An Anterior Cruciate Ligament Reconstruction Technique With 4-Strand Semitendinosus Grafts, Using Outside-In Tibial Tunnel Drilling and Suspensory Fixation Devices  Philippe Colombet, M.D., Nicolas Graveleau, M.D.  Arthroscopy Techniques  Volume 4, Issue 5, Pages e507-e511 (October 2015) DOI: 10.1016/j.eats.2015.05.014 Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 1 Anterior cruciate ligament reconstruction by the 4-strand semitendinosus technique is fully dependent on the harvested graft's length. Indeed, the graft needs to be around 70 mm long, with 20 mm on the femoral and tibial sides and 27 to 42 mm in the joint space. An adjustable Pullup cortical suspension device on each side allows the surgeon to adjust the graft length in the tunnels and to manage graft tension. Arthroscopy Techniques 2015 4, e507-e511DOI: (10.1016/j.eats.2015.05.014) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 2 The GraftTech graft preparation table is an essential tool to prepare the graft with an adjustable suspensory fixation required on each side, attached by brackets. The harvested semitendinosus tendon is then passed through the Pullup loops to constitute a 4-strand graft and is equally tensioned on the 4 strands. Arthroscopy Techniques 2015 4, e507-e511DOI: (10.1016/j.eats.2015.05.014) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 3 The figure-of-8 continuous stitch is a special stitch used to lock the first graft loop. This stitch is mandatory to secure and load the 4 graft strands. Two figure-of-8 stitches are made with a 5-mm interval, after which the graft is sutured normally along its full length. (4ST, 4-strand semitendinosus.) Arthroscopy Techniques 2015 4, e507-e511DOI: (10.1016/j.eats.2015.05.014) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 4 Final assembly of graft in tunnels. First, with the inside-out technique, the femoral tunnel is drilled with a 4.5-mm diameter (1). Second, a femoral socket with a length of 20 mm is drilled with a diameter corresponding to the graft's diameter (2). Finally, a full tibial tunnel with the same diameter as the graft (2) is drilled using the outside-in technique. Arthroscopy Techniques 2015 4, e507-e511DOI: (10.1016/j.eats.2015.05.014) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions