See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/228330018

Anatomy of the bands of the hamstring tendon: How can we improve harvest
quality?

Article  in  The Knee · July 2012

DOI: 10.1016/j.knee.2012.06.003 · Source: PubMed

CITATIONS READS

11 102

6 authors, including:

Nicolas Reina Gomez-Brouchet Anne

Centre Hospitalier Universitaire de Toulouse Centre Hospitalier Universitaire de Toulouse
124 PUBLICATIONS   401 CITATIONS    65 PUBLICATIONS   683 CITATIONS   

SEE PROFILE SEE PROFILE

Philippe Chiron
Centre Hospitalier Universitaire de Toulouse
188 PUBLICATIONS   1,569 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Molecular cancer View project

bone tumors View project

All content following this page was uploaded by Nicolas Reina on 23 December 2017.

The user has requested enhancement of the downloaded file.

This article appeared in a journal published by Elsevier. The attached
copy is furnished to the author for internal non-commercial research
and education use, including for instruction at the authors institution
and sharing with colleagues.
Other uses, including reproduction and distribution, or selling or
licensing copies, or posting to personal, institutional or third party
websites are prohibited.
In most cases authors are permitted to post their version of the
article (e.g. in Word or Tex form) to their personal website or
institutional repository. Authors requiring further information
regarding Elsevier’s archiving and manuscript policies are
encouraged to visit:
http://www.elsevier.com/copyright
 Author's personal copy

The Knee 20 (2013) 90–95

Contents lists available at SciVerse ScienceDirect

The Knee

Anatomy of the bands of the hamstring tendon: How can we improve

harvest quality?
Nicolas Reina a,⁎, Olivier Abbo b, Anne Gomez-Brouchet c, Philippe Chiron a,
Jacques Moscovici b, Jean-Michel Laffosse a
a
Institut Locomoteur, Service de Chirurgie Orthopédique et Traumatologique, Centre Hospitalier Universitaire Rangueil, Toulouse, France
b
Laboratoire d'Anatomie, Centre Hospitalier Universitaire Rangueil, Toulouse, France
c
Laboratoire d'Anatomie et Cytologie Pathologique, Centre Hospitalier Universitaire Rangueil, Toulouse, France

a r t i c l e i n f o a b s t r a c t

Article history: Background: The hamstring tendons, gracilis and semitendinosus are widely used in ligament and reconstruc-
Received 21 February 2012 tive surgery. Their accessory bands or insertions are technical pitfalls during harvesting.
Received in revised form 30 May 2012 Methods: Thirty fresh cadaver knees have been studied, in order to 1) determine the anatomy of the bands of
Accepted 5 June 2012 the gracilis and semitendinosus tendons, and, 2) to identify risk factors for failure during harvesting.
Results: Semitendinosus always had at least one band, sometimes two, strong, tendinous, and generally run-
Keywords:
ning to the fascia of gastrocnemius medialis to which they are attached, at an acute angle in a distal direction.
Knee
Tendon bands
Their presence is constant and they are only exceptionally found more than 100 mm from the tendon's tibial
Ligament reconstruction insertion. Gracilis shows the greatest anatomical variability, and over one quarter have no bands (although
Hamstring there may be as many as three). Their location, destination and angle of attachment to the tendon vary great-
Surgical risk ly. These bands are mainly aponeurotic and less strong, but must be carefully and widely dissected.
Conclusion: Anatomical variability makes harvesting of pes anserinus tendons difficult. Three simple anatom-
ical criteria have been highlighted that can be assessed by the surgeon during harvesting. The criteria are the
insertion, the direction and the anatomical type of the bands.
© 2012 Elsevier B.V. All rights reserved.

