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The Rule of Twos: Consistent Anatomical Landmarks for Hamstring Graft Harvesting
Author(s):
Jiang L. (Singapore)
,
Jiang L. (Singapore)
Affiliations:
Tay K.
,
Tay K.
Affiliations:
Tan A.
Tan A.
Affiliations:
ESSKA Academy. Jiang L. May 9, 2018; 209511; P07-262 Topic: Anatomy
Lei Jiang
Lei Jiang
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Abstract
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Objectives: Despite the popularity of hamstring grafts in the reconstruction of the of anterior cruciate ligament (ACL), there is no consensus in literature with respect to the incision and anatomical landmarks used in harvesting. The authors aim to evaluate the consistency of a novel hamstring graft harvesting technique facilitated by an aide-memoire, "The Rule of Twos", with a 2cm vertical incision made starting 2cm medial and 2cm distal to the tip of the tibial tuberosity, and hypothesize that the following key measurements can be approximated to 2cm: 1) Distance from the tip of the tibial tuberosity to the proximal edge of the conjoint tendon (TTD), 2) Width of the insertion of the conjoint tendon (CTW), 3) Length of the conjoint tendon (CTL).

Methods: Between Jan 2017 and June 2017, skeletally mature patients who underwent primary ACL reconstruction with hamstring grafts by a single, fellowship-trained sports surgeon were recruited for the prospective observational study. The age, gender, height and weight of all patients were recorded. The TTD, CTW and CTL were measured by the same senior surgeon (A.H.T.) after careful dissection of the structures to avoid interobserver error. Measurements were reported to the midpoint of a structure's attachment site and osseous landmarks and reported as averages. Progress notes and operative notes of all patients were reviewed to detect any graft harvesting complications.

Results: 14 (82.4%) male and 3 (17.6%) female patients were recruited with a mean age of 29.8±8.0 years and body mass index of 25.6±4.4 kg/m2. The "Rule of Twos" technique enabled successful identification and harvest of the hamstring tendons in all patients. The mean TTD, CTW and CTL were 19.4±1.4mm, 18.8±1.0mm and 20.1±1.0mm respectively. No complications of premature graft amputation, saphenous nerve injury or medial collateral ligament injury were noted in our patients.

Conclusions: The study has described a novel "Rule of Twos" technique as a useful aide-memoire in the localization of incision in hamstring harvesting, as well as in identifying the width and proximal extent of the conjoint tendon. The results demonstrate the consistency and safety of the technique. It is hoped that this technique can aid surgeons in the safe, reproducible harvesting of hamstring tendons via an easily recalled technique with a sound anatomical basis.

Keywords:
Hamstring graft; ACL reconstruction; Knee; Sports surgery;
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