Technical Note

Single-Bundle Anatomical Hardware-Free Anterior

Cruciate Ligament Reconstruction
Jinzhong Zhao, M.D.

Abstract: In anterior cruciate ligament (ACL) reconstruction, fixation of the graft with hardware is a routine procedure.
However, in some cases when the hardware is not intended to be used or is unavailable, ACL reconstruction with
hardware-free fixation must be the treatment of choice. We introduce a single-bundle anatomical hardware-free ACL
reconstruction technique in which a set of Y-shaped femoral tunnels is created for the fixation of the proximal end of the
graft over the bone bridge between the 2 outer orifices, and a transtibial ridge tunnel is created to set a suture loop with a
knot for the fixation of the distal end of the graft at the suture loop. We believe the introduction of this technique will
provide a reasonable option for single-bundle anatomical ACL reconstruction.

I n single-bundle anterior cruciate ligament (ACL)

reconstruction, the graft is routinely fixed with
hardware. However, various complications are related
technique is as effective as ACL reconstruction with
hardware fixation.

to hardware fixation.1-3 To avoid these related

complications, hardware-free fixations have been intro- Surgical Technique (With Video Illustration)
duced in the literature, with press-fit fixation as the main The surgical steps of the current technique are like
method.4,5 Here, we introduce an all-suture hardware- anatomical transtibial single bundle transtibial ACL
free fixation technique for single-bundle anatomical ACL reconstruction with hardware fixation.6 The procedure
reconstruction that we consider simpler than the press-fit is performed with the patient in the supine position. A
fixation. This technique is indicated when ACL recon- post is placed at the lateral side of the thigh to provide
struction is needed but hardware for graft fixation is support when the knee is flexed (Table 1).
unavailable, such as in the case of a preoperative over-
looked ACL injury, to provide a salvaging method. It is Grafting Harvesting and Preparation
also indicated when hardware fixation is not intended to The semitendinosus tendon and gracilis tendon are
be used either by the patients or the surgeons due to harvested and prepared to make a 7-stranded graft by
various reasons. Our clinical experience indicates this using 3 no. 2 ultra-high molecular weight polyethylene
sutures (Smith & Nephew; Andover, MA) as traction
and fixation sutures on the proximal end (Fig 1, Video
From the Department of Sports Medicine, Shanghai Sixth People’s Hospi- 1). The graft is composed of a 4-stranded semite-
tal, Shanghai Jiao Tong University, Shanghai, China.
ndinosus tendon and a 3-stranded gracilis tendon with a
The author reports the following potential conflicts of interest or sources of
funding: National Key Research and Development Program of China (grant usual length of >7 cm and a usual width of 8 to 10 mm.
no. 2018YFC1106200 and 2018YFC1106202), and the project of Shenkang
Hospital Development Center of Shanghai (grant no. 16CR3108B). Full Locating the Tibial and the Femoral Tunnels
ICMJE author disclosure forms are available for this article online, as The inner orifices of the tibial and femoral tunnel are
supplementary material. located respectively in the middle of ACL tibial and
Received February 12, 2021; accepted March 1, 2021.
femoral footprints and marked with a radiofrequency
Address correspondence to Jinzhong Zhao, M.D., Department of Sports
Medicine, Shanghai Sixth People’s Hospital, Shanghai Jiao Tong University, probe just as in routine anatomical transtibial single-
600 Yishan Rd., Shanghai 200233, China. E-mail: [email protected] or bundle ACL reconstruction. When there are no rem-
[email protected] nants at the footprints that can be used references, the
Ó 2021 THE AUTHORS. Published by Elsevier Inc. on behalf of the tibial tunnel is located at the middle of the anterolateral
Arthroscopy Association of North America. This is an open access article under
slope of the medial tibial eminence, and the femoral
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/
4.0/). tunnel is located at a point 5 mm anterior and proximal
2212-6287/21260 to the lowest point of the lateral wall of the femoral
https://doi.org/10.1016/j.eats.2021.03.002 notch.6

Arthroscopy Techniques, Vol 10, No 6 (June), 2021: pp e1609-e1613 e1609

e1610 J. ZHAO

Table 1. Step-by-Step Procedure of Single-Bundle

Anatomical Hardware-Free ACL Reconstruction
1. The semitendinosus tendon and the gracilis tendon are harvested.
A 7-stranded graft is made from these 2 tendons.
2. The inner orifices of the femoral and tibial tunnels are located and
marked with a radiofrequency probe.
3. The tibial tunnel is created, angulating the sagittal plane at
approximately 40 and the tibial axis at approximately 50 , with a
projection point on the lateral wall of the femoral notch within
5 mm distance to the desired location of the femoral tunnel.
4. A K-wire is drilled into the marked point of the femoral tunnel
though the tibial tunnel. The thick femoral socket is created.
5. The K-wire is overdrilled with a 4.5-mm cannulated drill. The
straight thin part of the femoral tunnels is created.
6. A K-wire is placed to the bottom of the thick femoral socket
through the far anteromedial portal and drilled through the lateral
cortex at the largest angle to the straight thin part of the femoral
tunnel, to create a diverging thin part femoral tunnel.
Fig 2. Arthroscopic intrafemoral tunnel view of left knee
7. Guide sutures are placed through the tibial tunnel and the bifur- through the anteromedial portal indicating the straight and
cating femoral tunnels. The fixing sutures from the proximal end diverging thin tunnel parts.
of the graft are pulled into the tunnels with the guide sutures.
8. The graft is pulled into the bottom of the femoral socket.
9. The proximal fixing sutures are exposed in the lateral gutter and overdrilled with a drill of the same size as the graft to
tied over the bone bridge between the 2 outer orifices. create a femoral socket (thick femoral tunnel part) to
10. A transtibial ridge tunnel is created. A suture loop with a large the expected length (which is usually 25-30 mm), and
knot is set through this tunnel. then overdrilled with a 4.5-mm drill through the outer
11. The sutures from the distal graft end are tied at the suture loop.
cortex to create the straight. thin femoral tunnel part.
ACL, anterior cruciate ligament.
Then, a far anteromedial portal is created. The knee is
flexed to 120 . A K-wire is placed through the far
Creating the Tibial Tunnel anteromedial portal to the bottom of the thick femoral
A 5-mm offset point-to-hole tibial tunnelelocating de- tunnel part and drilled through the lateral cortex with
vice (Aesculap, Tuttlingen, Germany) is placed into the the greatest angle to the direction of the straight thin
joint through the anteromedial portal. With the hook of femoral tunnel part. The K-wire is overdrilled with a
the device placed at the correct area, the spatial position of 4.5-mm cannulated drill. Thus, a set of bifurcate
the tunnel-locating device is adjusted to create a tibial femoral tunnel complexes, which include a large tunnel
tunnel in a plane that angulates the sagittal plane at segment, a straight, thin tunnel part, and a diverging
approximately 40 . In the tibial tunnel plane, the tibial thin tunnel part, is created (Figs 2 and 3).
tunnel angulates the tibial axis at approximately 50 .6
A K-wire is drilled through the tibia to the femur to
ensure that it can reach a point within 5 mm from the
femoral tunnel center. Microadjustment may be needed
through multiple tries. The K-wire is overdrilled to
create the expected size of the tibial tunnel.6

Creating a Y-Shaped Femoral Tunnel

Through the tibial tunnel, a K-wire is drilled to the
location of the femoral tunnel. The K-wire is first

Fig 3. Postoperative computed tomography images indicating

the orifice of the thick femoral tunnel part (A, posterior medial
Fig 1. Illustration of the fabrication of a 7-stranded graft from view of left knee) and the orifices of the straight and diverting
the semitendinosus tendon (ST) and the gracilis tendon (GT). thin tunnel parts (B, lateral view of the right knee).
 SINGLE-BUNDLE ANATOMICAL HARDWARE-FREE ACLR e1611

Fig 4. Passing the proximal fixing futures though the femoral tunnels (A, arthroscopic intrafemoral tunnel view of left knee
through the anteromedial portal) and exposing them at the outer orifices (B, arthroscopic view of the lateral gutter of left knee
through the anterolateral portal).

Graft Implantation superolateral pole of the patella. With tension of

In hyperflexion of the knee, a guide pin is placed in the fixation sutures, a shaver is placed in through the
through the far anteromedial portal into the thick superolateral portal to remove the synovium in
femoral socket and through the diverging part of the the lateral gutter to expose the outer orifices of the
femoral tunnels. Then, a guide suture is placed in with femoral tunnels and the fixing sutures (Fig 4B). Then,
the guide pin. The distal end of this guide suture is the suture limbs from the straight tunnel part are tied to
pulled through the tibial tunnel out. The knee is set at their counterparts from the diverging tunnel part over
90 of flexion. Another guide suture is placed through the bone bridge between the 2 orifices (Fig 5). The graft
the tibial tunnel, the thick femoral socket, and the is pulled back to complete proximal fixation.
straight part of the thin femoral tunnels.
Then, suture limbs at the proximal end of the graft are Distal Fixation
pulled through the tibial tunnel and the thick femoral A 4-cm long suture loop with a large knot is made from
socket, with the 2 limbs of each suture respectively multistrands of a no. 2 ultra-high-molecular-weight
through the straight and the diverging thin parts of the polyethylene suture (Fig 6). A 3.0-mm transverse trans-
femoral tunnels (Fig 4A). By pulling the fixation su- tibial ridge tunnel is made with a K-wire at a site distal to
tures, the graft is pulled through the tibial tunnel into the distal orifice of the tibial tunnel that accommodating
the end of the femoral socket. the graft. The suture loop is placed through the transtibial
ridge tunnel from lateral to medial side to set the knot over
Proximal Fixation the lateral orifice. At full extension, the sutures from the
The knee is set in full extension. A superolateral distal end of the grafts are tied to this suture loop to
patella portal is created approximately 2 cm from the complete the distal fixation of the graft (Fig 7).

Fig 5. Proximal fixation of the graft by tying the fixing sutures over the bone bridge between the outer orifices. (A) Arthroscopic
view of the lateral gutter of left knee through the anterolateral portal). (B) Illustration.
e1612 J. ZHAO

Fig 6. A suture loop with a knot is made with multistrand

ultra-high-molecular-weight polyethylene sutures.

Discussion
The most critical point of this technique is fabrication
of the bifurcate tunnel complex on the femoral side and
obtain enough long a bone bridge between the 2 outer
orifices. The current technique is suitable for single-
bundle anatomical ACL reconstruction, in which the Fig 8. Postoperative magnetic resonance image indicating the
thick graft going to the shallow tibial tunnel (sagittal view of
femoral tunnel is located in the anatomic center of the
left knee). Arrow indicates the shallow tibial tunnel.
ACL footprint, and it is easy to create the diverging part
of the femoral tunnels. It is not suitable for isometric
ACL reconstruction, in which the femoral tunnel is
located too deep in the femoral notch, and it is unreli-
able to create the diverging femoral tunnel part through Table 2. Pearls and Pitfalls of Single-Bundle Anatomical
the narrow femoral notch. In addition, it is suitable for Hardware-Free ACL Reconstruction
ACL reconstruction with a large graft (at least 8 mm) Pearls Pitfalls
1. Enough graft size is needed 1. During creation of the diverging
for ensure final graft femoral tunnel, the knee is
strength. Thus, a graft size flexed to 120 . Insufficient knee
8 mm is the best choice. flexion will result in a too-
When a 7-stranded posteriorly located lateral
semitendinosus tendon orifice.
egracilis tendon graft is still
not large enough, we
recommend using the
anterior half of the
peroneus longus tendon as a
supplement.
2. During creation of the tibial 2. During exposing the fixing
tunnel, elevation of the sutures with a shaver at the
tibial-aiming device to lateral gutter of the knee, the
create a shallow tibial sutures should be kept in
tunnel is the most critical tensioning to prevent
step. Drilling the K-wire suctioning and cutting of the
into the joint can help sutures by the shaver.
evaluate the projection of
the tibial tunnel.
3. Anatomical instead of 3. The knot in the suture loop
isometric femoral tunnel should be large enough
location is performed. compared with the to-be-
created transtibial ridge tunnel.
Otherwise, the suture loop
cannot be securely set at the
transtibial ridge tunnel.
4. The far anteromedial portal 4. The graft is fixed in full
should be medial enough to extension to prevent extension
maximize the angle limitation.
between the bifurcating
Fig 7. Illustration of distal fixation of the graft (left knee). The limbs of the femoral
fixing sutures from the graft are tied to a suture loop with a tunnels.
knot, which is set at a transtibial ridge tunnel. ACL, anterior cruciate ligament.
 SINGLE-BUNDLE ANATOMICAL HARDWARE-FREE ACLR e1613

Table 3. Advantages and Disadvantages of Single-Bundle experience indicates the fixing suture from the distal
Anatomical Hardware-Free ACL Reconstruction end of the graft can be tied to the suture loop tightly.
Advantages However, the knot in the suture loop must be large
1. The technique can be used as salvaging or planned procedure enough to securely set over the lateral tunnel orifice.
when hardware for graft fixation is not available or is not intended
The pearls and pitfalls and advantages and disadvantage
to be used.
2. Anatomical single-bundle ACL reconstruction can be realized. of the current technique are listed in Tables 2 and 3,
3. No hardware or implant is needed. respectively.
Disadvantages
1. Creation of the diverging part of the femoral tunnel may be
difficult in case of femoral notch stenosis.
2. There may be suture cutting into the bone bridge at the proximal
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