Hamstring tendon autograft has been shown to be an excellent option for anterior cruciate ligament (ACL) reconstruction. Adequate graft size can usually be achieved through either a double-bundle technique of semitendinosus and gracilis tendons or a quadruple-bundle technique using a single tendon. To minimize failure rates that result from graft insufficiency, a minimum graft thickness of 8 mm is recommended for reconstruction. However, certain patients possess small native hamstring tendons that do not allow for recommended graft thickness using either of these traditional techniques. Although patient characteristics such as gender, height, and weight have all been associated with hamstring tendon size, accurately predicting which patients will possess inadequate autograft size is not possible. Recognizing this problem intraoperatively after harvesting the tendon presents a difficult scenario for the surgeon. In this technical note, we describe an alternative technique for preparing hamstring tendon autograft that results in significantly increased thickness by essentially utilizing a quadruple-bundle technique with both tendons. We proceed to reconstruct the ACL using an all-inside technique with suture buttons on both the femoral and tibial tunnels. The technique can serve as a rescue method for patients with insufficient hamstring tendon thickness.
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