Hamstring graft preparation using a needleless suture loop

Placement of running, locking stitches during the harvest and preparation of hamstring tendons can be time consuming and requires placement of suture in the most distal and proximal 2 to 3 cm of the tendons. The authors have regularly used a needleless suture loop technique to both harvest and prepare autograft gracilis and semitendinosis tendons and to tension quadrupled hamstring tendon grafts during anterior cruciate ligament reconstruction. This cost-effective technique reduces exposure to needles, the time required to harvest and prepare the grafts, and the amount of suture in the tibial tunnel, while providing adequate fixation to tension the tendons as needed.     

Bore canal site in surgical reconstruction of the anterior cruciate ligament. Position--placement errors--anatomic measurement

The goal of surgical reconstruction of the anterior cruciate ligament (ACL) is restoration of its function as closely as possible to a physiological roll-and-glide mechanism. Clinical success means knee joint stability, physiological joint biomechanics, and full range of motion. Anatomical placement of the graft insertion points and anatomical direction of the drilled tunnels are necessary to obtain isometric (anatometric) conditions. Despite technical advances in (arthroscopic) surgery, it is not yet possible to obtain absolute "isometricity" for ACL grafts. However a "physiological" or "relative" isometricity seems to be sufficient for successful clinical results. In 1986 Werner Müller proposed the term "anatometrics" in ACL reconstruction to describe this graft behavior and function. The knee joint is a complex motion system including many active and passive stabilizing elements (ligaments, tendons, muscles) as well as a proprioceptive function of the central column ligaments. Reconstruction of this "system" required the surgeon to have good surgical skills and a well-based knowledge of knee anatomy and function. Wrong placement of insertion points and bone tunnels carry the risk for ensuing graft insufficiency and resultant joint instability. The knee "prefers" a destroyed graft over an overconstrained biomechanical situation! Intraoperative factors for failure may be technical mistakes and intraoperative measuring devices for isometry, which might not guarantee true relations in a ligamentous deficient knee. Therefore, visualization of insertion points (and drilling) under direct arthroscopic view is still preferred over generalized rules and distances as proposed by many commercially available rulers and tapers. Recently, navigation and computer-assisted placement techniques have been developed. The clinical standards of those techniques are still under investigation. At our institution, an arthroscopic approach (visualization, palpation) for ACL reconstruction with a bone-patellar-tendon-bone graft technique is used.     

Implant-free ACL reconstruction: a review

Implant-free anterior cruciate ligament (ACL) reconstruction is the fixation of ACL grafts without the need for artificial implants. Our aim was to study the evolution of this technique, review the biomechanical evidence and summarise the results. Implant-free graft fixation for bone patella tendon ACL reconstruction was first described in 1987. This concept of implant-free graft fixation was adapted for hamstring and quadriceps tendons as alternative graft sources. Various biomechanical studies have reported that by adhering to certain technical details, this technique provides comparable fixation strength as conventional ACL fixation. The outcome studies of implant-free ACL reconstruction also report clinical results similar to ACL reconstruction with conventional implants.     

Hamstring tendon harvesting. Reviewing anatomic relationships and avoiding pitfalls

The gracilis and semitendinosus tendons remain popular grafts for many reconstructive procedures, including anterior cruciate ligament reconstruction. Surgeons who use other grafts for ACL reconstruction should have the hamstring tendon techniques in their arsenal in the event other grafts are unavailable or undesirable. Detailed knowledge of the anatomy of the medial side of the knee is paramount to avoid potential pitfalls and ensure a successful tendon harvest.     

Double-stranded hamstring tendons for anterior cruciate ligament reconstruction.

Bone-patellar tendon-bone autograft is the most commonly used tissue for ACL reconstruction; however, the harvesting of patellar tendon as a free graft can lead to significant morbidity. Alternate grafts may lower morbidity, yet the most commonly used alternate grafts including the double-stranded semi-tendinosus or gracilis have not been studied biomechanically. This study investigated the morphometric and biomechanical properties of double-stranded semi-tendinosus and gracilis tendons separately along with the patellar and quadriceps tendons obtained bilaterally from six fresh, 77-year-old cadaveric specimens. The quadriceps tendon was the thickest and therefore had the largest cross-sectional area, whereas double-stranded semitendinosus had the highest mean peak load to failure (1029+/-158.4 N), 11.5% and 10.3% stronger than patellar tendon and quadriceps tendons, respectively. Midsubstance rupture occurred in the hamstring tendons, whereas the patellar and quadriceps tendons failed at the bone-tendon junctions. Semitendinosus tendons with higher cross-sectional area had higher peak loads to failure. This linear relationship between cross-sectional area and the peak load to rupture also was observed in the other tendon groups (except gracilis). These results indicate that despite a lower cross-sectional area of the double-stranded semitendinosus, this tendon demonstrated a comparable mean peak load to rupture and stress compared with patellar and quadriceps tendons. It also was demonstrated that combined double-stranded semitendinosus and gracilis tendons produce a stronger graft with initial strength twice that of the patellar tendon, but requires further testing.     

Anterior cruciate ligament reconstruction using hamstring tendon grafts

The annual incidence of more than 100,000 anterior cruciate ligament tears has increased with the rise of participation in sports in the general population, especially in females and older participants. Anterior cruciate ligament reconstruction is the standard of care in the young and/or athletically active individuals, based on prospective randomized studies. Replacement tissues to reconstruct the anterior cruciate ligament can be categorized as autograft, allograft, xenograft, and artificial replacements. Historically, xenograft and artificial replacements for the anterior cruciate ligament have failed dismally. As a result, autograft and allograft tissues commonly are used to reconstruct the anterior cruciate ligament. Autograft tissue currently is the most common source for grafts used worldwide. The two most common autograft tissues are the bone-patellar tendon-bone and hamstrings tendons. Controversy exists regarding the advantages and disadvantages of using each of these two tissues. The purpose of the current study was to review the basic science and clinical data regarding the use of the hamstring tendons in anterior cruciate ligament reconstruction.     

Anterior Cruciate Ligament Reconstruction: State of the Art

Abstract The rupture of the Anterior cruciate ligament (ACL) belongs to the most common ligament injuries of the human knee joint. ACL rupture results in an increased anterior translation and internal rotation of the tibia. Untreated knee instability causes a disintegration of the roll and sliding movement and a high incidence of secondary meniscus and chondral damages with consecutive or advanced arthritic changes. For deciding on a conservative or operative therapy, it is necessary to develop a high-risk profile. Elderly, inactive patients without instability symptoms can be treated conservatively; younger, active people and complex ligament injuries should receive an ACL replacement. The goal is to eliminate instability by maintaining the physiological kinematics of the knee. Anterior cruciate ligament may be reconstructed arthroscopically assisted by autologous tendons. Predominantly, hamstring- and bone-patellar-tendon grafts are used. No significant differences in knee laxity, clinically and functionally, were observed between both grafts. Various reconstruction techniques, single- or double-bundle techniques, were described. Successful replacement depends on a correct tunnel placement and reconstruction of the physiological band tension, a sufficient mechanical stability of fixation, an impingement-free range of motion and an adequate rehabilitation. A high degree of patient satisfaction in clinical and functional outcome could be evaluated.     

Flap coverage of dorsum of hand associated with extensor tendons injuries: A completely vascularized single-stage reconstruction

This study reports results in 12 patients treated with "completely vascularized single-stage approaches," so defined because skin, tendon, and nerve are transferred as a compound flap, and all are vascularized. A free dorsalis pedis cutaneotendinous flap was used in 7 patients, while a radial forearm cutaneotendinous island flap was transposed in 5 patients. A dorsalis pedis flap provides four vascularized extensor tendons (extensor digitorum comunis tendons), and the radial artery flap permits the inclusion of one completely vascularized tendon (palmaris longus) and two "strips" of vascularized tendons (flexor carpi radialis and brachioradialis). The flaps survived in all cases, and the transferred tendons were functioning well. The dorsalis pedis flap can be employed in the reconstruction of cutaneotendinous defects of the dorsum of the hand which require the use of three or four tendons grafts. We suggest the use of forearm cutaneotendinous flaps in cases of reconstruction of one or two extensor tendons. The "completely vascularized single-stage reconstruction" avoids prolonged hospitalization and results in a rapid restoration of near-normal function and appearance of the hand.     

Needle fixation technique in cartilage grafting.

