All-Inside Arthroscopic Anterior Cruciate Ligament Reconstruction and Internal Brace With Recycling Suture

Abstract

Anterior cruciate ligament (ACL) rupture is a common injury of the knee. Arthroscopic ACL reconstruction is a standard treatment for this condition. All-inside ACL reconstruction has many advantages compared with conventional techniques. However, there are still concerns regarding graft elongation and stability with all-inside ACL reconstruction. Here, we propose an arthroscopic technique using the shortening strands of a flexible suspensory button as an internal brace. This method provides the advantages of increased stability and ACL graft protection while using the same implant as the all-inside ACL reconstruction technique.

Fig 1

Graft preparation for all-inside ACL reconstruction and internal bracing with semitendinosus graft. The graft is prepared to approximately 6.5 cm in length with the femoral side attached to a TightRope RT (Arthrex), which has a cortical button, and the tibial side is attached to a TightRope ABS (Arthrex), which does not include a cortical button. (ACL, anterior cruciate ligament; ST, semitendinosus.)

Fig 2

The method of tibial tunnel preparation for all-inside ACL reconstruction and internal bracing of the left knee. (A) Retrograde reaming with a FlipCutter (Arthrex). The reaming length should be less than the overall tibial tunnel length measured. (B) Arthroscopic viewing from anterolateral portal of the left knee. The tibial aiming device is placed anterior to the posterior border of the anterior horn of the lateral meniscus. (C) Two shuttle sutures are passed through the tibial tunnel with the lower end of the Beath pin and retrieve together with femoral shuttle sutures through the anteromedial portal. (ACL, anterior cruciate ligament; LM, lateral meniscus.)

Fig 3

Graft passage for all-inside ACL reconstruction and internal bracing of the left knee. (A) The ACL graft is passed through the femoral socket first, and then the shortening strands (red line) of the TightRope (Arthrex) are alternately pulled to seat the graft in the femoral socket. (B) The loop marked by the white star shuttles the ACL graft through the tibial socket, and the loop markes by the red star shuttled the shortening strands from the femoral TightRope (Arthrex) through the tibial socket. (C) Illustrated drawing showing graft passage step. The red line represents the shortening strand sutures of the TightRope. (ACL, anterior cruciate ligament.)

Fig 4

The arthroscopic views and illustrated drawing from a patient who underwent all-inside ACL reconstruction and internal bracing of the left knee. (A) Retrieving the shortening strand (red star) sutures attached to the femoral TightRope (Arthrex) with the shuttle suture through the anteromedial portal. (B) The shortening strands (FiberWire) act as an internal brace-to protect the ACL graft. (C) An ABS button (Arthrex) is placed at the tibial cortex. The ACL graft is tensioned first, and then a knot is tied with the shortening strand sutures (red star) with optimal tension. (D) Illustrate drawing shown the finished construct. The red line represents the shortening strand sutures. (ACL, anterior cruciate ligament.)

Fig 5

Postoperative radiograph of the left knee following ACL reconstruction and internal bracing with shortening strands from the TightRope (Arthrex). (ACL, anterior cruciate ligament.)