.01). The mean Tegner score improved
from 5 to 6 points (p < 0.01). Sixty-five patients had
<3 mm of knee translation on arthrometric testing,
but six patients with marked laxity were not tested.
Three patients (4%) had a positive pivot shift test but
had no history of additional trauma to the knee. Six
patients (7%) had a traumatic rupture of the graft, oc-
curring at a mean of 10.7 months postoperatively. As-
sessment of the follow-up radiographs demonstrated
no evidence of progressive degenerative change com-
pared with the appearance on the preoperative radio-
graphs. However, tunnel expansion was noted in all
patients. The tibial tunnel expanded a mean of 17%
(range, 0% to 32%), and the femoral tunnel expanded
a mean of 29% (range, 0% to 40%).

CONCLUSIONS:
Reconstruction of the anterior cruciate ligament with
use of a four-strand hamstring tendon autograft elimi-
nated anterior tibial subluxation in 89% of patients
who were examined at a minimum of two years postop-
eratively. The overall rate of failure was 11%. The func-
tional knee scores were significantly increased at the
time of follow-up, but these results did not correlate
with the results of knee arthrometric testing.

ment reconstruction7-10. As such, the gracilis and

semitendinosus tendons represent an alternative
autograft donor material that may be used for re-
construction of the anterior cruciate ligament
without disturbance of the extensor mechanism.
We describe a current method of anterior cruciate FIG. 1-A
ligament reconstruction in which we make use The distal ends of the gracilis and semitendinosus tendons are
of a four-strand hamstring tendon construct. isolated at the pes anserinus through the use of an obliquely
oriented incision along the Langer lines made medial and infe-
SURGICAL TECHNIQUE rior to the tibial tubercle.

A regional anesthetic (epidural or spinal injection)

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FIG. 1-B

The ends of the tendons are isolated within the sartorius expansion with use of an angled clamp; the distal ends of the tendons are not
detached.

given prior to the skin incision. The limb in which gracilis tendon with use of a number-15 blade. An
the operation is to be performed is prepared with angled clamp is then used to localize the gracilis and
Betadine Surgical Scrub (povidone-iodine) and Be- semitendinosus tendons at their distal insertion on
tadine solution. The leg is wrapped with an adhesive the anterior aspect of the tibia (Figs. 1-A and 1-B).
plastic barrier drape distal to the level of the tibial Each tendon is identified and tagged prior to har-
tubercle. vest. Care should be taken to remove all soft-tissue
Next, the leg is exsanguinated, and a tourni- adhesions from each tendon before it is harvested;
quet placed around the proximal part of the thigh is the tendon is not detached from the tibia at this
inflated during tendon harvest. A 2 to 3-cm oblique point. A tendon harvester (Fig. 2) is placed around
incision is made directly over the pes anserinus in the distal end of the tendon and is advanced along
line with the hamstring tendons (Figs. 1-A and its substance into the proximal portion of the thigh
1-B). After the sartorius expansion has been identi- with the limb held in the so-called figure-of-four
fied, a longitudinal incision is made superior to the position (flexion of the knee and external rotation
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CRITICAL CONCEPTS

INDICATIONS:
Patients with anterior cruciate ligament tears who experience recurrent clinical symptoms of knee instability despite the ap-
plication of a supervised rehabilitation program or bracing are candidates for reconstruction of the anterior cruciate liga-
ment. Typically, candidates for anterior cruciate ligament reconstruction have a history of episodes of knee instability,
physical findings consistent with anterior cruciate ligament rupture (the Lachman and pivot shift tests), and diagnostic imag-
ing (magnetic resonance imaging) that confirms the presence of an anterior cruciate ligament tear. Daniel et al. suggested
that anyone who participates in a high-level activity or sport in excess of fifty hours per year should be considered a high-
demand individual who is at risk for episodes of instability following anterior cruciate ligament injury11. As such, anterior cruci-
ate ligament reconstruction should be strongly considered in these individuals, even in the absence of recurrent symptoms.

