No-tunnel anterior cruciate ligtament reconstruction: The transtibial all-inside technique

The purpose of this technical note is to describe the transtibial all-inside anterior cruciate ligament (ACL) reconstruction technique. This technique combines the advantages of previously described but technically demanding all-inside ACL reconstruction techniques with the ease and familiarity of transtibial guide pin placement, The all-inside technique uses bone sockets as opposed to bone tunnels in both the femur and the tibia and represents a no-tunnel technique. When performed with allograft tissue, the method requires only arthroscopic portals and percutaneous guide pin passage. In such cases, this represents a no-incision ACL reconstruction. The technique requires the use of a Dual Retrocutter (Arthrex, Naples, FL). This cannulated (trill is placed via the anteromedial arthroscopic portal and threads onto a transtibial, percutaneous, reverse-threaded guide pin. Because the (trill is assembled arthroscopically (within the joint), a skin incision is not required. The Dual Retrocutter is capable of retrograde and antegrade drilling. Thus, a single Dual Retrocutter achieves transtibial drilling of both tibial and femoral bone sockets. The transtibial all-inside technique may be performed with the use of any ACL graft option. Graft diameter should equal socket diameter. To prevent the graft from, bottoming-out during, tensioning and fixation, graft length must be less that) the sum of combined femoral plus tibial socket lengths plus ACL intra-articular distance. During the teaming curve, surgeons may choose to wait until the sockets have been prepared, so that graft length need not be estimated. If the graft is prepared before arthroscopic surgery is performed, a 79-mm graft length could be recommended as ideal. To prepare for graft passage, both femoral and tibial graft passing suture loops must be brought out the anteromedial arthroscopic portal without soft tissue interposition between or within the loops. To prepare for graft fixation, a nitinol wire must be brought into the joint via the transtibial, percutaneous guide pin tract for the purpose of guiding the introduction of a cannulated Retroscrewdriver. All of these goals may be accomplished in a single pass. The graft is fixed with femoral and tibial Retroscrews. Back-up fixation is optional and may be achieved by tying sutures over small, percutancously placed cortical buttons. Advantages of this technique may result from anatomic graft fixation at the levels of the femoral and tibial joint fines and from retrograde screw fixation, which may eliminate interference screw divergence and increase graft tension when the retrograde screw is advanced. Additionally. because this technique minimizes skin incisions and eliminates open bone tunnels, patients may experience decreased pain, more rapid return to function, and improved cosmesis.