Minimally Invasive Anterior Semitendinosus Harvest: A Technique to Decrease Saphenous Nerve Injury  Philippe Colombet, M.D., Nicolas Graveleau, M.D.  Arthroscopy Techniques  Volume 5, Issue 1, Pages e139-e142 (February 2016) DOI: 10.1016/j.eats.2015.10.011 Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 1 Patient positioning. The patient is placed in a supine position; the tourniquet is set high on the thigh (right knee). A leg holder is placed lateral to the thigh just at the tourniquet level. A multiposition foot rest is secured at the surgical table end to allow the surgeon to face the knee. The knee is free for full flexion, and the foot rest allows for different auto stable knee angulations, which are very helpful during the tendon harvest step especially to loosen the tendon and allow a large semitendinosus externalization. This positioning is essential when the tendon expansions are very proximal. Arthroscopy Techniques 2016 5, e139-e142DOI: (10.1016/j.eats.2015.10.011) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 2 Tendon localization. The first step is to locate the pes anserinus. Slight pressure is applied with the extremities of the fingers to the anteromedial tibial face, from top to bottom. When the fingers pass over the tendons, 2 consecutive bumps can be felt. The location of the tendons is marked with a permanent ink marker. This precaution allows the surgeon to place the incision just above the tendon, which is mandatory for a correct tendon approach. Arthroscopy Techniques 2016 5, e139-e142DOI: (10.1016/j.eats.2015.10.011) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 3 Skin incisions. This surgery requires 3 incisions: One 2 cm length incision for semitendinosus harvesting, located just above the 2 tendons (gracilis and semitendinosus) 2 cm medial to the tibial anterior tuberosity. One incision for the arthroscope portal is placed lateral to the patellar tendon flush with the patella to get a sky view on the tibia. One incision for the instrumental portal is located close to the medial condyle and 1 cm above the medial joint line. This minimally invasive technique requires a harvesting incision above the tendon; if this does not occur, this technique is not applicable. Arthroscopy Techniques 2016 5, e139-e142DOI: (10.1016/j.eats.2015.10.011) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 4 Semitendinosus selection. When selecting the semitendinosus tendon, the main issue is to be sure to grab the good one. After opening the facia superficialis, the semitendinosus is grabbed using a soft-tissue forceps as deeply as possible and pulling it towards the front. On the deeper face of the fascia, we can see both tendons: the gracilis and semitendinosus running along the face. The gracilis tendon presents characteristic small undulations on its surface. The gracilis is hooked using the tendon hooker and tracked strongly out of the wound. Then the 2 tendons are separated using round-ended scissors or, better, the probe handle. Then it is easy to hook the semitendinosus only, in complete safety. (MCL, medial collateral ligament.) Arthroscopy Techniques 2016 5, e139-e142DOI: (10.1016/j.eats.2015.10.011) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 5 Collecting semitendinosus tendon expansions. The semitendinosus tendon tendon always presents one or several expansions that must be harvested. To be sure that all of them are selected, we hook them one by one successively with the probe and the Landanger hook. This technique allows for the expansions to be attracted towards the front and to be progressively pulled out. To be sure that no expansion is left behind, 2 signs are needed: the first sign is that no expansion can be seized by the probe when it is dragged at the inferior part of the semitendinosus as deeply as possible, and the second sign is that the stripper can be easily inserted along the first 10 cm of the tendon without coming to a hard stop. Arthroscopy Techniques 2016 5, e139-e142DOI: (10.1016/j.eats.2015.10.011) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions