Arthroscopic anatomical double-bundle anterior cruciate ligament reconstruction for asian patient using a bone-patellar tendon-bone and gracilis tendon composite autograft: a technical note.

Abstract

Recent years have seen anterior cruciate ligament (ACL) reconstruction being performed in a broad range of patients, regardless of age, sex and occupation, thanks to great advances in surgical techniques, surgical instruments and basic research. In cases of ACL reconstruction, bone-patellar tendon-bone (BTB) graft or hamstring graft are frequency used. However, potential complications associated with tunnel enlargement due to soft tissue graft such as hamstring were reported. On the other hand, an altered rotational axis resulting in significantly greater translation of the lateral compartment in the single bundle compared with double bundle ACL reconstruction was reported.
A reconstruction procedure was modified for the ACL using a double bundle that is the combination of BTB and gracilis tendon composite autograft. Two tibial and two femoral bone tunnels are used to reconstruct two bundles of ACL; an anteromedial bundle (AMB) and a posterolateral bundle (PLB). The femoral bone tunnels are created just posterior to the resident's ridge. The tibial bone tunnels are created at the center of AM and PL tibial attachment, respectively. BTB is fixed in the AM tunnels produced on the anatomical points of tibia and femur. The gracilis graft is fixed in an anatomical PL tunnel produced. The mean width of BTB is 7 mm, since10 mm graft is sometimes not suitable for patients, especially small Asian people and females. For these patients, 10 mm graft is bigger than one third of patella tendon width.
The devised surgical procedure based on a combination of BTB and gracilis autograft is suitable reconstruction method for patients who have small or medium width of patellar tendon such as Asian people and females. This technique is also applicable to revision surgery.

Full text

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RESEARCHOpen Access
Arthroscopic anatomical double-bundle anterior
cruciate ligament reconstruction for asian patient
using a bone-patellar tendon-bone and gracilis
tendon composite autograft: a technical note
Takuya Tajima*, Etsuo Chosa, Keitaro Yamamoto and Nami Yamaguchi
Abstract
Background: Recent years have seen anterior cruciate ligament (ACL) reconstruction being performed in a broad
range of patients, regardless of age, sex and occupation, thanks to great advances in surgical techniques, surgical
instruments and basic research. In cases of ACL reconstruction, bone-patellar tendon-bone (BTB) graft or hamstring
graft are frequency used. However, potential complications associated with tunnel enlargement due to soft tissue
graft such as hamstring were reported. On the other hand, an altered rotational axis resulting in significantly
greater translation of the lateral compartment in the single bundle compared with double bundle ACL
reconstruction was reported.
Method and procedure: A reconstruction procedure was modified for the ACL using a double bundle that is the
combination of BTB and gracilis tendon composite autograft. Two tibial and two femoral bone tunnels are used to
reconstruct two bundles of ACL; an anteromedial bundle (AMB) and a posterolateral bundle (PLB). The femoral
bone tunnels are created just posterior to the resident’s ridge. The tibial bone tunnels are created at the center of
AM and PL tibial attachment, respectively. BTB is fixed in the AM tunnels produced on the anatomical points of
tibia and femur. The gracilis graft is fixed in an anatomical PL tunnel produced. The mean width of BTB is 7 mm,
since10 mm graft is sometimes not suitable for patients, especially small Asian people and females. For these
patients, 10 mm graft is bigger than one third of patella tendon width.
Conclusion: The devised surgical procedure based on a combination of BTB and gracilis autograft is suitable
reconstruction method for patients who have small or medium width of patellar tendon such as Asian people and
females. This technique is also applicable to revision surgery.
Keywords: Anterior cruciate ligament, Double bundle reconstruction, Resident?’?s ridge, Bone patellar tendon bone
graft, Gracilis tendon graft
Introduction
Anterior cruciate ligament (ACL) injury is a common
injury in sports activity. In most cases, ACL laxity
causes knee joint instability in sports activities such as
cutting or pivoting, which can lead to articular cartilage
degradation and/or meniscus injury. ACL reconstruction
is also often needed to prevent secondary osteoarthritis
[1-3].
Recent years have seen ACL reconstruction being per-
formed in a broad range of patients, regardless of age,
sex and occupation, thanks to great advances in surgical
techniques, surgical instruments and basic research [4].
In cases of anterior cruciate ligament reconstruction,
bone-patellar tendon-bone (BTB) graft or hamstring
graft are frequency used [5-9]. However, potential com-
plications associated with tunnel enlargement due to
soft tissue graft such as hamstring were reported
* Correspondence: kingt2@hotmail.com
Division of Orthopedic Surgery, Department of Medicine of Sensory and
Motor Organs, Faculty of Medicine, University of Miyazaki, 5200 Kihara,
Kiyotake, Miyazaki 889-1692, Japan
Tajima et al. Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology 2012, 4:9
http://www.smarttjournal.com/content/4/1/9
© 2012 Tajima et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.

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[10,11]. In cases of ACL reconstruction with BTB graft,
the bone tunnels are filled with bone plug in order to
decrease the risk of tunnel enlargement. On the other
hand, an altered rotational axis resulting in significantly
greater translation of the lateral compartment in the sin-
gle bundle compared with double bundle ACL recon-
struction was reported [12]. To meet these necessities,
the reconstruction method was modified using a double
bundle technique with BTB and gracilis autograft. BTB
corresponds to the anteromedial bundle of the ACL,
and gracilis tendon corresponds to the posterolateral
bundle of the ACL; this technique presents an alterna-
tive method for anatomical double bundle ACL recon-
struction. Written informed consent was obtained from
the patient for publication of this report and any accom-
panying images.
Surgical procedures
Arthroscopic evaluation
Surgery is performed under general anesthesia with the
patient in supine position on the operating table. The
arthroscopy is inserted into the joint cavity through the
anterolateral portal which is adjacent to external edge of
the patellar tendon. The ACL remnant, meniscus and
articular cartilage conditions are carefully confirmed.
Graft harvesting and preparation
Two transverse skin incisions are made in the ipsilateral
knee. A 3 cm long proximal incision is placed on the
distal side of the patella and a 4.5 cm long distal inci-
sion on the tibial tuberosity (Figure 1). A central third
of the patellar tendon with attached patellar and tibial
bone plug autograft is harvested with subcutaneous tun-
neling technique with the aim of leaving the infrapatel-
lar nerve undamaged and the major part of the
paratenon nonincised according to Kartus’s method
[13], and is harvested with following dimensions; a rec-
tangular shaped bone plug on patella of width 7 mm,
length 20 mm, and depth 7 mm. The defect in the ten-
don is left open. Both sides of the tissue sample are
trimmed and prepared to allow it to pass easily within
the 7 mm diameter. EndoButton-CL-BTB (Smith &
Nephew, Andover, MA) is attached on the femoral side
through the 1.8 mm diameter hole which is created on
the bone plug, and 2 FiberWires (Arthrex, Naples, FL)
are attached on the tibial side.
Gracilis tendon graft harvesting is performed through
the same distal incision which is described above. Sar-
torius fascia is incised along the course of the gracilis.
Gracilis tendon is mobilized using blunt finger dissec-
tion. Once the tendon is free from adhesion, gracilis
tendon is harvested using a tendon stripper. The double
or triple folded gracilis tendon is carefully prepared to
allow it to pass within the 5 or 5.5 mm diameter. Endo-
button-CL (Smith & Nephew, Andover, MA) is attached
on the femoral side. The baseball grove suture with a
fiberwire is performed on the tibial side
Notch preparation
The anteromedial portal and an additional accessory far
anteromedial portal are made. The soft tissues in the
notch are roughly excised with punch or mechanical
instruments. The remaining fibrous tissues on the lateral
notch wall are delicately removed using radiofrequency
device. Care was taken to completely preserve undula-
tion of the bony surface around the attachment area.
