How to Avoid Common Complications in Hamstrings Harvest for Anterior Cruciate Ligament Reconstruction: A Practical Guide

Document Type : TECHNICAL NOTE

Authors

1 Department of Orthopedic and Trauma Surgery, Magna Graecia University, Catanzaro, Italy

2 Department of Orthopedic and Trauma Surgery, Casa di Cura Caminiti, Villa San Giovanni (RC), Italy

3 Department of Medical and Surgical Sciences, Nutrition Unit, Magna Graecia University, Catanzaro, Italy

4 Twin Cities Orthopedics, Edina, Minnesota, USA

Abstract

More than 100,000 anterior cruciate ligament (ACL) reconstructions are performed annually in the 
United States and one of the most common autografts for ACL reconstruction (ACLR) is the HS tendons. 
Nevertheless, proper HS harvest can be challenging, and several complications can be encountered, 
including, iatrogenic neurovascular damage, premature amputation of the tendons, graft contamination, 
and postoperative hematoma. The aim of this technical note is to describe a safe and effective 
technique for autologous HS tendon harvest in ACLR.
 Level of evidence: V

Keywords

Main Subjects


1. Mall NA, Chalmers PN, Moric M, et al. Incidence and trends of 
anterior cruciate ligament reconstruction in the United 
States. Am J Sports Med. 2014; 42(10):2363-2370. doi: 
10.1177/0363546514542796.
2. Goldblatt JP, Fitzsimmons SE, Balk E, Richmond JC. 
Reconstruction of the anterior cruciate ligament: metaanalysis of patellar tendon versus hamstring tendon 
autograft. Arthroscopy. 2005; 21(7):791-803. 
doi:10.1016/j.arthro.2005.04.107.
3. Maeda A, Shino K, Horibe S, Nakata K, Buccafusca G. Anterior 
cruciate ligament reconstruction with multistranded 
autogenous semitendinosus tendon. Am J Sports Med. 1996; 
24(4):504-509. doi:10.1177/036354659602400416.
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(12):1948-1953. doi:10.1016/j.arthro.2013.08.025.
5. Candal-Couto JJ, Deehan DJ. The accessory bands of Gracilis 
and Semitendinosus: an anatomical study. Knee. 2003; 
10(4):325-328. doi: 10.1016/S0968-0160(02)00154-0.
6. Tuncay I, Kucuker H, Uzun I, Karalezli N. The fascial band 
from semitendinosus to gastrocnemius: the critical point of 
hamstring harvesting an anatomical study of 23 cadavers. 
Acta Orthopaedica. 2007; 78(3):361-363. 
doi:10.1080/17453670710013933.
7. Tifford CD, Spero L, Luke T, Plancher KD. The relationship of 
the infrapatellar branches of the saphenous nerve to 
arthroscopy portals and incisions for anterior cruciate 
ligament surgery. An anatomic study. Am J Sports Med. 2000; 
28(4):562-567. doi:10.1177/03635465000280042001.
8. Yucens M, Aydemir AN. Trends in Anterior Cruciate Ligament 
Reconstruction in the Last Decade: A Web-Based Analysis. J 
Knee Surg. 2019; 32(6):519-524. doi: 10.1055/s-0038-
1655764.
9. Olivos-Meza A, Suarez-Ahedo C, Jiménez-Aroche CA, et al. 
Anatomic Considerations in Hamstring Tendon Harvesting for Ligament Reconstruction. Arthrosc Tech. 2020; 
9(1):e191-e198. doi:10.1016/j.eats.2019.09.021.
10. LaPrade RF, Engebretsen AH, Ly TV, Johansen S, Wentorf FA, 
Engebretsen L. The anatomy of the medial part of the knee. J 
Bone Joint Surg Am. 2007; 89(9):2000-2010. 
doi:10.2106/JBJS.F.01176.
11. Judd D, Bottoni C, Kim D, Burke M, Hooker S. Infections 
following arthroscopic anterior cruciate ligament 
reconstruction. Arthroscopy. 2006; 22(4):375-384. 
