This is Jocelyn Wittstein from Duke University School of Medicine presenting today on all-inside ACL reconstruction. Specifically, this is all-inside ACL reconstruction that could be done with a quadrupled semitendinosus autograph or a quadriceps autograph using suspensory tibial and femoral fixation. A couple of notes, depending on what graft type you're using, if you're using a quadriceps, make sure that the maximum graft length you're using is 70 millimeters, 65 is preferable. You have to take care when you're doing your graft preparation that you do not extend the functional length of the graft by having too much suture between the graft and the tensionable suture loops. Remember, these are incomplete sockets on the femur and the tibia, so a graft that exceeds much more than 65 millimeters in length could have more potential for bottoming out and not being able to be maximally tensioned, especially in the setting of a smaller patient. If you're using a quadrupled semitendinosus graft, a maximum length of 270 millimeters is needed. The graft is going to be overlapped by approximately a centimeter with quadrupling and securing to the tensioning suture loops, and this will give you a length of approximately 65 millimeters. A minimum graft length of 245 millimeters is needed with 5 millimeters of overlap to give you a 60 millimeter graft, which may be a reasonable option in a smaller patient that may have smaller interosseous and interarticular distances. Remember that the quadrupled semitendinosus graft material is actually looped on the inside of the tensioning suture loop, so there's much less risk of functionally lengthening a 65 millimeter graft in terms of the graft being too long. Some of your landmarks will, of course, depend on which autograft you're taking. If you're utilizing a hamstring autograft, you're going to use your approach to harvest the semitendinosus also for placement of the tibial tunnel. If you're doing a quadriceps graft, you're going to have a superior harvest site at the superior pole of the patella and then have to make an additional incision to place your tibial guide at the medial tibia, but you could typically keep this little smaller as you're not also using that for harvest site. Your portals are typical of ACL reconstruction, with the exception that the medial portal will need to be a little bit larger to accommodate the graft, which is pulled into the joint through that portal, and then depicted here as well as our distal lateral femoral incision, which is used for placement of the outside end femoral guide. This image depicts a complete preparation of a quadrupled semitendinosus autograft, but of course, as we've discussed, you could do the same technique with the lung-tidacial reconstruction with the quadriceps graft, and I do this for both of these graft types in my practice. In this image here, I've marked with a purple marker the intraosseous distance, meaning the length from the button to the purple mark is the width of the lateral femoral condyle, and I can use that purple mark to indicate to me when the button should be engaged on the distal lateral femoral cortex. Alternatively, that tensioning suture loop can be shortened to the intraosseous distance such that at the point when the graft is at the opening of the femoral socket intraarticulately, we know that the button should engage on the lateral femoral cortex. Once the graft is fully prepped, we need to size both ends, and this will of course determine our femoral and tibial socket diameters. The femoral insertion of the ACL is identified first by identifying the posterior capsular reflection as viewed from the medial portal, and then identifying the footprint of the ACL directly anterior to that at the level of the nadir of the femoral condyle, so that when we place our outside-in guide, we have good visualization as to where we want that tip to be. We're viewing through the medial portal, and the guide is set at 90 degrees and advanced through the lateral portal, and then the guide arm is advanced down through that lateral femoral incision through the IT bend down to the femur. The socket should be created 20 to 25 millimeters in length, but not longer than that. Ideally, this much graft will be pulled into the socket, but not more. This allows you to avoid pulling too much graft into the femur so that you maintain the length of graft that you need for the intraarticular distance, as well as the portion that you need to dunk into the tibia. These images depict the entry point of the cutter, which is deployed and then used to create a socket in the femur. You can see the intact posterior wall there, as well as the walls of the socket and the intact lateral femoral cortex, with a lead suture advanced through that and then retrieved at the lateral portal for later use. Next, the arthroscope is repositioned through the lateral portal, and the medial portal is utilized for placement of a tibial guide. The tibial guide is centered over the tibial footprint, typically as posterior as the inner margin of the lateral meniscus and in line with the medial tibial eminence. The guide is positioned on the tibia, and then a cutter is advanced in, deployed to the appropriate size, and used to create a 30-millimeter socket. I like to create a 30-millimeter socket, as this gives me enough play for tensioning a full construct. If the tensioning is maximized on the femoral side, and I need to maximize the tensioning on the tibial side, we're not going to bottom out with a socket that's 30 millimeters in length. Typically, there's 20 millimeters of graft in the femur, 25 intra-articulately, and then 25 in the tibial socket. You can see the 30-millimeter socket would give you plenty of play for full tensioning. Prior to retrieving the lead suture from the tibial tunnel, the medial portal is enlarged slightly, and then in a single pass, the tibial suture is retrieved with the femoral lead suture out the medial portal to avoid creating a tissue bridge. You can see in the image on the right that the femoral and tibial lead sutures exit the medial portal. Next, the graft is loaded through the medial portal. You can see that the lead sutures are used to pull the button up through the medial portal, through the knee joint, until it engages the femoral cortex. And then this can be tensioned some, such that some of the graft is pulled in also through the medial portal. I do like to confirm that the button has exited the femoral cortex and ideally is deep to the IT band and opposed to the femoral cortex before any further tensioning is done. I do this by viewing with my arthroscope through the percutaneous distal lateral femoral incision. At this point, the graft is then dunked into the tibial socket utilizing the lead tibial suture. And it's important to dunk a suture that is tied to the tensioning suture loop so that you don't accidentally tension your suture loops as you're dunking. Here you can see the graft being dunked into the tibial tunnel. Sometimes this will create a suction-type sound or sensation as the graft dunks. And you can visualize the graft and make sure that it is fully seated in the tibia. And then the graft can be tensioned on the femoral side, which is depicted in the images on the right. You can see where it's partly tensioned and then fully tensioned by shortening the femoral loop fully. Tibial fixation and tensioning is completed utilizing the tensionable suture loop and a button that is loaded onto it. I do like to place a small entrenchment. I typically use the trocar from the scope behind the button to keep the limbs symmetric as I'm tensioning it down. And then I pull it out at the end. And then the button is tensioned firmly on the intact cortex, which overlies just the small entry point for creation of the incomplete tibial socket. Typically tension over a small bump at 20 degrees of flexion. And then assess final stability to see if I want to add any additional backup fixation suture anchor. You can also go back and tension on both sides to make sure both sides are fully tensioned at this time. The final construct has this appearance with the button on the femur as well as the tibia and the fully tensioned graft interarticular.

ACL reconstruction

quadrupled semitendinosus

quadriceps autograft

graft tensioning

graft fixation

autograft

suspensory fixation

graft preparation

surgical techniques