Harvesting the hamstring tendons for ACL reconstruction is routinely done from an antero-medial incision directly ... read more ↘ over the pes anserinus. This approach can be time consuming, leaves an unsightly tender scar and is often associated with injury to branches of the saphenous nerve. Since 2001 we have been using a simple less invasive technique approaching the tendons from a postero-medial incision in the popliteal fossa in over 2000 patients.
Technique:
The knee was flexed to approximately 30 degrees and the hip maximally externally rotated to approach a figure-of-four position – in this position the semitendinosus tendon can be easily palpated. A small transverse incision in line with the skin creases was made directly over the semitendinosus tendon in the postero-medial aspect of the popliteal fossa where it lies subcutaneously. The site of the incision is visible as a small dimple overlying the tendon – this dimple has previously been named “Jobert`s groove” in Pernkopf’s topographical anatomy atlas (18). (We owe this information to Prof. Strehle, Institute of Anatomy III, Frankfurt). The groove represents the plane between the adductor muscles and the semitendinosus tendon and marks the medial border of the popliteal fossa. With the knee flexed, the neuro-vascular bundle lies at a safe distance laterally and deep to the hamstring tendons. Subcutaneous tissue overlying the tendon is usually scarce, even in obese patients. Obesity, therefore, never posed a problem to retrieve the tendon. Once the skin incision was made, the fascia covering the tendon was cut longitudinally under direct vision. A curved artery clip was hooked around the tendon and armed with a FiberTape band. With the knee flexed to 90° the tendon was mobilised and pulled out of the wound.
An open tendon stripper was threaded over the tendon and gently pushed proximally to release the tendon off its insertion into the muscular attachment. The free end of the tendon was then delivered out of the wound. At this point we scraped remaining muscular tissue off the proximal tendon to facilitate passage of a closed tendon stripper. The tendon stripper was advanced distally whilst a controlled pull on the tendon was maintained. With slow careful twisting motions the tendon harvester was pushed distally to release the tendon from its insertion at the proximal tibia. As the semitendinosus tendon lies underneath the sartorius fascia at this level, damage to the saphenous nerve which lies on top of the sartorial fascia does not occur (19). Distally, the stripper becomes palpable through the skin over the medial aspect of the proximal tibial crest and perforation of the skin will be avoided. In cases where the length of the semitendinosus tendon was less than 240mm, the gracilis tendon was harvested in a similar fashion. It lies approximately 10mm medial to the semitendinosus tendon and can be delivered through the same skin incision. The skin was closed with interrupted non-absorbable sutures.