Anterior cruciate ligament (ACL) is one of the most vulnerable ligaments of athletes' knee joints, about 200,000 people suffered ACL lesions every year in the United States. In the current trends, ACL reconstruction (ACLR) is the standard surgical procedure for restoring the patients’ knee stability[2-4]. To the best of our knowledge, ACLR with preservation of tibial stump have been more accepted among the majority of orthopedists. Because it has some theoretical advantages, such as accelerating the reconstructed ACL revascularization, ligamentation, the restoration of proprioceptive feelings and the healing of the graft[5-9].
Since the early 1990s, ACL repair has been proposed to treat the ACL injuries. Although having good outcomes in the early follow-up, not with promising mid-term results, this technique was forgotten. But now ACL repair has been recommended again.
So we aim to provide a new technique of combining the ACL reconstruction and repair together which can theoretically providing the best benefits for patients. This technique is appropriate for those patients who has the proximal ACL avulsion, and is in the acute phase.
ACL femoral avulsions and good quality of ACL stump tissue are confirmed on magnetic resonance imaging and the patients are in the acute stage(<3 weeks)(Figure 1). When the above conditions are met, we will treat it with our new technique combining the ACL reconstruction and repair (Video and animation).
Preparing and patient positioning
After receiving the lumbar anesthesia, the patient is in the supine position waiting for surgery. Using a tourniquet at the base of the thigh routinely, we disinfect the whole injured leg including the foot. Then the single-use sterile towel is applicated for covering the disinfected leg. When beginning the operation, the injured leg is drapped at the operating table. All cases are operated by the same surgeon.
An anterolateral, anteromedial and parapatellar portals are made for diagnostic arthroscopy. Any chondral lesions and meniscus tears are examined under arthroscopy using the probe. Finally, the ACL femoral avulsions are confirmed (Figure 2).
The gracilis and semitendinosus are harvested for tendon graft. The harvested tendons are weaved for 4 or 5 or 6 strands so that its diameter is approximately 8 mm. A NO.2 high strength sutures are weaving at the both free ends of the tendon. According to the length of the femoral tunnel, we choose the adjustable-loop or fixed-loop cortical suspension devices.
After passing the hamstring tendon through the loop of the endobutton, we bind the tendon graft with a 2-0 absorbable suture preventing the multi-strands graft spreading.
At the center of the femoral footprint, the 2.0mm K wire is applied to drill the femoral tunnel and then the femoral tunnel is enlarged with the proper-size reamer. When the femoral tunnel is finished, A guide pin carrying a NO.5 suture pass through the femoral tunnel. The surgeon drill the tibial tunnel through the C-type guide.
Preparation of the ACL stump
One stich on the ACL stump is applicated with PDS suture using the SutureLasso and then the PDS suture is replaced with the NO.2 high strength suture. 1-2 stiches with the NO.2 high strength suture are on the ACL stump using the SutureLasso again (Figure 3). When the stiches are prepared, the passage of the NO.5 suture(for traction) and the NO.2 high strength suture through the tibial tunnel are finished by a grasper.
Pass the two free ends of the NO.2 high strength suture through the holes on the endobutton (Figure 4) and both the NO.2 high strength suture and traction suture on the endobutton pass through the loop of the NO.5 suture. Pull the NO.5 suture to allow the passage of all the sutures into the bone tunnel. At last, the tendon graft is introduced into the bone tunnel and tighten the high strength suture to pull the ACL stump to the femoral footprint (Figure 5). Finally, the high strength suture is knotted and fastened on the endobutton which is on the lateral femoral cortex. A peek interference screw is fixed in the tibial tunnel. Finally, check the reconstructed graft tension with a probe and Lachman test and anterior drawer test is done to check the knee stability.
For the first 3 months, we recommend the patients the use of a knee brace. In order to control the swelling and pain, ice packs are also advised. The range of the knee motion is restricted to 90° in the next three months. Nevertheless, full weight is permitted with the leg in extension when the patient can tolerate the pain without no stiches on the meniscuses. Straight leg lift exercises are encouraged. Two months after surgery, patients can go to the gym for muscle training. Three months after surgery, patients can remove braces and engage in non-confrontational activities such as jogging and swimming.