Thanks, Mike. My disclosures, I'll be presenting a device in the videos is an Arthrex device. So size does matter here with hamstring autograft, and this is certainly one of the things when I was a fellow is getting as big a hamstring as you can and making sure you got both the gracilis and the semitendinosus, and even with getting both of them, it oftentimes was less than eight millimeters. And we know there's an increased failure rate if your graft diameter is less than eight millimeters. These are the old techniques where you're taking a quadrupled strand, passing over either some sort of cross pin or fixing it in place, but the idea is quadrupled. There are four strands going intra-articulately and fixed. With some of the newer devices, you're going to see that there are eight strands going across it. We know that in biomechanical studies, too, diameter is less than eight, higher failure rate, weaker, and the idea of supplementing the autograft with allograft to increase the width of the graft does not improve outcomes. It still behaves like an allograft with higher failure rates, similar to allograft seen in allograft reconstruction in a younger population. So what do you do? Prepare for success, guarantee success, and it all starts with the harvest. So position your, the position of your incision's got to be in the right place, about a finger breadth below the tubercle. Feel the hamstring tendons, dissect both of them out, and I think this is something that the fellows should practice all the time. And I think using a closed-tendon stripper, as you'll see, almost makes it foolproof in terms of preventing laceration of the graft. It's really with the open-tendon strippers where you have an issue with graft harvest. You want to suture through it, and I think the key, as you'll see here, is using this closed-tendon stripper. The key is flexing the leg, too, to take tension so that graft harvester can pass underneath the fascia. If you don't flex the leg, there's a chance with an open-tendon stripper that you can hit the sciatic nerve. I know it sounds crazy, but there are several cases out there where that complication has occurred. And the same thing you can do with the gracilis. Just trying to get to the next slide. Okay. Can you advance that slide for me, please? Back one, please. Okay. In terms of preparation, we talked about... So this is the game-changer, certainly for me, where here we're just using the semi-T, and instead of just using two strands, you're actually folding it over, you're whip-stitching it here. So now you have, in this case, you're folding it over again on itself. So instead of the quadrupled with the semi-T and gracilis, you're just using the semi-T here. And in this case, you're getting up to an 8.5-millimeter graft. You whip-stitch this at several locations. If you want, and you know this is going to be small at a 7-millimeter, even with just a semi-T, if you take the gracilis tendon, oftentimes when you use both in this type of configuration, you can get up from 9 to as high as an 11-millimeter diameter graft. Next slide, please. Actually, I got it. And this is just showing the passage with the button. So this is an all-inside technique. Most of you know how to do it. So again, if your graft is even short in these cases, you can limit the tunnel distance in both the femur and the tibia, both as low as 15 millimeters. And that could, again, help if you have a short graft as well. Next slide. So some of the PEARLS hamstring autograft tendons are utilized. They can be sized to 8 to 9 millimeters, oftentimes with just a semi-tendinosis alone being used. Tendon length is usually set at 70 millimeters. Pete's case is 55, but you could certainly go lower. This allows the 20 to 25-millimeter tendon in both ephemeral and tibial tunnels, as well as an intra-articular length of 15 to 20 millimeters. So in conclusion, if the hamstring graft is smaller than 8 millimeters diameter, there's a high risk of failure. The technique described eliminates concern. Close-tendon stripper is definitely helpful, prevents graft laceration. Start with the semi-tendinosis, add the gristillus as needed. Typically when both are whip-stitched with this technique presented, the graft diameter is typically between 9, 5, and 11 millimeters. Thank you.

graft size

hamstring autograft

failure rate

Arthrex device

closed-tendon stripper