To the Editor:
In response to the recent Technical Note by James H. Lubowitz, M.D.,
1
I submit to you an alternative “all-inside” technique for socket-based (tibia and femur) anterior cruciate ligament (ACL) reconstruction. My preferred technique features femoral socket preparation via the anteromedial (AM) portal2
with femoral-side graft fixation via a bioabsorbable cross-pin (Bio-TransFix; Arthrex, Naples, FL)3
and a retrocut tibial socket (drilled from inside the joint to create the tibial socket) with tibial fixation via a retrograde interference screw as described by Morgan et al.4
The graft is either hamstring autograft or anterior tibialis tendon allograft.Femoral socket preparation through the AM portal ensures the advantage of reliable socket placement at the anatomic origin (2-o’clock position for a left knee and 10-o’clock position for a right knee) independent of tibial socket preparation.
2
The goals of the approach are to identify what I term the “under-the-wall” position and then, using an awl to make a hole above that point based on the proposed diameter for the femoral socket, to ideally leave approximately 0.5 mm intact for the tunnel floor. Such a socket position allows a dual limb graft (tibialis allograft) to be placed corresponding to the AM and posterolateral ACL bundles (similar to a technique proposed by Caborn and Chang5
), which are later suspended by the cross-pin.The technical advantages of this technique include femoral socket preparation and fixation independent of tibial socket or tunnel preparation, strong fixation,
3
, 6
a limited number of incisions, and alleviation of excessively long bone tunnels in the tibia.1
Our experience with limited-incision all-inside ACL reconstructions has also shown clinical benefit relative to much less need for postoperative analgesia, faster return to work and daily activities in the short term, and a decreased number of supervised physical therapy visits for cost savings. We continue to monitor the outcome of these patients functionally. At this early term of follow-up, we are pleased by our promising results.
References
- No-tunnel anterior cruciate ligament reconstruction: The transtibial all-inside technique.Arthroscopy. 2006; 22 (Available online at www.arthroscopyjournal.org): 900.e1-900.e11
- Femoral tunnel position in anterior cruciate ligament reconstruction using three techniques: A cadaver study.Arthroscopy. 1999; 15: 750-756
- Mechanical properties of soft tissue femoral fixation devices for anterior cruciate ligament reconstruction.Am J Sports Med. 2004; 32: 635-640
- Anatomic tibial graft fixation using a retrograde bio-interference screw for endoscopic anterior cruciate ligament reconstruction.Arthroscopy. 2002; 18: E38
- Single femoral socket double-bundle anterior cruciate ligament reconstruction using tibialis anterior tendon: Description of a new technique.Arthroscopy. 2005; 21 (Available online at www.arthroscopyjournal.org): 1273.e1-1273.e5
- Biomechanical comparison of the bioabsorbable Retroscrew system, Bioscrew Xtralok with stress equalization tensioner, and 35-mm Delta screws for tibialis anterior graft–tibial tunnel fixation in porcine tibiae.Am J Sports Med. 2005; 33: 1057-1064
Article info
Identification
Copyright
© 2007 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.
ScienceDirect
Access this article on ScienceDirectLinked Article
- No-Tunnel Anterior Cruciate Ligament Reconstruction: The Transtibial All-Inside TechniqueArthroscopyVol. 22Issue 8
- PreviewThe purpose of this technical note is to describe the transtibial all-inside anterior cruciate ligament (ACL) reconstruction technique. This technique combines the advantages of previously described but technically demanding all-inside ACL reconstruction techniques with the ease and familiarity of transtibial guide pin placement. The all-inside technique uses bone sockets as opposed to bone tunnels in both the femur and the tibia and represents a “no-tunnel” technique. When performed with allograft tissue, the method requires only arthroscopic portals and percutaneous guide pin passage.
- Full-Text
- Preview