Exact placement of onlay cartilage grafts in auricular reconstruction and rhinoplasty demands technical experience. Recycled straight and curved needles have been used in a percutaneous manner for cartilage fixation. The method is easy, noninvasive, and is a time-saving procedure that can be used in various situations requiring a cartilage graft through a small incision.     

Tendon allografts in knee ligament surgery.

This paper describes the experiences of the Orthopaedic Service and the Scottish National Blood Transfusion Service in Edinburgh in establishing a tissue bank for allograft tendons used in knee ligament reconstruction surgery. Ninety-five tendons have been harvested from 23 donors, and 36 grafts have been implanted in 30 knees for either primary ligament reconstruction (group 1, 4 knees), revision ligament reconstruction (group 2, 11 knees), or in patients with multiple ligament deficiency (group 3, 15 knees). The basic science of ligament allografts, donor screening and the role of tendon allografts are reviewed.     

Viscoelasticity and temperature variations decrease tension and stiffness of hamstring tendon grafts following anterior cruciate ligament reconstruction

BACKGROUND: Hamstring tendon grafts used for anterior cruciate ligament reconstruction are typically harvested early in the surgical procedure and are preconditioned prior to reimplantation. Postoperatively, the grafts undergo stress relaxation and warm from the temperature of the operating room to body temperature. The hypothesis of this study was that the tension within semitendinosus and gracilis tendon grafts and the stiffness of the grafts significantly decrease postoperatively because of both stress relaxation and an increase in temperature. METHODS: Double-strand grafts were created from six semitendinosus tendons and six gracilis tendons harvested from cadaver specimens. The grafts were loaded to 65 N while at operating-room temperature (20 degrees C). After fifteen minutes of stress relaxation, graft tension was measured and the grafts were stretched by 0.1 mm to determine stiffness. The tension and stiffness measurements represented graft properties immediately following reconstruction. Additional tension and stiffness measurements were made following three hours of stress relaxation and after increasing the temperature to the body temperature at the knee (34 degrees C). Both types of graft were examined for differences in stiffness and tension due to stress relaxation and the temperature increase. RESULTS: For both types of graft, the tension and stiffness decreased following stress relaxation to approximately 50% and 80%, respectively, of the value immediately after reconstruction. Increasing the temperature decreased the tension and stiffness further to approximately 40% and 70%, respectively, of the value after reconstruction for both types of graft. All changes in tension and stiffness were significant (p < 0.01). CONCLUSIONS: Graft tension and stiffness achieved immediately following reconstruction are not maintained postoperatively because of stress relaxation and a temperature increase. This could lead to increased knee laxity.     

Arthroscopic anterior cruciate ligament reconstruction using autogenous hamstring tendon graft without detachment of the tibial insertion

This article describes a modified arthroscopic technique of anterior cruciate ligament reconstruction using quadrupled hamstring tendon graft. The autogenous semitendinosus and gracilis grafts are harvested without detachment of the tibial insertion. To obtain longer grafts, the accessory tibial insertions of the hamstring tendons are dissected. The EndoButton (Acufex Microsurgical, Andover, MA) is used for femoral fixation and two spiked staples are used for tibial fixation in a belt buckle fashion. Then the residual anterior laxity is restored by additional absorbable interference screw fixations. In this technique, more viable graft is obtained and more firm distal fixation is achieved by preservation of the tibial insertion of hamstring tendons.     

A modified technique of two-staged extensor tendon reconstruction in zones 6–8 in a patient with absent palmaris/plantaris tendons: A case report

IntroductionThe indications for two-staged extensor tendon reconstruction are rare and only 14 previously reported cases were found in the literature. In these cases, silicone rods are inserted in the first stage. Few months later, the palmaris longus / plantaris tendon grafts are usually used to replace the silicone rods.Case reportwe encountered a patient with major defects of the extensor tendons of all fingers extending from the proximal one third of zone 6 to zone 8. The patient had no palmaris or plantaris tendons. We utilized a modified technique of reconstruction using the split flexor carpi radialis as the tendon graft and the flexor carpi ulnaris as the motor tendon. At final follow-up, there was full active extension of the fingers. However, there was limitation of wrist flexion because of the harvesting of both wrist flexors.DiscussionWe describe a modified technique of two-staged extensor tendon reconstruction which may be used in patients with absent palmaris/ plantaris tendons.ConclusionIn patients with absent palmaris/ plantaris tendons and major defects of the extensor tendons of all fingers, the use of split flexor carpi radialis is an adequate alternative for reconstruction and gives a good functional outcome.     

