How Do You Manage the Hamstring Autograft that is Prematurely Amputated During Graft Harvest?

When using a hamstring autograft for anterior cruciate ligament (ACL) reconstruction, the strongest construct is the quadrupled gracilis (GR)-semitendinosis (ST) graft. ^{1, 2} This graft construct relies upon the doubling of each tendon limb, around a post, to create a four-stranded graft that passes through the articular space. Grafts are typically obtained by isolating these tendons at their tibial insertion at the pes anserinus expansion. During graft harvest, care must be taken to avoid premature amputation of each of these tendons. Such a complication may result in there being an inadequate amount of autograft tissue remaining for ACL reconstruction. As such, the harvesting portion of this case remains its most critical step. Unfortunately, the premature amputation of one or both of these tendons will occur with even the most skilled surgeons at the helm. The surgeon should take a three-tiered approach to this complication, starting with prevention, progressing to salvage, and finally substitution.