Combined Anterior Cruciate Ligament and Anteromedial Oblique Ligament Reconstruction Using the Rectus Femoris Tendon: Description of Surgical Technique

Abstract

We present a technique for combined anterior cruciate ligament and anteromedial oblique ligament reconstruction using the rectus femoris tendon graft. Anatomic anterior cruciate ligament reconstruction and anteromedial reinforcement are performed with a single rectus femoris graft. The rectus femoris tendon graft is harvested in a reproducible and minimally invasive approach. The surgical technique requires no special instruments and consists of 3 bone tunnels. Fixation is performed with interference screws.

Fig 1

The left knee is shown, and the patient is in the supine position. A 3-cm longitudinal skin incision is made from the superior pole of the patella at the junction of the lateral and middle third.

Fig 2

The left knee is shown. After 2 longitudinal incisions are made in the rectus femoris tendon, a 10-mm width graft is created. The rectus femoris tendon is elevated from the remaining quadriceps tendon with the aid of a hemostatic forceps.

Fig 3

The left knee is shown. The distal free end of the graft is whipstitched with nonabsorbable sutures. The dissection of the rectus femoris tendon graft is extended proximally for 7 to 8 cm using scissors.

Fig 4

The right knee is shown. A closed tendon stripper is pushed carefully with the knee in 20° of flexion and the rectus femoris tendon graft is harvested. Usually, the total length ranges from 28 to 35 cm.

Fig 5

The muscle fibers are removed from the rectus femoris tendon graft. The distal portion is folded to form a double graft for the anterior cruciate ligament portion of the graft. The anteromedial oblique ligament portion of the graft is the proximal remainder without folding.

Fig 6

The left knee is shown. A high anterolateral portal is created first. The preservation of intermediate and deep laminae of the quadriceps tendon allows a knee arthroscopy without fluid leakage.

Fig 7

The left knee is shown. The anterior cruciate ligament (ACL) femoral tunnel is made using an outside-in technique. A lateral skin incision is made along the lateral aspect of the distal femur. The tip of the drill guide is placed at the femoral footprint of the ACL.

Fig 8

The left knee is shown. Femoral anterior cruciate ligament graft fixation is performed in an outside-in manner using an interference screw.

Fig 9

The left knee is shown. Tibial anterior cruciate ligament graft fixation is performed with the graft tensioned and the knee at 20° of flexion.

Fig 10

The left knee is shown. The medial epicondyle is identified by palpation.

Fig 11

The left knee is shown. A guidewire is drilled via free hand, starting at the medial epicondyle anterior portion. The anteromedial oblique ligament femoral tunnel is created with a 6-mm drill.

Fig 12

The right knee is shown. The remaining graft, without folding that exits the tibial tunnel, is passed beneath subcutaneous tissue in the medial side.

Fig 13

Anteromedial oblique ligament graft is fixed with an interference screw in neutral rotation and full extension in left knee.