Suspensory Anterior Tibial Fixation in the Anatomic Transtibial Posterior Cruciate Ligament Reconstruction  Ashraf Elazab, M.D., M.Sc., Yong Seuk Lee, M.D., Ph.D., Seo Goo Kang, M.D.  Arthroscopy Techniques  Volume 5, Issue 1, Pages e71-e77 (February 2016) DOI: 10.1016/j.eats.2015.10.008 Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 1 The arthroscope is inserted through the anterolateral portal and passed to the posteromedial (PM) compartment through the intercondylar notch; the PM portal is established, and a switching stick is inserted through the PM portal for later insertion of the arthroscope. Arthroscopy Techniques 2016 5, e71-e77DOI: (10.1016/j.eats.2015.10.008) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 2 The arthroscope is inserted through the anteromedial portal and passed to the posterolateral compartment through the intercondylar notch, the posterolateral portal is established, and the shaver is inserted. Arthroscopy Techniques 2016 5, e71-e77DOI: (10.1016/j.eats.2015.10.008) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 3 The arthroscope is introduced from the posteromedial portal, and the motorized shaver is introduced from the posterolateral portal. The posterior septum is pushed with a shaver tip, and the trans-septal portal (arrow) is made at the central portion of the posterior septum behind the posterior cruciate ligament (PCL) with the shaver. Arthroscopy Techniques 2016 5, e71-e77DOI: (10.1016/j.eats.2015.10.008) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 4 A posterior cruciate ligament (PCL) tibial drill guide adjusted to a 50° to 55° angle is introduced through the anteromedial portal. The tip of the guide hook is pointed toward the PCL fovea, which is the anatomic landmark for the proper tibial tunnel site, and a guide pin is introduced toward the PCL fovea at the center area in the coronal plane and a 7-mm anterior area of the posterior margin of the PCL fovea in the sagittal plane. The arrow marks the trans-septal portal (arrow). Arthroscopy Techniques 2016 5, e71-e77DOI: (10.1016/j.eats.2015.10.008) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 5 The arthroscope is introduced from the posteromedial portal, and the shaver is introduced from the posterolateral portal and used to protect the posterior structure by pushing it away during tibial tunnel drilling with the FlipCutter drill guide system. (PCL, posterior cruciate ligament.) Arthroscopy Techniques 2016 5, e71-e77DOI: (10.1016/j.eats.2015.10.008) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 6 After tibial tunnel preparation, a passing wire is passed from the tibial tunnel and grasped from inside the joint to exit from the anteromedial portal; it will be used for graft passage inside the tibial tunnel. (PCL, posterior cruciate ligament.) Arthroscopy Techniques 2016 5, e71-e77DOI: (10.1016/j.eats.2015.10.008) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 7 The arthroscope is introduced from the anterolateral portal, and a posterior cruciate ligament femoral guide set is introduced through the anteromedial portal. It is located at the posterior cruciate ligament remnant on the lateral aspect of the medial femoral condyle. The tip is positioned 5 mm posterior to the distal border of the articular cartilage of the medial femoral condyle. A guidewire is used to localize and to guide the drill to the proper site for the femoral tunnel. Arthroscopy Techniques 2016 5, e71-e77DOI: (10.1016/j.eats.2015.10.008) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 8 Outside-in femoral drilling is performed along with placement of a guide pin. Arthroscopy Techniques 2016 5, e71-e77DOI: (10.1016/j.eats.2015.10.008) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 9 Viewing from the posteromedial portal, the surgeon checks the inserted graft (left). The graft is pulled inside the tibial tunnel until the TightRope RT device become outside the tunnel. Then, the suture connected to the TightRope RT is used to flip it and to fit it firmly to the cortex of the proximal tibia (right). (PCL, posterior cruciate ligament.) Arthroscopy Techniques 2016 5, e71-e77DOI: (10.1016/j.eats.2015.10.008) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 10 A passing wire is introduced from outside through the femoral tunnel and pulled from inside the joint to the anteromedial portal. It is used to pass the graft to the femoral tunnel (left). The graft is tensioned and fixed on the femoral side by an interference screw, and the fixation is augmented by a spiked washer and screw (right). Arthroscopy Techniques 2016 5, e71-e77DOI: (10.1016/j.eats.2015.10.008) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 11 As viewed from the anterolateral portal (left) and posteromedial portal (right), the reconstructed graft is well surrounded by the remnant posterior cruciate ligament (PCL). (ACL, anterior cruciate ligament.) Arthroscopy Techniques 2016 5, e71-e77DOI: (10.1016/j.eats.2015.10.008) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 12 Postoperative anteroposterior and lateral radiographs showing the TightRope RT button, which is well seated on the anteromedial proximal tibia, and the spiked washer and screw, which are used to ligate the excess graft around it after tensioning and securing of the femoral end of the graft by an interference screw. Arthroscopy Techniques 2016 5, e71-e77DOI: (10.1016/j.eats.2015.10.008) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions