Interlinked Hamstrings for Combined ALL and ACL Reconstruction: A Novel Technique

Coimbatore, India: Santosh Sahanand et al described a novel technique which is simple, easily reproducible and avoids additional implants for ALL in the tibia. The study " combined ACL and ALL reconstruction with a novel anatomic technique using hamstring tendon autograft and fixed loop suspensory device" was published in Indian Journal of Orthopaedics.

25 patients who underwent combined reconstruction of ACL and ALL were evaluated retrospectively. International Knee Documentation Committee (IKDC) Score, Tegner Lysholm Knee Score, grade of pivot shift was assessed at a final follow-up.

Graft Harvest and Preparation Semitendinosus tendon (ST) and gracilis tendon (GT) are harvested through a 4 cm oblique anteromedial incision over the proximal one-third of the tibia. ST is quadrupled and loaded with a suspensory device. GT is prepared as a single bundle with Krakow stitches at either end using fibre wire. Length of GT (GT1) equaling quadrupled ST is incorporated with it to reconstruct ACL and the remaining portion of GT (GT2) is passed through the loop of the suspensory device to recreate ALL. This configuration allows obtaining 8 mm diameter for ACL and 4.5 mm diameter for ALL graft which gives a press fit for GT2.

Common Femoral ACL and ALL Tunnel Lateral wall of the intercondylar notch is prepared and a common femoral tunnel is drilled in an inside-out manner using free-hand technique creating a anatomical femoral tunnel. The entry of femoral tunnel is either at 2 or 10'o clock position for left and right knee, respectively. The tunnel is drilled so that it exits proximal and posterior to the lateral femoral epicondyle, which is the femoral footprint for ALL which is visualized later after graft passage using the scope through the stab incision, thus confirming tunnel position of GT2.

Tibial tunnel for ACL is made using standard ACL tibial aimers. The tibial tunnel for ALL is made using an ACL tibial aimer, with its tip placed mid way between Gerdy's tubercle and fibular head around 10 mm below the joint line. Sleeve of the aimer is placed on the medial aspect of the knee just below the reamed ACL tibial tunnel and avoiding tunnel convergence. ALL tibial tunnel is reamed to a diameter of 4.5 mm. Graft Passage and Fixation Once tunnels have been drilled to respective graft diameters, a wire loop is passed through both ACL tibial and femoral tunnels. The loop is then retrieved from the femoral side through a small stab incision and iliotibial (IT) band is split. The hamstring graft is then shuttled by using the loop with ALL graft in front and ACL graft behind. Once ALL graft has exited the femur, endobutton is flipped for ACL graft femoral fixation. Interference screw is used for tibial fixation of ACL graft in 30° knee flexion. It is to be noted that since ALL graft is being passed through the loop of endobutton, it will remain fixed under the endobutton once it is flipped which is confirmed by direct visualization using the scope through the stab incision.

ALL graft is tunneled under IT band and passed through tibial ALL tunnel. Fibrewire sutures of ALL graft is tied under appropriate tension to ethibond suture threads of ACL graft near tibial tunnel over the bony bridge between the two tunnels with the knee in full extension and neutral rotation without using additional implants for fixation.

Postoperative Course Radiographs are taken post surgery to ensure proper tunnel position. Patients are allowed to do partial weight-bearing mobilization with brace for first 3 weeks. Knee bending is started on day 1 and gradually increased to 90° by the end of the third week. For the first 3 months, open chain exercises with band, closed chain exercises and core exercises are initiated. Patients are allowed to return to sports usually at the end of 9 months.

Further reading:

Interlinked Hamstrings for Combined Anterolateral and Anterior Cruciate Ligament Reconstruction: A Novel Technique for ALL

Santosh Sahanand, Ankit Jose et al

Indian Journal of Orthopaedics (2022) 56:621–627

https://doi.org/10.1007/s43465-021-00551-x