Surgical Technique

The semitendinosus and gracilis tendons are harvested through an oblique anterior-medial incision along the upper border of the pes-anserine tendons. Turning down of the medial corner of the pes anserinus identified the tendons. Both were harvested with a closed-looped tendon stripper. The tendons, which ranged in length from 20 cm to 24 cm, were covered with a moist sponge for later preparation.

Any meniscal and interarticular pathology was then addressed, and the grafts were prepared (Fig. 6.43). The best 19cm of each graft was trimmed from the tendons, and the proximal end of one was sewn to the distal end of the other with No. 2 Ti-Cron suture. The tendon was then looped over a No. 5 Ti-Cron suture to be used to pull the graft into the knee. The proximal 3 cm of the tendon, which would reside in the femoral tunnel, was then sewn to bundle each of the four strands together for the portion with No. 0 Vicryl suture. The proximal and distal ends of the graft were then sized with cylindrical sizing tubes at 0.5 mm increments.

A soft tissue notchplasty was performed and only if bony impingement was noted was a bony notchplasty performed. Using the Howell Tibial Guide (ArthroCare, Biomet, Warsaw, IN), a guide wire was introduced into the tibia at an angle of approximately 50° to 55°, a tibial tunnel of approximately 5 cm in length was created. The position of the guide wire was verified with the arthroscope.

A tibial drill of the corresponding size to the graft was introduced into the tibia to create a tibial tunnel. A transtibial guide was selected to leave a 1-mm to 2-mm posterior bone bridge. The guide was placed and was followed by placement of a guide wire. After the verification of the location of a mark made on the femur by the drill to indicate the location of the femoral tunnel, a femoral tunnel was drilled to 30mm.

The tibial aperture was cleaned and the femoral tunnel compacted with a notcher. The knee was then cycled and the femoral fixation tested. A femoral BioScrew guide wire was then introduced ensuring that the screw and wire were placed parallel with the graft. The femoral BioScrew was then introduced into the femoral tunnel.

With the arthroscope in the joint, a guide wire was then passed into the joint anterior to the graft through the tibial tunnel. The knee was then placed at 20° of extension on the table. With distal tension on the graft and a posterior force was applied to the tibia, the tibial BioScrew was introduced. No specific effort was made to place the BioScrew at the aperture of the tibial tunnel. Secondary fixation was used on the tibia in 15 cases where the bony fixation of the tibial screw seemed suboptimal intraoperatively.

BioScrew sizes were selected such that the femoral screw was of the same size or 1 mm smaller than the tunnel drilled and the tibial screw was generally 1 mm larger in diameter than the tibial tunnel drill bit.

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