Reconstruction of maxillectomy defects with free flaps--comparison of immediate and delayed reconstruction: a retrospective analysis of 51 cases.

To establish a standard reconstructive material we compared outcomes after immediate and delayed reconstruction. Of the 21 patients who had immediate reconstruction, six patients had upper horizontal plane reconstruction. All bone grafts survived without infection or absorption. Of the 30 patients who had delayed reconstruction, 22 patients had upper horizontal plane reconstruction, with vascularised bone in 14 patients, non-vascularised bone or cartilage in five patients, and hydroxyapatite bone block in three. Postoperative infections developed in three of four patients for whom costal cartilage was used, and in all three patients for whom hydroxyapatite blocks were used. Non-vascularised bone or cartilage grafts are preferable for immediate reconstruction because of their technical simplicity. Vascularised bone grafts or osteocutaneous flaps are preferable for delayed reconstruction, however, as in most cases the operating field is contaminated by bacterial.     

Reconstruction of maxillectomy defects with free flaps - comparison of immediate and delayed reconstruction: A retrospective analysis of 51 cases

To establish a standard reconstructive material we compared outcomes after immediate and delayed reconstruction. Of the 21 patients who had immediate reconstruction, six patients had upper horizontal plane reconstruction. All bone grafts survived without infection or absorption. Of the 30 patients who had delayed reconstruction, 22 patients had upper horizontal plane reconstruction, with vascularised bone in 14 patients, non-vascularised bone or cartilage in five patients, and hydroxyapatite bone block in three. Postoperative infections developed in three of four patients for whom costal cartilage was used, and in all three patients for whom hydroxyapatite blocks were used. Non-vascularised bone or cartilage grafts are preferable for immediate reconstruction because of their technical simplicity. Vascularised bone grafts or osteocutaneous flaps are preferable for delayed reconstruction, however, as in most cases the operating field is contaminated by bacterial.     

Anatomische vordere Kreuzbandersatzoperation mittels Semitendinosus- und Grazilissehne in fremdmaterialfreier Press-fit-Technik

An innovative technique for anterior cruciate ligament (ACL) reconstruction has been developed in 1998 which allows the grafts to be fixed by press-fit to the femoral and tibial tunnel without any hardware. The semitendinosus (ST) and gracilis tendons (GT) are built into a sling by tying a knot with the tendon ends and securing the knot after conditioning by sutures. For the femoral tunnel the anteromedial porta is used. The correct anatomic position of the single femoral tunnel is checked using intraoperative lateral fluoroscopy by placing the tip of a K-wire to a point between the anteromedial and posterolateral bundle insertion sites. A femoral bottleneck tunnel is drilled to receive the knot of the tendons. The tendon loops filled the tibial tunnel without any suture material. The loops are fixed at the tibial tunnel outlet with tapes over a bone bridge. Between 1998 and 1999 a prospective randomized study (level 1) was conducted comparing this technique with a technique using bone-patellar-tendon graft and press-fit fixation without hardware. In conclusion it was found that implant-free press-fit ACL reconstruction using bone-patella-tendon (BPT) and hamstring tendon (HT) grafts proved to be an excellent procedure to restore stability and function of the knee. Using hamstring tendons (ST and GT) significantly lower donor site morbidity was noted. Kneeling and knee walking pain persisted to be significantly more intense in the BPT up to 9 years after the operation. Re-rupture rates, subjective findings, knee stability and isokinetic testing showed similar results for both grafts. This is the first level I study which demonstrates cartilage protection by ACL reconstruction as long as the meniscus is intact at index surgery, shown by bilateral MRI analysis 9 years post-operation. There was no significant difference in the average grade of chondral and meniscus lesions between BPT and HT and in comparison of the operated to the intact knee, except for grade 3-4 lesions found at the 9 year follow-up, which were significantly higher in the BPT group.     

