Anterior Cruciate Ligament Reconstruction Using

Hamstring Tendon Autograft With Preserved

Insertions
Ravi Gupta, M.S., D.N.B., M.N.A.M.S., F.A.M.S., F.I.M.S.A.,
Raj Bahadur, M.S., F.A.M.S., F.R.C.S., F.I.M.S.A., Anubhav Malhotra, M.B.B.S.,
Gladson David Masih, M.Sc., and Parmanand Gupta, M.S.

Abstract: We present a technique for anterior cruciate ligament (ACL) reconstruction using hamstring tendon autograft
with preserved tibial insertions. The tendons, harvested with an open-ended tendon stripper while their tibial insertions
are preserved, are looped around to prepare a quadrupled graft. The femoral tunnel is drilled independently through a
transportal technique, whereas the tibial tunnel is drilled in a standard manner. The length of the quadrupled graft and
loop of the RetroButton is adjusted so that it matches the calculated length of both tunnels and the intra-articular part of
the proposed ACL graft. After the RetroButton is flipped, the graft is manually tensioned with maximal stretch on the free
end, which is then sutured to the other end with preserved insertions. We propose that preserving the insertions is more
biological and may provide better proprioception. The technique eliminates the need for a tibial-side fixation device, thus
reducing the cost of surgery. Furthermore, tibial-side fixation of the free graft is the weakest link in the overall stiffness of
the reconstructed ACL, and this technique circumvents this problem. Postoperative mechanical stability and functional
outcome with this technique need to be explored and compared with those of ACL reconstruction using free hamstring
autograft.

T he most common surgical treatment for an anterior

cruciate ligament (ACL)edeficient knee is recon-
struction of the ligament using an autograft, either a
reconstructed ACL.8,9 We hypothesized that using a
technique that preserves the insertions of the hamstring
tendons on the tibial side would eliminate the disad-
quadrupled semitendinosus and gracilis (STG) tendon vantages of a free graft, such as poor proprioception,
free hamstring graft or a free boneepatellar ten- tibial-side fixation being the weakest link in the overall
donebone graft.1 The objective mechanical stability of a construct, and the added cost of using a tibial-side fix-
reconstructed ACL ranges from 85% to 90%,2 and this ation device for a free graft.
has correlated poorly with functional outcome; lack of
proprioception is thought to be one of the reasons for
poor correlation.3-7 Furthermore, tibial-side fixation of
the free graft has been observed to be the weakest link
in the overall stiffness of the construct of the

From the Department of Orthopaedics, Government Medical College and

Hospital (R.G., A.M., G.D.M., P.G.), Chandigarh; and Baba Farid University
of Health Sciences (R.B.), Punjab, India.
The authors report that they have no conflicts of interest in the authorship
and publication of this article.
Received August 9, 2015; accepted December 28, 2015.
Address correspondence to Ravi Gupta, M.S., D.N.B., M.N.A.M.S., F.A.M.S.,
F.I.M.S.A., Department of Orthopaedics, Government Medical College and
Hospital, Chandigarh, India. E-mail: ravikgupta2000@yahoo.com
Ó 2016 by the Arthroscopy Association of North America. Open access
under CC BY-NC-ND license.
2212-6287/15758 Fig 1. With the tibial insertions of the tendons left intact, an
http://dx.doi.org/10.1016/j.eats.2015.12.007 open-ended tendon stripper is used to harvest the graft.

Arthroscopy Techniques, Vol 5, No 2 (April), 2016: pp e269-e274 e269

e270 R. GUPTA ET AL.

Fig 4. The length of the tunnel is measured with a depth

gauge.

(Fig 1). The proximal free ends of the tendons are su-
Fig 2. The femoral point of entry is marked with a bone awl tured together by wrapping the broader aponeurosis of
at the junction of the lateral condylar ridge and bifurcate ridge the semitendinosus around the gracilis tendon using
with arthroscopic guidance. No. 5 Ethibond suture (Ethicon, Somerville, NJ). The

Technique
An oblique incision is performed, positioned proximal
and medial to the insertion of the pes anserinus
(Video 1). The infrapatellar branch of the saphenous
nerve is preserved. A nick is made on the sartorius
fascia. The insertions of the STG tendons are identified,
and any associated fascial bands are carefully dissected
with forceps, scissors, and finger dissection. With the
tibial insertions of the tendons left intact, an open-
ended tendon stripper is used to harvest the graft

