Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction With a Free Quadriceps Tendon Autograft Sergiu Caterev, M.D., Dan Viorel Nistor, M.D.,

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Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction With a Free Quadriceps Tendon Autograft Sergiu Caterev, M.D., Dan Viorel Nistor, M.D., Adrian Todor, M.D., Ph.D. Arthroscopy Techniques Volume 5, Issue 5, Pages e1063-e1067 (October 2016) DOI: 10.1016/j.eats.2016.05.015 Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 1 The tibial anterior cruciate ligament (ACL) footprint (red line) is measured with an arthroscopic ruler (Linvatec bullseye, Native ACL Ruler, ConMed Linvatec) introduced through the central portal in order to see whether it accommodates a double-bundle technique. In this case it measures 17 mm. The 30° scope is in the anterolateral viewing portal. Right knee at 90°. Arthroscopy Techniques 2016 5, e1063-e1067DOI: (10.1016/j.eats.2016.05.015) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 2 The free quadriceps tendon graft, after harvest, on the back table. High-strength sutures (Hi-Fi, ConMed Linvatec, Largo, FL) are seen placed on the distal end (red arrow), which will be used to attach the suspensory device (XO Button, ConMed, Linvatec). This end of the graft will enter the femoral tunnel. The graft is split into 2 bundles with the use of scissors (black arrow) along the natural plane of cleavage between the rectus femoris and vastus intermedius providing the anteromedial and posterolateral bundles, which will enter in the tibial tunnels during the double-bundle anterior cruciate ligament reconstruction. Arthroscopy Techniques 2016 5, e1063-e1067DOI: (10.1016/j.eats.2016.05.015) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 3 The free quadriceps tendon graft on the back table. The posterolateral bundle is marked with a sterile marking pen for easier identification during graft passage (black arrow). (AM, anteromedial; PL, posterolateral.) Arthroscopy Techniques 2016 5, e1063-e1067DOI: (10.1016/j.eats.2016.05.015) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 4 Arthroscopic view with the 30° scope in the anterolateral portal. A guide pin is seen introduced in the posterolateral bundle center (PL) and another guide pin is seen in the anteromedial bundle center (AM) of the tibial footprint. In addition, the passing suture from the femoral tunnel out the AM portal can also be seen (star). This suture will be used to pull the graft in the femoral tunnel, right knee. Arthroscopy Techniques 2016 5, e1063-e1067DOI: (10.1016/j.eats.2016.05.015) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 5 Intraoperative picture during anatomic double-bundle anterior cruciate ligament reconstruction on a right knee. The scope is in the anterolateral portal (AL). The black arrow indicates the posterolateral purple passing suture secured with a clamp. The red arrow indicates the anteromedial white passing suture also secured with a clamp. The patient is supine on the operating table, and the knee flexed to 90°. This is after the tunnels are drilled and just before graft passage. (AM, anteromedial portal; C, central portal.) Arthroscopy Techniques 2016 5, e1063-e1067DOI: (10.1016/j.eats.2016.05.015) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 6 Intraoperative picture during anatomic double-bundle anterior cruciate ligament (ACL) reconstruction on a right knee. The scope is in the anterolateral portal (red arrow). The graft is being pulled through the anteromedial portal (black arrow) with the posterolateral bundle oriented (yellow star) such that it will enter the femoral tunnel in the correct position (shallow in the ACL footprint). The patient is supine on the operating table, and the knee flexed to 90°. Arthroscopy Techniques 2016 5, e1063-e1067DOI: (10.1016/j.eats.2016.05.015) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 7 Intraoperative picture during anatomic double-bundle anterior cruciate ligament reconstruction on a right knee. The scope is in the anterolateral portal (red arrow). The posterolateral (PL) bundle has been pulled through the anteromedial (AM) portal, inside the joint and out the PL tunnel (black arrow). The AM bundle is seen outside the joint waiting for the same routing. The patient is supine on the operating table, and the knee flexed to 90°. Arthroscopy Techniques 2016 5, e1063-e1067DOI: (10.1016/j.eats.2016.05.015) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 8 Arthroscopic view with the 30° scope in the anterolateral portal. The quadriceps double-bundle graft is seen in final position after the anterior cruciate ligament reconstruction was performed. The posterolateral and anteromedial bundles are seen in correct position. The probe (star) is introduced through the central portal between the bundles, right knee. (AM, anteromedial; PL, posterolateral.) Arthroscopy Techniques 2016 5, e1063-e1067DOI: (10.1016/j.eats.2016.05.015) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions