All-inside anterior cruciate ligament graft link: graft preparation technique

Abstract

The anatomic single-bundle, all-inside anterior cruciate ligament graft-link technique requires meticulous graft preparation. The graft choice is no-incision allograft or gracilis-sparing, posterior semitendinosus autograft. The graft is linked, like a chain, to femoral and tibial TightRope cortical suspensory fixation devices with adjustable-length graft loops (Arthrex, Naples, FL) in the following manner: the graft is quadrupled, and the free ends are first whip-stitched and then sutured with a buried-knot technique, 4 times through each strand in a loop. The graft is placed on a tensioning station under approximately 20 lb of tension during arthroscopic preparation of the knee and then removed from the tensioner and inserted into all-inside femoral and tibial sockets through the anteromedial arthroscopic portal.

Figure 1

A graft preparation station facilitates preparation and tensioning of the graft construct. The 2 posts (silver, far left with button-holding post and calibrated tensioner [in pounds and Newtons], and right with suture-holding post) of an ACL graft preparation stand are, respectively, loaded with ACL Femoral TightRope Reverse Tension (white adjustable graft loop on left with silver button in holder and blue passing suture) and ACL Tibial Buttonless TightRope (white larger adjustable loop on right for the Attachable Button System (ABS) with white tensioning sutures on far right). Graft tissue (above) meets preparation specifications including length of no more than 270 mm and diameter (doubled) of no more than 8.5 mm.

Figure 2

(A) Before the graft (white tissue held in white gloves) is sewn, it must be loaded, looped, in linkage with ACL femoral (left, attached to tensioner) and tibial (right, obscured by white glove) TightRopes. (B) The graft (white tissue) is loaded, quadrupled, in linkage with ACL femoral (left, attached to tensioner, partially obscured by black glove) and tibial (right, attached to suture-holding post) TightRopes, and the free ends of the graft are passed to the same side of the loop (below black glove) so that they may be whipstitched together with No. 2 FiberLoop (blue whipstitch suture tails in white glove). (C) Next, the graft is baseball stitched into the final, quadrupled loop using 4 interrupted, traditional strands of No. 0 FiberWire high-strength suture. Each stitch is passed through each of the 4 strands of graft collagen (white tissue), and the suture free limb is wrapped once around the collagen bundles, creating a self-reinforcing suture noose.

Figure 3

The graft (white tissue) is baseball stitched into the final, quadrupled loop using an interrupted, traditional strand of No. 0 FiberWire high-strength suture (blue suture in free needle). One should note that the central 2 free limbs of the graft have previously been whipstitched with No. 2 FiberLoop (blue suture placed in previously placed rows, below free needle). Each stitch must pass through each strand of graft collagen, and the suture limbs are wrapped once around the collagen bundles, creating a self-reinforcing suture noose when tied. In addition, the central strands are the first sutured, so on completion of the suture noose, the final stitch from peripheral to central (as illustrated) will result in a buried-knot technique. Video 1 provides full details.

Figure 4

The GraftLink collagen loop (white central tissue) is sewn in linkage with an ACL femoral TightRope adjustable graft loop (white adjustable graft loop on left with silver button in holder and blue passing suture) and ACL Tibial Buttonless TightRope (white larger adjustable loop on right for Attachable Button System with white tensioning sutures on far right). The surgeon holds the graft diameter sizing block measuring one-half–millimeter sizing increments and graft length in mm (shown). Two sutures are placed on the tibial side of the graft and 2 on the femoral side, using a total of 4 interrupted, traditional strands of No. 0 FiberWire high-strength suture. Each of these 4 stitches is passed through each of the 4 strands of graft collagen (white tissue), and the suture free limb is wrapped once around the collagen bundles, creating a self-reinforcing suture noose. The graft, prior to tensioning, should be 50 to 70 mm in length, with a goal of not measuring more than 75 mm after tensioning. A graft-link construct is created, similar to the links in a chain, where a femoral ACL TightRope and tibial ACL TightRope Reverse Tension are linked within each end of the loop.