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Orthopaedic Surgery Cartilage Repair
Arthroscopic Double Bundle Anterior Cruciate Ligament Reconstruction
Using only the Semitendinosus Tendon
a report by
Alberto Gobbi, Paolo Arrigoni and Ramces Francisco
Orthopaedic Arthroscopic Surgery International
Anatomical studies have shown that the anterior cruciate ligament (ACL) EndoButton
®
CL (Smith & Nephew Endoscopy, Andover, MA) needed are
is anatomically formed by two functional bundles, the anteromedial (AM) set aside. Then, with the endobutton attached, the diameter of each
and the posterolateral (PL) (see Figure 1). Their nomenclature is related to bundle is measured using 0.5mm increment sizers to correspond with the
the insertion sites on the tibial plateau.
1
diameter of the femoral and tibial tunnels. The grafts are then pre-
tensioned and pre-conditioned prior to implantation with cyclic flexion
Injuries of the ACL are usually treated with arthroscopically assisted and extension of the knee under maximum manual tension.
2,3
reconstruction harvesting the graft from the central third of the patellar
tendon or the hamstring tendons.
1–3
During recent years, classic Arthroscopic Anterior Cruciate Ligament Reconstruction
procedures have been focused on reconstituting the AM bundle with Standard AM and anterolateral portals are created. While the graft is
limited care to the possible residual pivoting instability. Recent being prepared at the back table, the two femoral and two tibial tunnel
biomechanical analysis on anatomically double bundle reconstructed preparations are completed. The anatomic footprints of the native ACL
knees demonstrates that anterior tibial translation is significantly closer to on both the femoral and tibial insertion sites are used as a guide for
that of an intact knee and produces better rotator stability than classic tunnel placement. The PL femoral tunnel is drilled initially using an
ACL techniques.
4–16
At present, renewed interest is focused on the ‘outside-in’ technique. This tunnel is approximately placed at either the 9
performance of an anatomic double bundle reconstruction technique o’clock (right knee) or the 3 o’clock (left knee) position. A customised PL
that is supposed to be capable of achieving better knee stability, tunnel guide specifically designed to reach either position for this tunnel
especially in terms of rotational control.
1,6,13
The authors describe a placement (Shino’s anterolateral guide, Smith & Nephew Endoscopy,
technique for a double bundle ACL reconstruction using the Andover, MA) is used. Next, two convergent tibial tunnels are prepared
semitendinosus tendon alone, with less morbidity at the donor site.
17
using the anatomical footprints of the ligament as a guide for the
tunnel’s exit points in the joint. Finally, the AM tunnel placed either at the
Surgical Technique 11 o’clock or the 1 o’clock position is drilled through the AM portal. The
After spinal or general anaesthesia has been delivered, the patient is average diameter of the tunnel is 6mm. Once ready, the PL bundle graft
positioned supine on the operating table with the tourniquet placed at is passed first, followed by the AM bundle graft, letting the endobuttons
the proximal aspect of the thigh. A lateral support is placed at the level on the femoral cortex (see Figure 2). The tibial end of the graft is secured
of the tourniquet cuff while a foot bar is positioned at the end of the using a post-screw construct (Smith & Nephew Endoscopy, Andover, MA)
table to enable the knee to be fixed at 90° flexion while, at the same with the AM bundle fixed at 60° of flexion and the PL bundle fixed at full
time, allowing sufficient provision for full range of motion during surgery. extension. The graft is then checked for impingement together with the
Next, the tourniquet is inflated to 300mmHg and a 3cm vertical incision knee’s range of motion and stability using the Lachman’s test. Finally,
centered approximately 5cm below the medial joint line, midway post-operative radiograms are taken to confirm the positions of both the
between the tibial tubercle and the posteromedial aspect of the tibia, is tunnels and the graft (see Figures 1 and 2).
performed. The sartorial fascia is incised and the semitendinosus tendon
is dissected. The tendon’s accessory limbs are identified and freed prior
to the use of an open tendon stripper to avoid cutting the tendon Dr Alberto Gobbi is Founder and Director of Orthopaedic
prematurely and allow complete detachment of the tendon from its
Arthroscopic Surgery International in Italy. He previously
served as physician for the Italian Motorcycle Federation for
proximal attachment. The distal limb of the tendon is then detached from
the sport of motocross. He was one of the first Italian
its tibial insertion, saving as much length as possible. Measurement of the
surgeons to become a member of the American Academy of
Orthopaedic Surgeons and the Arthroscopy Association of
tendon follows. As long as the semitendinosus tendon measures at least
North America. He is a member of the board of the
28cm the harvesting of the gracilis is avoidable. International Cartilage Research Society, the Arthroscopy
Committee of the International Society of Arthroscopy and
Knee Surgery, and the Cartilage Committee of the European
Preparation of the Double Bundle Semitendinosus Graft
Surgery Knee Arthroscopy Society. He has been a presenter at
At the back table, while the femoral and tibial tunnels are being
several international meetings and has published many
scientific papers. Dr Gobbi completed his speciality training in
prepared, the surgical assistant prepares the double bundle graft. Graft
orthopaedics and traumatology at the University of Milan and
preparation begins with the removal of all excess tissues attached to the his training in sports medicine at the University of Genova. He
semitendinosus tendon with the use of a curette. The tendon is then cut
obtained his doctoral degree in medicine and surgery from the
State University of Milan in 1983.
in half with each half folded and whipstitched at its end with Fiberwire
sutures (Arthrex, Naples, FL). Once the depth of the femoral tunnels (AM
E: sportmd@tin.it
and PL) is determined with the depth gauge, the appropriate sizes of the
© TOUCH BRIEFINGS 2007 85
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