Tibial bone bridge and bone block fixation in double-bundle anterior cruciate ligament reconstruction without hardware: a technical note

Current techniques for tibial graft fixation in four tunnels double bundle (DB) anterior cruciate ligament (ACL) reconstruction are by means of two interference screws or by extracortical fixation with a variety of different implants. We introduce a new alternative tibial graft fixation technique for four tunnels DB ACL reconstruction without hardware. About 3.5 to 5.5 cm bone cylinder with a diameter of 7 mm is harvested from the anteromedial (and posterolateral) tibial bone tunnel (s) with a core reamer. The anteromedial (AM) and posterolateral (PL) hamstring tendon grafts (or alternatively tendon allografts) are looped over an extracortical femoral fixation device and cut in length according to the total femorotibial bone tunnel length. The distal 3 cm of each, the AM- and PL bundle graft are armed with two strong No. 2 nonresorbable sutures and the four suture ends of each graft are tied to each other over the 2 cm wide cortical bone bridge between the tibial AM and PL bone tunnel. In addition the AM- and/or PL bone block which was harvested at the beginning of the procedure is re-impacted into the two tibial bone tunnels. A dorsal splint is used for the first two postoperative weeks and physiotherapy is started the second postoperative day. The technique is applicable for four tunnels DB ACL reconstruction in patients with good tibial bone quality. The strong fixation technique preserves important tibial bone stock and avoids the use of tibial hardware which knows disadvantages. It does increase tendon to bone contact and tendon-to-bone healing and does reduce implant costs to those of a single bundle (SB) ACL reconstruction. Revision surgery may be facilitated significantly but the technique should not be used when bony defects are present. In case of insufficient bone bridge fixation or bone blocks hardware fixation can be applied as usual.