Introduction and History: Four-strand hamstring (4HS) Anterior Cruciate Ligament Reconstruction (ACLR) has increased in popularity recently. This is because newer fixation methods have increased the stability results to equal to or better than those of Bone Patellar Tendon Bone (BPTB) grafts. The hamstring harvest is generally thought to be the most difficult part of the procedure. Endobutton femoral fixation combined with cortical screw tibial fixation has provided excellent stability results with hamstring grafts.
Posterior Mini-Incision Hamstring Harvest Approach for ACLR: Some surgeons have chosen to use allografts instead of 4HS due to a lack of comfort with the hamstring harvest. In particular, the hamstring tendons can be cut too short to use if inter-tendinous cross connections are not cut first. The posterior mini-incision harvest allows these cross-connections to be easily visualized and sectioned where they exist postero-medially. It also allows easier identification of the tendons. Finally it allows the anterior incision to be shorter which should diminish the degree of anterior leg numbness that can occur and provides excellent cosmesis.
Technique of 4HS ACLR with Endobutton and Whipstitch/Post Fixation: This technique has provided excellent stability results and a zero percent incidence of graft failure. There have been no instances of hardware problems or removal for symptoms.
Meta-Analysis of BPTB and Hamstring Clinical Series: A meta-analysis of all English language Hamstring and Bone-Patellar-Tendon-Bone clinical series is described. Four-strand hamstring grafts had the highest stability rates, followed by BPTB and then two strand hamstring grafts. Aperture fixation had no advantage over cortical fixation for hamstring grafts. Good results were obtained with both cortical and interference screws for BPTB grafts.