doi:10.1016/j.arthro.2005.12.002.
12. Baron JE, Shamrock AG, Cates WT, et al. Graft Preparation 
with Intraoperative Vancomycin Decreases Infection after 
ACL Reconstruction: A Review of 1,640 Cases. J Bone Joint 
Surg Am. 2019; 101(24):2187-2193. 
doi:10.2106/JBJS.19.00270.
13. Naendrup JH, Marche B, de Sa D, et al. Vancomycin-soaking of 
the graft reduces the incidence of septic arthritis following 
ACL reconstruction: results of a systematic review and metaanalysis. Knee Surg Sports Traumatol Arthrosc. 2020; 
28(4):1005-1013. doi: 10.1007/s00167-019-05353-1.
14. Offerhaus C, Balke M, Hente J, Gehling M, Blendl S, Höher J. 
Vancomycin pre-soaking of the graft reduces postoperative 
infection rate without increasing risk of graft failure and 
arthrofibrosis in ACL reconstruction. Knee Surg Sports 
Traumatol Arthrosc. 2019; 27(9):3014-3021. doi: 
10.1007/s00167-018-5323-6.
15. Hesselvig AB, Arpi M, Madsen F, Bjarnsholt T, Odgaard A, the 
ICON Study Group. Does an Antimicrobial Incision Drape 
Prevent Intraoperative Contamination? A Randomized 
Controlled Trial of 1187 Patients. Clin Orthop Relat Res. 
2020; 478(5):1007-1015. 
doi:10.1097/CORR.0000000000001142.
16. Lubowitz JH. All-inside anterior cruciate ligament graft link: 
graft preparation technique. Arthrosc Tech. 2012; 1(2):e165-
168. doi:10.1016/j.eats.2012.06.002.
17. Pasque CB, Geib TM. Intraoperative anterior cruciate 
ligament graft contamination. Arthroscopy. 2007; 23(3):329-
331. doi:10.1016/j.arthro.2005.12.010.
18. Phegan M, Grayson JE, Vertullo CJ. No infections in 1300 
anterior cruciate ligament reconstructions with vancomycin 
pre-soaking of hamstring grafts. Knee Surg Sports Traumatol 
Arthrosc. 2016; 24(9):2729-2735. doi: 10.1007/s00167-015-
3558-z.
19. Laprade RF, Wijdicks CA. Surgical technique: development of 
an anatomic medial knee reconstruction. Clin Orthop Relat 
Res. 2012; 470(3):806-814. doi: 10.1007/s11999-011-2061-
1.
20. LaPrade RF, Spiridonov SI, Coobs BR, Ruckert PR, Griffith CJ. 
Fibular collateral ligament anatomical reconstructions: a 
prospective outcomes study. Am J Sports Med. 2010; 
38(10):2005-2011. doi: 10.1177/0363546510370200.
21. Lange-Asschenfeldt B, Marenbach D, Lang C, et al. 
Distribution of Bacteria in the Epidermal Layers and Hair 
Follicles of the Human Skin. Skin Pharmacol Physiol. 2011; 
24(6):305-311. doi: 10.1159/000328728.
22. Rezapoor M, Tan TL, Maltenfort MG, Parvizi J. Incise Draping 
Reduces the Rate of Contamination of the Surgical Site During 
Hip Surgery: A Prospective, Randomized Trial. J Arthroplasty. 
2018; 33(6):1891-1895. doi:10.1016/j.arth.2018.01.013.
23.Jacobson C, Osmon DR, Hanssen A, et al. Prevention of wound 
contamination using DuraPrep solution plus Ioban 2 drapes. 
Clin Orthop Relat Res. 2005; 439:32-37. 
doi:10.1097/01.blo.0000182245.29830.bc.
24. Grayson JE, Grant GD, Dukie S, Vertullo CJ. The in vitro elution 
characteristics of vancomycin from tendons. Clin Orthop 
Relat Res. 2011; 469(10):2948-2952. doi: 10.1007/s11999-
011-1768-3.
25. Pérez-Prieto D, Torres-Claramunt R, Gelber PE, Shehata TMA, 
Pelfort X, Monllau JC. Autograft soaking in vancomycin 
reduces the risk of infection after anterior cruciate ligament 
reconstruction. Knee Surg Sports Traumatol Arthrosc. 2016; 
24(9):2724-2728. doi: 10.1007/s00167-014-3438-y.
26. Goebel ME, Drez D, Heck SB, Stoma MK. Contaminated rabbit 
patellar tendon grafts. In vivo analysis of disinfecting 
methods. Am J Sports Med. 1994; 22(3):387-391. doi: 
10.1177/036354659402200315.
27. Curtis BR, Huang BK, Pathria MN, Resnick DL, Smitaman E. 
Pes Anserinus: Anatomy and Pathology of Native and 
Harvested Tendons. AJR Am J Roentgenol. 2019; 
213(5):1107-1116. doi:10.2214/AJR.19.21315.
28. Sabat D, Kumar V. Nerve injury during hamstring graft 
harvest: a prospective comparative study of three different 
incisions. Knee Surg Sports Traumatol Arthrosc. 2013; 
21(9):2089-2095. doi: 10.1007/s00167-012-2243-8.
29. Ruffilli A, De Fine M, Traina F, Pilla F, Fenga D, Faldini C. 
Saphenous nerve injury during hamstring tendons harvest: 
Does the incision matter? A systematic review. Knee Surg 
Sports Traumatol Arthrosc. 2017; 25(10):3140-3145. doi: 
10.1007/s00167-016-4217-8.
30. Luo H, Yu J kuo, Ao Y fang, et al. Relationship between 
different skin incisions and the injury of the infrapatellar 
branch of the saphenous nerve during anterior cruciate 
ligament reconstruction. Chin Med J (Engl). 2007; 
120(13):1127-1130.
31. Tavakoli Darestani R, Bagherian Lemraski MM, Hosseinpour 
M, Kamrani-Rad A. Electrophysiological Assessment of Injury 
to the Infra-patellar Branch(es) of the Saphenous Nerve 
during Anterior Cruciate Ligament Reconstruction Using 
Medial Hamstring Auto-grafts: Vertical versus Oblique 
Harvest Site Incisions. Arch Trauma Res. 2013; 2(3):118-123. 
doi:10.5812/atr.11146.
32. Kjaergaard J, Faunø LZ, Faunø P. Sensibility loss after ACL 
reconstruction with hamstring graft. Int J Sports Med. 2008; 
29(6):507-511. doi: 10.1055/s-2008-1038338.
33. Papastergiou SG, Voulgaropoulos H, Mikalef P, Ziogas E, 
Pappis G, Giannakopoulos I. Injuries to the infrapatellar 
branch(es) of the saphenous nerve in anterior cruciate 
ligament reconstruction with four-strand hamstring tendon 
autograft: vertical versus horizontal incision for harvest. Knee 
Surg Sports Traumatol Arthrosc. 2006; 14(8):789-793. doi: 
10.1007/s00167-005-0008-3.
34. Sanders B, Rolf R, McClelland W, Xerogeanes J. Prevalence of 
Saphenous Nerve Injury After Autogenous Hamstring 
Harvest: An Anatomic and Clinical Study of Sartorial Branch 
Injury. Arthroscopy. 2007; 23(9):956-963. 
doi:10.1016/j.arthro.2007.03.099.
35. Grassi A, Perdisa F, Samuelsson K, et al. Association between 
incision technique for hamstring tendon harvest in anterior cruciate ligament reconstruction and the risk of injury to the 
infra-patellar branch of the saphenous nerve: a meta-analysis. 
Knee Surg Sports Traumatol Arthrosc. 2018; 26(8):2410-
2423. doi: 10.1007/s00167-018-4858-x.
36. Babu S, Gupte C, Gajjar S, Morris H. The ‘sentinel’ vessel: an 
anatomical landmark to identify the pes anserinus during 
hamstrings harvest for ACL reconstruction. Eur J Orthop Surg 
Traumatol. 2019; 29(5):1115-1118. doi: 10.1007/s00590-
019-02408-4.
37. Warren LF, Marshall JL. The supporting structures and layers 
on the medial side of the knee: an anatomical analysis. J Bone 
Joint Surg Am. 1979; 61(1):56-62.
38. Olewnik Ł, Gonera B, Podgórski M, Polguj M, Jezierski H, 
Topol M. A proposal for a new classification of pes anserinus 
morphology. Knee Surg Sports Traumatol Arthrosc. 2019; 
27(9):2984-2993. doi: 10.1007/s00167-018-5318-3.
39. Reina N, Abbo O, Gomez-Brouchet A, Chiron P, Moscovici J, 
Laffosse JM. Anatomy of the bands of the hamstring tendon: 
