Editorial Commentary: Goldilocks and the Three Grafts: Managing Tendon Harvest and Graft Length Problems in Autograft Anterior Cruciate Ligament Reconstruction

Abstract

Autograft hamstring tendon harvest in anterior cruciate ligament (ACL) reconstruction can occasionally result in a graft length that is inadequate for creation of a robust ACL graft. Patients at risk for an abnormally short hamstring may also be high risk for ACL reinjury. Graft augmentation with allograft may be a suboptimal solution to this problem. Therefore, a reliable means for preoperative estimation of hamstring tendon length by magnetic resonance imaging measurement could avoid this pitfall. However, even with a reliable correlation between magnetic resonance imaging measurement and actual harvested tendon length, establishing a simple, clinically relevant threshold below which hamstring grafts should be avoided remains elusive. By contrast, all-soft-tissue quadriceps autograft avoids the potential length problems inherent to both bone tendon bone (graft-tunnel mismatch) and hamstring tendon grafts, but intermediate- and long-term outcome studies are still needed to validate all-soft-tissue quadriceps autograft in ACL reconstruction.

The Association Between Anterior Cruciate Ligament Length and Femoral Epicondylar Width Measured on Preoperative Magnetic Resonance Imaging or Radiograph

“…Gilmer suggested that accurate preoperative assessment is more important than ever to prevent inadequate graft size before harvest. 23 If accurate information about intra-articular ACL length is known preoperatively, it could assist in making informed decisions about graft selection of adequate length for the specific patient. The mean ACL length was measured to be 40.6 mm on the oblique sagittal MRIs.…”

“…MRI is a routine part of preoperative evaluation for ACL reconstruction and should be readily available to surgeons. 23 However, the reality is that the cost of MRI, the waiting periods, and the availability thereof in certain countries can be challenging. It would therefore be useful to have an alternative means by which the length of the ACL can be determined, should an MRI not be available.…”