Arthroscopic All-Inside Posterior Cruciate Ligament Reconstruction: Overcoming the “Killer Turn”  Attique Vasdev, M.S., Ashok Rajgopal, M.S., M.Ch., F.R.C.S., Himanshu Gupta, M.S., Vivek Dahiya, D.N.B., Vipin Chand Tyagi, D.Ortho.  Arthroscopy Techniques  Volume 5, Issue 3, Pages e501-e506 (June 2016) DOI: 10.1016/j.eats.2016.01.033 Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 1 Quadrupled semitendinosus GraftLink construct. Arthroscopy Techniques 2016 5, e501-e506DOI: (10.1016/j.eats.2016.01.033) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 2 Tripled GraftLink with semitendinosus. Arthroscopy Techniques 2016 5, e501-e506DOI: (10.1016/j.eats.2016.01.033) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 3 Tibial jig (Arthrex) visualized with a 70° arthroscope through the anterolateral portal with the knee in 90° of flexion and introduced through the anteromedial portal 16 mm below the posterior edge of the tibia in the center of the tibial posterior cruciate ligament footprint. Arthroscopy Techniques 2016 5, e501-e506DOI: (10.1016/j.eats.2016.01.033) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 4 With the knee in 90° of flexion, by use of a 70° arthroscope to visualize through the anterolateral portal, once the tibial socket is made, the FlipCutter is removed, keeping the all-inside sleeve in position. A No. 5 Ethibond suture is passed through the eye of a reversed drill pin and pulled out of the posteromedial portal with a suture retriever to create a suture shuttle from the tibial socket (arrow). Arthroscopy Techniques 2016 5, e501-e506DOI: (10.1016/j.eats.2016.01.033) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 5 The 70° arthroscope is exchanged with a 30° arthroscope and switched from the anterolateral portal to the anteromedial portal. A spade-tipped drill pin is then passed from the anterolateral portal to the middle of the posterior cruciate ligament stump, keeping the knee in 90° of flexion to allow for drilling of the femoral socket. Arthroscopy Techniques 2016 5, e501-e506DOI: (10.1016/j.eats.2016.01.033) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 6 On completion of the femoral socket, a suture shuttle is passed into the joint by pulling the drill pin out of the medial condyle, making sure to leave the loop of the shuttle in the joint. The 30° arthroscope is then switched back to the anterolateral portal, and the loop is delivered into the posterior compartment of the knee and pulled out of the posteromedial portal to create (A) a suture shuttle from the femoral socket. (B) Shuttle from tibial socket. Arthroscopy Techniques 2016 5, e501-e506DOI: (10.1016/j.eats.2016.01.033) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 7 The threads (4 each) of the TightRope RT on either side of the GraftLink are passed into the suture shuttles to enable the TightRope devices to be pulled out of the femoral and tibial sockets. This facilitates the eventual passage and tensioning of the graft in the socket. Arthroscopy Techniques 2016 5, e501-e506DOI: (10.1016/j.eats.2016.01.033) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 8 After the femoral TightRope RT is pulled out of the femoral socket with the help of the femoral suture shuttle, the TightRope RT is tensioned to pull the femoral end of the graft into the femoral socket. The tibial end of the graft can still be visualized outside the posteromedial portal (arrow). Arthroscopy Techniques 2016 5, e501-e506DOI: (10.1016/j.eats.2016.01.033) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 9 The tibial TightRope RT is pulled out of the tibial socket with the help of the tibial suture shuttle (arrow) and tensioned with the knee in 70° of flexion as only single-bundle posterior cruciate ligament reconstruction is performed. Arthroscopy Techniques 2016 5, e501-e506DOI: (10.1016/j.eats.2016.01.033) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 10 Postoperative radiographs of all-inside posterior cruciate ligament reconstruction with suspensory system. (A) TightRope RT on femur. (B) TightRope ABS on tibia. Arthroscopy Techniques 2016 5, e501-e506DOI: (10.1016/j.eats.2016.01.033) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions