No-Tunnel Anterior Cruciate Ligament Reconstruction: The Transtibial All-Inside Technique

The purpose of this technical note is to describe the transtibial all-inside anterior cruciate ligament (ACL) reconstruction technique. This technique combines the advantages of previously described but technically demanding all-inside ACL reconstruction techniques with the ease and familiarity of transtibial guide pin placement. The all-inside technique uses bone sockets as opposed to bone tunnels in both the femur and the tibia and represents a “no-tunnel” technique. When performed with allograft tissue, the method requires only arthroscopic portals and percutaneous guide pin passage. In such cases, this represents a “no-incision” ACL reconstruction. The technique requires the use of a Dual Retrocutter (Arthrex, Naples, FL). This cannulated drill is placed via the anteromedial arthroscopic portal and threads onto a transtibial, percutaneous, reverse-threaded guide pin. Because the drill is assembled arthroscopically (within the joint), a skin incision is not required. The Dual Retrocutter is capable of retrograde and antegrade drilling. Thus, a single Dual Retrocutter achieves transtibial drilling of both tibial and femoral bone sockets. The transtibial all-inside technique may be performed with the use of any ACL graft option. Graft diameter should equal socket diameter. To prevent the graft from “bottoming-out” during tensioning and fixation, graft length must be less than the sum of combined femoral plus tibial socket lengths plus ACL intra-articular distance. During the learning curve, surgeons may choose to wait until the sockets have been prepared, so that graft length need not be estimated. If the graft is prepared before arthroscopic surgery is performed, a 79-mm graft length could be recommended as ideal. To prepare for graft passage, both femoral and tibial graft passing suture loops must be brought out the anteromedial arthroscopic portal without soft tissue interposition between or within the loops. To prepare for graft fixation, a nitinol wire must be brought into the joint via the transtibial, percutaneous guide pin tract for the purpose of guiding the introduction of a cannulated Retroscrewdriver. All of these goals may be accomplished in a single pass. The graft is fixed with femoral and tibial Retroscrews. Backup fixation is optional and may be achieved by tying sutures over small, percutaneously placed cortical buttons. Advantages of this technique may result from “anatomic” graft fixation at the levels of the femoral and tibial joint lines and from retrograde screw fixation, which may eliminate interference screw divergence and increase graft tension when the retrograde screw is advanced. Additionally, because this technique minimizes skin incisions and eliminates open bone tunnels, patients may experience decreased pain, more rapid return to function, and improved cosmesis.     

All-Inside Anterior Cruciate Ligament Graft-Link Technique: Second-Generation, No-Incision Anterior Cruciate Ligament Reconstruction

We describe an anatomic, single-bundle, all-inside anterior cruciate ligament (ACL) graft-link technique using second-generation Flipcutter guide pins (Arthrex, Naples, FL), which become retrograde drills, and second-generation cortical suspensory fixation devices with adjustable graft loop length: femoral TightRope (Arthrex) and tibial ACL TightRope-Reverse Tension (Arthrex). The technique is minimally invasive using only four 4-mm stab incisions. Graft choice is no-incision allograft or gracilis-sparing, posteriorly harvested semitendinosus material. The graft is sutured 4 times through each strand in a loop and linked, like a chain, to femoral and tibial adjustable TightRope graft loops. With this method, graft tension can be increased even after graft fixation. The technique may be modified for double-bundle ACL reconstruction.     

Aperture Fixation in Arthroscopic Anterior Cruciate Ligament Double-Bundle Reconstruction

The native anterior cruciate ligament (ACL) consists of 2 bundles, which have distinct biomechanical yet synergistic functions with respect to anterior tibial translation and combined rotatory loads. Traditionally, most ACL reconstruction techniques have primarily addressed the restoration of the anteromedial bundle, and less consideration was given to the posterolateral bundle. Recently, various ACL double-bundle reconstruction techniques have been described. With most of these techniques, however, an indirect extra-anatomic fixation far from the articular surface was performed. Because extra-anatomic fixation techniques, rather than aperture fixation techniques, are associated with graft tunnel motion, windshield wiper action, and suture stretch-out, concerns may arise regarding delayed biological incorporation, tunnel enlargement, and secondary rotational and anterior instability. We, therefore, present a novel arthroscopic technique that reapproximates the footprints of native ACL with the use of double-strand semitendinosus and gracilis autografts for reconstruction of the anteromedial and posterolateral bundles, respectively. A separate femoral and tibial tunnel is drilled for each double-strand autograft. The femoral tunnel for the anteromedial bundle is drilled primarily through a transtibial technique, and the femoral tunnel for the posterolateral bundle is drilled via an accessory anteromedial portal with the use of a 4-mm offset drill guide in the anteroinferior aspect of the femoral tunnel for the anteromedial bundle. Bioabsorbable interference screws are used in aperture fixation for anatomic fixation of each bundle. This technique attempts to reproduce closely the native ligament and its biomechanical function.     

Outcome of double bundle anterior cruciate ligament reconstruction using crosspin and aperture fixation

Background:

Double bundle anterior cruciate ligament (DBACL) reconstruction is said to reproduce the native anterior cruciate ligament (ACL) anatomy better than single bundle anterior cruciate ligament, whether it leads to better functional results is debatable. Different fixation methods have been used for DBACL reconstruction, the most common being aperture fixation on tibial side and cortical suspensory fixation on the femoral side. We present the results of DBACL reconstruction technique, wherein on the femoral side anteromedial (AM) bundle is fixed with a crosspin and aperture fixation was done for the posterolateral (PL) bundle.

Materials and Methods:

Out of 157 isolated ACL injury patients who underwent ACL reconstruction, 100 were included in the prospective study. Arthroscopic DBACL reconstruction was done using ipsilateral hamstring autograft. AM bundle was fixed using Transfix (Arthrex, Naples, FL, USA) on the femoral side and bio interference screw (Arthrex, Naples, FL, USA) on the tibial side. PL bundle was fixed on femoral as well as on tibial side with a biointerference screw. Patients were evaluated using KT-1000 arthrometer, Lysholm score, International Knee Documentation Committee (IKDC) Score and isokinetic muscle strength testing.

Methods:

Out of 157 isolated ACL injury patients who underwent ACL reconstruction, 100 were included in the prospective study. Arthroscopic DBACL reconstruction was done using ipsilateral hamstring autograft. AM bundle was fixed using Transfix (Arthrex, Naples, FL, USA) on the femoral side and bio interference screw (Arthrex, Naples, FL, USA) on the tibial side. PL bundle was fixed on femoral as well as on tibial side with a biointerference screw. Patients were evaluated using KT-1000 arthrometer, Lysholm score, International Knee Documentation Committee (IKDC) Score and isokinetic muscle strength testing.

Results:

The KT-1000 results were evaluated using paired t test with the P value set at 0.001. At the end of 1 year, the anteroposterior side to side translation difference (KT-1000 manual maximum) showed mean improvement from 5.1 mm ± 1.5 preoperatively to 1.6 mm ± 1.2 (P < 0.001) postoperatively. The Lysholm score too showed statistically significant (P < 0.001) improvement from 52.4 ± 15.2 (range: 32-76) preoperatively to a postoperative score of 89.1 ± 3.2 (range 67-100). According to the IKDC score 90% patients had normal results (Category A and B). The AM femoral tunnel initial posterior blow out was seen in 4 patients and confluence in the intraarticular part of the femoral tunnels was seen in 6 patients intraoperatively. The quadriceps strength on isokinetic testing had an average deficit of 10.3% while the hamstrings had a 5.2% deficit at the end of 1 year as compared with the normal side.

Conclusion:

Our study revealed that the DBACL reconstruction using crosspin fixation for AM bundle and aperture fixation for PL bundle on the femoral side resulted in significant improvement in KT 1000, Lysholm and IKDC scores.     

Medial portal technique for single-bundle anatomical Anterior Cruciate Ligament (ACL) reconstruction

The aim of the paper is to describe the medial portal technique for anatomical single-bundle anterior cruciate ligament (ACL) reconstruction. Placement of an ACL graft within the anatomical femoral and tibial attachment sites is critical to the success and clinical outcome of ACL reconstruction. Non-anatomical ACL graft placement is the most common technical error leading to recurrent instability following ACL reconstruction. ACL reconstruction has commonly been performed using a transtibial tunnel technique in which the ACL femoral tunnel is drilled through a tibial tunnel positioned in the posterior half of the native ACL tibial attachment site. ACL reconstruction performed using a transtibial tunnel technique often results in a vertical ACL graft, which may fail to control the combined motions of anterior tibial translation and internal tibial rotation which occur during the pivot-shift phenomenon. The inability of a vertically oriented ACL graft to control these combined motions may result in the patient experiencing continued symptoms of instability due to the pivot-shift phenomenon. The medial portal technique in which the ACL femoral tunnel is drilled through an anteromedial or accessory anteromedial portal allows consistent anatomical ACL tunnel placement. This paper describes the advantages of the medial portal technique, indications for the technique, patient positioning, proper portal placement, anatomical femoral and tibial tunnel placement, graft tensioning and fixation.     

A New Double-Bundle Anterior Cruciate Ligament Reconstruction Using the Posteromedial Portal Technique With Hamstrings

We describe a new double-bundle reconstruction method for ruptured anterior cruciate ligament using a posteromedial portal technique. Reconstruction materials are semitendinosus tendon (STT) and gracilis tendon (GT). STT is used as the substitute for the anteromedial bundle (AMB) and fixed to the tunnels produced on the tibia and the femur. GT is used as the substitute for the posterolateral bundle (PLB) and fixed to the tunnels on the tibia and the femur. This femoral tunnel for the PLB is created through a posteromedial portal. These procedures are performed using the inside-out technique. The posteromedial portal provides an accurate access to the femoral attachment of the PLB. This surgical technique can avoid overlapping of the 2 femoral tunnels and destruction of the posterior cortex of the lateral condyle on the femur during the preparation of the PLB. Our technique does not need another tibial tunnel for the PLB; the 1 tibial tunnel enables double-bundle reconstruction and prevents tibial tunnel expansion.     

Anterior cruciate ligament (ACL) reconstruction with quadriceps tendon autograft and press-fit fixation using an anteromedial portal technique

ABSTRACT: BACKGROUND: This article describes an arthroscopic anterior cruciate ligament (ACL) reconstruction technique with a quadriceps tendon autograft using an anteromedial portal technique. METHODS: A 5 cm quadriceps tendon graft is harvested with an adjacent 2 cm bone block. The femoral tunnel is created through a low anteromedial portal in its anatomical position. The tibial tunnel is created with a hollow burr, thus acquiring a free cylindrical bone block. The graft is then passed through the tibial tunnel and the bone block, customized at its tip, is tapped into the femoral tunnel through the anteromedial portal to provide press-fit fixation. The graft is tensioned distally and sutures are tied over a bone bridge at the distal end of the tibial tunnel. From the cylindrical bone block harvested from the tibia the proximal end is customized and gently tapped next to the graft tissue into the tibial tunnel to assure press fitting of the graft in the tibial tunnel. The distal part of the tibial tunnel is filled up with the remaining bone.All patients were observed in a prospective fashion with subjective and objective evaluation after 6 weeks, 6 and 12 months. RESULTS: Thirty patients have been evaluated at a 12 months follow-up. The technique achieved in 96.7% normal or nearly normal results for the objective IKDC. The mean subjective IKDC score was 86.1 [PLUS-MINUS SIGN] 15.8. In 96.7% the Tegner score was the same as before injury or decreased one category. A negative or 1+ Lachman test was achieved in all cases. Pivot-shift test was negative or (+) glide in 86.7%. The mean side-to-side difference elevated by instrumental laxity measurement was 1.6 [PLUS-MINUS SIGN] 1.1 mm. Full ROM has been achieved in 92.3%. The mean single one-leg-hop index was 91.9 [PLUS-MINUS SIGN] 8.0 at the follow-up. CONCLUSIONS: Potential advantages include minimum bone loss specifically on the femoral side and graft fixation without implants.     

