Table 2.

Pearls and Pitfalls Associated With Quadruple (4-Strand) Hamstring Autograft Harvest for Anterior Cruciate Ligament Reconstruction

Pearls	• Four-stranded (quadruple) hamstring grafts are among the strongest grafts biomechanically (at time equals zero).
	• Perform an examination under anesthesia and confirm the diagnosis of ACL injury prior to harvesting hamstring tendons
	• Understand the anatomy: the semitendinosus and gracilis originate from the ischial tuberosity and ischiopubic ramus, respectively
	• Release first tendon with tendon stripper: pass tendon stripper first and ensure at least 10-12 cm of free tendon
	○ Steady traction on the sutures on the free end of the tendon combined with an equally steady push of the tendon stripper toward the hamstring origin at the pelvis should allow for a smooth release of the tendon
Pitfalls	• Take care to avoid injury to the superficial medial collateral ligament, which lies deep to the tendons near this area of convergence; injury to the medial collateral ligament can be avoided by visualizing this structure
	• The pes anserine insertion is in close proximity to the infrapatellar branch and sartorial branch of the saphenous nerve, and injury to these nerves are common complications during harvest; injury to the nerve branches can be avoided by using a knife for the skin incision only, followed by blunt dissection of the subcutaneous tissue down to the sartorial fascia
	• Prior to using the tendon stripper to remove the grafts, the surgeon should be confident in his or her dissection of accessory insertions and fascial bands to prevent premature amputation of the graft

ACL, anterior cruciate ligament.