Hybrid Anterior Cruciate Ligament Reconstruction: Introduction of a New Technique for Anatomic Anterior Cruciate Ligament Reconstruction

Recently, anatomic or double-bundle reconstruction of the anterior cruciate ligament (ACL) has been presented in an effort to more accurately restore the native anatomy. These techniques create 2 tunnels in both the femur and tibia to reproduce the bundles of the ACL. However, the increased number of tunnels, particularly on the femoral side, has raised some concerns among authors and surgeons. We describe a technique to reconstruct the 2 distinct bundles of the ACL by using a single femoral tunnel and 2 tibial tunnels, the “hybrid” ACL reconstruction. The femoral tunnel is drilled through an anteromedial arthroscopy portal, which allows placement in a more anatomic position. Fixation in the femur is achieved with a novel device that separates a soft-tissue graft into 2 independently functioning bundles. Once fixed in the femur, the anteromedial and posterolateral bundles of the graft are passed through respective tunnels at the anatomic footprint on the tibia. These bundles are independently tensioned, which creates a reconconstruction that is similar to the native ACL. The technique presented provides surgeons with an alternative to other double-bundle techniques involving 4 tunnels.     

Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction With Anatomic Aimers

Graft positioning is a key issue in anterior cruciate ligament (ACL) reconstruction and even more sensitive in double-bundle reconstruction, where 2 tunnels have to be drilled within the ACL footprints at both the femoral and tibial insertion sites. Specific ancillary instruments have been developed to facilitate the positioning of the 4 sockets necessary when performing anatomic double-bundle ACL reconstruction. This technical note describes the rationale and the step-by-step method of using the specific aimers developed for this purpose. However, a prerequisite for successful double-bundle ACL reconstruction is a good knowledge of ACL footprint anatomy.     

Supplemental Tibial Fixation for Anterior Cruciate Ligament Reconstruction

This report describes transosseous backup suture fixation for anterior cruciate ligament (ACL) grafts of all varieties, used to distally augment proximal screw fixation in the tibia. Using a simple suture configuration, this method secures the ACL graft to the tibial cortex in conjunction with a proximal interference screw. The technique is applicable for all graft configurations, including allograft, autograft, bone, and both 2- and 4-strand soft-tissue grafts. The described technique is intended to be used for secondary or backup fixation of the graft in the tibial tunnel and not as primary fixation. This construct can be reproducibly created, making use of the sutures that are typically present on the graft after the interference screw is placed. This technique for backup tibial fixation precludes the need for external hardware, which in many instances may be symptomatically proud. Furthermore, use of this technique may represent a potential cost savings because no additional devices or equipment is used or purchased. This technique is simple, fast, and inexpensive, making use of available constructs to enhance the security of graft fixation during ACL reconstruction.     

Injury to the Anterior Tibial Artery during Bicortical Tibial Drilling in Anterior Cruciate Ligament Reconstruction

Many complications have been reported during or after anterior cruciate ligament (ACL) reconstruction, including infection, bleeding, tibial tunnel widening, arthrofibrosis, and graft failure. However, arterial injury has been rarely reported. This paper reports a case of an anterior tibial arterial injury during bicortical tibial drilling in arthroscopic ACL reconstruction, associated with an asymptomatic occlusion of the popliteal artery. The patient had a vague pain which led to delayed diagnosis of compartment syndrome and delayed treatment with fasciotomy. All surgeons should be aware of these rare but critical complications because the results may be disastrous like muscle necrosis as in this case.     

关节镜下应用EndoPearl和Intrafix固定腘绳肌肌腱重建前交叉韧带

目的 关节镜下采用腘绳肌肌腱和EndoPearl与Intrafix重建前交叉韧带.方法 31例前交叉韧带断裂患者在关节镜下采用四股腘绳肌肌腱重建前交叉韧带,股骨端应用EndoPearl和可吸收界面螺钉固定,胫骨端应用Intrafix固定,术后系统康复.结果 全部获随访,平均15.5个月(12～20个月).术前Lysholm评分平均为(54.2±5.4)分,术后为(98.4±0.2)分.与术前相比差异有显著性意义(P＜0.05).结论 关节镜下采用腘绳肌肌腱和EndoPearl与Intrafix重建前交叉韧带操作简单,固定可靠,疗效肯定.     

Anterior Cruciate Ligament Reconstruction in Patients with Generalized Joint Laxity

Generalized joint laxity is a genetically determined component of overall joint flexibility. The incidence of joint laxity in the overall population is approximately 5% to 20%, and its prevalence is higher in females. Recently it was noticed that individuals with generalized joint laxity are not only prone to anterior cruciate ligament injuries but also have inferior results after a reconstruction. Therefore, an anterior cruciate ligament reconstruction in patients with generalized laxity should be undertaken with caution due to the higher expected failure rate from the complexity of problems associated with this condition. It is also necessary to identify the risk factors for the injury as well as for the post operative outcome in this population. A criterion that includes all the associated components is necessary for the proper screening of individuals for generalized joint laxity. Graft selection for an anterior cruciate reconstruction in patients with ligament laxity is a challenge. According to the senior author, a hamstring autograft is an inferior choice and a double bundle reconstruction with a quadriceps tendon-bone autograft yields better results than a single bundle bone-patella tendon-bone autograft. Future studies comparing the different grafts available might be needed to determine the preferred graft for this subset of patients. Improved results after an anterior cruciate ligament reconstruction can be achieved by proper planning and careful attention to each step beginning from the clinical examination to the postoperative rehabilitation.     

No Tunnel 2-Socket Technique: All-Inside Anterior Cruciate Ligament Double-Bundle Retroconstruction

This report describes an all-inside, double-bundle anterior cruciate ligament retroconstruction (all-inside ×2 technique), which is a less invasive technique because of the use of sockets (2 femoral and 2 tibial) instead of complete bone tunnels. When performed with allograft, this may be termed a “no-incision” technique. The femoral sockets are reamed via the anteromedial arthroscopic portal. The tibial sockets are created with the all-inside RetroDrill (Arthrex, Naples, FL) from within the joint. The posterolateral bundle graft is passed first and shuttled through the anteromedial portal and fixed on the femur with a RetroButton (Arthrex), interference screw, or both. It is then fixed on the tibia with a bioabsorbable RetroScrew (Arthrex) near full extension. The anteromedial bundle graft is passed through next, and the process is repeated with tibial fixation performed at 45° of flexion. Posterolateral and anteromedial tibial fixation may be backed up by tying over a cortical button.     

关节镜下应用EndoPearl与Intrafix固定双侧绳肌肌腱一期重建膝关节前后交叉韧带

目的探讨关节镜下应用EndoPearl与Intrafix固定双侧腘绳肌肌腱同时重建膝关节前后交叉韧带的近期临床效果。方法对2004年6月~2005年3月收治的10例膝关节前后交叉韧带同时断裂的患者,切取双侧腘绳肌腱,2条半腱肌腱和2条股薄肌腱分别对折成四束,折端固定同直径EndoPearl。关节镜下利用两组移植物同时分别重建膝前后交叉韧带。股骨端应用可吸收界面螺钉顶压固定EndoPearl与移植肌腱,胫骨端应用Intrafix固定四束肌腱。结果10例均获得随访,平均7.5个月(6~15个月),切口Ⅰ期愈合,无感染。其中新鲜损伤4例,陈旧性损伤6例,合并后外侧复合体损伤3例,均予同期修复,合并内侧副韧损伤6例,未予特殊处理,5例曾急诊修复腘动静脉。术后3个月膝关节活动范围均超过120°,无伸膝受限,后抽屉试验Ⅰ度阳性2例,其余为阴性;Lyshlom评分(92.6±3.2)分。结论关节镜下应用EndoPearl与Intrafix固定双侧腘绳肌肌腱同时重建膝关节前后交叉韧带方法确切,可有效恢复膝关节功能。     

Twenty-Year Experience of a Double-Bundle Anterior Cruciate Ligament Reconstruction

Double-bundle (DB) anterior cruciate ligament (ACL) reconstruction using a four-strand semitendinosus tendon was started in our department in July 1994. The motivation for starting the procedure was that the EndoButton with an inside-out procedure instrument became available in Japan. A review article of our DB ACL reconstruction procedure was summarized for the twentieth anniversary of the surgical procedure. Initial tension setting of the two grafts was changed in the first 8 years to achieve better stability during DB ACL reconstruction. A randomized clinical trial (RCT) was started in July 2002 to clarify superiority of the DB procedure to single-bundle (SB) reconstruction under the concept of anatomic reconstruction. Several anatomic studies were performed to describe normal ACL anatomy, which is essential for realizing anatomic reconstruction. A remnant-preserving technique would be an additional option for our DB procedure to improve reconstruction outcomes. Thus, a new remnant-preserving DB procedure was started in 2012. The reproducibility of the new procedure was investigated using three-dimensional computed tomography images. More complex procedures were performed using a transtibial technique and EndoButtons. Initial tension balancing between the two grafts was important for a better outcome. Superiority of knee stability after the DB compared to that after the SB procedure was clarified by the RCT. However, no patient consensus has been reached on any subjective advantage to the DB procedure. Studies of normal ACL anatomy have left questions unresolved regarding where the two tunnels should be created for direct and indirect insertions based on normal anatomy. A new remnant-preserving DB ACL procedure has been practiced. The procedure was more reproducible with respect to creating the femoral tunnel. DB ACL reconstruction using a semitendinosus tendon is an attractive option when pursuing a better outcome for patients.     

Double-Bundle Reconstruction of the Anterior Cruciate Ligament Using the Transtibial Technique

We present an arthroscopic surgical procedure for double-bundle transtibial anterior cruciate ligament reconstruction with 2 tibial and femoral tunnels using autologous semitendinosus and gracilis tendons. The first aim is to attempt to create the femoral tunnels correctly through the tibial tunnels. To achieve this, a new tibial guide was used that permitted the simultaneous preparation of the anteromedial and posterolateral tibial tunnels. The intra-articular landmark is the tibial spine region, whereas the extra-articular landmarks are the anterior profile of the medial collateral ligament and the anterior tibial apophysis. We also describe transverse femoral fixation with biopins (1 for each femoral tunnel) after the preparation of the 2 tibial and femoral tunnels.     

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.     

前交叉韧带陈旧损伤22例诊治体会

目的探讨前交叉韧带(ACL)陈旧损伤的诊治及疗效。方法 2010年1月至2011年12月,采用关节镜下单束自体四股腘绳肌腱重建ACL。本组共22例(男18例,女4例),年龄18～46岁(平均31.6岁);观察术后Lysholm评分及关节前向松弛度差值变化。结果所有病例均获得随访,随访时间7~24个月(平均12.5个月),均未发生感染、血管神经损伤、内固定物松动及深静脉血栓等并发症;术前Lysholm评分为42~64分(平均53.2分),关节前向松弛度差值3.4~4.3 mm(平均3.72 mm);术后Lysholm评分为88~96分(平均93.2分),关节前向松弛度差值1.2~2.4 mm(平均1.64mm)。结论关节镜下自体四股腘绳肌腱重建ACL,是一种治疗ACL陈旧损伤的可靠方法,术中在治疗关节失稳的同时,需同时对关节内软骨、半月板等结构损伤进行修复,以增强膝关节的稳定性。本方法疗效确切,值得临床推广应用。