Technical note: Anterior cruciate ligament reconstruction in the presence of an intramedullary femoral nail using anteromedial drilling

AIM To describe an approach to anterior cruciate ligament(ACL) reconstruction using autologous hamstring by drilling via the anteromedial portal in the presence of an intramedullary(IM) femoral nail.METHODS Once preoperative imagining has characterized the proposed location of the femoral tunnel preparations are made to remove all of the hardware(locking bolts and IM nail). A diagnostic arthroscopy is performed in the usual fashion addressing all intra-articular pathology. The ACL remnant and lateral wall soft tissues are removed from the intercondylar, to provide adequate visualization of the ACL footprint. Femoral tunnel placement is performed using a transportal ACL guide with desired offset and the knee flexed to 2.09 rad. The Beath pin is placed through the guide starting at the ACL's anatomic footprint using arthroscopic visualization and/or fluoroscopic guidance. If resistance is met while placing the Beath pin, the arthroscopy should be discontinued and the obstructing hardware should be removed under fluoroscopic guidance. When the Beath pin is successfully placed through the lateral femur, it is overdrilled with a 4.5 mm Endobutton drill. If the Endobutton drill is obstructed, the obstructing hardware should be removed under fluoroscopic guidance. In this case, the obstruction is more likely during Endobutton drilling due to its larger diameter and increased rigidity compared to the Beath pin. The femoral tunnel is then drilled using a best approximation of the graft's outer diameter. We recommend at least 7 mm diameter to minimize the risk of graft failure. Autologous hamstring grafts are generally between 6.8 and 8.6 mm in diameter. After reaming, the knee is flexed to 1.57 rad, the arthroscope placed through the anteromedial portal to confirm the femoral tunnel position, referencing the posterior wall and lateral cortex. For a quadrupled hamstring graft, the gracilis and semitendinosus tendons are then harvested in the standard fashion. The tendons are whip stitched, quadrupled and shaped to match the diameter of the prepared femoral tunnel. If the diameter of the patient's autologous hamstring graft is insufficient to fill the prepared femoral tunnel, the autograft may be supplemented with an allograft. The remainder of the reconstruction is performed according to surgeon preference. RESULTS The presence of retained hardware presents a challenge for surgeons treating patients with knee instability. In cruciate ligament reconstruction, distal femoral and proximal tibial implants hardware may confound tunnel placement, making removal of hardware necessary, unless techniques are adopted to allow for anatomic placement of the graft. CONCLUSION This report demonstrates how the femoral tunnel can be created using the anteromedial portal instead of a transtibial approach for reconstruction of the ACL.     

Patellar tendon autograft versus hamstring tendon autograft in arthroscopic anterior cruciate ligament reconstruction: appraisal of the evidence

Arthroscopy–assisted reconstruction of a torn anterior cruciate ligament (ACL) is a commonly performed surgical procedure. The type of graft used for ACL reconstruction has traditionally been an autograft; the more commonly used grafts are the bonepatellar tendon–bone (BPTP) and hamstring tendons, namely the gracilis and semitendinosus tendons (GST). We surveyed the evidence concerning the outcome of patients treated by arthroscopic reconstruction of the ACL with either BPTP or GST. On basis of several welldesigned studes, specifically 5 meta–analyses and one systematic review, we critically discuss the best evidence available today regarding ACL reconstruction. This evidence suggests that BPTP may be considered for patients performing high–demand activities not involving repetitive kneeling.     

Scaphoid reconstruction with vascularized bone grafts from the distal radius

The aim of the present technical report is to describe the alternative solutions for the reconstruction of scaphoid nonunions with pedicled vascularized bone grafts from the distal radius. The surgical technique for the reconstruction A. of proximal scaphoid nonunions with pedicled bone grafts (based on the 1,2 or on the 2,3 intercomparmtental arteries) or with capsular bone grafts from the dorsal distal radius and B. of waist nonunions of the scaphoid with grafts from the palmar distal radius, pedicled on the palmar carpal arch, is presented. Vascularized bone grafts from the adjacent radius are used for the treatment of scaphoid nonunions to enhance union and to revascularize a nonviable proximal pole. The most suitable graft is selected according to the location of the nonunion (at the waist or the proximal pole of the scaphoid) and to the previous procedures/scars at the wrist level.