Four-strand hamstring autograft is a common choice for anterior cruciate ligament reconstruction. A potential disadvantage of hamstring autograft for anterior cruciate ligament reconstruction is the inherent variability in graft diameter. Multiple studies have shown increased revision rates when using an undersized hamstring graft. Using an EndoButton (Smith & Nephew, Andover, MA) for femoral tunnel fixation, we convert a standard quadrupled hamstring graft into a 5-strand graft by creating 3 equal strands of the typically larger semitendinosus combined with a doublestranded gracilis. This technique may help alleviate some surgeon reluctance to use a hamstring graft by providing an intraoperative "bailout" option for an unexpectedly small tendon. On the basis of current data, increasing the diameter of the graft in these situations may decrease revision rates.F our-strand hamstring autograft is a common choice for anterior cruciate ligament (ACL) reconstruction. Advocates for its use cite a decreased potential for catastrophic extensor mechanism complications and a decreased incidence of anterior knee pain associated with central-third boneepatellar tendonebone (BPTB) autograft. In addition, biomechanical testing of 4-strand gracilis and semitendinosus autograft has shown a higher load to failure than that with BPTB autograft.

Anterior cruciate ligament (ACL) reconstruction techniques continue to evolve as surgeons seek to improve surgical process and outcome measures. On the basis of published data showing improved biomechanics, many surgeons now attempt to better re-create native ACL anatomy in reconstruction. Use of flexible reamer technology and a 70 arthroscope allows for excellent visualization of the native ACL anatomy, as well as precise and independent drilling of the tibial and femoral reconstruction tunnels, while offering several surgical and technical advantages compared with other drilling techniques. This technical note with accompanying video describes our use of the Smith & Nephew Clancy anatomic cruciate guide/flexible drill system (Smith & Nephew, London, England) with a 70arthroscope.

Rotator cuff repair techniques continue to evolve in an effort to improve repair biomechanics, maximize the biologic environment for tendon healing, and ultimately improve patient outcomes. The arthroscopic transosseousequivalent technique was developed to replicate the favorable tendon-bone contact area for healing seen in open transosseous tunnel repair. In this technical note and accompanying video, we present our all-arthroscopic transosseousequivalent rotator cuff repair technique with a focus on technical pearls. Double-row suture anchor techniques were developed in an attempt to increase the tendon-footprint contact area, improve unacceptably high retear rates, and ultimately improve functional outcomes. Transosseousequivalent repair, as described by Park et al., 1 sought to further maximize the tendon-footprint contact area and biomechanics by simulating a traditional open repair through transosseous tunnels. This technique preserves the suture limbs of the medial row, bridging them over the tendon's native insertion with fixation in the lateral humeral cortex. In this technical note with accompanying video (Video 1), we present an example of an arthroscopic transosseous-equivalent double-row rotator cuff repair. Surgical TechniqueWe prefer an interscalene block with sedation to maximize the duration of patient analgesia and intraoperative blood pressure control while diminishing the potential for cerebral hypoxic events. The patient is situated in the beach-chair position, and the shoulder and upper extremity are prepared and draped in standard aseptic fashion. Prophylactic antibiotics are infused within 1 hour of surgical incision.A modified posterior arthroscopic portal is established 1 cm inferior and 1 cm medial to the posterolateral corner of the acromion to ensure optimal visualization of both the subacromial space and glenohumeral joint. A standard anterosuperior portal is made under direct visualization, and a systematic diagnostic glenohumeral arthroscopy is performed. Careful attention is paid to the long head of the biceps and subscapularis tendinous insertion to evaluate for concomitant pathology. The arthroscope is then introduced into the subacromial space, and a midlateral portal 1 cm posterior and 3 to 4 cm distal to the midpoint of the lateral acromion is established. This portal can be tailored to the specific anatomy of the tear and desired anchor placement. A thorough bursectomy is performed with an arthroscopic shaver and radiofrequency device. A limited acromioplasty to co-plane the anterolateral acromion and elute marrow elements can be performed subsequent to the repair to limit osseous bleeding.After completion of the bursectomy, the configuration of the tear is characterized. The tendon is mobilized with a combination of subacromial and paraglenoid releases. Paraglenoid releases can be performed with a radiofrequency wand while one is viewing within the glenohumeral joint, releasing the interval between the superior labrum and undersurface of the rotator cuff (Fig 1)....

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