Preparation of Eight Strands Hamstring Tendon Graft for Anterior Cruciate Ligament Reconstruction Regardless Fixation Methods: Technical Note

Background: Anterior cruciate ligament reconstruction is one of the most commonly performed procedures in orthopedics. There are several reconstruction graft choices that can be used to reconstruct the anterior cruciate ligament, with autograft hamstring tendons being one of the most commonly used. Study Design: Technical note. Purpose: The purpose of this paper is to describe in details eight strands hamstring graft preparation technique to increase graft diameter for anterior cruciate ligament reconstruction. Methods: Hamstring tendons one of the most commonly used graft for anterior cruciate ligament reconstruction. Preparation of a hamstring graft varies according to patient characteristics and surgeon preference. It is common for the tendons to be folded over each other in order to increase the thickness of the donor graft. In order for the folded tendons to act as one unit they are sutured together using a whip stitch technique. Results: The option adopted in the present technique was to make quadrupled each one of hamstring tendons to get eight strands ACL graft, which led to increase graft diameter size which gives higher knee stability and long-term survival of the graft. Conclusion: Using this technique increasing graft diameter size by increasing number of folds regardless fixation methods, to ensure long-term survival of small-sized hamstring tendon graft tissue which is common in our population especially non-athletic.


Introduction
The anterior cruciate ligament (ACL) is one of the most commonly injured structures of the knee [1]. Several different methods have been used for the treatment of the unstable anterior cruciate ligament deficient knee. These methods differ in the surgical techniques and in the type of graft used (autograft, allograft and synthetic) [2]. The hamstring tendon autograft has been used as an alternative to the BPTB graft due to the reduced donor-site morbidity and significantly improved fixation technique and are currently considered as one of the most common grafts used in ACL reconstruction [3].
Certain conditions such as multiplicity of ligaments injuries and small-sized diameter of the harvested grafts which are common in our population led to developing of this technique to obtaining higher knee stability and to ensure longterm survival of small-sized hamstring tendon graft tissue by Case Report increasing number of folds of tendon to obtain larger graft diameter. It is common for the tendons to be folded over each other in order to increase the thickness of the donor graft. In order for the folded tendons to act as one unit they are sutured together using a whip stitch technique [4]. The donor graft is then passed through the tibial tunnel and into the femoral tunnel and fixed using a variety of fixation meth-a tendon stripper and released from its muscular attachment proximally while bending the knee in 90° and advancing the stripper in a proximal direction.

Graft preparation
The graft preparation and configuration is easily done in a graft preparation system Acufex graft master III (Smith & Nephew, Andover, MA). Removal of excess muscular tissue from each tendon is done and unstable parts of the tendon are removed. If ST and GC tendons are harvested, they should be twisted in a reverse orientation in order that the proximal end of the ST is nearby to the distal end of the GC graft and vice versa then each end whip stitched. The graft(s) are estimated in a graft preparation system and measurements of length of each harvested tendon(s) are made to define which graft preparation method is more suitable for that specific ACL reconstruction. The graft configuration is then done (folded) to determine the appropriate graft length and diameter.

Eight-strand graft configuration
Each tendon can be whip stitched separately or whip stitched together in a reverse orientation (proximal end of the ods including screws, suspensory apparatus and transfixion devices which may be metallic, polymer or bio-absorbable. Commonly, both hamstring tendons are doubled to get quadrupled graft, even with this technique in case of small sized tendon, the graft diameter size maybe less than 8 mm which may led to early graft failure [5]. In this technique, each tendon is quadrupled to get 8 strands ACL graft with diameter more than 8 mm regardless fixation methods. In addition, quadrupled semitendinosus tendon can be used alone for ACL graft and gracilis tendon can be used for anterolateral ligament (ALL) reconstruction.

Graft harvest
For hamstring tendon autograft, the semitendinosus (ST) and/or gracilis (GC) can be harvested from the surgical side or the contralateral side. A vertical anteromedial incision at the level of the tibial tubercle is used to expose the sartorius fascia, which covers the hamstring tendons. An incision in the sartorial fascia permits the exposure of the tendons. The tendons are recognized and then placed separately through

Conclusion
The aim of using this technique is increasing graft diameter size by increasing number of folds regardless fixation methods, to ensure long-term survival of small-sized hamstring tendon graft tissue which is common in our population especially non-athletic.