CONTRAINDICATIONS:

The following conditions are contraindications to this method of anterior cruciate ligament reconstruction:
• Loss of knee motion due to acute injury
• Arthrofibrosis9
• Infection
• Tricompartmental osteoarthritis
• Inflammatory arthropathy
• Unwillingness of patient to participate in postoperative rehabilitation
• Skeletally immature individuals (other physeal preserving methods should be used)
continued

FIG. 2-A

A tendon harvester is gently advanced up the gracilis or semitendinosus tendon with the operative limb held in the “figure-of-four” position.
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of the hip) (Figs. 2-A, 2-B, and 2-C). Gentle coun- dial gastrocnemius. When the gracilis and semiten-
tertraction is applied to the distal end of the tendon dinosus tendons have been harvested proximally,
with use of an angled retractor or clamp. When the the distal tendon insertions are sharply removed
harvester is advanced past the muscle-tendon junc- from the tibia (Fig. 2).
tion, the tendon releases proximally and is then The four-strand hamstring tendon graft is pre-
pulled out of the harvesting device and out of the pared by first removing all muscle fibers. Each free
tibial incision. Care should be taken during the har- end of the harvested tendons is prepared by placing
vest of the two tendons to avoid premature graft a nonabsorbable braided number-2 suture in an in-
amputation. If resistance is met during the harvest terlocking fashion 3 to 4 cm from the tendon end
maneuver, the surgeon should inspect the tendon (Fig. 3). Maximal manual tension is applied at this
substance at the distal end of the tendon for soft- step to eliminate creep in the graft construct; a
tissue adhesions, especially in the region of the me- commercial tensioning device (Acufex Microsurgi-

FIG. 2-B

The harvester is advanced with steady pressure.

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cal, Andover, Massachusetts)

CRITICAL CONCEPTS | continued
may also be used to tension the
PITFALLS:
graft prior to implantation. Next,
the two tendons are passed
The primary pitfall of this technique relates to the harvest of the hamstring
tendons from the pes anserinus. Anatomically, the gracilis and semitendino-
through a suture loop to form
sus tendons lie deep to the sartorius expansion and superficial to the medial the four-strand construct that
collateral ligament. As such, it is quite easy to mistakenly undermine the tib- will be used to reconstruct the
ial fibers of the medial collateral ligament during isolation of the distal end of anterior cruciate ligament; the
the hamstrings. This pitfall is most easily avoided by sweeping the tip of an graft diameter is then deter-
angled clamp away from the tibial cortex when isolating the hamstring ten-
mined with use of a graft sizing
dons beneath the sartorius expansion. When the tendons are isolated, all
anomalous soft-tissue attachments, especially those that attach the two
device (Linvatec, Largo, Flor-
tendons to the fascia of the medial head of the gastrocnemius, should be ida). The graft is then set aside in
meticulously detached. Failure to remove these attachments may cause mal- a moist sponge.
tracking of the harvesting device and premature tendon amputation12. Following preparation of
continued the graft, a diagnostic arthros-
copy is performed with use of an

FIG. 2-C

Countertraction on the distal end of the tendon is maintained with use of an angled retractor or clamp. Following release of the proximal as-
pect of the tendons, the distal ends of the tendons are detached from the anterior aspect of the tibia.
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FIG. 3

The gracilis and semitendinosus are separated and individually prepared by the placement of nonabsorbable interlocking sutures along the
free end of each tendon.

