The purpose of the present paper is to describe the isoanatomical, single bundle, bone-patellar tendon-bone A3B-ACL reconstruction technique (A3B=Anatomical Bruderholz, Burkart, Biedert) in detail. The technical key factors and the pitfalls are highlighted. In addition, the pros and cons of the technique are discusse

Arnold, Markus

Biedert, Roland

Hirschmann, Michael

van Loon, Corné

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TECHNICAL NOTEIsoanatomical bone-patellar tendon-bone single-bundle ACLreconstruction: the wedge that gives the edge!Markus P. Arnold • Roland M. Biedert •Corne´ van Loon • Michael T. HirschmannReceived: 29 December 2010 / Accepted: 5 March 2011 / Published online: 22 March 2011 Springer-Verlag 2011Abstract The purpose of the present paper is to describethe isoanatomical, single bundle, bone-patellar tendon-boneA3B-ACL reconstruction technique (A3B = AnatomicalBruderholz, Burkart, Biedert) in detail. The technical keyfactors and the pitfalls are highlighted. In addition, the prosand cons of the technique are discussed.Keywords ACL reconstruction  Single-bundletechnique  Isoanatomical  Patellar tendon autograftIntroductionIn the early years of arthroscopic anterior cruciate ligament(ACL) reconstruction, most authors focused more ontechnical convenience than restoration of the nativeattachment of the ACL. These were the years of the pop-ular single-incision technique [1–3]. When it became clearthat the clinical results could be improved [4], it wasrealized that this single-incision technique did not restorethe native anatomy of the ACL. Instead of correctingthis obvious mistake, opinion leaders stepped from a non-anatomical single-bundle ACL reconstruction to muchmore complicated double- and even triple-bundle ACLreconstruction techniques [5–7]. These techniques havebeen promoted in particular by the industry, as at leasttwofold fixation devices are needed. A tremendous effortwas undertaken to prove the biomechanical and clinicalsuperiority of the double-bundle ACL reconstructiontechniques, but to date the evidence is weak [8, 9].In the meantime, others have developed well function-ing, relatively simple, reproducible, anatomical single-bundle ACL reconstruction techniques [10–15]. The prin-ciples of this technique have been proven by several ana-tomical and biomechanical studies [10, 16–18]. Althoughthere is a considerable body of scientific data on thetreatment of ACL lesions, the optimal surgical methodstill seems to be more a matter of preference than evidence[19–21].The purpose of the present paper is to describe theisoanatomical, single bundle, bone-patellar tendon-boneA3B-ACL-reconstruction technique (A3B = AnatomicalBruderholz, Burkart, Biedert) in detail. The technical keyfactors and the pitfall are highlighted. In addition the prosand cons of the technique are discussed.Technical notePreoperative testing and positioning of the patientBefore ACL reconstruction, the ligament laxity is testedusing the pivot shift and Lachman‘s test. The patient ispositioned supine. The thigh is put in a leg holder with thelower leg hanging, and the distal femur orientated hori-zontally. A tourniquet is used, which is put approximately10 cm proximally to the patella.M. P. Arnold (&)  M. T. HirschmannDepartment of Orthopaedic Surgery and Traumatology,Kantonsspital Bruderholz, 4101 Bruderholz, Switzerlande-mail: markus-p.arnold@unibas.chR. M. BiedertSportclinic Villa Linde, 2503 Biel, SwitzerlandC. van LoonRijnstate Ziekenhuis, NL 6815 AD Arnhem, The Netherlands123Eur J Orthop Surg Traumatol (2012) 22:77–80DOI 10.1007/s00590-011-0793-yHarvesting and preparation of the graftFor harvesting of the bone-patellar tendon-bone autograft,a longitudinal incision at the lateral border of the patellartendon starting from the distal pole of the patella to a pointapproximately 3 cm distally to the tibial tuberosity isperformed. Then, the paratenon is incised in its midline andbluntly separated from the patellar tendon. A 10-mm-widecentral strip of the patellar tendon is prepared. Beforeharvesting of the proximal bone block, two 1.8-mm drillholes are made in the proximal corners of the block in orderto avoid fracturing of the patella while harvesting the graft.The preparation of the proximal bone block (10 mm widthdistally, converging to 8 mm proximally, length of theblock about 14 mm) is finished using an 8-mm oscillatingsaw and 8-mm osteotome.The bone block and the proximal patellar tendon arearmed with two resorbable sutures each (Vicryl 0, Johnson& Johnson, Spreitenbach, Switzerland). The knot is placedon the most proximal edge of the bone block. Then, thepatellar tendon is excised down to the bursa just proximalto the tibial tuberosity. The surgical key factor here is thatat the patellar tendon is incised using a cone-shaped metaltemplate. The preparation of the distal bone block (10 mmwide at the tendon’s side, 20 mm long, diverging distally to13 mm width) is finished using an 8-mm oscillating sawand 10-mm osteotome, resulting in a three-dimensionalconical wedge-shaped bone block. The bone block theneasily enters the 10-mm femoral tunnel, and the proximalbone block interlocks with the tunnel wall leading to a safefemoral fixation of the graft.The bone block and the distal patellar tendon are armedwith two resorbable sutures each (Vicryl 0, Johnson &Johnson, Spreitenbach, Switzerland), and the distal borderof the patellar tendon is marked with a blue stripe (Fig. 1).The defect of the patella and tibial tuberosity is filled with asmall piece of Spongostan (Johnson & Johnson, Spreiten-bach, Switzerland).The harvest site is closed by suturing of the medial andlateral remaining patellar tendon (PDS 0, Johnson &Johnson, Spreitenbach, Switzerland).Arthroscopic surgeryFemoral and tibial tunnel preparationA high anterolateral portal in the corner between the patellaand the patella tendon, and a second, low anteromedialportal is established. Then, the intercondylar notch and thetibial and femoral ACL-attachment area are cleaned using ashaver blade. It is of crucial importance to visualize theposterior attachment area of the ACL at the deep posteriorfemoral condyle through the medial portal, in particular thebone cartilage interface.A second incision (approximately 3 cm long) is per-formed starting approximately 4 cm proximal to the lateralepicondyle. The iliotibial tract is split longitudinally ante-rior to the intermuscular septum. A hook is placed underthe lateral vastus muscle and bluntly elevated. Then, thefemoral bone is identified. The outside in aiming device(Instrumed, Luzern, Switzerland) is placed into the centreof the native ACL attachment indicating the proximal entrypoint of the eventual guide wire. This guide wire is intro-duced into the joint from proximal to distal. After verifi-cation of the desired tunnel position via the medial portal,which is quite low in the native ACL attachment, theK-wire is over drilled using a 10-mm cannulated drill bit.The PCL is protected with a curette that is placed directlyin front of the intraarticular tunnel entry point; the sharpedges of the tunnel wall are debrided.Then, the 10-mm tunnel is expanded in outside intechnique using a manual mill bit (distal: 9 mm, proximal13 mm). This step is meticulously controlled via themedial portal (Fig. 2). In this fashion, a cone-shapedfemoral tunnel is created outside in, which narrows toFig. 1 Schematic representation of the prepared BPTB graft. Notethe small, tapered bone block A originating from the patella and thewedge-shaped bigger bone block B originating from the tibialtuberosity, which will be tapped outside in into the cone-shapedfemoral tunnel, blocking itself78 Eur J Orthop Surg Traumatol (2012) 22:77–8012310 mm diameter at the former femoral attachment area(Fig. 3). The tunnel opening is almost round since thetunnel direction is virtually perpendicular to the inner bonesurface. The mill bit is left in place to minimize fluid lossthrough the femoral tunnel.For the tibial tunnel preparation, a tibial aiming device(Acufex, Smith & Nephew, Andover, MA, USA) is placedbetween the tibial spines close to the shallow border of thePCL. Then, a guide wire is introduced under arthroscopiccontrol through the aiming device. The tunnel is expandedto a diameter of 10 mm. The tibial tunnel aperture isdebrided from soft tissue with a shaver blade.Antegrade graft introduction and femoral fixationShuttle sutures are inserted through the femoral tunnel,grasped with a clamp, and passed out in antegrade directionthrough the tibial tunnel. The graft is then inserted into thefemoral tunnel under assistance of a probe, which helps toguide the bone block into the joint. During this maneuver,the rotation of the bone block has to be meticulouslycontrolled. The tendon backside should face against ante-rior. Hence, the tendon fibers, which emerge eccentricallyfrom the bone block, are placed as posterior as possiblemimicking the round shape of the bone cartilage interface(Fig. 4).Under constant pull on the distal sutures, the bone blockis tapped into the femoral tunnel until the bone block doesnot move toward the joint. This is generally the case whenthe blue mark becomes visible at the level of the tunnelaperture. The fixation of the bone block within the femoraltunnel is checked under arthroscopic control pulling on thedistal sutures.Tibial fixationThe graft is preconditioned in 10 cycles, and the isometryof the graft is checked. In most cases, the graft will bepulled into the tibial tunnel during the last 20 of extension.The graft is then fixed in 20 of flexion using a Biocom-posite interference screw (Arthrex, Naples, FL, USA).Then, the fascia and the subcutaneous layer are closed inlayers on both sites.Disadvantages of the techniqueThe only minor disadvantage of the proposed technique isthe need for a short second skin incision on the distal lateralthigh.Fig. 2 The manual mill bit entering the femoral tunnel, creating theoutside in cone-shaped tunnel. It is under constant control with thearthroscope in the medial portal viewing inside outFig. 3 Schematic representation of the creation of the cone-shapedfemoral tunnel. The 10-mm femoral tunnel is expanded using themanual mill bit allowing for a press fit fixation of the wedge-shapedbone block in the cone-shaped tunnelFig. 4 The ACL graft in place. Note the high–low extension of thegraft (between the two white arrows) mimicking the placement of thenormal ACLEur J Orthop Surg Traumatol (2012) 22:77–80 79123Advantages of the techniqueThe proposed ACL reconstruction technique offers theopportunity to place the femoral tunnel in the centre of thenative ACL attachment, which is lower than usuallyachieved in transtibial ACL techniques [22]. In addition,the femoral tunnel aperture has a circular shape with adefined diameter rather than an ovaloid shape when thedrill enters the notch in a tangential direction.In comparison with techniques where the medial portalis used for drilling of the femoral tunnel, there is no risk todamage the medial femoral condyle.It is an easy and reproducible ACL reconstructiontechnique. Every step of the surgery is arthroscopicallycontrolled, and hence, it can be routinely used in teachinghospitals.As no fixation device is used on the femoral side, it isless costly than other described techniques. In addition,revision surgery is considered to be less difficult. Thesurgeon is not limited due to the initial tunnel or fixationdevice in placing the femoral tunnel.Conflict of interest No benefits in any form have been or will bereceived from a commercial party related directly or indirectly to thesubject of this manuscript.References1. Howell SM (1998) Principles for placing the tibial tunnel andavoiding roof impingement during reconstruction of a tornanterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc6(1):S49–S552. Howell SM, Clark JA (1992) Tibial tunnel placement in anteriorcruciate ligament reconstructions and graft impingement. ClinOrthop 283:187–1953. Reat JF, Lintner DM (1997) One-versus two-incision ACLreconstruction. A prospective, randomized study. Am J KneeSurg 10(4):198–2084. Lohmander LS, Ostenberg A, Englund M, Roos H (2004) Highprevalence of knee osteoarthritis, pain, and functional limitationsin female soccer players twelve years after anterior cruciate lig-ament injury. Arthritis Rheum 50(10):3145–31525. Fu FH, Ranawat A (2007) Tensioning in double-bundle ACLreconstruction. Arthroscopy 23(9):1027; author reply 1027-10286. Shino K, Nakata K, Nakamura N, Mae T, Ohtsubo H, Iwahashi T,Nakagawa S (2005) Anatomic anterior cruciate ligamentreconstruction using two double-looped hamstring tendon graftsvia twin femoral and triple tibial tunnels. Op Tech Orthop15:130–1347. Siebold R, Dehler C, Ellert T (2008) Prospective randomizedcomparison of double-bundle versus single-bundle anterior cru-ciate ligament reconstruction. Arthroscopy 24(2):137–1458. Kanaya A, Ochi M, Deie M, Adachi N, Nishimori M, Nakamae A(2009) Intraoperative evaluation of anteroposterior and rotationalstabilities in anterior cruciate ligament reconstruction: lower femoraltunnel placed single-bundle versus double-bundle reconstruction.Knee Surg Sports Traumatol Arthrosc 17(8):907–9139. Meredick RB, Vance KJ, Appleby D, Lubowitz JH (2008) Out-come of single-bundle versus double-bundle reconstruction of theanterior cruciate ligament: a meta-analysis. Am J Sports Med36(7):1414–1421. doi:10.1177/036354650831796410. Arnold MP, Verdonschot N, van Kampen A (2005) ACL graftcan replicate the normal ligament’s tension curve. Knee SurgSports Traumatol Arthrosc 13(8):625–63111. Bernard M, Hertel P, Hornung H, Cierpinski T (1997) Femoralinsertion of the ACL. Radiographic quadrant method. Am J KneeSurg 10(1):14–2112. Deehan DJ, Pinczewski L (2002) How I do it: Endoscopicanterior cruciate ligament reconstruction using a four strandhamstring tendon construct. 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Scopp JM, Jasper LE, Belkoff SM, Moorman CT 3rd (2004) Theeffect of oblique femoral tunnel placement on rotational con-straint of the knee reconstructed using patellar tendon autografts.Arthroscopy 20(3):294–29919. Duquin TR, Wind WM, Fineberg MS, Smolinski RJ, Buyea CM(2009) Current trends in anterior cruciate ligament reconstruc-tion. J Knee Surg 22(1):7–1220. Hospodar SJ, Miller MD (2009) Controversies in ACL recon-struction: bone-patellar tendon-bone anterior cruciate ligamentreconstruction remains the gold standard. Sports Med Arthrosc17(4):242–24621. Kopf S, Musahl V, Tashman S, Szczodry M, Shen W, Fu FH(2009) A systematic review of the femoral origin and tibialinsertion morphology of the ACL. Knee Surg Sports TraumatolArthrosc 17(3):213–21922. Arnold MP, Kooloos J, van Kampen A (2001) Single-incisiontechnique misses the anatomical femoral anterior cruciate liga-ment insertion: a cadaver study. 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Isoanatomical bone-patellar tendon-bone single-bundle ACL reconstruction: the wedge that gives the edge!

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Isoanatomical bone-patellar tendon-bone single-bundle ACL reconstruction: the wedge that gives the edge!

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