{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T14:43:47Z","timestamp":1787755427313,"version":"build-2784847793"},"reference-count":26,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"2","content-domain":{"domain":["lww.com","ovid.com"],"crossmark-restriction":true},"short-container-title":[],"abstract":"\n Background:<\/jats:title>\n \n Hamstring tendon autograft remains a popular graft choice for anterior cruciate ligament (ACL) reconstruction because of its favorable biomechanical properties, lower donor-site morbidity, and comparable functional outcomes to bone-patellar tendon-bone (BPTB) autograft\n 1\u20135<\/jats:sup>\n . However, variability in hamstring graft size and length remains a challenge, particularly in female or short-statured patients\n 7<\/jats:sup>\n . Smaller graft diameters are consistently associated with increased failure and revision rates, with grafts of <8 mm demonstrating inferior outcomes\n 6,7,18,19<\/jats:sup>\n . Magnussen et al.\n 6<\/jats:sup>\n reported revision rates of 13.6% for grafts of <7 mm compared with 1.7% for grafts of \u22658 mm, and Park et al.\n 18<\/jats:sup>\n and Mariscalco et al.\n 19<\/jats:sup>\n reported no revisions in grafts of \u22658 mm. Although some studies have suggested slightly higher laxity or failure rates with hamstring grafts compared with BPTB in certain populations\n 3,20\u201322<\/jats:sup>\n , large systematic reviews have shown no significant differences in return to sport, rerupture rates, or patient-reported outcomes when grafts are appropriately sized\n 23,24<\/jats:sup>\n . The 5-strand hamstring autograft configuration has demonstrated comparable clinical outcomes to the traditional 4-strand construct while more reliably achieving large graft diameters\n 9,10,12<\/jats:sup>\n . The present video article outlines the key steps and technical pearls and pitfalls of performing a 5-strand hamstring autograft ACL reconstruction.\n <\/jats:p>\n <\/jats:sec>\n \n Description:<\/jats:title>\n The semitendinosus and gracilis are harvested after reflecting the sartorial fascia and removing the attached adhesions and bands from each tendon. If a 4-strand configuration is <8 mm in diameter, a 5-strand technique is utilized, tripling the semitendinosus and doubling the gracilis. A diagnostic knee arthroscopy is performed. The tibial tunnel is drilled through an accessory anteromedial portal over the residual ACL tibial footprint. The femoral tunnel is drilled with use of an over-the-top guide and subsequently reamed to a depth of 25 mm via independent femoral drilling at the center of the femoral ACL footprint. Femoral stabilization is then achieved with interference screw fixation, the knee is cycled, and screw-and-sheath tibial fixation is performed.<\/jats:p>\n <\/jats:sec>\n \n Alternatives:<\/jats:title>\n \n Nonoperative treatment includes formal physical therapy that emphasizes strengthening, stretching, and neuromuscular control\n 11<\/jats:sup>\n . Surgical alternatives include ACL reconstruction using BPTB or quadriceps tendon autograft or allograft tissue. In cases of insufficient hamstring graft length or diameter, hybrid graft constructs incorporating allograft tissue may be considered\n 12<\/jats:sup>\n .\n <\/jats:p>\n <\/jats:sec>\n \n Rationale:<\/jats:title>\n \n Hamstring tendon autograft offers reliable long-term results for ACL reconstruction with a well-established biomechanical profile\n 1,2<\/jats:sup>\n , reduced anterior knee pain\n 3<\/jats:sup>\n , and clinical outcomes comparable to BPTB and quadriceps autograft\n 4,5,14<\/jats:sup>\n . Although biomechanical studies have demonstrated similar ultimate load to failure and cyclic elongation between 4- and 5-strand constructs\n 9,16<\/jats:sup>\n , the 5-strand technique significantly increased the likelihood of achieving a graft diameter of >8 mm, which has been associated with improved stiffness and lower revision rates\n 6,17\u201319<\/jats:sup>\n . Brzezinski et al. demonstrated larger mean graft diameters with 5-strand constructs (9.32 mm) compared with 4-strand constructs (7.96 mm), without biomechanical compromise\n 16<\/jats:sup>\n .\n <\/jats:p>\n <\/jats:sec>\n \n Expected Outcomes:<\/jats:title>\n \n Hamstring tendon autograft ACL reconstruction results in outcomes comparable to BPTB and quadriceps autografts, with similar graft failure rates, knee stability, and functional outcomes, and lower rates of anterior knee pain (11.5% versus 17.4%, respectively)\n 4,5,14<\/jats:sup>\n . However, increased failure rates have been reported in younger patients and those with generalized ligamentous laxity\n 13,15<\/jats:sup>\n . Krishna et al. reported significantly larger graft diameters with 5-strand constructs compared with 4-strand constructs (9.06 \u00b1 0.60 versus 8.13 \u00b1 0.32 mm, respectively; p < 0.05), with no difference in functional outcomes when grafts were adequately sized\n 9<\/jats:sup>\n .\n <\/jats:p>\n <\/jats:sec>\n \n Important Tips:<\/jats:title>\n \n \n \n Avoid injury to the superficial medial collateral ligament during harvest.<\/jats:p>\n <\/jats:list-item>\n \n Release all fascial bands prior to proximal tendon harvest to avoid premature amputation of the tendon.<\/jats:p>\n <\/jats:list-item>\n \n Harvesting the periosteal footprint may increase graft length by 3 to 4 cm.<\/jats:p>\n <\/jats:list-item>\n \n Remove graft creep with tensioning and knee cycling before fixation.<\/jats:p>\n <\/jats:list-item>\n \n A femoral interference screw should be placed parallel to the tunnel.<\/jats:p>\n <\/jats:list-item>\n \n Preserve 2 mm of posterior femoral wall to avoid posterior wall blowout.<\/jats:p>\n <\/jats:list-item>\n <\/jats:list>\n <\/jats:p>\n <\/jats:sec>\n \n Acronyms and Abbreviations:<\/jats:title>\n \n \n \n ACL = anterior cruciate ligament<\/jats:p>\n <\/jats:list-item>\n \n ACLR = anterior cruciate ligament reconstruction<\/jats:p>\n <\/jats:list-item>\n \n AM = anteromedial<\/jats:p>\n <\/jats:list-item>\n \n BPTB = bone-patellar tendon-bone<\/jats:p>\n <\/jats:list-item>\n \n HT = hamstring tendon<\/jats:p>\n <\/jats:list-item>\n \n MRI = magnetic resonance imaging<\/jats:p>\n <\/jats:list-item>\n \n QT = quadriceps tendon<\/jats:p>\n <\/jats:list-item>\n \n ROM = range of motion<\/jats:p>\n <\/jats:list-item>\n <\/jats:list>\n <\/jats:p>\n <\/jats:sec>","DOI":"10.2106\/jbjs.st.25.00009","type":"journal-article","created":{"date-parts":[[2026,5,15]],"date-time":"2026-05-15T18:01:11Z","timestamp":1778868071000},"update-policy":"https:\/\/doi.org\/10.1097\/lww.0000000000001000","source":"Crossref","is-referenced-by-count":0,"title":["Five-Strand Hamstring Autograft Anterior Cruciate Ligament Reconstruction"],"prefix":"10.2106","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0386-1060","authenticated-orcid":false,"given":"J. Christian","family":"Peterson","sequence":"first","affiliation":[{"name":"OU Health, University of Oklahoma, Oklahoma City, Oklahoma City, Oklahoma"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-4738-3415","authenticated-orcid":false,"given":"William L.","family":"Justice","sequence":"additional","affiliation":[{"name":"Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0009-4168-6663","authenticated-orcid":false,"given":"Nathaniel","family":"Tchangou","sequence":"additional","affiliation":[{"name":"Drexel University College of Medicine, Philadelphia, Pennsylvania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4303-4131","authenticated-orcid":false,"given":"Kevin B.","family":"Freedman","sequence":"additional","affiliation":[{"name":"Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","published-online":{"date-parts":[[2026,4]]},"reference":[{"issue":"2","key":"bib1-20260515","doi-asserted-by":"crossref","first-page":"202","DOI":"10.1177\/03635465990270021501","article-title":"A biomechanical analysis of matched bone-patellar tendon-bone and double-looped semitendinosus and gracilis tendon grafts","volume":"27","author":"Wilson","year":"1999","journal-title":"Am J Sports Med."},{"issue":"4","key":"bib2-20260515","doi-asserted-by":"crossref","first-page":"1067","DOI":"10.1007\/s00590-022-03247-6","article-title":"Biomechanics of hamstring tendon, quadriceps tendon, and bone-patellar tendon-bone grafts for anterior cruciate ligament reconstruction: a cadaveric study","volume":"33","author":"Hart","year":"2023","journal-title":"Eur J Orthop Surg Traumatol."},{"issue":"1","key":"bib3-20260515","doi-asserted-by":"crossref","first-page":"2","DOI":"10.1177\/03635465030310011501","article-title":"Arthroscopic anterior cruciate ligament reconstruction: a metaanalysis comparing patellar tendon and hamstring tendon autografts","volume":"31","author":"Freedman","year":"2003","journal-title":"Am J Sports Med."},{"issue":"6","key":"bib4-20260515","doi-asserted-by":"crossref","first-page":"2325967117709735","DOI":"10.1177\/2325967117709735","article-title":"Long-Term Outcomes in Anterior Cruciate Ligament Reconstruction: A Systematic Review of Patellar Tendon Versus Hamstring Autografts","volume":"5","author":"Poehling-Monaghan","year":"2017","journal-title":"Orthop J Sports Med."},{"issue":"2","key":"bib5-20260515","doi-asserted-by":"crossref","first-page":"450","DOI":"10.1016\/j.arthro.2016.09.020","article-title":"Outcome of Patellar Tendon Versus 4-Strand Hamstring Tendon Autografts for Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Prospective Randomized Trials","volume":"33","author":"Chee","year":"2017","journal-title":"Arthroscopy."},{"issue":"4","key":"bib6-20260515","doi-asserted-by":"crossref","first-page":"526","DOI":"10.1016\/j.arthro.2011.11.024","article-title":"Graft size and patient age are predictors of early revision after anterior cruciate ligament reconstruction with hamstring autograft","volume":"28","author":"Magnussen","year":"2012","journal-title":"Arthroscopy."},{"issue":"7","key":"bib7-20260515","doi-asserted-by":"crossref","first-page":"882","DOI":"10.1016\/j.arthro.2014.03.028","article-title":"Hamstring autograft size can be predicted and is a potential risk factor for anterior cruciate ligament reconstruction failure","volume":"30","author":"Conte","year":"2014","journal-title":"Arthroscopy."},{"issue":"6","key":"bib8-20260515","doi-asserted-by":"crossref","first-page":"e1923","DOI":"10.1016\/j.asmr.2022.07.010","article-title":"The Use of Five-Strand Hamstring Autograft to Increase the Graft Size in Anterior Cruciate Ligament Reconstruction-A Prospective Cohort Study With Satisfactory Early Clinical Results","volume":"4","author":"Wan","year":"2022","journal-title":"Arthrosc Sports Med Rehabil."},{"issue":"3","key":"bib9-20260515","doi-asserted-by":"crossref","first-page":"2325967118760815","DOI":"10.1177\/2325967118760815","article-title":"A 5-Strand Hamstring Autograft Achieves Outcomes Comparable to Those of a 4-Strand Hamstring Autograft With a Graft Diameter of 8 mm or More in Anterior Cruciate Ligament Reconstruction","volume":"6","author":"Krishna","year":"2018","journal-title":"Orthop J Sports Med."},{"issue":"13","key":"bib10-20260515","doi-asserted-by":"crossref","first-page":"3502","DOI":"10.1177\/03635465221128581","article-title":"STABILITY Group. Performance of 5-Strand Hamstring Autograft Anterior Cruciate Ligament Reconstruction in the STABILITY Study: A Subgroup Analysis","volume":"50","author":"Lodhia","year":"2022","journal-title":"Am J Sports Med."},{"issue":"4","key":"bib11-20260515","doi-asserted-by":"crossref","first-page":"807","DOI":"10.1177\/0363546519825500","article-title":"Coper Classification Early After Anterior Cruciate Ligament Rupture Changes With Progressive Neuromuscular and Strength Training and Is Associated With 2-Year Success: The Delaware-Oslo ACL Cohort Study","volume":"47","author":"Thoma","year":"2019","journal-title":"Am J Sports Med."},{"issue":"4","key":"bib12-20260515","doi-asserted-by":"crossref","first-page":"1014","DOI":"10.1177\/0363546519849483","article-title":"Hamstring Autograft Versus Hybrid Graft for Anterior Cruciate Ligament Reconstruction: A Systematic Review","volume":"48","author":"Wang","year":"2020","journal-title":"Am J Sports Med."},{"issue":"9","key":"bib13-20260515","doi-asserted-by":"crossref","first-page":"2086","DOI":"10.1177\/0363546519854762","article-title":"Anterior Cruciate Ligament Reconstruction in Young Female Athletes: Patellar Versus Hamstring Tendon Autografts","volume":"47","author":"Salem","year":"2019","journal-title":"Am J Sports Med."},{"issue":"3","key":"bib14-20260515","doi-asserted-by":"crossref","first-page":"660","DOI":"10.1177\/03635465231222279","article-title":"A Prospective Randomized Controlled Trial Investigating Quadriceps Versus Hamstring Tendon Autograft in Anterior Cruciate Ligament Reconstruction","volume":"52","author":"Ebert","year":"2024","journal-title":"Am J Sports Med."},{"issue":"7","key":"bib15-20260515","doi-asserted-by":"crossref","first-page":"2337","DOI":"10.1016\/j.arthro.2021.02.021","article-title":"Generalized Joint Laxity Is Associated With Increased Failure Rates of Primary Anterior Cruciate Ligament Reconstructions: A Systematic Review","volume":"37","author":"Krebs","year":"2021","journal-title":"Arthroscopy."},{"issue":"5","key":"bib16-20260515","doi-asserted-by":"crossref","first-page":"e1731","DOI":"10.1016\/j.asmr.2022.06.020","article-title":"Five-Strand Hamstring Grafts are Biomechanically Comparable to Four-Strand Grafts and Offer Greater Diameter for Anterior Cruciate Ligament Reconstruction","volume":"4","author":"Brzezinski","year":"2022","journal-title":"Arthrosc Sports Med Rehabil."},{"issue":"3","key":"bib17-20260515","doi-asserted-by":"crossref","first-page":"93","DOI":"10.1302\/2058-5241.3.170038","article-title":"Hamstring autograft size importance in anterior cruciate ligament repair surgery","volume":"3","author":"Figueroa","year":"2018","journal-title":"EFORT Open Rev."},{"issue":"5","key":"bib18-20260515","doi-asserted-by":"crossref","first-page":"1111","DOI":"10.1007\/s00167-012-2085-4","article-title":"Factors predicting hamstring tendon autograft diameters and resulting failure rates after anterior cruciate ligament reconstruction","volume":"21","author":"Park","year":"2013","journal-title":"Knee Surg Sports Traumatol Arthrosc."},{"issue":"12","key":"bib19-20260515","doi-asserted-by":"crossref","first-page":"1948","DOI":"10.1016\/j.arthro.2013.08.025","article-title":"The influence of hamstring autograft size on patient-reported outcomes and risk of revision after anterior cruciate ligament reconstruction: a Multicenter Orthopaedic Outcomes Network (MOON) Cohort Study","volume":"29","author":"Mariscalco","year":"2013","journal-title":"Arthroscopy."},{"issue":"3","key":"bib20-20260515","doi-asserted-by":"crossref","first-page":"576","DOI":"10.1007\/s00167-012-1947-0","article-title":"Long-term follow-up of patellar tendon grafts or hamstring tendon grafts in endoscopic ACL reconstructions","volume":"21","author":"Gifstad","year":"2013","journal-title":"Knee Surg Sports Traumatol Arthrosc."},{"issue":"2","key":"bib21-20260515","doi-asserted-by":"crossref","first-page":"381","DOI":"10.1007\/s00167-018-5029-9","article-title":"Increased knee laxity with hamstring tendon autograft compared to patellar tendon autograft: a cohort study of 5462 patients with primary anterior cruciate ligament reconstruction","volume":"27","author":"Cristiani","year":"2019","journal-title":"Knee Surg Sports Traumatol Arthrosc."},{"issue":"10","key":"bib22-20260515","doi-asserted-by":"crossref","first-page":"1946","DOI":"10.1177\/0363546509339577","article-title":"Patellar tendon versus hamstring tendon autografts for anterior cruciate ligament reconstruction: a randomized controlled trial using similar femoral and tibial fixation methods","volume":"37","author":"Taylor","year":"2009","journal-title":"Am J Sports Med."},{"issue":"8","key":"bib23-20260515","doi-asserted-by":"crossref","first-page":"1996","DOI":"10.1177\/03635465241295713","article-title":"Return to Sport and Graft Failure Rates After Primary Anterior Cruciate Ligament Reconstruction With a Bone-Patellar Tendon-Bone Versus Hamstring Tendon Autograft: A Systematic Review and Meta-analysis","volume":"53","author":"Connors","year":"2025","journal-title":"Am J Sports Med."},{"issue":"2","key":"bib24-20260515","doi-asserted-by":"crossref","first-page":"100","DOI":"10.1016\/j.knee.2014.11.014","article-title":"A meta-analysis of bone-patellar tendon-bone autograft versus four-strand hamstring tendon autograft for anterior cruciate ligament reconstruction","volume":"22","author":"Xie","year":"2015","journal-title":"Knee."},{"issue":"2","key":"bib25-20260515","doi-asserted-by":"crossref","first-page":"127","DOI":"10.5115\/acb.2014.47.2.127","article-title":"Pes anserinus and anserine bursa: anatomical study","volume":"47","author":"Lee","year":"2014","journal-title":"Anat Cell Biol."},{"issue":"2","key":"bib26-20260515","doi-asserted-by":"crossref","first-page":"90","DOI":"10.1016\/j.knee.2012.06.003","article-title":"Anatomy of the bands of the hamstring tendon: how can we improve harvest quality?","volume":"20","author":"Reina","year":"2013","journal-title":"Knee."}],"container-title":["JBJS Essential Surgical Techniques"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.ovid.com\/10.2106\/JBJS.ST.25.00009","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T13:42:54Z","timestamp":1787751774000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.ovid.com\/10.2106\/JBJS.ST.25.00009"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,4]]},"references-count":26,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2026]]}},"URL":"https:\/\/doi.org\/10.2106\/jbjs.st.25.00009","relation":{},"ISSN":["2160-2204"],"issn-type":[{"value":"2160-2204","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4]]}}}