arthroscopy pump with pressure cilitate visualization of the pos- portion of the lateral femoral
control. Upon insufflation of teromedial intra-articular condyle (the so-called over-the-
the knee, the tourniquet on the
proximal part of the thigh is re- CRITICAL CONCEPTS | continued
leased. A full assessment of all
intra-articular structures is per- Other pitfalls of this technique relate to placement of the tunnel during ante-
rior cruciate ligament reconstruction. It is crucial that both tunnels be placed
formed. Meniscal tears and carti-
in such a manner that the femoral notch does not encroach upon the graft
lage lesions are treated surgically superiorly or laterally as this may result in loss of motion or recurrent insta-
prior to reconstruction of the bility of the knee. The tibial tunnel should emerge in the posterior aspect of
anterior cruciate ligament. the anterior cruciate ligament footprint. The femoral tunnel should be placed
When the decision has been in a posterior, superior, and lateral position within the prepared femoral
made to proceed with recon- notch. Posterior positioning for the femoral tunnel requires visualization of
the over-the-top position. In attempting to move the femoral tunnel to a pos-
struction of the anterior cruciate
terior position, it is important to understand that moving the tunnel too far
ligament, the patient is placed in posteriorly may compromise the integrity of the tunnel by violating the poste-
a mild Trendelenburg position, rior wall, creating a so-called back-wall blowout. Widely available commercial
the foot of the table is maxi- aiming devices (Arthrex, Naples, Florida) that facilitate guidewire placement
mally flexed, and a bump is based on the over-the-top position help surgeons to avoid this complication.
placed beneath the knee (Fig. 4). Moreover, the surgeon should place the guidewire for the femoral tunnel in
the one o’clock position (for the right knee) or the eleven o’clock position (for
Next, the remnant of the ante-
the left knee) within the femoral notch. Placement of the tunnel in these po-
rior cruciate ligament is removed sitions prevents the creation of a vertically oriented anterior cruciate liga-
with use of a rotating basket ment graft.
shaver, and a lateral femoral continued
notchplasty is performed to fa-
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FIG. 4

The position of the knee for anterior cruciate ligament reconstruction: the patient is in a slight Trendelenburg position, the knee is flexed to
approximately 90°, and a bump is placed beneath the knee. The notchplasty and tunnel preparation are performed with the knee in this
position.

top position), and to prevent anterior and lateral tive anterior cruciate ligament insertion on the
graft impingement (Fig. 5). tibia (the anterior cruciate ligament footprint)
The diameters of the tibial and femoral tun- (Figs. 6-A through 6-D). Power reaming of the
nels are based on the diameter of the four-strand femoral tunnel is done over the guidewire; the size
hamstring graft construct. A commercial aiming of the tibial tunnel should match the measured di-
guide (Linvatec) is used to create the tibial tun- ameter of the graft. Care should be taken to protect
nel. This aiming device, which is used to place a the posterior cruciate ligament during reaming of
guidewire for tunnel reaming, typically enters the both the tibial and femoral tunnels. Following
anteromedial aspect of the tibia and emerges intra- reaming of the tibial tunnel, excess osseous debris
articularly within the posterior portion of the na- is removed with use of a rotating basket shaver. The
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knee flexion angle should ap-

CRITICAL CONCEPTS | continued
proximate 90° prior to prepara-
tion of the femoral tunnel. The Finally, the surgeon must confirm the stability of the graft following the “flip”
primary femoral tunnel is cre- of the Endobutton onto the femoral cortical surface. Usually, manual tension
ated posteriorly, superiorly, and applied distally to the graft following Endobutton placement should confirm
laterally within the femoral that the anchor is stable. The surgeon should be able to sense a back-and-
notch (the one o’clock position forth rocking motion of the Endobutton on the femoral cortex by alternately
pulling the two sutures that are attached to it. Failure to sense this motion
for the right knee and the eleven
should raise suspicion that the Endobutton has not passed out of the tunnel
o’clock position for the left knee) and onto the femoral cortex13. Moreover, erroneous placement of the En-
with use of a power reamer over dobutton within the soft tissues of the distal aspect of the femur has also
a guidewire. The reamer size that been described14. This mistake may be avoided by routinely marking the ap-
is used to create the femoral tun- propriate amount of graft length that should enter the tunnel on the basis of
nel should match the diameter of the intraoperative measurements; this mark should not enter far into the
the tibial tunnel. Two to three femoral tunnel during passage of the graft. Intraoperative radiography or fluo-
millimeters of bone should be roscopy can also be used to confirm appropriate placement of the device on
the femoral cortex when there is doubt.
left between the posterior mar-
continued
gin of the femoral tunnel and the
posterior cortex of the lateral
femoral condyle. At this point, length to facilitate the healing of is created, it is lengthened with
the femoral tunnel should mea- graft to bone within the tunnel. use of a 4.5-mm reamer. Exten-
sure between 25 and 30 mm in After the primary femoral tunnel sion of the tunnel begins at the

