Double-Bundle Anterior Cruciate Ligament Reconstruction: The Italian Experience

Abstract

In our original technique, semitendinosus/gracilis tendons are harvested without detaching their tibial insertion, and sutures are tightened at their free proximal extremities. The tibial tunnel is performed in the medial-posterior portion of the native anterior cruciate ligament tibial insertion. For the femoral tunnel, the knee is flexed at 130° and the guide pin is advanced in the 9:30 clockwise position until it passes the lateral femoral condyle cortex. The exit point in the lateral aspect of the femur has to be immediately above the end of the lateral femoral condyle. After the lateral incision, the tendons are passed over the top. The correct placement is found by palpating the posterior tubercle of the lateral femoral condyle. The stitches on the free proximal end of the tendons are tied onto the passing suture that is pulled through the joint to the over the top position. A suture loop is introduced into the joint through the anteromedial portal using a suture passer and then pulled into the femoral tunnel under the arthroscopic view. The stitches on the free end of the tendons are looped again onto the passing suture, which is pulled through the femoral tunnel, the knee joint, and the tibial tunnel to retrieve back the graft from the tibial incision. The combined gracilis and semitendinosus graft are then tensioned and fixed with a transosseous suture or a staple. This technique reproduces the kinematic effect of posterolateral and anteromedial anterior cruciate ligament bundles with a 4-stranded graft, although achieving a better anatomic and functional result.