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Safety of Hamstring Harvest:

The semitendinosis and gracilis tendons are often used in orthopaedics for reconstruction of ACL deficient knees as well as being used for reconstructions of the shoulder, elbow, ankle, and foot.  The question arises for this research study (hamstring arthroplasty) is specifically, what are the risks and long term morbidity of hamstring harvest?

Specific risks and morbidity of hamstring harvest include saphenous nerve damage (1,12,13) and weakness (2-11).   In terms of hamstring harvest, the avoidance of saphenous nerve damage depends on experience and careful technique.  The issue of weakness is more complicated.  In general, it can be demonstrated that there is a 7-21% weakness of knee flexion strength when measured with specialized equipment. (4,10)  More important, however, it is also demonstrated that over time, the hamstring tendons regenerate (14,15) and strength improves over time (3), and the knee flexion weakness does not appear to interfere with activities of daily living and sports, as determined by objective research studies. (2,3,6,8).

In terms of objective weakness using specific testing equipment it is clear that there is some residual weakness following hamstring harvest.
In the study by Burks et al (Arthroscopy 2005)4, the authors utilized isokinetic testing on hamstring harvest patients and determined that "at 12 months the mean 60 degrees/second deficit was 21% and the deficit at 180 degrees/second was 13%. (4)  In another study by Condouret et al (Rev Chir Orthop Reparatrice Appar Mot., 2008)10, the authors noted that an "average deficit of 14 to 18%" in hamstring harvest patients. (10)

It is well documented, however, that the hamstring tendons regenerate (14,15), postoperative weakness improves, and that the residual weakness demonstrated on isokinetic testing machines does not appear to be clinically significant.  In the study by Simonian et al (Arthroscopy 1997)6, the authors evaluated patients that had had hamstring harvest and noted that "the average percent quadriceps and hamstring strength of the operated compared with the non operated extremities were 93.7% and 95.3%".  They concluded "that tendon harvest of the semitendinosus and gracilis muscles does not significantly compromise function and strength despite a more proximal insertion of the retracted tendons." (6)
In another recent study (Ardern, Arthroscopy 2010)2, the authors conclude that "these findings show that the choice of hamstring tendon graft-that is, semitendinosus alone or semitendinosus and gracilis-is unlikely to significantly influence postoperative hamstring strength outcomes in athletes returning to sports postoperatively." (2)
In the report by Samuelsson et al (Arthroscopy 2009) 3 the authors attempted "summarize and assess current evidence from randomized controlled trials (RCTs) on anterior cruciate ligament injuries, with special reference to graft type and surgical technique." They noted that
"semitendinosus and gracilis tendon harvesting probably reduces hamstring muscle strength for approximately 1 year."
In the study by Takeda et al (Am J Sports Med, 2006)8, the authors used an MRI study to evaluate function after hamstring harvest.  They concluded that "the semitendinosus and gracilis muscles are able to restore or maintain their contractile capability after harvest of their tendons for anterior cruciate ligament reconstruction, regardless of the degree of regeneration."(8)

Finally, what is most important in the middle aged patient (which are the most likely to undergo autologous hamstring resurfacing), is that hamstring harvest is safe and does not impair function after harvest when used for ACL reconstruction. (16-18).   Because the totality of the evidence points to minimal risk and minimal morbidity from hamstring harvest, it is not unexpected that this tendon has been used not only for ACL reconstruction but also for a variety of other types of reconstructive procedures.  A medline search has demonstrated the following clinical articles on use of hamstring harvest/reconstruction other than ACL surgery: 9 article for foot and ankle surgery (19-27), 6 articles for shoulder surgery (28-33), 4 articles for elbow surgery (34-37), and 12 articles for knee medial femoral ligament reconstruction (38-49).

In conclusion, there is abundant clinical evidence that hamstring harvest is safe not only for ACL surgery, but also for use in a wide variety of situations in which joint reconstruction is required.  There is every reason to expect that hamstring harvest for the purposes of this research study will pose no additional risks than have already been documented in the literature.