FIG. 5

Arthroscopic photograph demonstrating a metal probe that is placed at the so-called over-the-top position on the posterior aspect of the lat-
eral femoral condyle as visualized through a completed lateral femoral notchplasty in a right knee. The lateral femoral condyle is shown in
the right portion of the photograph; the posterior cruciate ligament is shown to the left.
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FIG. 6-A

A commercial guide is used to ad-

vance a guidewire from the antero-
medial aspect of the tibia to the
anterior cruciate ligament foot-
print.

FIG. 6-B

The tibial tunnel is created with use of a power reamer.

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FIG. 6-C

A second guidewire is then

placed in the eleven
o’clock position (for the left
knee) or the one o’clock
position (for the right
knee), and the femoral tun-
nel is created with use of a
power reamer to a depth of
25 to 30 mm.

FIG. 6-D

A 4.5-mm reamer is then used to further

extend the femoral tunnel through the an-
terior aspect of the lateral femoral cortex
to facilitate placement of the Endobutton.
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FIG. 7-A

The Endobutton CL (Smith and Nephew) shown with the number-2 and number-5 sutures placed to facilitate advancement of the graft con-
struct through the bone tunnels.

superiormost portion of the primary femoral tun- CL with a 25-mm polyester loop; a construct con-
nel and emerges at the anterolateral femoral cortex sisting of 25 mm of graft and 25 mm of the polyes-
(Figs. 6-A through 6-D). The distance between the ter loop is created within the femoral tunnel.
anterolateral femoral cortex and the intra-articular After the appropriate Endobutton CL has been
opening of the femoral tunnel is determined with selected, a nonabsorbable number-2 suture is
use of a depth gauge. Femoral fixation is estab- placed in one of the outermost openings of the En-
lished with use of an Endobutton CL (Endobutton dobutton, and a nonabsorbable number-5 suture is
CL, Smith and Nephew, Andover, Massachusetts). placed in the other opening (Fig. 7). The four-
This device is available with a closed loop of poly- strand hamstring graft is created by passing two of
ester tape that ranges in length from 20 to 50 mm. the free hamstring tendon ends through the closed
The surgeon calculates the total loop length neces- polyester loop (Figs. 7-A and 7-B). A slotted
sary to facilitate placement of at least 25 mm of the guidewire is then passed through the tibial and
four-strand hamstring graft within the femoral femoral tunnels and is isolated percutaneously on
tunnel. For example, a total femoral tunnel length the skin of the distal aspect of the femur; the lead
(femoral tunnel aperture to lateral femoral cortex) number-2 and number-5 sutures that were at-
of 50 mm would require the use of an Endobutton tached to the Endobutton are then pulled through
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the tunnels with use of the slot-

