Anterior Cruciate Ligament Reconstruction Using Hamstring Tendon Autograft With Preserved Insertions  Ravi Gupta, M.S., D.N.B., M.N.A.M.S., F.A.M.S., F.I.M.S.A., Raj Bahadur, M.S., F.A.M.S., F.R.C.S., F.I.M.S.A., Anubhav Malhotra, M.B.B.S., Gladson David Masih, M.Sc., Parmanand Gupta, M.S.  Arthroscopy Techniques  Volume 5, Issue 2, Pages e269-e274 (April 2016) DOI: 10.1016/j.eats.2015.12.007 Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 1 With the tibial insertions of the tendons left intact, an open-ended tendon stripper is used to harvest the graft. Arthroscopy Techniques 2016 5, e269-e274DOI: (10.1016/j.eats.2015.12.007) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 2 The femoral point of entry is marked with a bone awl at the junction of the lateral condylar ridge and bifurcate ridge with arthroscopic guidance. Arthroscopy Techniques 2016 5, e269-e274DOI: (10.1016/j.eats.2015.12.007) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 3 A guide pin is introduced into the femur, and with the knee in maximal hyperflexion, a 4.5-mm cannulated drill bit is used to create a tunnel in the femur. Arthroscopy Techniques 2016 5, e269-e274DOI: (10.1016/j.eats.2015.12.007) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 4 The length of the tunnel is measured with a depth gauge. Arthroscopy Techniques 2016 5, e269-e274DOI: (10.1016/j.eats.2015.12.007) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 5 Length of femoral tunnel (length A) and length of tibial tunnel plus intra-articular part of graft (length B). Arthroscopy Techniques 2016 5, e269-e274DOI: (10.1016/j.eats.2015.12.007) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 6 No. 5 Ethibond suture (left arrow) is passed into the tunnel, and the loop (right arrow) is parked inside the joint. Arthroscopy Techniques 2016 5, e269-e274DOI: (10.1016/j.eats.2015.12.007) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 7 By use of an anterior cruciate ligament tibial guide, the tibial tunnel is reamed. Arthroscopy Techniques 2016 5, e269-e274DOI: (10.1016/j.eats.2015.12.007) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 8 The Ethibond suture loop placed through the femoral tunnel into the joint is retrieved from the tibial tunnel with a grasper. Arthroscopy Techniques 2016 5, e269-e274DOI: (10.1016/j.eats.2015.12.007) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 9 The length of the tibial tunnel and the intra-articular part of the proposed anterior cruciate ligament graft is measured with a depth gauge. Arthroscopy Techniques 2016 5, e269-e274DOI: (10.1016/j.eats.2015.12.007) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 10 A marking suture (arrow) is placed on the hamstring tendons just opposite the entry of the tibial tunnel so that when the graft is pulled inside the joint, the mark stays at the entry of the tunnel. Arthroscopy Techniques 2016 5, e269-e274DOI: (10.1016/j.eats.2015.12.007) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 11 The length of the quadrupled graft and loop of the RetroButton is adjusted so that it exactly corresponds to length A (length of femoral tunnel) plus length B (length of tibial tunnel plus intra-articular part of graft). Arthroscopy Techniques 2016 5, e269-e274DOI: (10.1016/j.eats.2015.12.007) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 12 The sutures of the RetroButton are pulled through the tibial and femoral tunnels by loading them onto the Ethibond loop placed in the tunnels. Arthroscopy Techniques 2016 5, e269-e274DOI: (10.1016/j.eats.2015.12.007) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 13 The free end of the graft exiting the tibial tunnel is pulled to maximal stretch and the joint moved through full range of motion at least 10 times to remove any kinks in the graft. Arthroscopy Techniques 2016 5, e269-e274DOI: (10.1016/j.eats.2015.12.007) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 14 With maximal stretch on the free end of the graft, it is sutured to the preserved end. Arthroscopy Techniques 2016 5, e269-e274DOI: (10.1016/j.eats.2015.12.007) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions