Trantibial anterior cruciate ligament double bundle reconstruction technique: two tibial bundle in one tibial tunnel

The anterior cruciate ligament (ACL) consists of two functional bundles that behave independently throughout the range of knee motion. Many two-bundle reconstruction techniques have been introduced to restore the function of the two bundles of the ACL. Generally, two femoral and two tibial tunnels are made during the surgery for a two-bundle ACL reconstruction. However, the procedure is technically demanding and time consuming. This paper describes one-tibial-two-femoral ACL double bundle reconstruction technique with a sextuple-stranded hamstring autograft. The anteromedial femoral tunnel is made using transtibial drilling technique and posterolateral femoral tunnel is made using outside-in technique. The two bundles in a single tibial tunnel are separated using biodegradable interference screw. Stable and adequate femoral fixation of the two bundles with a transtibial fixation and bioabsorbable screw can be obtained. This technique is relatively simple, and replicates the anatomy and differential behavior of the two native bundles of ACL more effectively.     

Single Femoral Socket Double-Bundle Anterior Cruciate Ligament Reconstruction Using Tibialis Anterior Tendon: Description of a New Technique

The native anterior cruciate ligament (ACL) has been shown to consist of 2 functional bundles with independent behavior throughout range of knee motion. Conventional arthroscopic ACL reconstruction techniques selectively recreate the anteromedial bundle of the native ACL only. Numerous studies have reported the failure to restore normal knee kinematics in an ACL-deficient knee using a single-bundle reconstruction. It has been suggested that by reconstructing both the anteromedial and posterolateral bundles of the ACL, more normal knee kinematics may be achieved. Several authors have described surgical techniques to recreate the 2 functional bundles and they range from using 2 femoral tunnels to using a single femoral tunnel with the other bundle passed over the top. This article describes a new technique of recreating the 2 functional bundles of the ACL with tibialis anterior tendon allograft using a single femoral socket.     

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.     

Anatomically Oriented Anterior Cruciate Ligament Reconstruction with a Bone–Patellar Tendon–Bone Graft via Rectangular Socket and Tunnel: A Snug-fit and Impingement-Free Grafting Technique

An anterior cruciate ligament (ACL) reconstruction technique is described to place bone–patellar tendon–bone (BPTB) graft in an anatomically oriented fashion to mimic the 2 bundles of the normal ACL, based on the concept of twin tunnel ACL reconstruction, to maximize the graft-tunnel interface. In this technique, the attached bone plug is introduced into a rectangular femoral socket via a halfway rectangular tibial tunnel for the anterior portion of the graft to function as the anteromedial bundle and for its posterior portion to behave as the posterolateral bundle. A snug fitting of the graft is achieved not only at the femoral socket, but also in the tibial tunnel.     

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.     

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.     

前交叉韧带解剖双束重建中股骨隧道建立路径的比较研究

目的前瞻性研究在关节镜下前交叉韧带（ACL）解剖双束重建术中,采用经胫骨隧道与经前内人路定位建立股骨隧道的可行性与准确性。方法在连续30例ACL患者的解剖双束重建术中,首先分别以45°、55°角钻取胫骨隧道,关节内出口分别在ACL胫骨解剖附丽区印记的前内和后外,保留1～2mm间隔骨桥;关节外入口分别位于胫骨结节内侧和内侧副韧带前缘的前方,间隔以两枚Washer不重叠为准,分别用于前内侧束和后外侧束的移植重建。然后分别经两胫骨隧道,将两根球头空心钻的钻杆自胫骨隧道插入关节内,观察两钻头杆能否到达理想的股骨隧道,录像记录并进行统计学分析。结果在本组30例患者中,经胫骨前内侧束隧道插入的钻头杆,在股骨侧的指向全部偏高、偏前,无一例能完全或部分到达股骨侧前内侧或后外侧束隧道口;而经胫骨后外侧束隧道的钻头杆,经屈或伸膝调整角度后,5例（16．7％）可完全到达、8例（26．7％）可部分到达股骨的前内侧束隧道口;有2例（6．7％）可完全到达、6例（20．0％）部分到达股骨的后外侧束隧道口。而经前内入路屈膝120°后,28例（93．3％）定位可达到理想位置。结论在ACL解剖双束移植重建中,经胫骨隧道定位钻取股骨隧道的方法不可靠、准确性差、变异较大、可重复性差;而经前内入路方法可调节性强、准确性好、股骨隧道短、不受胫骨隧道方向、角度和直径的影响、简便易行、重复性好;但应注意要在较大的屈膝角度下定位钻取。     

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.     