After clearage of the lateral notch wall, a meticulous
effort is made to find out a linear ridge in posterior
one-third of the lateral notch wall. The bony ridge
called resident’s ridge is a useful landmark for anatomi-
cal femoral tunnel drilling in arthroscopic ACL recon-
struction [14]. Usually, notch plasty is not performed.
Tunnel preparation
For femoral tunnel preparation, a guide pin is inserted
using the ACL guide system into the joint from the far-
medial portal. Two independent sockets and tunnels are
created just posterior to the resident’s ridge in inside-
out fashion with the knee flexed beyond 135 degree.
After tunnels are drilled using a 4.5 mm cannulated
Figure 1 Skin incision. Two transverse skin incisions and harvested
bone patellar tendon bone (BTB) graft. A 3 cm long proximal
incision is placed on the distal side of the patella, and a 4.5 cm
long distal incision on the tibial tuberosity.
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reamer along the guide pin, a tunnel of anteromedial
bundle of width 7 mm, and a tunnel of posteolateral
bundle of width 5-5.5 mm are created using a transpor-
tal technique (Figure 2). A tunnel of anteromedial bun-
dle is positioned at the 1:30-o’clock orientation for the
left knee or at 10:30-o’clock for the right knee [4]. A
tunnel of posterolateral bundle is positioned at the 2:30-
0’clock orientation for the left knee or at 9:30-o’clock
for the right knee.
To insert a guidewire for tibial tunnel preparation, a
tibial aimer (Smith & Nephew, Andover, MA) was used.
The aimer tip portion is introduced into the joint cavity
through the medial infrapatellar portal with the knee
flexed 90 degree. The tibial aimer tip portion is placed
at the center of the posteolateral bundle attachment on
the tibia, which is located at the most posterior aspect
of the area between the tibial eminences, and 5 mm
anterior to the posterior cruciate ligament at the anato-
mical positions proposed by Yasuda et al. [4]. A guide
wire 2 mm in diameter is drilled in the tibia. Next, a
guide wire for the anteromedial bundle is inserted with
the same aimer. The tibial aimer tip portion is placed at
the center of the tibial attachment of the anteromedial
bundle. Careful observation is made to confirm that the
guide wires are placed at right position and do not
penetrate the medial collateral ligament. Two indepen-
dent bone tunnels are created; a tunnel of anteromedial
bundle of width 7 mm, and a tunnel of posteolateral
bundle of width 5-5.5 mm (Figure 3).
Graft passage and fixation
The gracilis tendon graft for the posterolateral bundle is
introduced through the tibial tunnel to the femoral
tunnel using a passing pin. The Endobutton is flipped
on the femoral cortical surface. Next, the BTB graft for
the anteromedial bundle is placed in the same manner.
Thus, the 2 bundles are intra-articularly placed with def-
ferent directions (Figure 4). The bone plug in the ante-
romedial tibial tunnel is fixed with 6-7 mm Softsilk
screw (Smith & Nephew, Andover, MA) with the knee
in 20 degree of flexion applying maximum manual trac-
tion. An assistant surgeon simultaneously applies a ten-
sion of 40 N to the gracilis tendon graft for
Figure 2 Femoral tunnels. Arthroscopic findings of position of the
femoral tunnels. Two independent bone tunnels are created just
behind the resident’s ridge.
Figure 3 Tibial tunnels. Arthroscopic findings of position of the
tibial tunnels. Two independent bone tunnels are created in the
attachment of anterior cruciate ligament (ACL) The length of the
tunnel is measured with scaled probe, and suitable size of
Endobutton-CL and CL-BTB are determined, respectively.
Figure 4 Arthroscopic findings of reconstructed ACL double
bundle.
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posteolateral bundle in the tibial tunnel using the tensi-
ometer, and the graft is fixed to tibia using double spike
plate system (Meira, Aichi,Japan) with the knee in a
position of 20 degree flexion (Figure 5A and 5B).
Discussion
Recently, ACL reconstructive procedures such as endo-
scopic anatomical double bundle technique using ham-
string graft which are passed through two tibial and two
femoral bone tunnels have improved and reported excel-
lent outcome [4]. Moreover, in Bedi’s report, an altered
rotational axis resulted in significantly greater transla-
tion of the lateral compartment in the anatomical cen-
ter-center single bundle ACL reconstruction compared
with anatomical double bundle ACL reconstruction [12].
On the other hand, patients with ACL deficient knees
that were treated with hamstring graft showed tunnel
widening [10,11]. BTB is one of the popular grafts used
for ACL reconstruction. The advantages of using the
BTB graft include strength, ready availability, strong
bone to bone fixation, and prompt healing of the bone
plugs. However, sometimes, over 10 mm graft is not sui-
table for patients, especially small Asian people and
females. For these patients, 10 mm graft is bigger than
one third of patella tendon width [15].
The present procedure is anatomical graft route dou-
ble bundle reconstruction using 7 mm BTB graft for
anteromedial bundle. BTB with a bone block at the both
ends of graft is applied to minimize tunnel enlargement.
The disadvantage and limitation of present procedure is
not only harvesting the gracilis tendon, but also the
BTB, which thus increases the risk of harvest site mor-
bidity. However, the Sartorius and semitendinosus ten-
dons will function well and that graft site morbidity can
be minimized if the gracilis tendon alone is harvested.
In terms of the tension load for soft tissue graft in dou-
ble bundle ACL reconstruction, manual maximum does
not recommended [16]. However, the tension load for
BTB graft in double bundle technique is still controver-
sial. In the present procedure, BTB graft is applied with
maximum manual traction according to Hara’s method
[17]. After an average 15 months follow-up of sixteen
Asian patients (thirteen males and three females) treated
using this technique, the preliminary post-operative clin-
ical results showed no definite laxity. The bone tunnel
enlargement was not observed at radiological examina-
tion. However, in the future, long term clinical and radi-
ological studies as well as a biochemical study will be
required.
There have been several reports on reconstructing
techniques using BTB and hamstring for the ruptured
ACL [17,18]. However, these procedures did not repre-
sent an anatomical reconstruction in a tunnel position
or routes strictly. Moreover, 10 mm BTB graft is bigger
than one third of patella tendon width of Asian patient.
To solve these problems, an anatomical double bundle
ACL reconstructive procedure using BTB and gracilis
composite autograft was modified and improved.
Figure 5 A and B Postoperative radiograph. A: anterior to posterior view, B: lateral view.
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Conclusion
This modified technique uses a BTB and gracilis compo-
site autograft for anatomical double bundle ACL recon-
struction. The present procedure can have advantages of
using BTB graft for double bundle technique, and
reduce the risk of tunnel enlargement. It would be a
useful treatment method for those ACL deficient
patients who have small or medium width of patella ten-
don such as Asian people or females. This technique is
also applicable to revision surgery.
Abbreviations
ACL: Anterior cruciate ligament; BTB: Bone-patellar tendon-bone; AMB:
Anteromedial bundle; PLB: Posteromedial bundle.
Authors’ contributions
TT participated in the design of the study and performed surgery. KY and
NY carried out surgery. EC participated in the design and coordination. All
authors read and approved the final manuscript.
Authors’ information
M.D, Ph.D
Assistant professor of Division of Orthopedic Surgery, Department of
Medicine of Sensory and Motor Organs, Faculty of Medicine, University of
Miyazaki
Member of Japanese Orthopaedics Society
Member of Japanese Orthopaedics Society for Sports Medicine
Member of Japanese Society of Clinical Sports Medicine
Member of Japanese Orthopaedics Society Knee, Arthroscopy and Sports
Medicine
Competing interests
The authors declare that they have no competing interests.
Received: 20 June 2011 Accepted: 14 March 2012
Published: 14 March 2012
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doi:10.1186/1758-2555-4-9
Cite this article as: Tajima et al.: Arthroscopic anatomical double-bundle
anterior cruciate ligament reconstruction for asian patient using a
bone-patellar tendon-bone and gracilis tendon composite autograft: a
technical note. Sports Medicine, Arthroscopy, Rehabilitation, Therapy &
Technology 2012 4:9.
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