1 Prevalence of saphenous nerve injury after autogenous hamstring harvest: an anatomic and clinical study of sartorial branch injury.
2 - Hamstring strength recovery after hamstring tendon harvest for anterior cruciate ligament reconstruction: a comparison between graft types
3 - Treatment of ACL injuries with special reference to graft type and surgical technique: an assessment of randomized controlled trials.
4 - The effects of semitendinosus and gracilis harvest in anterior cruciate ligament reconstruction
5 - Isokinetic evaluation of internal/external tibial rotation strength after the use of hamstring tendons for anterior cruciate ligament reconstruction.
6 - Assessment of morbidity of semitendinosus and gracilis tendon harvest for ACL reconstruction.
7 - Decrease of knee flexion torque in patients with ACL reconstruction: combined analysis of the architecture and function of the knee flexor muscles.
8 - Hamstring muscle function after tendon harvest for anterior cruciate ligament reconstruction: evaluation with T2 relaxation time of MRI.
9 - Influence of medial hamstring tendon harvest on knee flexor strength after anterior cruciate ligament reconstruction
10- Isokinetic assessment with two years follow-up of anterior cruciate ligament reconstruction with patellar tendon or hamstring tendons
11- A comparison of bone-patellar tendon-bone and bone-hamstring tendon-bone autografts for anterior cruciate ligament reconstruction.
12- Injury to the infrapatellar branch of the saphenous nerve in ACL reconstruction: comparison of horizontal versus vertical harvest site incisions
13- Prevalence of saphenous nerve injury after autogenous hamstring harvest: an anatomic and clinical study of sartorial branch injury.
14-Semitendinosus muscle in anterior cruciate ligament surgery: Morphology and function
15-Regeneration of the Semitendinosus Tendon after Its Use in Anterior Cruciate Ligament Reconstruction. A Histologic Study of Three Cases
16- Four-strand hamstring tendon autograft for ACL reconstruction in patients aged 50 years or older
17- Autologous hamstring anterior cruciate ligament reconstruction in patients older than 40
18- Anterior cruciate ligament reconstruction in patients over 40 years using hamstring autograft.
19- Free gracilis interposition arthroplasty for severe hallux rigidus
20- Failed first metatarsophalangeal arthroplasty salvaged by hamstring interposition arthroplasty: metallic debris from grommets
21- Autogenous graft repair using semitendinous tendon for a chronic multifocal rupture of the extensor hallucis longus tendon: a case report.  
22- Soft-tissue arthroplasty for hallux rigidus 
23- Delayed rupture of EHL and EDC tendons after breaching anterior capsule with a radiofrequency probe during ankle arthroscopy
24- Reconstruction of a chronic extensor hallucis longus tendon laceration with a gracilis tendon autograft
25- Chronic isolated distal tibiofibular syndesmotic disruption: diagnosis and management
26- Ipsilateral free semitendinosus tendon graft transfer for reconstruction of chronic tears of the Achilles tendon 
27- Free hamstrings tendon transfer and interference screw fixation for less invasive reconstruction of chronic avulsions of the Achilles tendon.
28- Semitendinosus tendon graft versus a modified Weaver-Dunn procedure for AC joint reconstruction in chronic cases: a prospective comparative study.
29- Acromioclavicular reconstruction using autogenous semitendinosus tendon graft: results of revision surgery in chronic cases.
30- Clinical results of single-tunnel coracoclavicular ligament reconstruction using autogenous semitendinosus tendon
31- A salvage procedure for failed weaver-dunn reconstruction
32- Coracoclavicular ligament reconstruction using a semitendinosus graft for failed acromioclavicular separation surgery.
33- Clinical outcomes of coracoclavicular ligament reconstructions using tendon grafts
34- Reconstruction of a chronic distal biceps tendon rupture 4 years after initial injury.
35- Triceps reconstruction using hamstring graft for triceps insufficiency or recurrent rupture.
36- Repair of chronic distal biceps tendon ruptures using autologous hamstring graft and the Endobutton
37- Repair of chronic distal biceps brachii tendon rupture using free autogenous semitendinosus tendon
38- Anatomical transverse patella double tunnel reconstruction of medial patellofemoral ligament with a hamstring tendon autograft for recurrent patellar dislocation
39- Clinical and radiological outcome of medial patellofemoral ligament reconstruction with a semitendinosus autograft for patella instability.
40- A long-term follow-up study after medial patellofemoral ligament reconstruction using the transferred semitendinosus tendon for patellar dislocation.
41- Hybrid medial patellofemoral ligament reconstruction using the semitendinous tendon for recurrent patellar dislocation: minimum 3 years' follow-up.
42- Clinical results of isolated reconstruction of the medial patellofemoral ligament for recurrent dislocation and subluxation of the patella
43- Medial patellofemoral ligament reconstruction for subluxating patellofemoral arthroplasty 
44- Visual analog scale assessment after medial patellofemoral ligament reconstruction: with or without tibial tubercle transfer
45- Dual tunnel medial patellofemoral ligament reconstruction for patients with patellar dislocation using a semitendinosus tendon autograft
46- Hamstring graft fixation in MPFL reconstruction at the patella using a transosseous suture technique
47- Anatomical reconstruction of the medial patellofemoral ligament using a free gracilis autograft
48- Technical note: anatomical reconstruction of the medial patellofemoral ligament using a free gracilis autograft
49- Reconstruction of the medial patellofemoral ligament with gracilis tendon autograft in transverse patellar drill holes

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