Fig 3. A guide pin is introduced into the femur, and with the
knee in maximal hyperflexion, a 4.5-mm cannulated drill bit Fig 5. Length of femoral tunnel (length A) and length of tibial
is used to create a tunnel in the femur. tunnel plus intra-articular part of graft (length B).
 HAMSTRING AUTOGRAFT WITH PRESERVED INSERTIONS
Fig 6. No. 5 Ethibond suture
(left arrow) is passed into the
tunnel, and the loop (right ar-
row) is parked inside the joint.
tendons are looped around a No. 5 Ethibond suture,
thus creating a quadrupled graft. The graft is sized with
a sizer. Standard anterolateral and far-medial arthro-
scopic portals are made. The femoral point of entry is
marked with a bone awl at the junction of the lateral
condylar ridge and bifurcate ridge using arthroscopic
guidance (Fig 2). A guide pin is introduced into the
femur. With the knee in maximal hyperflexion, a 4.5-
mm cannulated drill bit is used to create a tunnel in the
femur (Fig 3). The length of the tunnel (length A) is
measured with a depth gauge (Figs 4 and 5). Reaming
of the tunnel is performed with a femoral reamer cor-
responding to the size of the quadrupled tendon. No. 5
Ethibond suture is passed into the tunnel and the loop
parked inside the joint (Fig 6). The tibial tunnel is
drilled in a routine manner using an ACL tibial guide
(Fig 7). The Ethibond suture loop placed through the
femoral tunnel into the joint is retrieved from the tibial
tunnel with a grasper (Fig 8). The length of the tibial
tunnel and the intra-articular part of the proposed
Fig 7. By use of an anterior cruciate ligament tibial guide, the
tibial tunnel is reamed.
e271
ACL graft (length B) is measured with a depth gauge
(Figs 5 and 9); this length is added to the already
measured length of the femoral tunnel to determine the
exact length of both tunnels plus the intra-articular
portion of the graft (length A plus length B). A
marking suture is placed on the hamstring tendons just
opposite the entry of the tibial tunnel so that when the
graft is pulled inside the joint, the mark stays at the
entry of the tunnel (Fig 10). A RetroButton (Arthrex,
Naples, FL) is loaded onto the quadrupled graft. The
length of the quadrupled graft and loop of the Retro-
Button is adjusted so that it exactly corresponds to
length A plus length B (Fig 11). The sutures of the
RetroButton are pulled through the tibial and femoral
tunnels by loading them onto the Ethibond loop placed
in the tunnels (Fig 12). The RetroButton is flipped
outside the femoral tunnel onto the cortex. The free
end of the graft exiting the tibial tunnel is pulled to
maximal stretch and the joint moved through full range
of motion at least 10 times to remove any kinks in the
graft (Fig 13). The tightness of the ACL graft is checked
arthroscopically with a probe. With maximal stretch on
the free end of the graft, it is sutured to the preserved
end (Fig 14).
Discussion
Kim et al.10 in 1997 proposed the preservation of the
tibial insertions of the STG tendons while harvesting
the graft, with an additional fixation by a double spiked
washer on the tibial side. In 2010 a new technique was
developed in which the STG graft was harvested while
solely relying on the tibial insertions of the hamstring
tendons and femoral fixation of the graft was achieved
with 2 bioabsorbable RigidFix pins (Mitek [Johnson &
Johnson], Mumbai, India); a transtibial technique was
used for drilling of the femoral tunnel.11 In our method,
we have used a transportal technique and the femoral
fixation has been achieved by a RetroButton (Arthrex)
instead of RigidFix pins. In 2013 Natali et al.12 described
e272 R. GUPTA ET AL.

Fig 8. The Ethibond suture loop

placed through the femoral tun-
nel into the joint is retrieved
from the tibial tunnel with a
grasper.

Fig 9. The length of the tibial

tunnel and the intra-articular
part of the proposed anterior
cruciate ligament graft is
measured with a depth gauge.

