The 5-Strand Hamstring Graft in Anterior Cruciate Ligament Reconstruction Rushyuan Jay Lee, M.D., and Theodore J. Ganley, M.D.
Abstract: The use of anterior cruciate ligament reconstruction in the pediatric and adolescent population has been increasing in recent years. Autograft hamstring graft is favored in this population, but these patients often have smaller hamstring tendons that yield smaller final graft constructs. These smaller grafts are associated with an increased need for revision surgery. We describe a technique for obtaining a larger-diameter anterior cruciate ligament graft construct from autologous hamstring graft without allograft supplementation.
T
he recognition of and attention to anterior cruciate ligament (ACL) injury and ACL reconstruction in the pediatric and adolescent population have been increasing in recent years. The traditional adult approach of using a 4-strand hamstring construct has been favored in this population because open physes preclude the use of the boneepatellar tendonebone autograft at the level of the physes and allograft is not as desirable in children. However, younger, smaller patients have been noted often to yield smaller hamstring tendons,1 leading to smaller final graft sizes. Furthermore, it has been shown that smaller graft size, in younger patients, has been associated with an increased rate of revision surgery.2 Our technique shows how to prepare a 5-strand hamstring graft and increase the final diameter of the ACL graft in a combination femoral cortical button and tibial interference screw construct.
Technique The hamstring autograft is first harvested with the surgeon’s preferred technique, with care to maximize From The Children’s Hospital of Philadelphia (R.J.L., T.J.G.); and Perelman School of Medicine, University of Pennsylvania (T.J.G.), Philadelphia, Pennsylvania, U.S.A. The authors report the following potential conflict of interest or source of funding: T.J.G. receives support from OrthoPediatrics. He was a paid consultant for the year 2012-2013. He is not currently a paid consultant. Received February 25, 2014; accepted July 16, 2014. Address correspondence to Theodore John Ganley, M.D., The Children’s Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, U.S.A. Ó 2014 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved. 2212-6287/14160/$36.00 http://dx.doi.org/10.1016/j.eats.2014.07.002
tendon length, especially in the semitendinosus. Then, with the tendons on the graft preparation table and cleaned of soft tissues, the length and the feasibility of tripling the semitendinosus are assessed. The gracilis is doubled. For our pediatric patients, we aim for a final length of 8 to 9 cm depending on the patient’s height. For all tripled semitendinosus constructs, an additional 1.5 cm is required for securing the tripled end. Thus, for a final construct length of 8 cm, the semitendinosus graft requires 24 cm for the 3 folded strands plus an additional 1.5 cm, for a total recommended starting length of 25.5 cm. Similarly, for a final construct length of 9 cm, 28.5 cm is recommended. We describe the equipment and technique for graft preparation in this report and review the steps in an instructional video (Video 1). Equipment The following equipment is used for our technique: FiberLoop, No. 2 with straight needle; ACL TightRope RT; Graft Prep Station; and BioComposite Interference Screw (Arthrex, Naples, FL). Semitendinosus Graft Preparation (8-cm Final Graft Length) For semitendinosus graft preparation, the steps are as follows: 1. The folds are marked out on the tendon, from the end: 8 cm (first fold), 16 cm (second fold), and 24 cm (third fold). 2. After the third fold, an additional 1.5 cm is marked out; this is the “folded end,” where the graft will be secured to itself. This also represents the end of the final graft. After the 25.5-cm mark, the additional graft can be trimmed later (Fig 1A).
Arthroscopy Techniques, Vol 3, No 5 (October), 2014: pp e627-e631
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Fig 1. Graft preparation. (A) The folds and areas of whipstitching are marked out on the tendons. A 25.5-cm semitendinosus graft, marked out for a final folded construct length of 8 cm, is shown. The areas of whipstitching are highlighted in green, each 2 cm in length, except for at the third fold, where an additional 1.5 cm is whipstitched. (B) The longer of the 2 grafts, the semitendinosus, is marked out as depicted in A. The areas of whipstitching are highlighted with a marker, and the symbols indicate the planned folds (solid arrows indicate the first fold; asterisks indicate the second fold; open arrows indicate the third fold). The shorter of the 2 grafts is the gracilis, which is marked out to be doubled. (C) The grafts are whipstitched, and the extraneous graft has been trimmed. The arrows indicate the planned folds. Ó 2014. T. J. Ganley. All Rights Reserved.
Fig 2. Strands 1 and 2 of semitendinosus. (A) The semitendinosus graft is passed once through the loop of the cortical button, which itself has been secured to a post on the graft preparation board. (B) As the semitendinosus graft is pulled through the loop, it is folded at the first 8-cm mark (solid arrow). (C) The whipstitch in the midsubstance of the semitendinosus (asterisk) is pulled to tension the first and second strands equally. (D) The first and second strands are secured to a post, whereas the third strand remains free (open arrow). Ó 2014. T. J. Ganley. All Rights Reserved.
FIVE-STRAND HAMSTRING GRAFT
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Fig 3. Strand 3 of semitendinosus. (A) The semitendinosus graft is passed a second time through the loop of the cortical button and pulled through. (B) Once pulled through, the graft is folded a third time. The open arrow indicates the third fold. (C) The whipstitch at the third fold is tensioned, pulling the slack out of the third strand. (D-F) The tails of the whipstitch at the third fold are then secured back to the whipstitch upstream, where the whipstitch was first anchored. This suture is tied and then cut, completing the 3-strand semitendinosus. Ó 2014. T. J. Ganley. All Rights Reserved.
3. The graft is whipstitched. We use the Arthrex SpeedWhip technique with FiberLoop for whipstitching our grafts (Fig 1B). a. Two centimeters of the end of the graftdthe “free end”dis whipstitched (from 0 to 2 cm). b. Two centimeters of the mid portion of the graft adjacent to the second fold is whipstitched (from 14 to 16 cm). The whipstitch ends just before the second fold, allowing for some relaxation of the graft and suture. c. The first 2 whipstitches allow for individual tensioning of the first 2 strands. d. Finally, 3.5 cm of the folded end of the graft is whipstitched, from 22 to 25.5 cm. This allows for tensioning of the third strand and for securing the tripled graft to itself. Folding of Semitendinosus For folding of the semitendinosus, the steps are as follows: 1. The cortical button device is secured on a post on the Arthrex graft preparation board so that the loop is
2. 3.
4. 5. 6.
accessible for graft passage. Our preferred device is Arthrex ACL Tightrope RT. The graft is passed once through the cortical button (Fig 2A), folding it at the 8-cm mark (Fig 2B). The whipstitch at the second fold is tensioned, pulling the slack out of the first and second strands (Fig 2C). Then, the first and second strands are secured to a post (Fig 2D). The graft is passed a second time through the cortical button (Fig 3A), folding it at the 24-cm mark (Fig 3B). The whipstitch at the third fold is tensioned, pulling the slack out of the third strand (Fig 3C). Once adequate tension is achieved, the whipstitch at the third fold is secured back upstream either to the suture itself or to the graft if appropriate (Fig 3D-3F).
Gracilis Preparation The shorter graft is measured and whipstitched on both ends to create a folded length similar to that of the semitendinosus. It is passed through the loop of the cortical button and tensioned individually (Fig 4).
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Fig 4. Gracilis preparation. (A) The shorter graft is passed through the loop of the cortical button and (B) tensioned individually. Ó 2014. T. J. Ganley. All Rights Reserved.
Graft Fixation For graft fixation, the steps are as follows: 1. The free whipstitch sutures are tensioned individually for both the semitendinosus and gracilis (Fig 5). 2. After the cortical button is passed through the femoral socket, each suture limb on the tibial side is tensioned. There are 2 sutures on both the semitendinosus and gracilis, allowing equal tensioning of the graft while placing the interference screw. We prefer to use the Arthrex Biocomposite Interference Screw.
Discussion Insufficient graft diameter is of concern when performing ACL reconstruction in the pediatric population. Although other methods are available, we believe the described technique provides a viable option making the most of an autologous graft. This method provides the advantage of augmentation of the final graft diameter without combining it with allograft tendon. We have noted a graft diameter increase of 1 to 1.5 mm
in general. The main challenge to this 5-strand technique is ensuring that each of the 3 strands of the semitendinosus has adequate tension. With careful measurement and placement of whipstitches, this construct can be equally tensioned (Table 1). The pediatric population is at risk of ACL graft failure from a multitude of factors. Pediatric ACL reconstruction patients have been shown to be predisposed to small autograft sizes. It has been shown that predictors of smaller hamstring size include shorter height, younger age, and female gender.1 Smaller autograft sizes yield smaller-diameter folded constructs, which ultimately are weaker ACL grafts. Hamner et al.3 reported that these small grafts have a weaker ultimate failure load. Furthermore, Magnussen et al.2 have studied the predictors of early revision after ACL reconstruction with hamstring autograft. They reported that smaller graft size, 8 mm in diameter or less, in patients younger than 20 years, is associated with more revisions. A multicenter study has shown that smaller hamstring autograft size is a predictor of poorer patientreported outcomes.4 It is suggested that larger ACL graft sizes will yield more successful ACL outcomes. Table 1. Indications, Contraindications, Key Points, and Pearls
Fig 5. Combined 5-strand construct. The free whipstitch sutures are tensioned individually for both the semitendinosus and gracilis, with a goal of equal tension in each strand. Ó 2014. T. J. Ganley. All Rights Reserved.
Indications Need for a larger final graft diameter than would be provided with a quadrupled autograft hamstring construct. Contraindications Inadequate starting total graft length of the semitendinosus, which yields an inadequate final construct length. Key points Careful autograft hamstring harvest, maximizing tendon length, is a prerequisite for our technique. Precise measurement and whipstitching of the semitendinosus allow equal final tensioning of the tripled strand. Pearls The whipstitch of the semitendinosus in the midsubstance at the second fold has a tendency to allow relaxation of the graft and suture. Thus the whipstitch should end just before, instead of at, the second fold. When tensioning the semitendinosus on the graft preparation board, the surgeon should ensure equal tension of the first and second strands before tensioning and securing the third strand.
FIVE-STRAND HAMSTRING GRAFT
Pediatric patients are also at risk because of their age and activity level. For ACL reconstruction with patellar tendon grafts, Shelbourne et al.5 have shown that younger patients are more prone to failure. Other studies have also shown that younger, more active patients have a higher risk of failure.2,6,7 Whenever graft size is of concern, our 5-strand hamstring graft technique allows a larger-diameter ACL graft construct, using only autologous hamstring graft.
References 1. Tuman JM, Diduch DR, Rubino LJ, Baumfeld JA, Nguyen HS, Hart JM. Predictors for hamstring graft diameter in anterior cruciate ligament reconstruction. Am J Sports Med 2007;35:1945-1949. 2. Magnussen RA, Lawrence JT, West RL, Toth AP, Taylor DC, Garrett WE. Graft size and patient age are predictors of early revision after anterior cruciate ligament reconstruction with hamstring autograft. Arthroscopy 2012;28:526-531.
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3. Hamner DL, Brown CH Jr, Steiner ME, Hecker AT, Hayes WC. Hamstring tendon grafts for reconstruction of the anterior cruciate ligament: Biomechanical evaluation of the use of multiple strands and tensioning techniques. J Bone Joint Surg Am 1999;81:549-557. 4. Mariscalco MW, Flanigan DC, Mitchell J, et al. The influence of hamstring autograft size on patient-reported outcomes and risk of revision after anterior cruciate ligament reconstruction: A Multicenter Orthopaedic Outcomes Network (MOON) Cohort Study. Arthroscopy 2013;29:1948-1953. 5. Shelbourne KD, Gray T, Haro M. Incidence of subsequent injury to either knee within 5 years after anterior cruciate ligament reconstruction with patellar tendon autograft. Am J Sports Med 2009;37:246-251. 6. Borchers JR, Pedroza A, Kaeding C. Activity level and graft type as risk factors for anterior cruciate ligament graft failure: A case-control study. Am J Sports Med 2009;37:2362-2367. 7. Salmon L, Russell V, Musgrove T, Pinczewski L, Refshauge K. Incidence and risk factors for graft rupture and contralateral rupture after anterior cruciate ligament reconstruction. Arthroscopy 2005;21:948-957.
Abstract: The use of anterior cruciate ligament reconstruction in the pediatric and adolescent population has been increasing in recent years. Autograft hamstring graft is favored in this population, but these patients often have smaller hamstring tendons that yield smaller final graft constructs. These smaller grafts are associated with an increased need for revision surgery. We describe a technique for obtaining a larger-diameter anterior cruciate ligament graft construct from autologous hamstring graft without allograft supplementation.
T
he recognition of and attention to anterior cruciate ligament (ACL) injury and ACL reconstruction in the pediatric and adolescent population have been increasing in recent years. The traditional adult approach of using a 4-strand hamstring construct has been favored in this population because open physes preclude the use of the boneepatellar tendonebone autograft at the level of the physes and allograft is not as desirable in children. However, younger, smaller patients have been noted often to yield smaller hamstring tendons,1 leading to smaller final graft sizes. Furthermore, it has been shown that smaller graft size, in younger patients, has been associated with an increased rate of revision surgery.2 Our technique shows how to prepare a 5-strand hamstring graft and increase the final diameter of the ACL graft in a combination femoral cortical button and tibial interference screw construct.
Technique The hamstring autograft is first harvested with the surgeon’s preferred technique, with care to maximize From The Children’s Hospital of Philadelphia (R.J.L., T.J.G.); and Perelman School of Medicine, University of Pennsylvania (T.J.G.), Philadelphia, Pennsylvania, U.S.A. The authors report the following potential conflict of interest or source of funding: T.J.G. receives support from OrthoPediatrics. He was a paid consultant for the year 2012-2013. He is not currently a paid consultant. Received February 25, 2014; accepted July 16, 2014. Address correspondence to Theodore John Ganley, M.D., The Children’s Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, U.S.A. Ó 2014 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved. 2212-6287/14160/$36.00 http://dx.doi.org/10.1016/j.eats.2014.07.002
tendon length, especially in the semitendinosus. Then, with the tendons on the graft preparation table and cleaned of soft tissues, the length and the feasibility of tripling the semitendinosus are assessed. The gracilis is doubled. For our pediatric patients, we aim for a final length of 8 to 9 cm depending on the patient’s height. For all tripled semitendinosus constructs, an additional 1.5 cm is required for securing the tripled end. Thus, for a final construct length of 8 cm, the semitendinosus graft requires 24 cm for the 3 folded strands plus an additional 1.5 cm, for a total recommended starting length of 25.5 cm. Similarly, for a final construct length of 9 cm, 28.5 cm is recommended. We describe the equipment and technique for graft preparation in this report and review the steps in an instructional video (Video 1). Equipment The following equipment is used for our technique: FiberLoop, No. 2 with straight needle; ACL TightRope RT; Graft Prep Station; and BioComposite Interference Screw (Arthrex, Naples, FL). Semitendinosus Graft Preparation (8-cm Final Graft Length) For semitendinosus graft preparation, the steps are as follows: 1. The folds are marked out on the tendon, from the end: 8 cm (first fold), 16 cm (second fold), and 24 cm (third fold). 2. After the third fold, an additional 1.5 cm is marked out; this is the “folded end,” where the graft will be secured to itself. This also represents the end of the final graft. After the 25.5-cm mark, the additional graft can be trimmed later (Fig 1A).
Arthroscopy Techniques, Vol 3, No 5 (October), 2014: pp e627-e631
e627
e628
R. J. LEE AND T. J. GANLEY
Fig 1. Graft preparation. (A) The folds and areas of whipstitching are marked out on the tendons. A 25.5-cm semitendinosus graft, marked out for a final folded construct length of 8 cm, is shown. The areas of whipstitching are highlighted in green, each 2 cm in length, except for at the third fold, where an additional 1.5 cm is whipstitched. (B) The longer of the 2 grafts, the semitendinosus, is marked out as depicted in A. The areas of whipstitching are highlighted with a marker, and the symbols indicate the planned folds (solid arrows indicate the first fold; asterisks indicate the second fold; open arrows indicate the third fold). The shorter of the 2 grafts is the gracilis, which is marked out to be doubled. (C) The grafts are whipstitched, and the extraneous graft has been trimmed. The arrows indicate the planned folds. Ó 2014. T. J. Ganley. All Rights Reserved.
Fig 2. Strands 1 and 2 of semitendinosus. (A) The semitendinosus graft is passed once through the loop of the cortical button, which itself has been secured to a post on the graft preparation board. (B) As the semitendinosus graft is pulled through the loop, it is folded at the first 8-cm mark (solid arrow). (C) The whipstitch in the midsubstance of the semitendinosus (asterisk) is pulled to tension the first and second strands equally. (D) The first and second strands are secured to a post, whereas the third strand remains free (open arrow). Ó 2014. T. J. Ganley. All Rights Reserved.
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Fig 3. Strand 3 of semitendinosus. (A) The semitendinosus graft is passed a second time through the loop of the cortical button and pulled through. (B) Once pulled through, the graft is folded a third time. The open arrow indicates the third fold. (C) The whipstitch at the third fold is tensioned, pulling the slack out of the third strand. (D-F) The tails of the whipstitch at the third fold are then secured back to the whipstitch upstream, where the whipstitch was first anchored. This suture is tied and then cut, completing the 3-strand semitendinosus. Ó 2014. T. J. Ganley. All Rights Reserved.
3. The graft is whipstitched. We use the Arthrex SpeedWhip technique with FiberLoop for whipstitching our grafts (Fig 1B). a. Two centimeters of the end of the graftdthe “free end”dis whipstitched (from 0 to 2 cm). b. Two centimeters of the mid portion of the graft adjacent to the second fold is whipstitched (from 14 to 16 cm). The whipstitch ends just before the second fold, allowing for some relaxation of the graft and suture. c. The first 2 whipstitches allow for individual tensioning of the first 2 strands. d. Finally, 3.5 cm of the folded end of the graft is whipstitched, from 22 to 25.5 cm. This allows for tensioning of the third strand and for securing the tripled graft to itself. Folding of Semitendinosus For folding of the semitendinosus, the steps are as follows: 1. The cortical button device is secured on a post on the Arthrex graft preparation board so that the loop is
2. 3.
4. 5. 6.
accessible for graft passage. Our preferred device is Arthrex ACL Tightrope RT. The graft is passed once through the cortical button (Fig 2A), folding it at the 8-cm mark (Fig 2B). The whipstitch at the second fold is tensioned, pulling the slack out of the first and second strands (Fig 2C). Then, the first and second strands are secured to a post (Fig 2D). The graft is passed a second time through the cortical button (Fig 3A), folding it at the 24-cm mark (Fig 3B). The whipstitch at the third fold is tensioned, pulling the slack out of the third strand (Fig 3C). Once adequate tension is achieved, the whipstitch at the third fold is secured back upstream either to the suture itself or to the graft if appropriate (Fig 3D-3F).
Gracilis Preparation The shorter graft is measured and whipstitched on both ends to create a folded length similar to that of the semitendinosus. It is passed through the loop of the cortical button and tensioned individually (Fig 4).
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R. J. LEE AND T. J. GANLEY
Fig 4. Gracilis preparation. (A) The shorter graft is passed through the loop of the cortical button and (B) tensioned individually. Ó 2014. T. J. Ganley. All Rights Reserved.
Graft Fixation For graft fixation, the steps are as follows: 1. The free whipstitch sutures are tensioned individually for both the semitendinosus and gracilis (Fig 5). 2. After the cortical button is passed through the femoral socket, each suture limb on the tibial side is tensioned. There are 2 sutures on both the semitendinosus and gracilis, allowing equal tensioning of the graft while placing the interference screw. We prefer to use the Arthrex Biocomposite Interference Screw.
Discussion Insufficient graft diameter is of concern when performing ACL reconstruction in the pediatric population. Although other methods are available, we believe the described technique provides a viable option making the most of an autologous graft. This method provides the advantage of augmentation of the final graft diameter without combining it with allograft tendon. We have noted a graft diameter increase of 1 to 1.5 mm
in general. The main challenge to this 5-strand technique is ensuring that each of the 3 strands of the semitendinosus has adequate tension. With careful measurement and placement of whipstitches, this construct can be equally tensioned (Table 1). The pediatric population is at risk of ACL graft failure from a multitude of factors. Pediatric ACL reconstruction patients have been shown to be predisposed to small autograft sizes. It has been shown that predictors of smaller hamstring size include shorter height, younger age, and female gender.1 Smaller autograft sizes yield smaller-diameter folded constructs, which ultimately are weaker ACL grafts. Hamner et al.3 reported that these small grafts have a weaker ultimate failure load. Furthermore, Magnussen et al.2 have studied the predictors of early revision after ACL reconstruction with hamstring autograft. They reported that smaller graft size, 8 mm in diameter or less, in patients younger than 20 years, is associated with more revisions. A multicenter study has shown that smaller hamstring autograft size is a predictor of poorer patientreported outcomes.4 It is suggested that larger ACL graft sizes will yield more successful ACL outcomes. Table 1. Indications, Contraindications, Key Points, and Pearls
Fig 5. Combined 5-strand construct. The free whipstitch sutures are tensioned individually for both the semitendinosus and gracilis, with a goal of equal tension in each strand. Ó 2014. T. J. Ganley. All Rights Reserved.
Indications Need for a larger final graft diameter than would be provided with a quadrupled autograft hamstring construct. Contraindications Inadequate starting total graft length of the semitendinosus, which yields an inadequate final construct length. Key points Careful autograft hamstring harvest, maximizing tendon length, is a prerequisite for our technique. Precise measurement and whipstitching of the semitendinosus allow equal final tensioning of the tripled strand. Pearls The whipstitch of the semitendinosus in the midsubstance at the second fold has a tendency to allow relaxation of the graft and suture. Thus the whipstitch should end just before, instead of at, the second fold. When tensioning the semitendinosus on the graft preparation board, the surgeon should ensure equal tension of the first and second strands before tensioning and securing the third strand.
FIVE-STRAND HAMSTRING GRAFT
Pediatric patients are also at risk because of their age and activity level. For ACL reconstruction with patellar tendon grafts, Shelbourne et al.5 have shown that younger patients are more prone to failure. Other studies have also shown that younger, more active patients have a higher risk of failure.2,6,7 Whenever graft size is of concern, our 5-strand hamstring graft technique allows a larger-diameter ACL graft construct, using only autologous hamstring graft.
References 1. Tuman JM, Diduch DR, Rubino LJ, Baumfeld JA, Nguyen HS, Hart JM. Predictors for hamstring graft diameter in anterior cruciate ligament reconstruction. Am J Sports Med 2007;35:1945-1949. 2. Magnussen RA, Lawrence JT, West RL, Toth AP, Taylor DC, Garrett WE. Graft size and patient age are predictors of early revision after anterior cruciate ligament reconstruction with hamstring autograft. Arthroscopy 2012;28:526-531.
e631
3. Hamner DL, Brown CH Jr, Steiner ME, Hecker AT, Hayes WC. Hamstring tendon grafts for reconstruction of the anterior cruciate ligament: Biomechanical evaluation of the use of multiple strands and tensioning techniques. J Bone Joint Surg Am 1999;81:549-557. 4. Mariscalco MW, Flanigan DC, Mitchell J, et al. The influence of hamstring autograft size on patient-reported outcomes and risk of revision after anterior cruciate ligament reconstruction: A Multicenter Orthopaedic Outcomes Network (MOON) Cohort Study. Arthroscopy 2013;29:1948-1953. 5. Shelbourne KD, Gray T, Haro M. Incidence of subsequent injury to either knee within 5 years after anterior cruciate ligament reconstruction with patellar tendon autograft. Am J Sports Med 2009;37:246-251. 6. Borchers JR, Pedroza A, Kaeding C. Activity level and graft type as risk factors for anterior cruciate ligament graft failure: A case-control study. Am J Sports Med 2009;37:2362-2367. 7. Salmon L, Russell V, Musgrove T, Pinczewski L, Refshauge K. Incidence and risk factors for graft rupture and contralateral rupture after anterior cruciate ligament reconstruction. Arthroscopy 2005;21:948-957.
