Arthroscopic Anterior Cruciate Ligament Reconstruction: All-Inside Double-Socket Approach

Abstract

The normal anterior cruciate ligament (ACL) has intraarticular attachments that sense no bone tunnels. Ideally, an ACL substitute should be positioned and fixed at these normal attachment points. Prior studies have defined the precise attachment points of the ACL, which has led to guidelines for reproducible tunnel positioning to these locations for ACL reconstruction.^1–7 These studies have focused on the importance of precise anatomic tunnel positioning, but recently the position of graft fixation as it relates to resultant graft forces, graft elongation, and creep with early postoperative range of motion has become an important issue.^5,6,8 Morgan et al⁵ have reported that fixation testing points at the anatomic attachment points of the original ACL were nearly isometric when compared to the peripheral fixation points either within or external to traditional ACL reconstruction bone tunnels. The difference between anatomic and nonanatomic fixation on the tibial side with a common anatomic femoral fixation point was 3 to 5 mm. Ishibashi et al⁸ have also reported that tibial fixation close to the tibial plateau resulted in the most stable reconstructed knee, with increasing instability as the level of fixation moved away from the tibial plateau. Using a common anatomic femoral fixation site, the displacement of the tibia increased and the in-situ force of the ACL graft decreased as the tibial fixation site moved further away from the tibial plateau in ACL-reconstructed knees.