Isolierter Bündelersatz bei Partialruptur des vorderen Kreuzbandes

Objective

Partial augmentation of isolated tears of the anteromedial and posterolateral bundle of the anterior cruciate ligament (ACL) with autologous hamstring tendons. The intact fibers of the ACL are preserved.

Indications

Symptomatic isolated tear of the anteromedial or posteromedial bundle of the ACL or rotational instability after ACL reconstruction with malplaced tunnels (e.g., high femoral position)

Contraindications

In revision cases: loss of motion due to malplaced ACL and excessive tunnel widening of the present tunnels with the risk of tunnel confluence.

Surgical technique

Examination of anterior–posterior translation and rotational instability under anesthesia. Diagnostic arthroscopy, repetition of the clinical examination under direct visualization of the ACL, meticulous probing of the functional bundles. Resection of ligament remnants, preparation/preservation of the femoral and tibial footprint. Harvesting one of the hamstring tendons, graft preparation. Positioning of a 2.4 mm K-wire in the anatomic center of the femoral anteromedial/posterolateral bundle insertion, cannulated drilling according to the graft diameter. Positioning of a 2.4 mm K-wire balanced according to the femoral tunnel at the tibia, cannulated drilling. Insertion of the graft and fixation.

Postoperative management

Analogous to that for ACL reconstruction.     

3D CT evaluation of femoral and tibial tunnels in anatomic double bundle anterior cruciate ligament reconstruction

BackgroundAn anatomical double bundle ACL reconstruction replicates the anatomy of native ACL as the tunnels are made to simulate the anatomy of ACL with AM and PL bundle foot prints. The goal of anatomic ACL reconstruction is to tailor the procedure to each patient’s anatomic, biomechanical and functional demands to provide the best possible outcome. The shift from single bundle to double bundle technique and also from transtibial to transportal method has been to provide near anatomic tunnel positions.PurposeTo determine the position of femoral and tibial tunnels prepared by double bundle ACL reconstruction using three dimensional Computed tomography.Study designA prospective case series involving forty patients with ACL tear who underwent transportal double bundle ACL reconstruction.MethodComputed tomography scans were performed on forty knees that had undergone double bundle anterior cruciate ligament reconstruction. Three-dimensional computed tomography reconstruction models of the knee joint were prepared and aligned into an anatomical coordinate axis system for femur and tibia respectively. Tibial tunnel centres were measured in the anterior-to-posterior and medial-to-lateral directions on the top view of tibial plateau and femoral tunnel centres were measured in posterior to anterior and proximal-to-distal directions with anatomic coordinate axis method. These measurements were compared with published reference data.ResultsAnalysing the Femoral tunnel, the mean posterior-to-anterior distances for anteromedial and posterolateral tunnel centre position were 46.8% ± 7.4% and 34.5% ± 5.0% of the posterior-to-anterior height of the medial wall and the mean proximal-to-distal distances for the anteromedial and posterolateral tunnel centre position were 24.1% ± 7.1% and 61.6% ± 4.8%. On the tibial side, the mean anterior-to-posterior distances for the anteromedial and posterolateral tunnel centre position were 28.8% ± 4.3% and 46.2% ± 3.6% of the anterior-to posterior depth of the tibia measured from the anterior border and the mean medial-to-lateral distances for the anteromedial and posterolateral tunnel centre position were 46.5% ± 2.9% and 50.6% ± 2.8% of the medial-to-lateral width of the tibia measured from the medial border. There is high Inter-observer and Intra-observer reliability (Intra-class correlation coefficient).Discussion and conclusionFemoral AM tunnel was positioned significantly anterior and nearly proximal whereas the femoral PL tunnel was positioned significantly anterior and nearly distal with respect to the anatomic site. Location of tibial AM tunnel was nearly posterior and nearly medial whereas the location of tibial PL tunnel was very similar to the anatomic site Evaluation of location of tunnels through the anatomic co-ordinate axes method on 3D CT models is a reliable and reproducible method. This method would help the surgeons to aim for anatomic placement of the tunnels. It also shows that there is scope for improvement of femoral tunnel in double bundle ACL reconstruction through transportal technique.     

Arthroscopic Double-Bundle Anterior Cruciate Ligament Reconstruction: An Anatomic Approach

The anterior cruciate ligament consists of 2 functional bundles, the anteromedial and the posterolateral bundle. Anterior cruciate ligament reconstruction has traditionally focused on recreating the anteromedial bundle, while the reconstruction of the posteromedial bundle has not routinely been addressed. The authors, from 2 academic centers, present a technique of arthroscopic anterior cruciate ligament reconstruction that restores both the anteromedial and the posterolateral bundle using either semitendinosus and gracilis autografts or tibialis anterior allografts. This technique represents a novel approach to restore the anteromedial and the posterolateral bundle at their anatomic insertion sites on both the tibia and the femur through separate bone tunnels. We believe that our double-bundle anatomic anterior cruciate ligament reconstruction closely reapproximates the native insertion sites of the anterior cruciate ligament on the tibia and the femur while more closely recreating the biomechanical function of the native ligament.     

Review article: anatomic double bundle anterior cruciate ligament reconstruction

The anterior cruciate ligament (ACL) consists of 2 bundles: a slightly larger anteromedial bundle and a posterolateral bundle, named according to their relative tibial insertion sites. Both bundles are crucial to knee stability. Although it is more technically demanding, a double bundle ACL reconstruction restores the knee biomechanics better and provides more rotational stability than a single bundle ACL reconstruction. Intermediate and long-term clinical investigation including the measurement of rotational laxity and the evaluation of osteoarthritic change is needed to confirm biomechanical and short-term clinical outcomes.     

膝关节前交叉韧带胫骨止点的软组织解剖标记

背景：膝关节前交叉韧带（ACL）重建时,胫骨骨道定位不准会产生重建韧带与髁间窝的撞击或起不到维持膝关节稳定性的作用。因此,确定ACL胫骨止点的位置非常重要。目的：研究膝关节ACL胫骨止点前内束（AMB）和后外束（PLB）与软组织标记后交叉韧带（PCL）和外侧半月板前角的距离,从而明确ACL胫骨止点在胫骨平台的位置,为ACL损伤双束重建提供理论支持。方法：解剖18个膝关节尸体标本（左膝10个,右膝8个）,测量ACL中点、AMB中点、PLB中点与PCL和外侧半月板前角的距离,并分析左、右膝关节是否存在差异。结果：AMB中点与PCL和外侧半月板前角的距离分别为（15.00±3.97）mm和（19.78±4.10）mm;PLB中点与两者的距离分别为（10.17±5.56）mm和（19.50±4.40）mm;ACL中点与两者的距离分别为（12.67±4.52）mm和（19.61±3.87）mm。左右膝关节ACL中点、AMB中点、PLB中点与软组织解剖标记的距离无明显统计学差异。结论：膝关节ACL损伤行手术重建时,可采用PCL和外侧半月板前角作为定位标记。     

In vitro comparison of elongation of the anterior cruciate ligament and single- and dual-tunnel anterior cruciate ligament reconstructions.

