The distal semitendinosus tendon inserts at the pes anserinus on the medial tibial surface, posterior to the gracilis and anterior to the semimembranosus. It is the longest hamstring tendon (approximately 20-25 cm) and is the primary hamstring graft tendon for ACL reconstruction because of its length, thickness (approximately 5 mm diameter before preparation), and donor site recovery. A small accessory tendon often attaches it to the medial gastrocnemius aponeurosis.
The semitendinosus tendon is the workhorse hamstring autograft for ACL and PCL reconstruction. When doubled (two-strand) it provides a 9-10 mm diameter graft, and when combined with gracilis and quadrupled it provides a 7-9 mm graft. The accessory slip to the medial gastrocnemius must be released before stripper advancement to avoid premature tendon amputation. Donor site morbidity includes medial hamstring weakness and occasional semitendinosus tendon regeneration (a functional fibrous band, not true tendon). Graft diameter on MRI before ACL reconstruction can be estimated from the tendon.
An unrecognised accessory semitendinosus tendon slip to the medial gastrocnemius aponeurosis is encountered by the tendon stripper during harvest, prematurely amputating the graft at mid-thigh and providing insufficient graft length for tunnel fixation; palpating the accessory slip and dividing it before stripper advancement prevents this complication.
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