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• W2130794329 abstract "Dear Editor,We would like to thank the readers of International Orthopaedics for their questions on our work [1]. In response to these observations, we would like to make the following comments:The manuscript describes a standard double bundle femoral tunnel position, similar to many publications on the creation of two different and divergent tunnels that start from the ligament’s footprint in the notch. Tunnels are created with an ‘outside-in’ guide, their distance inside the notch is 6 mm, they are divergent in the coronal and sagittal plane and their far lateral distance on the lateral femoral cortex is 2 cm. The optimal distance between the two femoral tunnels in the notch should be approximately 5 mm, but stable fixation can be achieved even with a smaller distance of 3 mm [2]. Figure 5 in our article shows a lateral X-ray, where the divergence of the tunnels in the coronal plane is never as obvious as in an anteroposterior X-ray (see Fig. 3; [1]).Larger tunnel enlargement on the tibial side of ACL reconstruction than the femoral side has been previously documented [3]. The absence of femoral implant did not affect the stability of the construction in our series, and the authors’ explanation is recorded in the Discussion section: “The absence of pathological femoral widening could be explained by the loop formation of the graft with four 90° angles on the femoral side and the tangential pull-out force.” Tibial position was centred on the ACL footprint, and we used a larger diameter drill to accommodate a larger graft size (since both ends were in the same tunnel) and to cover the maximum of the ligament’s tibial insertion. Therefore, a “non-anatomical” position of the graft on the tibia is not appropriate for this technique.The term “anatomical” is used, especially in the recent literature, not only to describe the single or multiple bundle formation of the construction, but also to describe a graft that is placed in the patient’s native ligament insertion area (‘footprint’) [4]. The term anatomical responds to a reconstruction that involves a graft, which covers as much as possible of the native ligament’s insertion area [5–7]. Femoral ACL insertion has been traditionally more controversial than the tibial side, which poses fewer difficulties to identify [6]. The concept of “single bundle anatomical reconstruction” has been well documented by other surgeons who perform ACL surgery using a single bundled graft [5, 8, 9].In our technique the graft is tensioned and cycled separately after passing through the PL portal and after being temporarily held with a Kocher clamp. After this step, the graft is looped through the AM femoral tunnel to the tibia for its final tension and fixation. Successful long-term results from implant-free ACL fixations are not new [10, 11].The authors share the same scepticism as the readers on the absence of fixation on the femur and are performing an on-going study to compare the results between this technique and the addition of a separate fixation of the PL bundle and the creation of two tibial tunnels.The purpose of this manuscript is to describe a surgical technique that focuses on the loop passage of the hamstrings around the lateral femoral cortex. Comparison of the long-term efficiency of single versus double bundle ACL reconstruction is beyond the scope of this study, and remains a matter of constant research and controversy.The purpose of the study was to record graft tunnel motion, osteoclast-mediated bone resorption and subsequent tunnel widening with this technique, which are all well-known issues in ACL reconstruction, regardless of graft and fixation used. All these data are presented in the results section.The steps for graft passage are described below:The graft is led with a loop suture in a “tibia-to-femur” direction, from the tibial tunnel and into the PL femoral tunnel. An additional interference screw could be optionally applied now in the femoral PL tunnel at 0o of knee flexion (Fig. 1a). A second suture loop is passed from the tibia tunnel in front of the PL bundle and into the femoral AM tunnel. With the use of a Kelly (or similarly curved) clamp, which is directed from the femoral PL skin incision (under the fascia lata and in close contact with the femoral cortex) to the femoral AM skin incision, the suture is retrieved in the femoral PL skin incision (Fig. 1b) and the graft is pulled in a “femur-to-tibia” direction to the tibial tunnel (Fig. 1c).Fig. 1The steps of graft passage are: (a) after the drilling of two separate femoral tunnels, (b) a suture loop is guided from the PL femoral tunnel to the tibial tunnel, (c) the graft is pulled from the tibia to the PL femoral tunnel, (d) a second suture loop ...The term “double femoral socket” in the abstract refers to the two femoral tunnels used in this technique.Although, ACL reconstruction is performed widely nowadays, the authors share the opinion that it still remains a procedure that should be performed by experienced surgeons. Even “single” bundle ACL reconstruction can present difficulties, intraoperative complications and demands anatomical and technical knowledge that require surgical expertise. Furthermore, from our practice, the described technique has been adopted by other less experienced knee surgeons who perform less than 50 ACL reconstructions per year as their primary method for ACL reconstruction, and has been embraced as one of our most popular methods of ACL reconstruction from the orthopaedic fellows who have attended our unit in recent years. The purpose of the article is to focus on a cost-effective operative technique with the use of fewer implants and with the innovation of looping the graft around the lateral femoral cortex as a method of biological fixation." @default.
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• W2130794329 date "2012-05-15" @default.
• W2130794329 modified "2023-09-25" @default.
• W2130794329 title "Reply to comment on Prado et al.: A new technique in double-bundle anterior cruciate ligament reconstruction using implant-free femoral fixation" @default.
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• W2130794329 doi "https://doi.org/10.1007/s00264-012-1568-8" @default.
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