This study evaluated strain in the normal anterior cruciate ligament (ACL) and compared it to four different double-strand hamstring tendon reconstructive techniques. Seventeen fresh-frozen knees from 11 cadavers were tested. The strain in the anteromedial and posterolateral bands of the native ACL and their equivalents in four autograft techniques were measured using differential variable reluctance transducers. The anteromedial band of the intact ACL shortened from 0 degree -30 degrees of flexion, then lengthened to 120 degrees; the posterolateral band of the intact ACL shortened from 0 degree - 120 degrees of flexion. Following ACL excision, these knees underwent reconstruction with double-strand hamstring tendons with either single tibial and femoral tunnels, single tibial and dual femoral tunnels, dual tibial and single femoral tunnels, or dual tibial and dual femoral tunnels. With the exception of the dual-band, dual-tunnel technique, all of the procedures placed greater strain on the reconstructive tissues than was observed on the native ACL, after approximately 30 degrees of flexion. These results indicate that dual-band hamstring tendon reconstructions placed with single tibial and femoral tunnels do not address the complexity of the entire ACL. Rather, these procedures appear to only duplicate the effect of the anteromedial band, while perhaps overconstraining the joint as a result of its inability to reproduce the function of the posterolateral band. During rehabilitation following ACL reconstruction, therefore, only from 0 degree - 30 degrees of the graft tissues are not significantly strained. Dual tibial and femoral tunnel techniques should be evaluated further to more closely recreate knee kinematics following ACL reconstruction.     

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.     

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.     

双束双隧道6股腘绳肌腱解剖重建前交叉韧带

目的探讨双束双隧道6股腘绳肌腱重建前交叉韧带（ACL）的可行性及近期疗效。方法对28例ACL损伤患者行关节镜下ACL重建术。采用股骨胫骨双隧道建立前内侧束（AMB）及后外侧束（PLB）。分别将股薄肌腱、半腱肌腱编织成3股肌腱,用于重建PLB与AMB。AMB与PLB股骨端均用Endobutton钢板固定,胫骨端AMB用Bio-Intrafix固定,PLB用Milagro可吸收界面螺钉固定。结果 28例均获随访,时间12-24（19.54±3.84）个月。根据Lysholm膝关节功能评分：术前为18-60（34.79±12.53）分,术后1年为90-98（95.54±2.06）分,差异有统计学意议（t=26.51,P〈0.01）。结论双束双隧道6股腘绳肌腱重建ACL,手术操作简便,固定牢固,效果可靠。     

Femoral and tibial tunnel position using a transtibial drilled anterior cruciate ligament reconstruction technique

This study evaluates the position of the femoral tunnel, which is achieved using a transtibial, single-bundle anterior cruciate ligament (ACL) reconstruction technique. The radiographs of 50 consecutive, primary single-bundle ACL reconstructed knees using this technique were reviewed. The angle between the femoral tunnel and the apex of the intercondylar notch was recorded. The average angle from the 12-o'clock vertical position to the femoral tunnel was 49 degrees (range, 39 degrees-59.2 degrees; SD = 3.9), corresponding to the 10:20 position on a clock face for a right knee. These results demonstrate that it is technically possible to create an obliquely oriented single-bundle femoral tunnel at approximately the 10:20 position through a tibial tunnel angled approximately 60 degrees from the proximal tibial joint surface. This correlates to a femoral tunnel approximately midway between the anteromedial and posterolateral bundle origins of the ACL.     

解剖重建前交叉韧带前内侧束或后外侧束的临床观察

目的探讨关节镜下应用可吸收Rigidfix交叉钉与Intrafix膨胀挤压螺钉固定自体或异体肌腱解剖重建膝关节前交叉韧带（ACL）的前内侧束或后外侧束的疗效。方法对18例ACL单束损伤患者,在关节镜下保留未损伤的部分ACL、建立骨隧道、穿过移植肌腱、股骨侧用可吸收Rigidfix交叉钉固定,胫骨侧用Intrafix膨胀挤压螺钉固定。结果 18例均获随访,时间6-27个月。术后患者疼痛均消失,关节稳定,恢复关节活动度,固定物无松动。1例出现关节积液和滑膜炎,经保守治疗后好转。IKDC分级：术前B级5例、C级10例、D级3例,术后A级8例、B级8例、C级2例,差异有统计学意义（P〈0.01）。Lysholm评分：术前（68.34±4.53）分,术后（93.24±3.61）分,差异有统计学意义（P〈0.01）。结论关节镜下应用Rigidfix交叉钉与In-trafix膨胀挤压螺钉固定自体或异体肌腱重建膝关节ACL的前内侧束或后外侧束,方法简便、固定确实,恢复其解剖结构,保留的部分束促进韧带愈合,利于膝关节本体觉建立和早期功能康复。