Anterior Cruciate Ligament Reconstruction Using Fixed Loop All-Inside (FLAI) Technique

Abstract

The aim of this surgical technical note is to provide a more secure option to prevent possible graft loosening with all-inside anterior cruciate ligament (ACL) reconstruction. A triple strategy is used. First, a fixed loop cortical device is used on the femoral side. Second, an internal brace augmentation for ACL graft is employed to prevent graft loosening during early postoperative period. Lastly, tying off the sutures of tibial adjustable loop after retensioning to secure its locking mechanism from slippage.

Fig 1

Use of an open stripper to harvest semitendinosus graft from patient’s right leg.

Fig 2

The semitendinosus graft of the right leg is looped between a fixed femoral button and adjustable tibial button.

Fig 3

The graft is measured about 65 mm to avoid any graft slackness during all-inside ACL reconstruction.

Fig 4

The graft is whipstitched about 20 mm from each side.

Fig 5

The graft diameter is measured to determine size of femoral and tibial sockets.

Fig 6

(A) An illustration showing the graft encircled between fixed femoral loop (red) and adjustable tibial loop (green). (B) Augmentation of the construct with internal brace (dashed violet line). The tape is loaded inside femoral closed loop with the graft. The tape is then wrapped and crossed inside the graft. The 2 free ends of the tape are loaded later over peripheral tibial buttonholes.

Fig 7

Augmentation of the construct with internal brace. The tape is loaded inside femoral closed loop (right sided loop) with the graft. The tape is then wrapped and crossed inside the graft. The 2 free ends of the tape are loaded later over peripheral tibial buttonholes (left sided loop).

Fig 8

An arthroscopic view of the right knee from accessory anteromedial portal showing a graduated guide pin introduced through anteromedial portal in the footprint of the ACL on medial wall of lateral femoral condyle.

Fig 9

An arthroscopic view of the right knee from accessory anteromedial portal showing a low-profile reamer introduced through anteromedial portal to drill femoral socket.

Fig 10

An arthroscopic view of the right knee from accessory anteromedial portal showing a femoral socket depth reaming to 25 mm.

Fig 11

An arthroscopic view of the right knee from anteromedial portal inside femoral tunnel showing socket depth with intact femoral cortex.

Fig 12

An illustration of distal femur of the right knee showing socket depth (S), femoral tunnel length (T), fixed loop length (L), and button diameter (B).

Fig 13

An arthroscopic view of the right knee from anterolateral portal showing a FlipCutter introduced to create tibial tunnel.

Fig 14

An arthroscopic view of the right knee from the anterolateral portal showing tibial and femoral shuttle sutures of different colors.

Fig 15

An arthroscopic view of the right knee from the anterolateral portal showing retrieval of femoral button from anteromedial portal.

Fig 16

An arthroscopic view of the right knee from the anterolateral portal showing the ACL graft is retrieved through the anteromedial portal into the femoral socket with the tibial part of graft (20 mm at edge of tunnel) still not retrieved.

Fig 17

Once the tibial button and the internal brace sutures are outside the tibial cortex, the internal brace strands are then shuttled through the tibial adjustable-loop peripheral holes.

Fig 18

Tensioning of tibial adjustable loop over upper tibial metaphysis of the right knee.

Fig 19

An arthroscopic view of the right knee from anterolateral portal showing well tensioned ACL graft without slackness. ACL, anterior cruciate ligament; LFC, lateral femoral condyle; PCL, posterior cruciate ligament.

Fig 20

Knot tying of tibial adjustable-loop sutures to close the loop and avoid slackness of its locking mechanism upon loading.