Anatomic Considerations in Hamstring Tendon Harvesting for Ligament Reconstruction

Through-tunnel reconstruction with Ligament Augmentation and Reconstruction System (LARS) for managing post-arthroplasty patellofemoral instability

BACKGROUND

Despite advancements in prosthetic designs and surgical techniques, patellar dislocation remains a rare but significant complication following total knee arthroplasty, with an incidence ranging between 0.15% and 0.5%. This condition often requires revision surgery to alleviate discomfort and restore joint function. Among the methods to address patellofemoral instability, medial patellofemoral ligament reconstruction has gained attention. In this case, we present the first report of using the synthetic Ligament Augmentation and Reconstruction System (LARS; Surgical Implants and Devices, Arc-sur-Tille, France) for medial patellofemoral ligament reconstruction following patellar dislocation after total knee arthroplasty, offering a novel approach to avoid donor site morbidity.

CASE PRESENTATION

An 87-year-old man with no significant comorbidities underwent NexGen posterior-stabilized-total knee arthroplasty (Zimmer Biomet, Warsaw IN) for advanced osteoarthritis in his left knee. Three months postoperatively, he experienced a persistent giving-way sensation and swelling in the knee after a fall. Physical examination revealed patellar subluxation, confirmed by imaging studies. A computed tomography scan showed no malrotation of the femoral or tibial components. The patient was diagnosed with a medial patellar retinacular tear and medial patellofemoral ligament rupture. He underwent medial patellofemoral ligament reconstruction using a Ligament Augmentation and Reconstruction System (LARS; Surgical Implants and Devices, Arc-sur-Tille, France) synthetic ligament, and the medial retinaculum was repaired. After a year of follow-up, the patient reported satisfactory knee stability, with no recurrence of patellar dislocation.

CONCLUSION

This case demonstrates the successful use of a synthetic Ligament Augmentation and Reconstruction System for Medial patellofemoral ligament reconstruction in managing post-arthroplasty patellar dislocation. It offers a less invasive alternative to autograft harvesting, reducing donor site morbidity while providing effective stabilization of the extensor mechanism. This approach could have significant clinical implications, particularly for elderly patients with compromised bone healing capacity.

Ultrasound-Guided Posteromedial Semitendinosus Tendon Harvest

Hamstring tendon autografts have emerged as the graft of choice by over 50% of sports surgeons worldwide performing anterior cruciate ligament reconstruction. A more recent technique in harvesting the semitendinosus tendon, the posteromedial approach, afforded multiple benefits compared with the anteromedial approach. However, for the inexperienced surgeon, the current techniques may not be as simple because of decreased tendon tension after general anesthesia induction and subcutaneous layer dissection, making it difficult to palpate the semitendinosus tendon. By utilizing ultrasound to assist us during our harvest, we can perform the procedure with increased accuracy and efficiency, which leads to a safer, more proficient, and less invasive procedure.

The Presence of a 'Sentinel' Vessel as an Anatomical Reference during Hamstring Tendon Harvesting-A Prospective Study

BACKGROUND

The identification of the branch of the inferior medial genicular artery (bIMGA) in anterior cruciate ligament reconstructions (ACLRs) has previously been considered a landmark by some surgeons, but its consistency remains debated. The aim of this investigation was to evaluate the variability in the appearance and location of bIMGA and to assess its validity as a reliable landmark during hamstring tendon harvesting procedures.

METHODS

This prospective, single-center study comprised 213 patients who underwent ACLR over a period of two years. The surgical procedures were conducted by the same surgical team, maintaining uniformity in the approach. The study sought correlations between patient demographics, level of activity, and the potential for successful identification of the bIMGA.

RESULTS

A statistically significant association between patient activity levels and successful identification of the bIMGA (p = 0.035) was observed. No significant correlations were found concerning patient demographic characteristics. bIMGA demonstrated a substantial degree of anatomical variability, rendering its consistent identification in the surgical field challenging.

CONCLUSIONS

Given the observed variability and the associated difficulty in its identification, the use of the bIMGA as a dependable anatomical reference during ACL graft harvesting is not recommended. This study confirms the inconsistency of bIMGA as a traditional landmark, underscoring the need for research aimed at identifying more consistent and reliable anatomical references to enhance the precision of surgical interventions in ACLR.

[Correlation study on the influencing factors of semitendinosus insertion location]

Objective

To investigate the relationship between the vertical distance from semitendinosus insertion to tibial plateau (S-T) and the physical characteristics of patients, in order to provide reference for incision design to expose the semitendinosus insertion.

Methods

The patients with ligament injury who underwent primary anterior cruciate ligament reconstruction between January 2022 and December 2022 were selected as the research subjects. The patients' baseline data were collected, including age, gender, height, and body mass. During reconstruction operation, the S-T was measured. Considering the S-T as the dependent variable and baseline data as the independent variable, multiple linear regression analysis was used to establish a regression equation to determine the possible influencing factors of semitendinosus insertion location.

Results

According to the selection standard, a total of 214 patients were enrolled, including 156 males and 58 females, aged (27±9) years (14-49 years), with a height of (174.7±6.8) cm (range, 160-196 cm) and a body mass of (73.43±12.35) kg (range, 53-105 kg). The S-T was (56.36±3.61) mm (range, 47-67 mm). The multiple linear regression analysis results showed that the height was positively correlated with S-T (β=0.407, SE=0.055, t=7.543, P<0.001); the regression equation was S-T=-14.701+0.407×height, R2=0.690.

Conclusion

There was a linear relationship between the height and semitendinosus insertion. The location of semitendinosus insertion estimated by the formula (S-T=-14.701+0.407×height) is reasonable, which provides a theoretical basis for rapid, accurate, and safe location of semitendinosus insertion and design of surgical incision in clinic.

Endoscopic-Assisted Hamstring Tendon Harvesting

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

Outside-in technique versus inside-out semitendinosus graft harvest technique in ACLR: a randomised control trial

Background

Paraesthesia after hamstring graft harvest is a ubiquitous complication in the early post-operative period, and its correlation with vertical versus horizontal skin incision are well documented. The purpose of the study is to evaluate the incidence and extent/area of sensory loss of saphenous nerve branches occurring with the outside-in (OI) versus inside-out technique (IO) of semitendinosus graft harvest from the sartorius fascia and to determine a better method of graft harvest.

Methods

Sixty patients who underwent isolated semitendinosus graft harvest during anterior cruciate ligament reconstruction (ACLR) between 2016 and 2017. Patients were randomised into two groups depending on the graft harvest technique: 30 in the OI group and 30 in the IO group. The area of sensory loss was mapped on the patients’ skin using tactile feedback from the patients at each follow-up (10 days, 1 month, 3 months, 6 months and 1 year). Then, the area of sensory changes for the infrapatellar branch (IPBSN) and sartorial branch (SBSN) of the saphenous nerve, incision length, graft harvest duration, and graft length were analysed statistically between the groups.

Results

In groups 1 and 2, 18/30 (60%) and 19/30 (63%) of patients, respectively, developed sensory changes, with no significant difference between the groups (p = 0.79). Isolated SBSN and IPBSN paraesthesia occurred in 2/60 (3%) and 19/60 (32%), respectively. Combined SBSN and IPBSN paraesthesia was present in 16/60 (27%) of patients. There was no significant difference in the area of the sensory deficit between OI and IO groups on the 10th post-operative day or at 1-month, 3-month or 1-year follow-up (p = 0.723, p = 0.308, p = 0.478, p = 0.128, respectively). However, at 6-month follow-up, the area of paraesthesia was significantly higher in the IO group (p = 0.009). The length of incision and duration of graft harvest was higher in the OI group than in the IO group (p = 0.002 and p = 0.007, respectively), and the total length of the graft was greater in the IO group (p = 0.04).

Conclusion

Incidence is equally distributed, area of iatrogenic saphenous nerve injury gradually decreases, and recovery is seen in the majority of the patients in both graft harvest techniques. IO graft harvesting technique is better in terms of graft harvest time and cosmetics and yields longer graft; however, area of paraesthesia, though not significant, was two-fold higher than the OI technique at 1-year follow-up.

Clinical relevance

IO graft harvest technique would enable the surgeon to adopt quicker graft harvest, smaller surgical scar and lengthier graft than the OI technique.

Level of evidence

Therapeutic randomised controlled prospective study, Level II.

Hamstring autograft utilization in reconstructing anterior cruciate ligament: Review of harvesting techniques, graft preparation, and different fixation methods

Rupture of the anterior cruciate ligament (ACL) is a common orthopedic injury. Various graft options are available for the reconstruction of ruptured ACL. Using the hamstring muscle as an autograft was first described in 1934, and it remains a commonly harvested graft for ACL reconstruction. Hamstring autografts can be harvested using the traditional anteromedial approach or the newer posteromedial technique. An isolated semitendinosus tendon can be used or combined with the gracilis tendon. There are numerous methods for graft fixation, such as intra-tunnel or extra-tunnel fixation. This comprehensive review discusses the different hamstring muscle harvesting techniques and graft preparation options and fixation methods. It provides a comprehensive overview for choosing the optimal surgical technique when treating patients.