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.