Anterior Cruciate Ligament Primary Repair With Independent Tensioning of the Anteromedial and Posterolateral Bundles  Patrick A. Smith, M.D., Jordan A. Bley, B.A.  Arthroscopy Techniques  Volume 6, Issue 6, Pages e2123-e2128 (December 2017) DOI: 10.1016/j.eats.2017.08.022 Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 1 During initial diagnostic arthroscopy, the fibers of the ACL are checked to ensure that satisfactory quality tissue exists at the proximal tear. This can then be mobilized with a probe to determine if the anteromedial, posterolateral, or both bundles will need to be repaired. In this case, laxity of both bundles from the femoral attachment site is noted. Arthroscopy Techniques 2017 6, e2123-e2128DOI: (10.1016/j.eats.2017.08.022) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 2 With the No. 2 FiberWire (Arthrex) attached in a cinch configuration to the proximal fibers of the anteromedial bundle, a 3.5-mm measuring pin (Arthrex) is drilled into the femur at the anatomic attachment site for the anteromedial bundle to measure the intraosseous distance for planned TightRope (Arthrex) suspensory fixation of a FiberTape (Arthrex) as an internal brace. Arthroscopy Techniques 2017 6, e2123-e2128DOI: (10.1016/j.eats.2017.08.022) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 3 The biocomposite 3-mm SutureTak (Arthrex) is placed at the anatomic attachment point of the posterolateral (PL) bundle on the femur. A Knee Scorpion (Arthrex) is then used to pass the smaller passing suture of the SutureTak through the PL bundle; this suture is passed through the loop of the shuttle suture of the device to splice onto itself for fixation as this suture is tightened for the PL bundle fixation. Arthroscopy Techniques 2017 6, e2123-e2128DOI: (10.1016/j.eats.2017.08.022) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 4 The FlipCutter tibial guide (Arthrex) is shown to allow drilling of a 3.5-mm guide pin from the proximal tibia through the tibial plateau into the center of the intact tibial anterior cruciate ligament fibers. This facilitates the SAMBBA technique for passage of a No. 2 TigerStick (Arthrex) as a shuttle to pull the FiberTape as an internal brace through the ACL. Arthroscopy Techniques 2017 6, e2123-e2128DOI: (10.1016/j.eats.2017.08.022) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 5 The TigerStick in its red sheath is visualized at the upper end of the intact ACL tibial fibers after passing through the middle of the native ligament via the SAMBBA technique. This suture loop will be used to pass the 2 free FiberTape ends down through the tibial stump and out the medial tibial incision to serve as an internal brace for the anteromedial bundle. The other end of the FiberTape is passed through the loop of the TightRope, with fixation accomplished with its suspensory button on the lateral femoral cortex. Arthroscopy Techniques 2017 6, e2123-e2128DOI: (10.1016/j.eats.2017.08.022) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 6 The No. 2 TigerWire cinch suture in the anteromedial bundle has been passed through the TightRope button before it is passed with the shuttle suture through the 3.5-mm femoral hole. In this way, the free end of the No. 2 TigerWire suture in the femoral anteromedial bundle fibers is passed out the lateral femoral cortex with the suspensory fixation button. The Tightrope button is flipped onto the lateral femoral cortex and the tape is hoisted into the femur with the shortening sutures. The free ends of the FiberTape are passed with the TigerWire suture through the ACL. After fixation of the free ends of the FiberTape on the tibial side with a biocomposite 4.75-mm SwiveLock anchor (Arthrex), the cinch No. 2 TigerWire suture is tied to the blue passing suture from the TightRope button for fixation of the anteromedial bundle ACL fibers back to its anatomic femoral attachment. This is done at 40° of knee flexion. The final position of the FiberTape is seen serving as an internal brace in the ACL. (ACL, anterior cruciate ligament.) Arthroscopy Techniques 2017 6, e2123-e2128DOI: (10.1016/j.eats.2017.08.022) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 7 The completed ACL primary repair. The knee is brought into full extension and the blue tightening suture from the knotless SutureTak is tightened to bring the posterolateral bundle fibers securely to its femoral attachment. Notice that there is no visible suture construct as the native ACL is reduced to its anatomic position with optimal tension of both bundles. (ACL, anterior cruciate ligament.) Arthroscopy Techniques 2017 6, e2123-e2128DOI: (10.1016/j.eats.2017.08.022) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions