The following is a surgical demonstration for an all-in-side ACL reconstruction to be done with a carcerous tendon autograft. In this case, the graft diameter is nine millimeters, and this is the left knee. As you can see, I'm going to create my thermal socket drilling through the anteromedial portal, which I generally do with the knee flexed to approximately 115 degrees of flexion. It allows a soft set guide to ensure optimal placement of the graft on the thermal side, but also to make sure I have a good back wall. So I drill my pin partway, then I remove the guide, as seen here, and then I drill my pin the rest of the way across the femur to measure the neurosis distance. I then ream with my low-profile nine-millimeter reamer over the guide pin to an appropriate depth to accommodate at least 20 millimeters of graft, ultimately in the thermal socket. Then utilize this pin to pull a passing suture to the thermal socket. I then bring the knee to 80 degrees or so of flexion and create my tibial socket through a small anteromedial incision. I drill my guide pin through the guide in an optimal position, evident with the retained ACL fibers for the footprint here, which also corresponds to the anterior attachment of the lateral miscus. I then remove the guide, open up the cutter to nine millimeters, and I retrocut the tibial socket generally to about 20 submillimeters to allow sub-millimeters extra for graft tensioning, but 20 millimeters of graft in the tibia. I pass a black-and-white passing suture to the tibia, retrieve it with a blue passing suture from the femur together to avoid a soft tissue bridge to the anteromedial portal. I measure the neurosis distance, so I mark that on my graft, again, to ensure I do not bottom out when I pass my graft in both sockets. Here's my suspension fixation button on the femur. With the passing suture here, flip this button on the latoformal cortex, hoist the graft to a depth of 20 millimeters into the femur, then I shuttle the tibia into the graft, now pulling at least, again, 20 millimeters of graft in the tibial socket. I apply my suspension button, and with the knee fully hyperextended with the handles, I secure my tibial fixation, then cycle the knee vigorously 20 times to eliminate any creep in the construct, and then I re-tension with the tensioning handles applied to the femur first, again, with the knee fully hyperextended, and then one more time in the tibia to complete my re-tensioning process in full hyperextension. Looking at stability of the joint, the Lachman test is now negative, as is the pivot shift and the anterior drawer. You can see the final construct, excellent position across the joint with excellent tautness. We do not routinely do a notchplasty, and you can see there is no sign for any impingement here with this graft.

ACL reconstruction

patellar tendon autograft

femoral socket

tibial socket

suspension fixation buttons

arthroscopic ACL reconstruction

carcerous tendon autograft

femoral and tibial socket

stability tests