Arthroscopic Double Bundle Anterior Cruciate Ligament Reconstruction Using only the Semitendinosus Tendon

Injuries of the ACL are usually treated with arthroscopically assisted reconstruction harvesting the graft from the central third of the patellar tendon or the hamstring tendons.^1–3 During recent years, classic procedures have been focused on reconstituting the AM bundle with limited care to the possible residual pivoting instability. Recent biomechanical analysis on anatomically double bundle reconstructed knees demonstrates that anterior tibial translation is significantly closer to that of an intact knee and produces better rotator stability than classic ACL techniques.^4–16 At present, renewed interest is focused on the performance of an anatomic double bundle reconstruction technique that is supposed to be capable of achieving better knee stability, especially in terms of rotational control.^1,6,13 The authors describe a technique for a double bundle ACL reconstruction using the semitendinosus tendon alone, with less morbidity at the donor site.¹⁷

Surgical Technique
After spinal or general anaesthesia has been delivered, the patient is positioned supine on the operating table with the tourniquet placed at the proximal aspect of the thigh. A lateral support is placed at the level of the tourniquet cuff while a foot bar is positioned at the end of the table to enable the knee to be fixed at 90° flexion while, at the same time, allowing sufficient provision for full range of motion during surgery. Next, the tourniquet is inflated to 300mmHg and a 3cm vertical incision centered approximately 5cm below the medial joint line, midway between the tibial tubercle and the posteromedial aspect of the tibia, is performed. The sartorial fascia is incised and the semitendinosus tendon is dissected. The tendon’s accessory limbs are identified and freed prior to the use of an open tendon stripper to avoid cutting the tendon prematurely and allow complete detachment of the tendon from its proximal attachment. The distal limb of the tendon is then detached from its tibial insertion, saving as much length as possible. Measurement of the tendon follows. As long as the semitendinosus tendon measures at least 28cm the harvesting of the gracilis is avoidable.

Preparation of the Double Bundle Semitendinosus Graft
At the back table, while the femoral and tibial tunnels are being prepared, the surgical assistant prepares the double bundle graft. Graft preparation begins with the removal of all excess tissues attached to the semitendinosus tendon with the use of a curette. The tendon is then cut in half with each half folded and whipstitched at its end with Fiberwire sutures (Arthrex, Naples, FL). Once the depth of the femoral tunnels (AM and PL) is determined with the depth gauge, the appropriate sizes of the EndoButton® CL (Smith & Nephew Endoscopy, Andover, MA) needed are set aside. Then, with the endobutton attached, the diameter of each bundle is measured using 0.5mm increment sizers to correspond with the diameter of the femoral and tibial tunnels. The grafts are then pretensioned and pre-conditioned prior to implantation with cyclic flexion and extension of the knee under maximum manual tension.^2,3