Posteromedial versus Anteromedial Hamstring Tendon Harvest for Anterior Cruciate Ligament Reconstruction: A Retrospective Comparison of Accidental Gracilis Harvests, Outcomes, and Operative Times

Abstract

Hamstring autografts are frequently harvested for anterior cruciate ligament reconstruction (ACLR), traditionally through the anteromedial (AM) approach. Recently, a posteromedial (PM) approach has been described. The primary purpose of this study was to compare rates of unintentional gracilis (Gr) harvest or premature tendon amputation with these approaches. We also sought to compare operative times and patient-reported outcome measures (PROMs) between both groups and between those with only semitendinosus (ST) grafts or with combined ST and Gr grafts. Patients who underwent ACLR with hamstring autograft by a single surgeon from 2014 to 2016 were retrospectively reviewed. An accidental harvest was identified as an unintentional Gr harvest or premature graft amputation. PROMs included the Knee Osteoarthritis and Outcomes Score, Western Ontario and McMaster Universities Osteoarthritis Index, and International Knee Documentation Committee score. Two out of 22 (9.1%) patients in the AM group had unintentional Gr tendon harvests, while none (out of 29) were identified in the PM group (p = 0.101). Group mean PROMs were not significantly different between patients in either group or patients with either ST-only grafts and those with combined ST + Gr. Average operative times and tourniquet times were significantly shorter with the PM approach versus the AM approach (101 ± 18.2 vs 129 ± 25.6 minutes, p = 0.002; 68 ± 14.8 vs 90 ± 28.9 minutes, p = 0.005). The PM approach was associated with a trend toward decreased risk of unintentional harvest of the Gr tendon and significantly decreased operative and tourniquet times without affecting knee outcomes compared with the traditional AM approach. Accidental Gr harvest was not associated with worse outcomes.

The Posteromedial Approach for Harvesting Hamstring Autografts Results in Fewer Incidents of Saphenous Nerve Injury Compared to the Conventional Anteromedial Approach: A Systematic Review and Meta-Analysis

“…Detailed information about the included studies can be found in Tables 1 and 2 . 17 18 19 20 21) For an overview of the study selection process, refer to Fig. 1 in the PRISMA flow diagram.…”

“…There were 5 studies 17 18 19 20 21) comparing anteromedial and posteromedial approaches for hamstring harvest that reported occurrences of saphenous nerve injury. The overall occurrences of saphenous nerve injury in the anteromedial and posteromedial techniques for hamstring harvest were 10.2% and 0.4%, respectively.…”

Premature hamstring graft amputation during harvesting in ACL reconstruction

“…Amputation during hamstring graft harvesting is rare, but when it occurs, the common cause is insufficient removal of the accessory branches of the gracilis and semitendinosus tendons [ 4 ]. The accessory attachments of the tendons cause transection of either the gracilis or semitendinosus tendon by misdirecting the tendon stripper, resulting in a shorter graft.…”

“…Anterior cruciate ligament (ACL) reconstruction is one of the most common operations in sports medicine [ 1 ], for which either a hamstring tendon or patellar tendon graft is commonly used [ 2 , 3 ]. There are some possible complications during or after hamstring graft harvesting such as premature graft amputation [ 4 ], medial collateral ligament injury [ 5 ] and infrapatellar branch of the saphenous nerve injury [ 6 , 7 ]. Premature graft amputation can occur by inadequate removal of the accessory branches of the hamstring tendons, poor surgical technique and/or too sharp tendon stripper [ 5 ].…”

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

“…Shu et al [ 43 ] retrospectively reviewed 29 patients who underwent a posteromedial harvest as described by Wilson et al [ 40 ]. Among these patients, 22 underwent an anteromedial harvest.…”