How can we improve harvest quality? Knee. 2013; 20(2):90-
95. doi:10.1016/j.knee.2012.06.003.
40. Solman CG, Pagnani MJ. Hamstring tendon harvesting. 
Reviewing anatomic relationships and avoiding pitfalls. 
Orthop Clin North Am. 2003; 34(1):1-8. doi:10.1016/s0030-
5898(02)00025-1.
41. Felli L, Revello S, Burastero G, et al. Single Intravenous 
Administration of Tranexamic Acid in Anterior Cruciate 
Ligament Reconstruction to Reduce Postoperative 
Hemarthrosis and Increase Functional Outcomes in the Early 
Phase of Postoperative Rehabilitation: A Randomized 
Controlled Trial. Arthroscopy. 2019; 35(1):149-157. 
doi:10.1016/j.arthro.2018.07.050.
42. Karaaslan F, Karaoğlu S, Yurdakul E. Reducing Intra-articular 
Hemarthrosis After Arthroscopic Anterior Cruciate Ligament 
Reconstruction by the Administration of Intravenous 
Tranexamic Acid: A Prospective, Randomized Controlled 
Trial. Am J Sports Med. 2015; 43(11):2720-2726. 
doi:10.1177/0363546515599629.
43. Chiang ER, Chen KH, Wang ST, et al. Intra-articular Injection 
of Tranexamic Acid Reduced Postoperative Hemarthrosis in 
Arthroscopic Anterior Cruciate Ligament Reconstruction: A 
Prospective Randomized Study. Arthroscopy. 2019; 
35(7):2127-2132. doi:10.1016/j.arthro.2019.02.018.
44. Nugent M, May JH, Parker JD, et al. Does Tranexamic Acid 
Reduce Knee Swelling and Improve Early Function Following 
Arthroscopic Meniscectomy? A Double-Blind Randomized 
Controlled Trial. Orthop J Sports Med. 2019; 
7(8):2325967119866122. doi: 
10.1177/2325967119866122.
45. Joos H, Leucht F, Riegger J, et al. Differential Interactive 
Effects of Cartilage Traumatization and Blood Exposure In 
Vitro and In Vivo. Am J Sports Med. 2015; 43(11):2822-2832. 
doi: 10.1177/0363546515602248.
46. Sever GB. Can infection after anterior cruciate ligament 
surgery be prevented by inserting a Hemovac drain into graft 
donor site? Jt Dis Relat Surg. 2020; 31(1). 
doi:10.5606/ehc.2020.71334.
47. Kanayama M, Oha F, Togawa D, Shigenobu K, Hashimoto T. Is 
closed-suction drainage necessary for single-level lumbar 
decompression? Review of 560 cases. Clin Orthop Relat Res. 
2010; 468(10). doi: 10.1007/s11999-010-1235-6.
48. Poorman CE, Passias PG, Bianco KM, Boniello A, Yang S, 
Gerling MC. Effectiveness of postoperative wound drains in 
one- and two-level cervical spine fusions. Int J Spine Surg. 
2014; 8:34. doi: 10.14444/1034.
49. Zhou X die, Li J, Xiong Y, Jiang L feng, Li W jun, Wu L dong. Do 
we really need closed-suction drainage in total hip 
arthroplasty? A meta-analysis. Int Orthop. 2013; 
37(11):2109-2118. doi: 10.1007/s00264-013-2053-8.
50. McCormack RG, Greenhow RJ, Fogagnolo F, Shrier I. Intraarticular drain versus no drain after arthroscopic anterior 
cruciate ligament reconstruction: a randomized, prospective 
clinical trial. Arthroscopy. 2006; 22(8):889-893. 
doi:10.1016/j.arthro.2006.05.004.
51. Karahan M, Erol B, Bekiroğlu N, Uyan D. Effect of drain placed 
in the donor site in the early postoperative period after 
arthroscopically assisted anterior cruciate ligament
reconstruction with quadrupled hamstring tendons. Am J 
Sports Med. 2005; 33(6):900-906. doi: 
10.1177/0363546504271503.
52. Straw R, Colclough K, Geutjens GG. Arthroscopically assisted 
ACL reconstruction. Is a drain necessary? Knee. 2003; 
10(3):283-285. doi: 10.1016/s0968-0160(02)00150-3.