1. Introduction less attention in the literature. We postulated that certain features

The hamstring tendons (or pes anserinus), particularly gracilis and
semitendinosus, are frequently used for reconstruction of the anterior
cruciate ligament, and the patellar ligament [1]. Harvesting is some-
times considered to be simple and minimally invasive, but there can
be technical pitfalls [2–6]. The hamstring tendons are at the centre of
an anatomical crossroads whose components lie in close proximity.
During embryological development, adhesions or bands may form be-
tween these various anatomical components (medial collateral liga-
ment, fascia superficialis, gastrocnemius aponeurosis and surrounding
connective layers) [7]. The creation of these bands is not constant,
there may be variations in number, location or even in histological
structure [7]. These adhesions or aponeurotic expansions may increase
the risk of failing to harvest an adequate graft and so jeopardise the
quality of the reconstruction. This risk can be lessened if the surgeon
has good knowledge of anatomy. Whereas the fascial band arising
from semitendinosus has been well described [8], the adhesions of
gracilis and their intertendinous relationships appear to have received
⁎ Corresponding author at: Institut Locomoteur, Service de Chirurgie Orthopédique
et Traumatologique, CHU Rangueil, 1, avenue Jean Poulhès, TSA 50032, 31059 Toulouse
Cedex 9, France. Tel.: + 33 619384032; fax: + 33 561322232.
E-mail address: nicolasreina@gmail.com (N. Reina).
may constitute a risk for harvest failure. Thus, the aim of this study was:
1) To describe the macroscopic and microscopic anatomical charac-
teristics of the bands arising from the gracilis and semitendinosus
tendons, and
2) To determine the features that could lead to difficulty in harvesting.
2. Materials and methods
An anatomical study of 30 knees in 15 fresh non-injected cadavers
(seven male and eight female) was carried out. The mean age was
70 years ± 10 years (range 47 to 86 years), and the mean height was
171 cm ± 11 cm (range 150 to 191 cm) and of medium build. The bio-
metric characteristics of the subjects are summarised in Table 1.
2.1. Dissection and anatomical study
The subjects were placed in a dorsal decubitus position with the
knee flexed at 90° and the limb in external rotation. The skin incision
was started at the level of the anterior tibial tuberosity, passed around
the medial aspect of the proximal tibia, continued up the internal as-
pect of the thigh and ended at the mid-thigh. The sartorius was in-
cised longitudinally in an L-shaped incision with the layer of the

0968-0160/$ – see front matter © 2012 Elsevier B.V. All rights reserved.
doi:10.1016/j.knee.2012.06.003
 Author's personal copy

N. Reina et al. / The Knee 20 (2013) 90–95 91

Table 1
Characteristics of the topographya of pes anserinus in 15 cadaver specimens.

Gender Age Height Ab Bc Cd De Eb

(years) (cm)
R L R L R L R L R L

1 M 75 170 6 10 26 28 48 45 37 38 28 20
2 F 68 167 20 15 7 6 50 46 19 19 20 22
3 F 47 162 0 0 10 6 47 43 22 19 22 21
4 M 80 181 0 8 23 25 42 50 27 25 30 28
5 M 72 173 0 0 16 17 48 40 8 8 21 26
6 F 71 157 5 9 24 18 35 39 21 24 26 24
7 F 69 162 5 8 23 22 38 43 17 22 70 65
8 M 62 169 5 0 16 19 39 43 36 21 23 28
9 F 70 157 12 0 16 18 42 42 8 16 19 26
10 F 61 166 3 5 22 26 42 37 0 18 18 22
11 F 78 162 5 9 18 14 42 24 12 11 29 26
12 M 76 191 0 0 25 24 56 54 27 26 23 32
13 M 86 173 12 9 19 19 42 45 36 32 23 22
14 F 75 150 4 11 16 16 35 29 22 29 16 11
15 M 56 179 6 8 19 23 37 42 19 21 32 26
Mean ± SD (range) 69.7 ± 10 (47–86) 168 ± 11 (150–191) 6 ± 5 (0–20) 19 ± 6 (6–25) 42 ± 7 (24–56) 21 ± 9 (0–38) 27 ± 12 (11–70)

Abbreviations: R right, L left, M male, F female, SD standard deviation, Min minimum, Max maximum.
a
Distances (A, B and C) and lengths (D and E) are given in millimetres.
b
A, distance between the conjoined tendon and the anterior tibial tuberosity in the sagittal plane. E, width of insertion of the conjoined tendon.
c
B, distance between the conjoined tendon and the tibial tuberosity in the transverse plane.
d
C, distance between the ventral margin of the medial tibial plateau and the proximal limit of the conjoined tendon.
e
D, length of the conjoined tendon from its origin to the bifurcation into the semitendinosus and gracilis tendons.

fascia superficialis, then reflected proximally to reveal the conjoined
tendon corresponding to the distal insertion common to the sem-
itendinosus and the gracilis tendons [9] (Fig. 1). The latter were not
dissected but were left in place in their connective tissue in order to
reproduce as closely as possible the normal condition for surgical
harvesting. The bands were then individually identified. Only those
that showed significant resistance to blunt finger dissection were
analysed. The various anatomical relationships were detailed (Fig. 1):
- The distance between the conjoined tendon and the anterior tibial
tuberosity in the sagittal plane (A) and the transverse plane (B),
- The distance between the ventral margin of the medial tibial pla-
teau and the proximal limit of the conjoined tendon (C),
- The length of the conjoined tendon from its origin up to the bifur-
cation of the semitendinosus and the gracilis (D) tendons and the
width of implantation (E) of the conjoined tendon.
The bands arising from the gracilis and semitendinosus tendons
were characterised: the distance between the origin of the band and
the distal tibial bony insertion of the tendon, the destination of the
band, angle (acute or obtuse) at which the band joins the tendon,
and the width of the band and macroscopic appearance (tendinous
or aponeurotic).
All measurements were carried out using a digital calliper (TESA CAL
IP 67 magna μ system, TESA SA, Renens, Switzerland, 0–150 mm, reso-
lution ± 0.01 mm) by the same observer.

2.2. Macroscopic and histological appearance

To confirm the existence of two histological types of bands, a mi-

croscopic study was carried out. Samples were taken from 10 bands.
These were fixed in formalin before being embedded in a paraffin
block, cut by microtome and stained with hematoxylin–eosin. The
samples were examined under optical microscopy by a pathologist
specialised in bone and joint pathology.

2.3. Statistical analysis

Statistical analyses were carried out with SPSS® 14.0 software

Fig. 1. Topography of pes anserinus. A, distance anterior tibial tuberosity/pes anserinus —
craniocaudal axis; B, distance anterior tibial tuberosity/pes anserinus — mediolateral axis;
C, distance pes anserinus/internal tibial plateau; D, length of the conjoined tendon; and E,
width of the conjoined tendon—tibial insertion. The typical bands of the gracilis can also be
seen, running together with the bands of the semitendinosus forming the fascial band and
rejoining the fascia of gastrocnemius medialis.
(SPSS Inc, Chicago, IL). Variances were compared using Levene's
test. Shapiro–Wilk test was used to assess normality of distributions
and Student's t test for mean comparisons of normal distributions of
continuous variables. Otherwise, the Wilcoxon and Kruskal–Wallis
non-parametric tests were chosen. For nominal variables, we used
the Chi-square test, and Fisher's exact test when the expected theo-
retical numbers were less than 5. The level of statistical significance
was p = 0.05. In a preliminary analysis (data not given), no significant
difference was found between the left and right sides for any of the
numerical values. Intraobserver and interobserver reproducibilities
of the distances measured, (A), (B) and (C), was assessed by calculat-
ing the intra- and interclass correlation coefficient (ICC) (Table 2).
Correlations between individual biometric parameters and the
 Author's personal copy

92 N. Reina et al. / The Knee 20 (2013) 90–95

Table 2 21 mm ± 9 mm (range 0 to 36 mm) and the width of its insertion on the tibia (E)
Intraobserver and interobserver reproducibilities of the distances measured. was 27 mm ± 12 mm (range 16 to 70 mm).

Anatomic Distance Intraobserver Interobserver

landmark reproducibilitya reproducibilitya 3.2. Gracilis

Anterior tibial Ab 0.85 [95% CI 0.69–0.92] 0.65 [95% CI 0.50–0.78] The gracilis tendon had at least one band in 22 out of 30 cases (Table 3). Two bands
tuberosity Bc 0.72 [95% CI 0.62–0.83] 0.61 [95% CI 0.51–0.76] were found in five cases and a third band was found in only one knee of a single
Ventral margin of Cd 0.90 [95% CI 0.85–0.95] 0.85 [95% CI 0.77–0.92] subject. When only a single band was present, it was inserted at a mean of
the lateral tibial 75 mm ± 29 mm (range 37 to 140 mm). When there were two or three bands, the
plateau first band was inserted at 46 mm ± 15 mm (range 30 to 72 mm). The difference be-
a tween the two groups was significant (p = 0.029). The mean width of the first band
Values are given as r2 = X [95% confidence interval].
b was 10 mm ± 8 mm (range 2 to 32 mm) and of the second band 11 mm ± 10 mm
A, distance between the conjoined tendon and the anterior tibial tuberosity in the
(range 2 to 42 mm). This difference was not significant but we observed that the
sagittal plane.
c bands became narrower as the distance increased (r2 = − 0.49 [95% CI − 0.75 to
B, distance between the conjoined tendon and the tibial tuberosity in the trans-
− 0.1], p = 0.02). None of these parameters (distance of insertion or width) correlated
verse plane.
d with the subjects' height. Of the 29 bands observed, all ran distally, at an acute angle in
C, distance between the ventral margin of the medial tibial plateau and the proxi-
17 cases and obtuse in 12 (Fig. 2). In 17 of 29 knees, they attached to the sem-
mal limit of the conjoined tendon.
itendinosus tendon and in 10 of 29 knees the bands ran towards the fascia of gastroc-
nemius medialis. The other bands ran towards various anterior destinations to rejoin
various measurements were calculated using Spearman's corre- the fibrous layers of the tibial periosteum or the surrounding aponeurotic gliding
planes.
lation coefficients.

3.3. Semitendinosus

3. Results
3.1. Tendon insertions
The anatomical characteristics of the conjoined tendon are summarised in Table 1.
Its insertion was found at a mean of 6 mm ± 5 mm (range 0 to 20 mm) distal to the tib-
ial tuberosity (distance A) and 19 mm ± 6 mm (range 7 to 25 mm) medially (B). Dis-
tance (C) was a mean of 42 mm ± 7 mm (range 35 to 56 mm) and was significantly
correlated with the biometric parameters of the subjects (r2 = 0.63 [95% CI 0.36 to
0.81], p = 0.0001). The conjoined part of the tendons (D) measured a mean of
The semitendinosus tendon presented at least one band in all subjects (Table 4). Two
bands were found in seven of the 30 knees (but bilaterally in only two cases). Three bands
were never found. The first band lay at a mean of 44 mm±26 mm (range 0 to 95 mm)
from the tibial insertion of the conjoined tendon and the second band, when present, lay at
a mean of 68 mm±28 mm (range 41 to 126 mm). The first bands described as 0 mm
were considered as originated from the semitendinosus because they were bound to it, at
the bottom part of the tendon and just at the conjoined tendon level. When only a single
band was present, it inserted at 45 mm±26 mm (range 0 to 95 mm) compared with
40 mm±24 mm (range 0 to 70 mm) when there were two bands; the difference was not
significant (p=0.63). The mean width of the bands was 23 mm±27 mm (range 3 to

Table 3
Characteristics of the bands of the gracilis tendon. Measurements are given in millimetres (mm). Missing values indicate an absence of bands. Values equal to 0 correspond to an
insertion at the origin of the tendon.

Number Band 1 Band 2 Band 3

of bands
Insertion Width Anga Appb Insertion Width Anga Appb Insertion Width Anga Appb

1 R 1 48 26 + A
L 2 50 32 − B 93 11 − B
2 R 2 37 18 + A 66 23 + A
L 2 30 19 − A 59 42 − A
3 R 1 79 3 − B
L 1 55 12 + A
4 R 3 42 9 − A 73 2 − A 80 9 − B
L 2 44 10 − A 87 2 + A
5 R 1 94 12 + A
L 1 79 14 + A
6 R 1 106 5 − B
L 0
7 R 0
L 0
8 R 0
L 1 95 4 + B
9 R 1 59 2 + B
L 1 46 6 − B
10 R 1 86 2 − A
L 1 140 2 + A
11 R 0
L 1 58 4 − A
12 R 0
L 0
13 R 1 115 3 − B
L 2 72 3 − B 80 19 − A
14 R 1 37 12 + A
L 1 49 5 + A
15 R 0
L 1 58 7 − A
Mean±SD (range) 1.0 ± 0.8 (0–3) 67 ±29 (30–140) 10 ±8 (2–32) 76 ± 13 (59–93) 17 ±15 (2–42) 80 9

Abbreviations: R right, L left, Min minimum, Max maximum, Ang Angle, App Appearance.
a
Angles are given as − if the attachment is at an acute angle, and + if the attachment is at an obtuse angle.
b
Type of band : B tendinous, A aponeurotic.
 Author's personal copy

N. Reina et al. / The Knee 20 (2013) 90–95 93

histological characteristics. Bands of aponeurotic type A were composed of translucid,

gliding connective tissue with low mechanical strength. Histologically they were com-
posed of non-oriented, low-density fatty connective tissue (Fig. 3). Type B bands had a
tendinous appearance with an orientated fascicular organisation (Fig. 4) that was high-
ly resistant to traction. Histologically the connective tissue was fibrillary, dense, orien-
tated, and very similar to a tendon. For the gracilis tendon, 19 bands were type A and
10 were type B. For the semitendinosus tendon, four were type A and 33 were type B
(Figs. 6 and 7).

4. Discussion

In this study 30 fresh non-injected knees were studies. This is the

only detailed description of these bands and their histological charac-
teristics. Three findings were noted:

• The hamstring insertion on the tibia has an important variability

Fig. 2. Left knee. Bands of the gracilis and semitendinosus tendons fusing towards distal
structures.
99 mm), with no significant difference between the first and the second. But as with the
gracilis, the greater the distance, the narrower the bands (r2 =−0.76 [95% CI −0.88 to
−0.55], pb 0.0001). The first band of semitendinosus was significantly wider than that of
gracilis: 25 mm±29 mm (range 3 to 99 mm) versus 10 mm±8 mm (range 2 to 32 mm)
(p=0.01) and it was also significantly closer to the tibial insertion of the conjoined tendon;
44 mm±25 mm (range 0 to 95 mm) versus 67 mm±28 mm (range 30 to 140 mm)
(Fig. 5). The direction of the adhesions of semitendinosus was distal in all cases and ran to-
wards the aponeurosis of gastrocnemius medialis in 33 cases out of 37. In five cases, a
band originated at the conjoined tendon.
3.4. Macroscopic and histological appearance
Macroscopic analysis revealed two types of bands; the first had an aponeurotic ap-
pearance (type A) and the second a tendinous appearance (type B), with distinct
and the only reliable landmark is the distance to the medial tibia
plateau.
• The number of bands is typically greater for semitendinosus as op-
posed to gracilis, but gracilis may have more than one band.
• Although semitendinosus presents more “tendon-like” bands than
gracilis, these vary considerably in insertion point (up to 140 mm
away), orientation and histological features.
This study used a descriptive approach from a surgeons point-of-
view. Simulation of the surgical harvest conditions, considering as
significant only the bands resistant to blunt finger dissection, is
open to criticism, but it is in this way that the tendons are identified
during the procedure before the stripper is used. A study of the liter-
ature did not suggest that the anatomy of the region changes with
ageing, but it should be noted that the mean age of the subjects in

Table 4
Characteristics of the bands of the semitendinosus tendon. Measurements are given in millimetres (mm). Missing values indicate an absence of bands. Values equal to 0 correspond
to an insertion at the origin of the tendon.

Number Band 1 Band 2

of bands
Insertion Width Anglea Appearanceb Insertion Width Anglea Appearanceb

1 R 1 40 23 − B
L 1 53 19 − B
2 R 1 37 16 − B
L 1 32 11 − B
3 R 1 34 55 − B
L 2 30 10 − B 50 14 + B
4 R 2 43 3 − B 60 15 − B
L 2 36 5 − B 50 8 − A
5 R 1 56 5 − B
L 1 54 10 − B
6 R 1 95 7 − B
L 1 81 5 − B
7 R 1 0 83 − B
L 1 0 38 − B
8 R 1 0 99 + B
L 1 0 96 + B
9 R 2 31 10 − B 70 5 + A
L 1 76 4 − B
10 R 2 69 5 − B 76 6 − A
L 1 70 11 − B
11 R 1 50 31 − B
L 1 40 38 − B
12 R 1 60 11 − B
L 1 46 15 − B
13 R 2 0 85 − B 126 4 − B
L 1 70 11 − B 41 39 + A
14 R 1 33 9 − B
L 1 70 12 − B
15 R 1 52 10 − B
L 1 63 16 − B
Mean ± SD (range) 1.2 ± 0.4 (1–2) 44 ± 26 (0–95) 25 ±29 (3–99) − 68 ±298 (41–126) 13 ±12 (34–39)

Abbreviations: R right, L left.

a
Angles are given as − if the attachment is at an acute angle, and + if the attachment is at an obtuse angle.
b
Type of band: A aponeurotic, B tendinous.
 Author's personal copy
94 N. Reina et al. / The Knee 20 (2013) 90–95
Fig. 3. Aponeurotic expansion. Right knee: an aponeurotic band arising from the
gracilis tendon which is held by the clamp.
Fig. 4. Tendinous expansion. This appearance is typical of bands arising from the
gracilis in the upper part of the photograph. They are fasciculated, whitish, tendon-
like and the fibres penetrate the tendon at an acute angle.
our series was considerably higher than that of most patients under-
going ligament or tendon repair.
The tibial tuberosity was an unreliable landmark for locating ten-
dons and that interobserver correlation was poor (ICC: r 2 = 0.61, [95%
CI 0.51 to 0.76]). The distance (C) of the tendon insertions measured
from the ventral margin of the medial tibial plateau appeared to be
much more reliable (ICC: 0.85 [95% CI 0.77 to 0.92]) and was very sig-
nificantly correlated with the subjects' height. This landmark should
therefore be preferred for locating the pes anserinus tendons, partic-
ularly as it is easily accessible during the surgical procedure. With
better identification, the incision of sartorius can be optimally placed
before dissection of gracilis and semitendinosus.
Fig. 5. Graphic representation of the bands insertion depending on bands width. Y-axis:
bands width, X-axis: distance of insertion. Red dots: Gracilis bands; Blue cross: sem-
itendinosus bands.
Fig. 6. Appearance on light microscopy. A type band: less organised, fat inclusions, apo-
neurotic connective tissue.
Semitendinosus has a relatively constant anatomy [8]; at least one
band and, in nearly a third of cases, two bands, but never three. These
bands were more likely to run towards the fascia of gastrocnemius
medialis and usually met the tendon at an acute angle. They were al-
most exclusively tendinous, and so more resistant to traction and dis-
section. They therefore seem to carry a greater risk for error during
harvesting. But they are constantly present and are only exceptionally
found at a distance greater than 100 mm.
Gracilis, however, showed greater anatomical variability. Bands
were absent in over a quarter of cases, but when present their number
ranged from one to three. The destination of the bands was also vari-
able, as was the angle of attachment to the tendon. In addition, this
study showed that if a band is present on the gracilis very close to the
tibial insertion, a second or even a third band should be sought, as the
first bands are significantly closer to the tibial insertion when another
band is present. This point is particularly important because this second
or third band is sometimes very wide (up to 42 mm), and the stripper
may be misdirected when the gracilis, itself rather narrow, is harvested.
But these are predominantly aponeurotic bands, less resistant to trac-
tion. Although this distance does not fix a limit that can exclude the
presence of other bands, it is still a good indicator. A second band was
never found at a distance greater than 100 mm. However, dissection
should be carried further than the 100 mm conventionally accepted in
the literature [9], as our study has shown that bands may lie at a dis-
tance of up to 140 mm; in this event, the band was a single one.
There are major differences between the semitendinosus and the
gracilis tendons in terms of number, location, direction and consisten-
cy of the bands. These differences are related to the muscle function
itself. Semitendinosus is a more powerful and thicker muscle than
gracilis, the forces generated are greater and account for the need
Fig. 7. Appearance on light microscopy. B type band: dense, oriented, tendinous con-
nective tissue.
 Author's personal copy
N. Reina et al. / The Knee 20 (2013) 90–95
Table 5
Risk evaluation according to three criteria. Main criterion is the macroscopic appearance (A aponeurotic or B tendinous). Second criterion is the destination (a aponeurotic connective
layers or b gastrocnemius or another tendon). Third is the angle of merging (+ obtuse or − acute).
for more stable fixation of the distal extremity of the tendon. The
gracilis tendon is subjected to lesser constraints, and so its anatomical
relationships are less demanding, in particular biomechanically. This
study provides macroscopic and histological arguments in support
of this concept. Two distinct types of band exist, and the tendinous
bands of the semitendinosus tendon are stronger than the aponeurot-
ic bands of the gracilis tendon.
The pes anserinus is an anatomical region which has been
studied by several authors [8,10–13]. It is important because ten-
dons in this region are widely used as grafts in numerous proce-
dures. Their harvesting is considered to be minimally invasive
and simple, but it nevertheless requires accurate knowledge of
anatomy.
Three anatomical parameters (macroscopic type, destination, angle
of attachment) have been identified in the bands that may be risk fac-
tors for failure during harvesting. These factors can be directly assessed
by the surgeon during harvesting. There are two macroscopic types;
type A, the aponeurotic type, has a less dense connective appearance
and its translucid fibres may run in many directions. Type B, the tendi-
nous type, has a connective appearance consisting of dense, whitish fi-
bres running in a single direction. This is the major characteristic that
defines the risk. On examination of the destination of the bands, two
sub-types can be identified, with bands running toward the surround-
ing aponeurotic connective layers (type a), and other bands coursing to-
wards stronger structures such as the gastrocnemius (fascial band) or
another tendon (type b). This second type in fact shows bands that
are stronger and therefore carry a higher risk. Lastly, the angle of attach-
ment to the tendon (which corresponds to the angle at which the fibres
of the band penetrate within the tendon), may be an obtuse angle from
the distal part that is, an angle greater than 90° (type +), or it may be an
acute angle (type −). The risk of misdirection of the stripper during
harvesting was lower with the first type. These three parameters can
thus be combined to estimate risk on a qualitative scale (Table 5),
from low risk (Aa+) for a structure with low mechanical strength and
thus low probability of leading to graft rupture, to major risk (Bb−) re-
lating to a very strong band whose fibres penetrating the tendon make
rupture more likely.
View publication stats
95
5. Conclusion
Both gracilis and semitendinosus have bands that represent risk of
failure during harvesting the tendons. This study has defined the var-
iability in number, the anatomy, and the particular characteristics of
these bands, knowledge of which may decrease this risk. The risk
can be assessed qualitatively from simple anatomical criteria that
can be assessed by the surgeon during the harvest itself. The criteria
are the insertion, the direction and the anatomical type of the bands.
References
[1] Freedman KB, D'Amato MJ, Nedeff DD, Kaz A, Bach BR. Arthroscopic anterior cru-
ciate ligament reconstruction: a metaanalysis comparing patellar tendon and
hamstring tendon autografts. Am J Sports Med 2003;31:2–11.
[2] Charalambous CP, Alvi F, Phaltankar P, Gagey O. Hamstring tendon harvesting—
effect of harvester on tendon characteristics and soft tissue disruption; cadaver
study. Knee 2009;16:183–6.
[3] Tuncay I, Karalezli N. Skin dimpling as a complication of hamstring harvesting
following anterior cruciate ligament reconstruction. J Knee Surg 2008;21:250–2.
[4] Sanders B, Rolf R, McClelland W, Xerogeanes J. Prevalence of saphenous nerve
injury after autogenous hamstring harvest: an anatomic and clinical study of sar-
torial branch injury. Arthroscopy 2007;23:956–63.
[5] Almazan A, Miguel A, Odor A, Ibarra JC. Intraoperative incidents and complica-
tions in primary arthroscopic anterior cruciate ligament reconstruction. Arthros-
copy 2006;22:1211–7.
[6] Burks RT, Crim J, Fink BP, Boylan DN, Greis PE. The effects of semitendinosus and
gracilis harvest in anterior cruciate ligament reconstruction. Arthroscopy 2005;21:
1177–85.
[7] Marshall JL, Warren RF, Wickiewicz TL, Reider B. The anterior cruciate ligament: a
technique of repair and reconstruction. Clin Orthop Relat Res 1979;143:97–106.
[8] Tuncay I, Kucuker H, Uzun I, Karalezli N. The fascial band from semitendinosus to
gastrocnemius: the critical point of hamstring harvesting: an anatomical study of
23 cadavers. Acta Orthop 2007;78:361–3.
[9] Solman Jr CG, Pagnani MJ. Hamstring tendon harvesting. Reviewing anatomic re-
lationships and avoiding pitfalls. Orthop Clin North Am 2003;34:1–8.
[10] Ivey M, Prud'homme J. Anatomic variations of the pes anserinus: a cadaver study.
Orthopedics 1993;16:601–6.
[11] Candal-Couto JJ, Deehan DJ. The accessory bands of gracilis and semitendinosus:
an anatomical study. Knee 2003;10:325–8.
[12] Mochizuki T, Akita K, Muneta T, Sato T. Pes anserinus: layered supportive struc-
ture on the medial side of the knee. Clin Anat 2004;17:50–4.
[13] Amatuzzi MM, Cocco LF, Di Dio LJ, Gotfryd AO. Surgical anatomy of the variations
of the arrangement of the tendons of the muscles of the pes anserinus in male
adults. Ital J Anat Embryol 2002;107:29–35.