Endoscopic Hamstring ACL Reconstruction

Robert W. Westermann

Mia S. Hagen

Bridget Mansell

Richard D. Parker

Sterile Instruments/Equipment (Fig. 41-1)

• 4.5-mm arthroscope

• 30-degree lens

• Light source

• Arthroscopy fluid: lactated Ringer solution or normal saline. Dilute epinephrine can be added safely at 1 mg/L.

• Tourniquet

• Verres outflow cannula

• No. 11 and no. 15 blades

• Two right angle munions

• Arthroscopic probe

• Arthroscopic shaver

• Coblation wand

• No. 2 FiberLoop suture × 4 (Arthrex, Naples, FL)

• Graft preparation station (Acufex shown, Smith & Nephew, Memphis, TN)

• Antibiotic solution in graduated cylinder for graft (1 g cefazolin or 80 mg gentamicin in 500 mL normal saline per patient allergy)

• Flexible femoral reaming system (Smith & Nephew, Memphis, TN)

• Tibial reaming system

• Curved curette or posterior cruciate ligament (PCL) protector

• Arthroscopic grasper

Figure 41-1 | Back table equipment needed for hamstring graft preparation.

• Femoral suspensory fixation (Endobutton, Smith & Nephew, Memphis, TN)

• Tibial fixation: 6.5-mm partially threaded cortical screw with washer

Positioning (Fig. 41-2A and B)

• Before preparation and draping, an intra-articular injection of 50 mg ropivacaine combined with 2 mg of Duramorph is inserted with sterile technique into the knee. This eliminates the need for a femoral nerve block, which can cause quadriceps inhibition.

Figure 41-2 | A. Our preferred patient positioning for hamstring ACL reconstruction. B. Patient positioning with plenty of room for knee flexion.

• Alternatively, regional blockade through the adductor canal also can be administered by the anesthesiologist in the preoperative area.

• A wide area is prepared two hand’s breadths above the patella to ensure an adequate sterile field for flexible femoral guidewire passing.

• A tourniquet is placed on the upper thigh; the operative leg is placed in an arthroscopic leg holder and the other leg in a well-leg holder.

• The patient should be distal enough on the bed so that there is room to flex the knee for femoral drilling.

• The table height is raised, and the foot of the bed is dropped. Sterile drapes are applied according to surgeon preference.

Surgical Approach (Fig. 41-3)

Hamstring Harvest

• An Esmarch bandage is used to exsanguinate the limb, and the tourniquet is inflated to 250 mm Hg.

Figure 41-3 | Outflow portal location, deep to the quadriceps tendon, superior lateral. P, inferior pole of the patella; LP, lateral portal just inferior to the inferior pole of the patella adjacent to the patellar tendon; MP, medial portal, mid-medial joint line; AMP, accessory medial portal, medial to the patellar tendon and 1 cm distal to joint line. An oblique incision is made for hamstring harvest to help avoid injury to the infrapatellar branch of the saphenous nerve.

• A half-sheet is placed over the surgeon’s lap, and the surgeon sits on a stool with the patient’s foot on his or her lap (Fig. 41-4).

Figure 41-4 | Injection of the hamstring harvest site and arthroscopy portals with local anesthetic and epinephrine prior to incision.

• The hamstring incision is four finger breadths beneath the medial joint line, in Langer lines. The pes anserinus tendons are palpated to locate the correct incision site. The tendency is to be too proximal with this incision.

• The skin over the hamstring harvest and arthroscopy portal sites is injected with local anesthetic and epinephrine prior to incision.

• Sharp dissection with the no. 15 blade is carried down to the level of the sartorial fascia, obtaining hemostasis as necessary. The sartorial fascia is cleared with sponge for manual dissection (Fig. 41-5).

Figure 41-5 | Sartorial fascia overlying hamstring tendons.

• The sartorial fascia is identified and incised in line above the hamstring tendons.

• Once a window is made, the fascia is opened proximally with scissors in line with the tendons, and distally more vertical (“hockey stick” shape) (Fig. 41-6A and B).

Figure 41-6 | A. Release of the sartorial fascia in a hockey stick fashion. B. Semitendinosus tendon retrieved with a right-angle device.

• A right-angle instrument is used to retrieve the semitendinosus inferiorly; then, a blue tie from a lap sponge is placed around the tendon.

• More proximally, the gracilis is identified, and a blue tie is placed around it (Fig. 41-7).

Figure 41-7 | A blue lap tie is placed around the semitendinosus, and the gracilis is identified more proximally.

• With both hamstring tendons identified, the semitendinosus is released from its insertion, and a FiberLoop is placed through the distal 3 cm of the tendon (Fig. 41-8).