Various arthroscopic techniques have been devised for fixation of tibial eminence avulsions, namely percutaneous K-wires, arthroscopy-guided screw fixation, staples, TightRope (Arthrex)–suture button fixation, and transosseous suture fixation. Such techniques provide well-pronounced advantages including less postoperative pain, a reduced hospital stay, and minimal scar with resultant earlier and more compliant rehabilitation. As for transosseous suture fixation, the standard technique comprises the creation of 2 tibial tunnels exiting on both sides of the footprint of the avulsion fracture using an anterior cruciate ligament tibial guide with the angle set at 45°. Our technique entails the creation of a single tibial tunnel directed from the proximal anteromedial tibia to the center of the tibial eminence. The technique uses Ethibond suture (No. 5) and/or FiberWire suture (Arthrex) to fix the tibial eminence by pulling the anterior cruciate ligament fibers and tightening the pullout suture at the tibial exit of the tunnel with a 4-hole button. This modified single-tunnel pullout suture technique is an appealing option that has proved to be effective and economical with a shorter operative time. Moreover, it provides a less invasive option for skeletally immature patients.

Patients with complete anterior cruciate ligament (ACL) injury have different degrees of rotational (internal rotation) laxity. A residual pivot shift has been found to be positive in more than 15% of cases after an accurate ACL reconstruction. Improved understanding of the existence, function, and biomechanical role of the anterolateral ligament (ALL) in controlling rotational instability of the knee has redirected and refocused attention on a supplemental extra-articular reconstruction of the ALL in conjunction with the intra-articular ACL reconstruction so as to restore normal kinematics of the knee. This Technical Note describes a technique that allows for a combined ACL and ALL reconstruction using autogenous hamstring graft (semitendinosus and gracilis tendons). One femoral tunnel is used connecting the anatomic femoral attachment of the ALL on the lateral wall of the lateral femoral condyle to the anatomic femoral ACL footprint on the medial wall of the lateral femoral condyle. The remaining part of the graft is fixed to the proximal tibia midway between Gordy's tubercle and the head of the fibula. This Technical Note describes a technique of both ACL and ALL reconstruction with a continuous hamstring graft.

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Despite the popularity of anterior cruciate ligament (ACL) reconstruction procedures, the ideal graft for reconstruction remains a matter of controversy. The ideal graft for ACL reconstruction should have histologic and biomechanical characteristics similar to those of the native ACL; should be quickly and fully incorporated within the bony tunnels; should maintain its viscoelastic properties for a long time; should have minimal donor-site morbidity; should be of sufficient length and diameter; should have minimal adverse effects on the extensor mechanism; should have no risk of rejection or disease transmission; and should be cost-effective and readily available. Synthetic grafts are not widely accepted because of their dangerous complications. The main sources of grafts for ACL reconstruction are allografts and autografts. Each type of graft has its own relative advantages and disadvantages. Allografts are not available in every country, besides being expensive, and there are many concerns regarding disease transmission. Autografts, particularly bone–patellar tendon–bone (BPTB), and hamstring tendon grafts have been the standard for ACL reconstruction. The main advantage of autogenous BPTB grafts is the direct bone-to-bone healing in the tunnel, whereas the main disadvantages of such grafts are related to donor-site morbidity, anterior knee pain, and extensor mechanism dysfunction. The popularity of autogenous hamstring tendon grafts for ACL reconstruction is increasing, but there are still concerns regarding the slow soft tissue–to–bone healing, with delayed healing and incorporation of the graft. We describe a technique for ACL reconstruction with autogenous hamstring-bone graft, aiming to produce a type of graft that combines the main advantages of BPTB and hamstring grafts, with avoidance of the main disadvantages of these 2 most commonly used graft types in ACL reconstruction.

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