Five and Six Strand Hamstring Grafts

In patients that have a high risk of instability, including those with loose joints, small tendons but large body mass, long chronicity with stretched out secondary restraints, revisions, and athletes who put large demands on their knees, use of a five or six strand hamstring autograft will add additional strength and stability.

Creation of a six-strand graft is simple as it entails simply adding another folded length of graft to a four-strand graft. Creation of a five-strand graft is a bit more complicated as one strand will not be folded and therefore cannot simply be placed over the suspending support. Instead the end must be sewn onto the top portion of the four-strand graft. Our most recent paper, which has not yet been accepted for publication, details how to create and use a five-strand graft. Additionally, it reports our stability results which demonstrate a better stability than our four- strand grafts. Because the paper is not yet published, we have supplied the abstract and the full section dealing with the five-strand graft construction near the bottom of this page.

A concern when creating 5 and 6 strand grafts is having enough tendon length to create so many strands. We recommend our posterior mini-incision hamstring harvest technique. We have posted a video which demonstrates this technique in detail in our hamstring harvest section. One important aspect that is discussed in this video is use of a tendon stripper of 7mm size. The 5 mm strippers that are in common use can usually harvest a tendon of about 18cm. By going to a 7mm stripper, Dr Prodromos can consistently get harvested tendons in the 30cm range. This extra length is essential to the creation of 5 and 6 strand grafts.

At the right is a video of a patient who had a previous allograft ACL repair which failed. Dr Prodromos replaced the allograft with a six strand, hamstring autograft. The images in the video were taken about one year after the ACL was replaced. The patient has excellent stability and has returned to skiing.

Five Strand Hamstring ACL Reconstruction: A New Technique With Better Long-Term Stability vs 4-Strand

by Chadwick Prodromos MD, Brian Joyce BA, Susan Finkle BSN, Kelvin Shi

Background: Four-strand hamstring (4HS) grafts used for Anterior Cruciate Ligament Reconstruction (ACLR) have been shown to have higher stability rates than two-strand.

Hypothesis: We hypothesized that a five-strand hamstring (5HS) graft would further increase stability relative to four-strand.

Type of Study : Cohort Study

Methods: 20 patients had 5HS ACL reconstruction using three-strand semitendinosus/two-strand Gracilis (3ST/2Gr). 18 returned for evaluation 89-112 months postoperatively. Results were compared with a previously reported cohort of 133 knees reconstructed by the same surgeon using four-strand HS grafts using 2ST/2Gr evaluated at 24-104 months postoperatively. Both had suspensory-cortical femoral and whipstitch-cortical screw tibial fixation. KT-1000, Noyes, Lysholm and SANE ratings were performed.

Results: All 5HS and 4HS knees were clinically stable, with no graft failures or re-injuries. Mean KT-1000 side-to-side difference was 0.47mm for 5HS vs. 1.0mm for 4HS for (p = 0.01). A reconstructed knee KT-1000 laxity increase of <1mm versus the normal knee was found in 88% of 5HS vs. 61% of 4HS (p = 0.04); of 2-3mm in 12% 5HS vs. 36% 4HS; of 4mm in 0% 5HS vs. 3% 4HS; and of >4mm in 0% 5HS and 4HS. 5HS and 4HS clinical ratings were high and did not significantly differ. There were no clinical signs of impingement.

Conclusions: 5HS ACLR had higher stability than a high stability 4HS cohort. Sufficient ST is virtually always available to fashion a 3ST/2Gr graft. 5HS provides a higher stability alternative to 4HS. It is especially useful for patients at high risk of instability.

Extracted from the surgical techniques section: (To create the 5 strand graft), the midpoint of the four-strand graft was tied to the Endobutton in what was then the standard technique using Dacron® tape. A whipstitch implanted into the femoral end of the third limb of ST was then tied to the loop of the tied Dacron® tape. ....
A lateral wall notchplasty of approximately 3mm was performed in all of the 5HS cases. The extent of the notchplasty varied slightly depending on the size and placement of the graft but in all cases was sufficient to avoid graft impingement


For full copies of Dr. Prodromos' articles or DVDs, please contact us at 847-699-6810 x207 or