Fig 10. A marking suture (arrow) is placed on the hamstring
tendons just opposite the entry of the tibial tunnel so that
when the graft is pulled inside the joint, the mark stays at the
entry of the tunnel.
Fig 11. The length of the quadrupled graft and loop of the
RetroButton is adjusted so that it exactly corresponds to
length A (length of femoral tunnel) plus length B (length of
tibial tunnel plus intra-articular part of graft).
 HAMSTRING AUTOGRAFT WITH PRESERVED INSERTIONS
Fig 12. The sutures of the RetroButton are pulled through the
tibial and femoral tunnels by loading them onto the Ethibond
loop placed in the tunnels.
Fig 13. The free end of the graft exiting the tibial tunnel is
pulled to maximal stretch and the joint moved through full
range of motion at least 10 times to remove any kinks in the
graft.
Fig 14. With maximal stretch on the free end of the graft, it is
sutured to the preserved end.
a technique for ACL reconstruction using distally
inserted doubled hamstring tendons fixed at the
femoral level using a second-generation cortical sus-
pensory device.
e273
Table 1. Advantages
Preserving the insertions of the hamstring tendons is more biological
and may provide better proprioception and, hence, a better
functional outcome in the postoperative period.
Because we are not severing the insertions of the STG tendons from
the tibia, the blood supply of the tendons remains intact, which
may facilitate superior healing of the graft and prevent graft
rupture.
Tibial-side fixation of the free graft is the weakest link in the overall
stiffness of the reconstructed ACL; our technique circumvents this
problem.
The technique eliminates the need for a tibial-side fixation device,
thus reducing the cost of surgery.
We propose that well-controlled, randomized comparative studies
need to be performed to compare the results of ACL reconstruction
using hamstring autograft with preserved insertions versus free
hamstring autograft.
ACL, anterior cruciate ligament; STG, semitendinosus and gracilis.
Table 2. Limitations and Pitfalls
Our technique is only possible with the use of an open-ended tendon
harvester.
If the harvested graft is short, then this procedure is not possible.
The minimum length of RetroButton loop available is 15 mm, and the
minimum length of graft required in the femoral tunnel is 15 mm.
Thus the femoral tunnel should be at least 30 mm long. If the
femoral tunnel length is less than 30 mm, then the RetroButton
cannot be used for femoral fixation of the graft.
Table 3. Risks
Ethibond has been used readily as a mode of fixation on the tibial side
in association with a suture disk. Hence we believe that sewing the
graft to itself using No. 5 Ethibond will provide sufficient strength to
the graft. However, because we are using suspensory fixation at
both the femoral and tibial ends, the theoretical risk of the
windshield-wiper effect exists.
Table 4. Pearls
Efforts must be taken to preserve the infrapatellar branch of the
saphenous nerve while harvesting the graft.
While harvesting the graft, the surgeon must be careful not to
prematurely amputate the graft.
The surgeon should keep the patient’s knee in maximal hyperflexion
during transportal drilling of the femoral tunnel to prevent a
blowout fracture of the posterior wall of the lateral femoral
condyle.
In our technique the tibial-side fixation is based on
preserved insertions only, thus eliminating the cost of a
tibial-side fixation device; the average cost of a bio-
interference screw in India is US $150. Furthermore,
because it is believed that tibial-side fixation is the
weakest link in the stiffness of a reconstructed ACL,8,9
by relying on the natural insertions of the STG ten-
dons on the tibia, we were also able to eliminate the
weakest link in the overall construct of the recon-
structed ACL.
e274 R. GUPTA ET AL.
Table 5. Tips
The harvested graft should be covered with moist gauze before
starting preparation of the tunnels to prevent it from drying and
desiccation.
The mathematical calculations must be correct while matching the
length of the graft and loop of the RetroButton (Arthrex, Naples,
FL) to the length of both the femoral and tibial tunnels plus the
intra-articular part of the proposed graft. Any error in these
calculations can result in the graft being lax or can cause problems
in flipping the RetroButton.
The marking suture placed on the hamstring tendons should be just
opposite the entry of the tibial tunnel so that when the graft is
pulled inside the joint, the mark stays at the entry of the tunnel.
Because we are not severing the insertions of the STG
tendons from the tibia, the blood supply of the tendons
remains intact. We believe that the preserved blood
supply may have a role in early and superior healing of
the graft and may have the potential to reduce the
incidence of late rupture of the graft (Table 1). How-
ever, further studies are required to prove this.
Our technique has certain limitations as well
(Table 2). It is possible only with the use of an open-
ended tendon harvester. If the harvested graft is
short, then this procedure is not possible. Furthermore,
the minimum length of graft required in the femoral
tunnel is 15 mm.13 The minimum length of Retro-
Button loop available is 15 mm. Thus the femoral
tunnel should be at least 30 mm long. If the femoral
tunnel length is less than 30 mm, then the RetroButton
cannot be used for femoral fixation of the graft.
Ethibond has been readily used as a mode of fixation
on the tibial side in association with a suture disk.14
Hence we believe that sewing the graft to itself using
No. 5 Ethibond will provide sufficient strength to the
graft. However, because we are using suspensory fixa-
tion at both the femoral and tibial ends, the theoretical
risk of the windshield-wiper effect exists (Table 3).14
Comparing the mechanical stability and functional
outcome of patients undergoing ACL reconstruction
using hamstring tendon autograft with preserved in-
sertions with those in patients undergoing ACL recon-
struction using free hamstring autograft is a very
interesting and promising subject and should be
explored (Tables 4-6).
Table 6. Manufacturers of Equipment Used in Our Technique
Open-ended tendon stripper: Arthrex, Naples, FL
Bone awl: Smith & Nephew, Mumbai, India
Cannulated drill bit: Smith & Nephew
Arthroscope: Stryker, Kalamazoo, MI
RetroButton: Arthrex
No. 5 Ethibond: Ethicon, Somerville, NJ
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