CRITICAL CONCEPTS | continued
ted guidewire. With use of the
number-5 suture primarily, the
AUTHOR UPDATE:
Endobutton-graft construct is
Since the completion of this study, many alternative methods of femoral and
pulled into position through the
tibial fixation have been developed specifically for use with hamstring and
tibial tunnel and then into its fi- soft-tissue anterior cruciate ligament grafts. The strength of the four-strand
nal position in the femoral tun- hamstring tendon autograft closely mimics that of similarly sized patellar
nel (Fig. 8). It is important to tendon grafts15. As such, the hamstring tendon autograft remains an attrac-
note that the Endobutton should tive graft choice in anterior cruciate ligament reconstruction. Currently, it is
be passed lengthwise through our preference to use cross-pin fixation on the femoral side for the anterior
both the tibial and the femoral cruciate ligament reconstruction with a four-strand hamstring tendon au-
tograft (Fig. 9). Ahmad et al. demonstrated that one type of cross-pin fixation
tunnel. A dyed, absorbable su-
(Bio-Transfix; Arthrex) possesses superior mechanical properties, with re-
ture is placed on the proximal gard to graft slippage, compared with the Endobutton and interference screw
end of the graft to delineate the fixation16. Cross-pin femoral fixation also eliminates the need for a long fem-
point that is 25 mm from the En- oral tunnel, which may aid in the elimination of the tunnel-widening phenom-
dobutton loop. This visual aid enon that we noted in our study. Our current preferred tibial fixation device is
alerts the surgeon that an appro- the Intrafix (Mitek, Norwood, Massachusetts). This device utilizes a sleeve-
priate length of graft has entered screw configuration that allows for the tensioning of individual graft limbs
and maximizes apposition of the graft tendon ends to bone. Kousa et al.
the femoral tunnel and that the
demonstrated that the Intrafix device possessed both the greatest strength
Endobutton is ready for deploy- on the single-cycle load-to-failure test and the lowest residual graft dis-
ment. Once the suture has en- placement among a group of soft-tissue screws and washer-post fixation
tered the femoral tunnel, the devices17.
Endobutton should be flipped

FIG. 7-B

The completed four-strand tendon autograft, with use of the Endobutton CL, immediately prior to graft insertion.
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FIG. 8

The four-strand hamstring construct is created by placing the hamstring tendons through the Endobutton loop. The graft is then pulled into
position with use of the large (number-5) suture attached to the Endobutton; the Endobutton should be advanced in a longitudinal fashion
through the tunnels. Once the device has been pulled through the anterior femoral cortex, the Endobutton is flipped to lie parallel with and
stabilized on the femoral cortex.

such that it sits parallel to or flush with the lateral is placed through the inferomedial arthroscopy
aspect of the femoral cortex to achieve femoral portal.
fixation of the graft (Fig. 8). This flipping maneu- The knee is then cycled several times from full
ver is performed with use of the lead sutures that extension to maximum flexion while manual ten-
are attached to the Endobutton device. Manual ten- sion is applied distally to the hamstring graft. The
sion applied to the distal end of the graft confirms arthroscope is then reinserted into the knee joint to
fixation on the femoral side. Fixation of the ham- confirm that the lateral or superior aspect of the
string graft to the femoral tunnel aperture is then femoral notch is not impinging on the graft. With
achieved with use of a bioabsorbable screw that the knee in 15° to 20° of flexion, a bioabsorbable
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FIG. 9

The authors’ current method of femoral (cross-pin) and tibial (screw-sleeve) fixation for anterior cruciate ligament reconstruction with a
hamstring tendon autograft.
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screw is applied to achieve tibial benefits to any research fund, foundation, educa- ning J, Abbott P. Infrapatellar contracture syn-
tional institution, or other charitable or nonprofit drome. An unrecognized cause of knee
fixation. A low-profile soft-tissue organization with which the authors are affiliated stiffness with patella entrapment and patella
staple is also applied to the distal or associated. infera. Am J Sports Med. 1987;15:331-41.

part of the graft at the cortical The line drawings in this article are the work of
9. Shelbourne KD, Wilckens JH, Mollabashy
A, DeCarlo M. Arthrofibrosis in acute anterior
opening of the tibial tunnel. If Jennifer Fairman (jfairman@fairmanstudios.com). cruciate ligament reconstruction. The effect
the graft does not emerge from of timing of reconstruction and rehabilitation.
doi:10.2106/JBJS.D.02805 Am J Sports Med. 1991;19:332-6.
the orifice of the tibial tunnel,
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grants or outside funding from the Institute for 17. Kousa P, Jarvinen TL, Vihavainen M, Kan-
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Sports Medicine Research, New York, NY. They did nus P, Jarvinen M. The fixation strength of six
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not receive payments or other benefits or a com- hamstring tendon graft fixation devices in an-
versus hamstring graft. Knee Surg Sports
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paid or directed, or agreed to pay or direct, any 8. Paulos LE, Rosenberg TD, Drawbert J, Man- 182-8.