Double-Bundle Anterior Cruciate Ligament Reconstruction

Thierry Pauyo

Marcio Bottene Villa Albers

Freddie H. Fu

Preoperative Considerations

• Anterior cruciate ligament (ACL) reconstruction should focus on the restoration of the ACL to its native dimensions, collagen orientation, and insertion sites, according to individual anatomy. This concept can be applied to single-bundle (SB) and double-bundle (DB) ACL reconstruction.¹

• Ultimately, the graft choice is based on graft characteristics and particularly on the estimated graft size. Based on the preoperative measurements of the tibial ACL footprint on sagittal and coronal cuts of the MRI, the native tibial footprint area is estimated (Fig. 48-1).²

• The target graft size is from 50% to 70% of the estimated native tibial insertion area.³ If the ACL footprint is more than 14 mm, a double-bundle ACL reconstruction is safe (Fig. 48-2).

Sterile Instrument/Equipment

• Tourniquet

• 30-degree arthroscopic camera

• Arthroscopic shaver

• ACL tibial guide

• Cannulated arthroscopic standard and flexible reamers

• Arthroscopic tunnel dilators

• Arthroscopic ruler

• Suspensory fixation for the femur

• Polyether ether ketone (PEEK) interference screw fixation for the tibia

Figure 48-1 | Sagittal (left) and coronal (right) MRI T2 of the injured ACL. The ACL footprint measures 22.6 mm, which is large enough to have a double-bundle ACL reconstruction.

Figure 48-2 | Reference table to decide between single- and double-bundle ACL reconstruction. The target graft size should be from 50% to 70% of the estimated native tibial insertion area. If the ACL footprint is more than 14 mm on the sagittal MRI, double-bundle ACL reconstruction is safe.

Positioning

• The patient is positioned supine, and the affected leg is placed in a circumferential leg holder (Fig. 48-3).

• Care is taken to pad all bony prominences, including the greater trochanter, the fibular head (peroneal nerve), and the elbow (radial nerve).

• A pneumatic tourniquet is placed on the upper thigh of the affected extremity.

• With the foot of the table dropped, the knee can be moved from full extension to 120 degrees of flexion.

• The affected leg is elevated for 3 minutes, and the tourniquet is inflated.

Figure 48-3 | The affected leg is placed in a circumferential leg holder.

Portals

• A three-portal technique is used to view the ACL footprint and perform the reconstruction.

• Anterolateral (AL), central (C), and accessory anteromedial (AAM) are used (Fig. 48-4).

• The AL portal is made first.

• It is just lateral to the patellar tendon and superior to the inferior pole of the patella.

Figure 48-4 | Portal placement of the three-portal technique for individualized anatomic double-bundle ACL reconstruction. Portals: AL, Anterolateral; AAM, accessory anteromedial; C, central.

• The C and AAM portals are placed under direct visualization with an 18-gauge needle.

• The C portal is placed along the medial border of the inferior patellar tendon.

• The 18-gauge needle should be in line with the native ACL.

• If this cannot be achieved, the C portal can be placed with a transtendinous technique.

▪ Care should be taken not to injure the intermeniscal ligament.

• The AAM portal is placed at the level of the joint line.

• This is ˜1.5 cm medial to the C portal.

• Debridement of the fat pad can improve viewing during placement of this portal.

• During portal placement, the spinal needle should:

▪ Pass safely above the medial meniscus

▪ Reach the center of the femoral ACL footprint

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