Chapter 22 Anatomical Double-Bundle Anterior Cruciate Ligament Reconstruction Procedure Using the Semitendinosus and Gracilis Tendons

Introduction

The anterior cruciate ligament (ACL) is composed of the anteromedial bundle (AMB) and the posterolateral bundle (PLB), each with a different function.¹^–³ Since 2000, the author has reported the surgical principle⁴ and the latest procedure⁵ for an anatomical double-bundle ACL reconstruction that is intended to anatomically reconstruct the AMB and the PLB. In addition, the author’s team reported a prospective cohort study to evaluate this anatomical double-bundle procedure in comparison with single-bundle and nonanatomical double-bundle ACL reconstruction procedures using hamstring tendon grafts.⁶ Our procedure has several noteworthy characteristics. First, all four ends of two tendon grafts are grafted at the center of the anatomical attachment of the AMB or the PLB, not only on the femur but also on the tibia. Second, we use the transtibial tunnel technique to create femoral tunnels. Third, we use the hamstring tendon-hybrid graft,^7,⁸ in which the femoral end is connected with an Endobutton CL and the tibial end is connected with a polyester tape. Fourth, we fix the polyester tape portion of the graft onto the tibia with two staples at 10 degrees of knee flexion, simultaneously applying a 30N load to each graft. In this chapter, the surgical principle and the procedure of our anatomical double-bundle ACL reconstruction are explained.

Procedure

Preparation for Arthroscopic Surgery

Surgery is performed with an air tourniquet in the standard supine position. An approximately 3-cm-long oblique incision is made in the anteromedial portion of the proximal tibia. The semitendinosus and gracilis tendons are harvested using a tendon stripper in the figure-four knee position. When the semitendinosus tendon is thick and long enough, the gracilis tendon is not harvested. At the beginning of arthroscopic surgery, a surgeon sits beside the knee joint of the patient. An edge of a drape is attached to a lumbar portion of the surgeon so that the patient’s leg hanging beside the table can be put on the surgeon’s knee in a sterile condition. This setup allows the surgeon to control the patient’s knee position using the surgeon’s own knee. An arthroscope is inserted through the lateral infrapatellar portal. After a routine arthroscopic examination, a remnant of the torn ACL is resected, leaving 1-mm-long ligament tissue at the femoral and tibial insertions, which can be used as landmarks for inserting guidewires.

Creation of Tibial Tunnels

In ACL reconstruction procedures with the transtibial tunnel technique, the greatest key to success is to create a tibial tunnel with an appropriate three-dimensional (3D) direction. In other words, a tibial tunnel should be created so that a guidewire for femoral tunnel creation can be easily inserted at a targeted point on the lateral condyle through the tibial tunnel. To create such a tibial tunnel, we use a specially designed wire guide, called a wire navigator (Fig. 22-1, A), which was developed in our previous study.^7,⁸ This device is composed of a navi-tip and a wire sleeve. The navi-tip consists of sharp tibial and femoral indicators. The axis of the wire sleeve passes through the tip of the tibial indicator (Fig. 22-1, B). First, a tibial tunnel for the PLB is created. The navi-tip is introduced into the joint cavity through the medial infrapatellar portal. The surgeon holds the tibia at 90 degrees of knee flexion, keeping the femur horizontal. The tibial indicator of the navi-tip is placed at the center of the PLB footprint on the tibia, which is located at the most posterior aspect of the area between the tibial eminences and 5 mm anterior to the posterior cruciate ligament (Fig. 22-2). Keeping the tibial indicator on this point, we aim the femoral indicator at the center of the PLB footprint on the femur (Fig. 22-3, A), which is precisely explained in the next section, and the proximal end of the extraarticularly located wire sleeve is fixed on the anteromedial aspect of the tibia through the skin incision made for the graft harvest. The proximal end and the direction of the wire sleeve are automatically determined depending on the direction of the intraarticular navi-tip (see Fig. 22-1, B). A Kirschner wire of 2 mm in diameter is drilled through the sleeve in the tibia. According to our basic studies, this tunnel does not injure this ligament because the insertion point of the wire on the anteromedial aspect of the tibia is located several millimeters anterior to the medial collateral ligament.⁴ The first tunnel is made with an approximately 6-mm cannulated drill corresponding to the measured diameter of the prepared substitute.

Fig. 22-1 The wire navigator (A) and the concept of wire navigation for the tibia (B). The wire navigator is composed of a navi-tip (A) and a wire sleeve (B). The navi-tip consists of the tibial indicator (C) and femoral indicator (D). The axis of the wire sleeve is passed through the tip of the tibial indicator. Keeping the tibial indicator at the targeted point on the tibia, we aim the femoral indicator at the targeted point (TP) on the femur. Subsequently, the direction and the insertion point of the wire are automatically determined.

Fig. 22-2 Two tibial tunnel outlets are shown. They are created at the center of the normal attachment of the anteromedial bundle (AMB) and posterolateral bundle (PLB).

Fig. 22-3 The navi-tip of the wire navigator in an arthroscopic visual field. First (A), keeping the tibial indicator at the center of the posterolateral bundle (PLB) footprint on the tibia, a surgeon aims the femoral indicator at the center of the PLB footprint on the femur. Then (B), keeping the tibial indicator at the center of the anteromedial bundle (AMB) footprint on the tibia, a surgeon aims the femoral indicator at the center of the AMB footprint on the femur.

Next, a Kirschner wire for the AMB reconstruction is drilled using the same wire navigator. The tibial indicator is placed at the center of the tibial footprint of the AMB, which is located at a point approximately 7 mm anterior to the center of the first tunnel (see Fig. 22-2). Keeping the tibial indicator on this point, we then aim the femoral indicator at the center of the femoral footprint of the AMB (Fig. 22-3, B). The wire sleeve is fixed on the anteromedial cortex of the tibia. A Kirschner wire is then drilled through the sleeve in the tibia. The knee should be extended to ensure that the tip of the second wire is located at a point 5 mm posterior to the anterior edge of the roof in the intercondylar notch. The second tunnel is drilled with an approximately 7-mm cannulated drill corresponding to the measured diameter of the prepared substitute. Subsequently, two intraarticular outlets are aligned in the sagittal plane (see Fig. 22-2).