Outside-in technique for creating the ACL femoral socket fell out of favor because the requirement for a lateral, distal, femoral, muscle splitting dissection results in a more invasive “2-incision” technique (7, 8, 24, 27). However, new technology, specifically narrow diameter guide pins that may be transformed into retrograde drills,(18, 25) allows “no-incision” outside-in techniques for creating the ACL femoral socket. Advantages of outside-in technique for creating the ACL femoral socket are that it is performed in the comfortable and familiar 90° knee flexion position (unlike AM portal technique); it is unconstrained, allowing independent, anatomic positioning of the femoral socket (unlike transtibial technique for drilling the femoral socket); and it may result in a longer socket (compared with AM portal technique) (18). In addition, outside-in drilling allows measurement of femoral interosseous distance prior to socket creation, using standard, outside-in femoral guides and guide pin sleeves. Premeasurement is a safety feature of the outside-in technique because a short distance may require that less graft tissue is contained within the femoral socket (28).

In addition to retrograde drilling pins, two additional technical developments simplify AI ACL reconstruction. The first development represents an evolution of cortical suspensory fixation button devices. First-generation cortical suspensory fixation buttons have fixed length graft loops, whereas second-generation cortical suspensory fixation buttons have graft loops that are adjustable in length, such that after the button flips and becomes fixed on the cortex, the graft loop may be tightened, pulling the graft in to the socket in a manner that completely fills the socket with graft substance. Furthermore, first-generation cortical suspensory fixation buttons were designed for femoral fixation, whereas second-generation adjustable graft loop buttons are effective for tibial (as well as femoral) fixation. Finally, second-generation adjustable graft loop buttons are unique in that when the graft loop is tightened, graft tension increases. Thus, for the first time, ACL surgeons may increase graft tension after the graft is fixed.

The second technical development that simplifies AI ACL reconstruction is the use of cannulas. Arthroscopic shoulder and hip surgeons have long understood the importance of cannulas for maintaining portals and preventing soft tissue from becoming intertwined in sutures. First, we recommend a cannula in the AM arthroscopic instrumentation portal to prevent soft tissue interposition. Second, we introduce a unique guide pin sleeve, which transforms into a cannula and maintains access to the narrow diameter guide pin tracks used to create AI sockets, allowing suture passage, and later graft passage, after ACL socket retroconstruction (6).

With regard to patient history, physical evaluation, imaging, classification and decision-making algorithms, AI ACL Graft-Link is not unique. Thus, the focus of this chapter will be on surgical technique, as described below. Of course, with any new surgical technique, patient education and appropriate informed consent with regard to risks, benefits, alternatives, and surgical and nonsurgical treatment options are of particular importance.

No-tunnel, AI socket ACL reconstruction using Graft-Link requires learning new graft preparation, socket creation, and graft fixation techniques. Graft preparation requires consideration of no-incision cosmesis when selecting graft sourceensuring that graft length (GL) is less than the sum of socket lengths (SLs) plus intra-articular graft distance so that the graft will not bottom out in the sockets during final graft tensioning, and learning the graft-link preparation technique. Femoral and tibial socket creation is with second-generation retrodrilling guide pins. Femoral and tibial fixation is with second-generation cortical suspensory fixation devices with pull sutures tensioning an adjustable graft loop.