Anatomic ACL reconstruction: rectangular tunnel/bone–patellar tendon–bone or triple-bundle/semitendinosus tendon grafting

Abstract

Anatomic ACL reconstruction is the reasonable approach to restore stability without loss of motion after ACL tear. To mimic the normal ACL like a ribbon, our preferred procedures is the anatomic rectangular tunnel (ART) technique with a bone-patellar tendon-bone (BTB) graft or the anatomic triple bundle (ATB) procedure with a hamstring (HS) tendon graft. It is important to create tunnel apertures inside the attachment areas to lessen the tunnel widening. To identify the crescent-shaped ACL femoral attachment area, the upper cartilage margin, the posterior cartilage margin and the resident’s ridge are used as landmarks. To delineate the C-shaped tibial insertion, medial intercondylar ridge, Parson’s knob and anterior horn of the lateral meniscus are helpful. In ART-BTB procedure which is suitable for male patients engaged in contact sports, the parallelepiped tunnels with rectangular apertures are made within the femoral and tibial attachment areas. In ATB-HS technique which is mainly applied to female athletes engaged in non-contact sports including skiing or basketball, 2 femoral and 3 tibial round tunnels are created inside the attachment areas. These techniques make it possible for the grafts to run as the native ACL without impingement to the notch or PCL. After femoral fixation with an interference screw or cortical fixation devices including Endobutton, the graft is pretensioned in situ by repetitive manual pulls at 15–20° of flexion, monitoring the graft tension with tensioners on a tensioning boot installed on the calf. Tibial fixation with pullout sutures is achieved using Double Spike Plate and a screw at the pre-determined amount of tension of 10–20N. While better outcomes with less failure rate are being obtained compared to those in the past, higher graft tear rate remains a problem. Improved preventive training may be required to avoid secondary ACL injuries.

Anterior Cruciate Ligament Reconstruction With Bone–Patellar Tendon–Bone Graft Through a Rectangular Bone Tunnel Made With a Rectangular Retro-dilator: An Operative Technique

“…Recently, good clinical results of ART-BTB ACL reconstruction have been reported. 1 , 2 , 3 , 4 Moreover, it has been shown that the behavior of the reconstructed knee is close to the biomechanical behavior of the normal knee as compared with the conventional round-tunnel BTB ACL reconstruction. 4 …”

“…To avoid the risk of femoral posterior wall injury or nerve damage, the inside-out technique or the conventional outside-in technique (to drill from the bone cortex to the joint) is selected depending on whether knee flexion to 140° can be achieved. 3 In addition, performing the insertion of the guide pin twice raises the risk of prolonged operating time and technical error.…”

“…The technique of anterior cruciate ligament (ACL) reconstruction has been improved in the past decade. Good clinical results have been reported with anatomic ACL reconstructions in which rectangular bone–patellar tendon–bone (BTB) graft was fixed into rectangular bone tunnels made at anatomic ACL insertion sites of the femur and tibia (anatomic rectangular tunnel [ART] BTB ACL reconstruction 1 , 2 , 3 , 4 ). Notwithstanding these good results, some problems have remained, 5 , 6 including procedural complexity and risk of damage to the femoral posterior tunnel wall, damage to nerves and blood vessels, and damage to cartilage.…”

In vivo length change of ligaments of normal knees during dynamic high flexion

“…We de ned the femoral, tibial and bular attachment areas of the ACL, PCL, dMCL, sMCL and lateral collateral ligament (LCL) according to the osseous landmark and magnetic resonance imaging (MRI) [8,10,[23][24][25][26][27][28][29][30][31]. The accuracy of the attachment area is 0.7 ± 0.1 mm [31].…”

A new method for tensioning of a chronic tibial bony avulsion of the posterior cruciate ligament as a posteromedial bundle and augmentation by anterolateral bundle reconstruction in a bicruciate ligament injury: A case report

“…An ALB graft fixation was also performed using the same plate and screw. Three months after the initial surgery, an anatomical ACL reconstruction 2 using rectangular tunnel/bone-patellar tendon-bone was performed ( Fig. 3 ).…”