Anterior Cruciate Ligament Double-Bundle Reconstruction With Hamstring Tendon Autografts

The anterior cruciate ligament (ACL) surgical technique via a 5-strand hamstring tendon autograft is designed with a conventional single-bundle reconstruction that has shown favorable results and an additional posterolateral (PL) bundle reconstruction. The conventional single-tunnel technique is performed for the tibial tunnel, and the double-tunnel technique is performed for the femoral tunnel. The anteromedial (AM) femoral tunnel is prepared with 1 mm of the posterior femoral cortex being left over the top at the 11- to 1-o’clock position. The PL femoral tunnel is prepared with the outside-in technique by use of a 4.5-mm cannulated reamer. The AM bundle is fixed with a rigid fixation system on the femoral side, and the PL bundle is fixed to tie with the miniplate from the outside femur. A double-bundle reconstruction with 5-strand hamstring autografts, in conjunction with a conventional AM bundle and an additional PL bundle, seems to be a very effective method for the treatment of ACL instabilities. Although the long-term clinical outcome of the procedure is yet to be determined, complications including graft impingement, limitation in range of motion, and residual instability have not been observed to date in the first 38 patients who have undergone our technique.     

Anatomic double-bundle anterior cruciate ligament reconstruction with hamstrings

This article describes a double-bundle gracilis and semitendinosus technique that guarantees a more anatomic anterior cruciate ligament (ACL) reconstruction and allows the surgeon to avoid the use of hardware for graft fixation. The tendons are harvested maintaining their tibial insertion. Sutures are tightened at the free proximal tendon ends to obtain a sufficient strength to traction. The tibial tunnel is located in the medioposterior part of the ACL tibial insertion. For the femoral tunnel, the knee is flexed around 130° and the guide pin is advanced until it passes the femoral cortex. The exit point in the lateral aspect of the femur should be immediately above the end of the lateral femoral condyle. After the lateral incision, the tendons are passed over the top. The correct placement is found by palpating the posterior tubercle of the lateral femoral condyle with a finger. The stitches on the free end of the tendons are tied onto the passing suture that is pulled through the knee joint into the over-the-top position. A suture loop is introduced into the joint through the anteromedial portal using a suture passer and then pulled into the femoral tunnel under the arthroscopic view. The stitches on the free end of the tendons are looped again onto the passing suture, which is pulled through the femoral tunnel, knee joint, and tibial tunnel to retrieve the graft from the tibial incision. The combined gracilis and semitendinosus tendons are then tensioned and secured with a transosseus suture knot. This technique attempts to reproduce the kinematic effect of both anteromedial and posterolateral bundle of the ACL with a 4-bundle reconstruction with a better performance from the anatomic and functional point of view.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 5 (May-June), 2003: pp 540–546     

Die Zwei-Bündel-Technik – eine anatomische Rekonstruktion des vorderen Kreuzbandes

OBJECTIVE: To improve the rotational stability of the knee by anatomic reconstruction of the anterior cruciate ligament by socalled double-bundle technique using anteromedial and posterolateral grafts from native semitendinosus and gracilis. The grafts are fixed with bioabsorbable screws utilizing aperture fixation. INDICATIONS: Complete tear of the anterior cruciate ligament with positive Lachman sign and pivot shift. CONTRAINDICATIONS: Open growth plate. Osteoarthritis > grade 1 according to J?ger & Wirth. Age > or = 50 years with low sports activity (relative contraindication). SURGICAL TECHNIQUE: Graft harvest of the semitendinosus and gracilis tendons via a 3-cm horizontal skin incision parallel to pes anserinus and preparation of the tendons as double-looped grafts. Arthroscopy, resection of the stump of the anterior cruciate ligament, and clearance of its origin and insertion. Tunnel placement by means of aiming devices in the following order: tibial posterolateral, tibial anteromedial, femoral anteromedial (transtibial or via the anteromedial portal in 120 degrees flexion), and femoral posterolateral (via additional medial arthroscopic portal). The anteromedial (semitendinosus tendon) and posterolateral (gracilis tendon) bundles are passed through the tunnels and fixed on the femoral side. Tibial fixation of the graft by bioresorbable interference screw with knee flexion of 45 degrees (anteromedial) and 10 degrees (posterolateral). POSTOPERATIVE MANAGEMENT: Depending on the degree of swelling, rehabilitation with partial weight bearing for 14 days and full range of motion. Return to sports after 6 months, no contact sports until 9 months. RESULTS: From May 2004 to June 2005, anatomic double-bundle reconstruction was performed in 19 patients (13 male, six female, average age 31 years [18-48 years]) with isolated anterior cruciate ligament rupture without concomitant lesions. Clinical follow-up examination on average at 21.3 months (16-30 months) postoperatively. The Lysholm Score improved from an average of 65.2 to 94.5 points (75-100 points). The IKDC (International Knee Documentation Committee) Score yielded nine very good and ten good results in the relevant subgroups of motion, effusion and ligament stability. Measurement of anteroposterior translation with the KT-1000 instrument at 134 N showed increased translation of 1.8 mm (-2 to 5 mm) compared to the contralateral knee.     

Anatomic Double Bundle: A New Concept in Anterior Cruciate Ligament Reconstruction Using the Quadriceps Tendon

Surgical procedures for double-bundle anterior cruciate ligament reconstruction, which currently use hamstring graft, have been described, but some concerns remain regarding graft fixation and the ability to obtain adequate bundle size. We report an original double-bundle anterior cruciate ligament reconstruction technique using a quadriceps tendon graft and a simplified outside-in femoral tunnel–drilling process. The graft consists of a patellar bone block with its attached tendon split into superior and inferior portions, which yields 2 bundles. The anteromedial tunnel is drilled from the outside through a small lateral incision by use of a guide. The posterolateral tunnel is made through the same incision with a specific guide engaged in the anteromedial tunnel. A single tibial tunnel is created. The graft is routed from the tibia to the femur with the bone block in the tibial tunnel and the 2 bundles in their respective femoral tunnels. After fixation of the bone block in the tibia, the 2 bundles are tensioned and secured separately in their femoral tunnels.     

Arthroscopic reconstruction of the anterior cruciate ligament using double anteromedial and posterolateral bundles

We propose a method for repairing the anterior cruciate ligament which takes advantage of the multifascular nature of the ligament to achieve better physiological anteroposterior and rotational stability compared with conventional methods. Arthroscopic reconstruction of the anteromedial and posterolateral bundles of the ligament closely reproduces normal anatomy. We have used this technique in 92 patients with anterior cruciate ligament laxity and present here the mid-term results. The hamstring tendons (gracilis and semitendinosus) are harvested carefully to obtain good quality grafts. Arthroscopic preparation of the notch allows careful cleaning of the axial aspect of the lateral condyle; it is crucial to well visualize the region over the top and delimit the 9 h-12 h zone for the right knee or the 12-15 h zone for the left knee. The femoral end of the anteromedial tunnel lies close to the floor of the intercondylar notch, 5 to 10 mm in front of the posterior border of the lateral condyle, at 13 h for the left knee and 11 h for the right knee. The femoral end of the posterolateral tunnel lies more anteriorly, at 14 h for the left knee and 10 h for the right knee. The tibial end of the posterolateral tunnel faces the anterolateral spike of the tibia. The tibial end of the anteromedial tunnel lies in front of the apex of the two tibial spikes half way between the anteromedial spike and the anterolateral spike, 8 mm in front of the protrusion of the posteriolateral pin. The posterolateral graft is run through the femoral and tibial tunnels first. A cortical fixation is used for the femoral end. The femoral end of the anteromedial graft is then fixed in the same way. The tibial fixation begins with the posterolateral graft with the knee close to full extension. The anteromedial graft is fixed with the knee in 90 degrees flexion. Thirty patients were reviewed at least six months after the procedure. Mean age was 28.2 years. Mean overall IKDC score was 86% (36% A and 50% B). Gain in laxity was significant: 6.53 preoperatively and 2.1 postoperatively. Most of the patients (86.6%) were able to resume their former occupation 2 months after the procedure. The different components of the anterior cruciate ligament and their respective functions have been the object of several studies. The anteromedial bundle maintains joint stability during extension and anteroposterior stability during flexion. The posterolateral bundle contributes to the action of the anteromedial bundle with an additional effect due to its position: rotational stability during flexion. In light of the multifascicular nature of the anterior cruciate ligament and the residual rotational laxity observed after conventional repair, our proposed method provides a more anatomic reconstruction which achieves better correction of anteroposterior and rotational stability. This technique should be validated with comparative trials against currently employed methods.     

All-Inside Anterior Cruciate Ligament Reconstruction

Anterior cruciate ligament (ACL) reconstruction is one of the most commonly performed knee operations. An “all-inside” technique creates bone sockets for ACL graft passage, as opposed to more traditional full bone tunnels, and typically incorporates suspensory fixation instead of screw fixation to secure the graft. This technique may be indicated for any ACL reconstruction surgery, where adequate bone stock exists to drill sockets and to use cortical fixation. The technique may be used with all soft tissue, as well as bone plug ACL grafts and autograft hamstring or quadriceps tendon; most allograft tendon options may be performed with an all-inside technique. Advantages include anatomic tunnel/socket placement, decreased postoperative pain and swelling, minimal hardware, appropriate graft tensioning and retensioning, and circumferential graft to bone healing. Tips for successful all-inside surgery include matching graft diameter to socket diameter, drilling appropriate length sockets based on individual graft length, so as not to “bottom out” the graft and confirming cortical button fixation intraoperatively. Potential complications include graft-socket mismatch, full-tunnel reaming, and loss of cortical fixation. Multiple studies have shown the all-inside technique to have similar or superior biomechanical properties and clinical outcomes compared to the more traditional full-tunnel ACL reconstruction techniques.     

Arthroscopic Posterior Cruciate Ligament Augmentation Using an Autogenous Hamstring Tendon Graft and the Posterior-Posterior Triangulation Technique

We describe a modification of the currently practiced arthroscopic posterior cruciate ligament (PCL) reconstruction techniques. We augmented the injured PCL with quadrupled autogenous hamstring tendon grafts using the arthroscopic posterior-posterior triangulation method and a single-incision transtibial approach. The tibial drill guide was introduced through the anteromedial portal and positioned onto the fossa for the PCL on the tibia under arthroscopic guidance from the posterolateral portal. The femoral tunnel was made 10 mm posterior to the articular cartilage of the medial femoral condyle by use of the anterior cruciate ligament Beath pin (Arthrex, Naples, FL) introduced through the far-inferior anterolateral portal. The tendon graft was positioned in the knee joint by use of the tibial and femoral double-folded silk loops that traversed the bony tunnels. The graft was fixed by use of bioabsorbable Intrafix screw systems (DePuy Mitek, Raynham, MA) at both the ends. The arthroscopic posterior-posterior triangulation method provides adequate exposure of the posterior knee compartment; this allows for convenient instrumentation and safe and accurate placement of the bony tunnels with preservation of the PCL remnants. We believe that retention of the remnant PCL fibers is biologic and contributes to earlier healing and strengthening of the tendon graft.     

Anteromedial Portal Technique for the Anterior Cruciate Ligament Femoral Socket: Pitfalls and Solutions

Creating the anterior cruciate ligament (ACL) femoral socket using the anteromedial (AM) portal technique has advantages. Furthermore, the technique is ideal for anatomic double-bundle (particularly posterolateral bundle) and all-inside ACL techniques. However, although the AM portal technique has advantages, the learning curve is steep when making the transition from familiar, transtibial reaming to the AM portal technique for ACL femoral tunnel creation. Complications and challenges are many when learning the AM portal technique. The purpose of this technical note is to describe tips and pearls for surgeons contemplating the transition to the AM portal technique for the ACL femoral socket.     

Implantatfreier Ersatz des vorderen Kreuzbandes in Double-bundle-Technik

Reconstruction of the anterior cruciate ligament using the double bundle technique provides better covering of the anatomic insertion site areas and fiber length change behavior. Biomechanical studies and intraoperative measurements with computer navigation systems document increased stability in particular due to rotational stability. To date the impact of the posterolateral bundle is questioned and clinical studies have reported divergent outcomes. In favor of enhanced rotational stability, some techniques leave the basic principles of aperture or central graft fixation, decreasing primary stability and running the risk of tunnel widening especially on the femoral site. Additional use of interference screws means increased implants and costs and bone void in cases of revision is challenging. A technique for anatomic double-bundle reconstruction without the use of implants is presented, which allows for femoral aperture fixation with high primary stability of both bundles. In terms of the knot/press-fit technique of Paessler in the U-shaped tendons, a knot is created at the free end, which serves as a rigid press-fit anchoring in bottleneck shaped femoral drill holes at the insertion site of the anteromedial and posterolateral bundles. The drill holes are prepared in flexion of 110–115° using common offset and target drill devices. Mersilen tapes are applied to introduce the grafts from femoral to tibial and to fix the tendons over a bony bridge on the tibial site after preconditioning. The gracilis tendon mimics the posterolateral bundle and is fixed in 20° of flexion, the semi- tendinosus tendon is used for the anteromedial bundle and is fixed in 40° of flexion. The advantages of the presented technique are the central, rigid femoral anchoring without hardware, the thin bone tunnels which show no tunnel widening and allow for an optimal bone tendon contact to enhance bony ingrowth. The technique is cost-efficient and provides anatomic double bundle reconstruction of the anterior cruciate ligament. The sacrifice of hardware ensures easy revisions. The disadvantages are the peripheral tibial fixation, the preparation of the tendons needs tendon length and the creation of tendon knots providing high stability requires practice. The two femoral bone tunnels have proved to be safe regarding the stability of the lateral femoral condyle.     

Arthroscopic Reconstruction of the Posterior Cruciate Ligament Using Tibial-Inlay and Double-Bundle Technique

Biomechanical research has suggested that the double-bundle and tibial inlay technique is superior to the single-bundle and the transtibial tunnel method for posterior cruciate ligament (PCL) reconstruction. A combination the posterior tibial inlay and femoral double-bundle technique is thought to be an ideal method for PCL reconstruction. Recently, we successfully performed arthroscopic PCL reconstruction using the tibial-inlay and double-bundle technique. Achilles tendon–bone allograft is used and the bone plug for the arthroscopic tibial inlay fixation is designed in a cylindrical shape and perpendicular to the fiber texture of the Achilles tendon. Achilles tendon is manually split into deep and superficial layers to reconstruct anterolateral and posteromedial bundles as the natural insertion of PCL. The intra-articular lengths of each bundle between tibial tunnel and 2 femoral tunnels are measured to achieve fixation of the graft to the original PCL attachment. After tibial bone plug fixation with an absorbable interference screw and additional suture anchoring, the anterolateral bundle is fixed in a reduction position with the knee in 90° of flexion and the posteromedial bundle is fixed nearly in extension. This procedure makes it possible not only to reproduce the original concept of PCL tibial inlay graft arthroscopically without posterior arthrotomy, but also to achieve a more anatomic PCL reconstruction of the 2 bundles.     

Technical Note: Double tibial tunnel using quadriceps tendon in anterior cruciate ligament reconstruction

Summary: To avoid complications related to the use of patellar tendon and hamstring (semitendinosus and gracilis) tendon and to create a more anatomic reconstruction, we present a new technique based on the use of quadriceps tendon placed in a single half femoral tunnel and double tibial tunnels. The graft, harvested by a central longitudinal incision, possesses the following characteristics: (1) a bone plug 20 mm long and 10 mm in diameter; (2) a tendon component 7 to 8 cm long, 10 mm wide, and 8 mm thick; and (3) division of the tendon longitudinally into 2 bundles while maintaining the patellar insertion. Every bundle has a width and thickness of approximately 5 mm and 8 mm, respectively. The total length of the graft is 9 to 10 cm. A 10-mm half femoral tunnel is drilled through a low anteromedial portal with the knee flexed at 120°. A suture loop is left in place in the half tunnel. A double tibial tunnel is drilled in a convergent manner (from outside to inside) obtaining an osseous bridge between the 2 tunnels. Two suture loops are passed trough the tibial tunnels and retrieved in a plastic cannula (10 mm) positioned in the anteromedial portal to allow the passage of the 2 bundles in the tibial tunnels. The suture loop left in the half tunnel permits the transportation of the bone plug in the femoral tunnel. Fixation is achieved by an interference screw at the femoral side and by 2 absorbable interference screws (1 for each tunnel). The advantages of this technique are a more cross-sectional area (80 mm²), greater bone-tendon interface, and a more anatomic reconstruction. Theoretically, easier bone incorporation, decreased windshield wiper and bungee effect, fewer donor site problems, and less tunnel enlargement can also be possible.     

Anterior cruciate ligament reconstruction with preservation of remnant bundle using hamstring autograft: technical note

During an arthroscopic examination for an anterior cruciate ligament (ACL) reconstruction, there is a relatively thick remnant ACL tibial stump attached to the posterior cruciate ligament (PCL) or rarely remained between the femur origin and the tibia insertion. We thought that preservation of the remnant ACL original bundle might promote graft healing or be helpful in preserving the proprioception and function to stabilize the knee. Therefore, we established a remnant preservation procedure without additional instruments during an ACL reconstruction using a bio-cross pin (RIGIDfix system: Mitek, Johnson & Johnson, USA) for the femoral tunnel fixation. The remnant ACL was sutured (usually three stitches) using a suture hook (Linvatec, Largo, FL), and both ends of the sutures were pulled to the far anteromedial (AM) portal. These sutures protected the remnant tissue during the ACL reconstruction because medial traction of these sutures can provide a wide view during the reconstruction. After the femoral and tibial tunnel formation, these sutures were pulled out to the inferior sleeve of the cross pin using a previously inserted wire loop via an inferior sleeve. After graft passage, a superior cross pin was first fixed and tibial fixation was then performed. Finally, inferior cross pin fixation was performed and ties were made at the entrance of the inferior cross pin.     

Femoral fixation of hamstring tendon autografts using the TransFix device with additional bone grafting in an anteromedial portal technique

Background The femoral fixation of hamstring tendon grafts by a cross-pin is an established method with excellent biomechanical properties. Until now, this surgical procedure was associated with a transtibial placement of the femoral tunnel and a graft-tunnel diameter mismatch due to the different volumes of the tendon loop and the tendon strands. Methods By use of an electrical knee positioning device, the transfixation technique can be performed safely through the anteromedial arthroscopic portal (transarticular technique), reaching the optimal lateral '10:30' position in the intercondylar notch. By use of a specific harvesting and implantation device, a cancellous bone plug is harvested and inserted into the femoral tunnel, thus stabilizing the tendon bundle and eliminating dead space in the tunnel. Conclusion The femoral cross-pin guarantees a secure anchorage of the graft, drilling through the anteromedial portal eases optimum tunnel placement, and the insertion of a solid cancellous bone plug eliminates the femoral graft-tunnel diameter discrepancy and improves the press-fit contact between graft and tunnel wall. The long-term benefit of this technical modification remains to be proven.