Anatomic anterior cruciate ligament reconstruction using the over-the-top passage of hamstring tendons

The anterior cruciate ligament (ACL) reconstruction using a double-bundle gracilis and semitendinosus technique guarantees a more anatomic reconstruction and allows the surgeon to avoid the use of hardware for graft fixation. The tendons are harvested, maintaining their tibial insertion. The tibial tunnel is located in the medioposterior part of the ACL tibial insertion. For the femoral tunnel, the guide pin is advanced from anteromedial portal to 10 o'clock position in the medial wall of the lateral condyle and passes until reach the femoral cortex. The exit point in the lateral aspect of the femur should be immediately above the end of the lateral femoral condyle. The tendons are passed over the top. The correct placement is found by palpating the posterior tubercle of the lateral femoral condyle with a finger. The stitches on the free end of the tendons are tied onto the passing suture that is pulled through the knee joint into the over-the-top position. A suture loop is introduced into the joint through the anteromedial portal using a suture passer and then pulled into the femoral tunnel. The stitches on the free end of the tendons are looped again onto the passing suture, which is pulled through the femoral tunnel, knee joint, and tibial tunnel to retrieve the graft from the tibial incision. The combined gracilis and semitendinosus tendons are then tensioned and secured with a transosseous suture knot. This technique attempts to reproduce the kinematic effect of both anteromedial and posterolateral bundle of the ACL.