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Anatomic All-Inside Anterior Cruciate LigamentReconstruction Using the Translateral Technique

Adrian J. Wilson, M.B.B.S., B.Sc., F.R.C.S., F.R.C.S.(Tr&Orth),Sam K. Yasen, M.B.B.S., B.Sc., M.R.C.S.,

Tamara Nancoo, M.A.(Cantab), M.B.B.Chir., P.G.Dip.(SEM), F.R.C.S.(Tr&Orth),Roger Stannard, James O. Smith, B.M., B.Sc., M.R.C.S., and

James S. Logan, M.B.B.S., B.Sc., M.R.C.S.

Abstract: There is growing evidence that anatomic placement of the femoral tunnel in anterior cruciate ligamentreconstruction confers biomechanical advantages over the traditional tunnel position. The anteromedial portal techniquefor anatomic anterior cruciate ligament reconstruction has many well-described technical challenges. This article describesthe translateral all-inside technique, which produces anatomic femoral tunnel placement using direct measurement of themedial wall of the lateral femoral condyle and outside-in drilling. All work is carried out through the lateral portal with allviewing through the medial portal. Thus there is no need for an accessory medial portal or hyperflexion of the knee duringfemoral socket preparation. A single quadrupled hamstring graft is used with cortical fixation at both the femoral and tibialtunnels.

ranstibial drilling remains themost popular method

Tfor creating the femoral tunnel in anterior cruciateligament (ACL) reconstruction. With this technique,femoral socket placement is dictated by the tibial tunnel,which invariably results in a relatively vertical positionof the graft. Although this technique has had good earlyclinical outcomes, the procedure has been shown tobe nonanatomic.1,2 This fails to restore normal kneekinematics,3,4 which in turn may lead to early-onsetosteoarthritis.5

An alternative technique for femoral tunnel prepara-tion is anteromedial (AM) portal drilling, in whichindependent drilling of the femoral and tibial tunnels isperformed.6 This approach requires an exact apprecia-tion of the intra-articular bony anatomy, particularly onthe medial face of the lateral femoral condyle, to define

From the Department of Orthopaedics, Basingstoke and North Hampshireospital, Hampshire Hospitals NHS Foundation Trust, Basingstoke, England.The authors report the following potential conflict of interest or source ofnding in relation to this article: Arthrex, Naples, FL.Received October 30, 2012; accepted December 17, 2012.Address correspondence to Adrian J. Wilson, M.B.B.S., B.Sc., F.R.C.S.,.R.C.S.(Tr&Orth), Department of Orthopaedics, Basingstoke and Northampshire Hospital, Hampshire Hospitals NHS Foundation Trust, Aldermas-n Road, Basingstoke RG24 9NA, England. E-mail: wilsonortho@gmail.com� 2013 by the Arthroscopy Association of North America2212-6287/12700/$36.00http://dx.doi.org/10.1016/j.eats.2012.12.002

Arthroscopy Techniques, Vol 2, No

tunnel placement. This can be difficult to establish usingtraditional lateral portal arthroscopic viewing, where thefemoral intercondylar and bifurcate ridges are not readilyidentified. Furthermore, use of the clock-face referencecan lead to a high or anterior placement of the graft.7

Recently, the concept of “anatomic” or “footprint” ACLreconstruction has been introduced. This has been shownto confer a biomechanical advantage over nonanatomicreconstruction.3 In its current form, anatomic femoralpreparation makes use of an accessory medial portal,8-10

which allows simultaneous medial viewing and prepara-tion of the femoral tunnel. Although this improves visu-alization of and access to the femoral tunnel entryposition, it can be technically challenging becauseof problems such as instrument crowding and hyper-flexion.11,12 The translateral technique, first published byus in July 2012,13 simplifies the process, with all workbeing carried out with the knee flexed to 90� and with norequirement for an accessorymedial portal. This technicalnote describes the translateral all-inside technique. Thishas all the advantages of the original techniquewhile alsopreserving the gracilis tendon as a secondary stabilizeror for use as a further graft in multiligament surgery(Table 1).

TechniqueThe translateral technique requires special instru-

ments. These instruments have been designed by the

2 (May), 2013: pp e99-e104 e99

Table 1. Indications, Contraindications, Tips, Pearls, Pitfalls, Key Points, and Limitations of Translateral All-Inside Technique forACL Reconstruction

IndicationsACL deficiency requiring reconstruction, especially when performed as part of multiligament reconstruction.

ContraindicationsContraindications for any surgical technique for ACL reconstruction.

AdvantagesDirectly measured anatomic placement of femoral tunnel without pitfalls of creating accessory medial portal.Single semitendinosus hamstring harvest.Gracilis preserved as secondary stabilizer or for use as further graft.Cortical fixation at both tibial and femoral sites.

Tips and pearlsThe lateral portal should be placed as close to the patellar tendon as possible to allow easy passage of the translateral instruments.The femoral anatomic midbundle point is halfway along a line from the deep articular margin to the shallow articular margin. Thiscorresponds to the bifurcate ridge.

The height of the center of the femoral tunnel is 2 mm plus the radius of the femoral tunnel above the low articular margin.The femoral jig is set at 110�.The tibial jig is set at 70�.The femoral socket is drilled to a depth of 20 mm.The graft is marked 20 mm from the femoral end. When this mark passes beyond the mouth of the socket, the button will have beenpulled free of the lateral femoral cortex.

Pitfalls and risksIt is important to identify and harvest only the semitendinosus. The technique can be performed with a quadrupled gracilis tendon, butgraft size is less reliable.

In cases of inadequate graft size, a quadrupled semitendinosus and gracilis tendon can be used. This is termed a mega-GraftLink.When one is retrieving the suture loops through the AM portal, they may become looped, making graft passage impossible. To avoid this,one should withdraw 1 end of each of the loops and form a snare at the end of the suture so that they cannot become intertwined.

Key pointsRF ablation of the medial wall of the lateral femoral condyle is vital to preserve the bony landmarks.During femoral preparation, all work is carried out through the lateral portal. All viewing is through the medial portal.The knee is flexed to 90� throughout.

LimitationsGraft preparation can be more time-consuming than traditional whipstitching.

e100 A. J. WILSON ET AL.

senior author to navigate around the distal aspect of thelateral femoral condyle while avoiding impingement onthe patellar tendon medially. They include a speciallyshaped Opes radiofrequency (RF) probe (Arthrex,Naples, FL) for soft-tissue debridement, a modifiedcurette, a curved dual-function marking and measuringdevice (Fig 1), and an anatomic aiming arm fora retrograde drill. These specific translateral tools aremanufactured by Arthrex. The author uses the Flip-Cutter (Arthrex) to create a “retrosocket” by outside-indrilling, as has been described by other authors,including Lubowitz et al.14

The patient is positioned supine with the knee flexedto 90�. A side support and footrest are used. A thightourniquet is used throughout. A modified anterolateral(AL) portal (Fig 2) is used, which is positioned slightlylower and more medial than the traditional high ALportal position. A 30� side-viewing arthroscope isinserted through the modified AL portal. A standardAM portal is then made under direct vision. Routinearthroscopic assessment is undertaken and appropriatesurgery carried out to address any chondral or meniscalpathology.A single semitendinosus tendon is harvested through

a curved incision over the pes anserinus. The tendon isloaded onto 2 adjustable suspensory devices (ACL

TightRope RT; Arthrex) and quadrupled to makea GraftLink (Arthrex) (Fig 3).15 In the first-generationtranslateral technique, both the semitendinosus andgracilis tendons were harvested. The tendons weredoubled to create a traditional 4-strand graft andsecured to a single TightRope at the femoral end. Thearthroscope is then swapped to the AM portal for theremainder of femoral preparation. The knee remainsflexed to 90� with no hyperflexion required throughoutthe procedure.The medial wall of the lateral femoral condyle is

prepared with the curved RF probe. The use of RFis essential to allow soft-tissue debridement whilepreserving the footprint of the native ACL and facilitatingidentification of the bony anatomic landmarks, namelythe bifurcate and intercondylar ridges.The curved marking device (Fig 1) is then inserted

through the lateral portal to determine and mark thecenter of the ACL footprint. Figure 4 shows the anatomicfootprint with the relevant measurements annotated.Two measurements are made; the first is made by use ofthe long axis of the measuring tool that measures fromdeep to shallow with the center of the ACL footprint atthemidpoint,16 which corresponds to the bifurcate ridge.A secondmeasurement is thenmade using the calibratedtip that determines the height of the center of the

Fig 1. (A) Curved marking/measuringdevice. This instrument allows directmeasurement of the medial wall of thelateral femoral condyle and anatomicpositioning of the femoral tunnel. (B)Measuring from low position: the viewis of the medial wall of the lateralfemoral condyle of the left knee fromthe AM portal with the knee at 90� offlexion. The height of the center of thefemoral tunnel is 2 mm plus the radiusof the tunnel above the low articularmargin. (C) Close-up of measuring arm.(D) Measuring deep to shallow or frontto back of notch. The anatomic ormidbundle position is halfway from thedeep to the shallow articular cartilage.Again, the view is from the AM portalat 90� of flexion.

TRANSLATERAL ALL-INSIDE TECHNIQUE e101

footprint from the low position. The measuring/markingdevice has a sharp tip, which allows the surgeon to markthe correct femoral tunnel position. Figure 5 shows thearthroscopic view during direct measurement of themedialwall of the lateral femoral condyle.A calibratedRFdevice, the Arthrex Caliblator, has recently been devel-oped to permit simultaneous soft-tissue clearance andmarking, significantly facilitating this process (Fig 6).The femoral and tibial tunnels are created by the ret-

rosocket approach: the FlipCutter aiming device isinserted through the modified AL portal and positionedat the premarked anatomic femoral origin (Fig 7). Withthe knee flexed to 90�, a 3.5-mm femoral pilot hole isthen created with the FlipCutter by an outside-in drillingtechnique. The end of the FlipCutter is deployed and

Fig 2. Translateral portal positions. This shows the left knee at90� of flexion with traditional and translateral portals. Thetranslateral portals are noticeably lower and more centralthan the traditional portals.

drilled in a retrograde manner to produce a femoralretrosocket. We routinely drill this socket to a depth of20 mm. A FiberStick (Arthrex), a stiffened plastic tubecontaining a highetensile strength loop of suture, is thenpassed through the femoral tunnel, and the containedFiberWire is retrieved from the knee joint. The tibialretrosocket is created by the same technique, with thetibial aiming jig placed in the midbundle position. Weroutinely drill this socket to a depth of 35 mm using theFlipCutter. A TigerStick (Arthrex), a stiffened plastic tubecontaining a looped, striped highetensile strengthsuture, is passed through the tibial tunnel, and the con-tained TigerWire is retrieved with the femoral FiberWire

Fig 3. Quadrupled semitendinosus tendon with 2 ACLTightRopes, forming a modified GraftLink construct. A singlesemitendinosus tendon is harvested through a curved incisionover the pes anserinus. The tendon is loaded onto 2 adjustablesuspensory TightRope RT devices and quadrupled to form themodified GraftLink construct.

Fig 4. Medial aspect of lateral femoralcondyle. The anatomic footprint of thenative ACL is shown, as are the grafttunnel and measurements. The positionof the femoral tunnel is in the anatomicmidbundle position. Reprinted withpermission.13 (PL, posterolateral.)

e102 A. J. WILSON ET AL.

simultaneously through the AM portal to ensure thatthere is no soft-tissue bridge. As an additional measure toprevent snagging or entwining of the looped sutures, 1end of each suture is pulled out of the AMportal to createa single strand. Pull-through loops are then fashioned atthe end of each suture for the TightRope buttons, whichare then pulled into their respective sockets. First, thefemoral TightRope RT is pulled through to “bottom out,”or fully seat, the graft within the femoral socket. By doingthis we avoid inadvertently pulling too much of the graftlink into the femoral socket. We then turn our attentionto the tibial socket, and the Tibial TightRope RT is passedthrough the tibial tunnel. The GraftLink is pulled into thetibial retrosocket, and final tensioning is achieved in fullextension by reciprocal toggling of the 2 suture ends tosnug the graft home. Cortical suspensory fixation is thusachieved at both ends of the graft. The knee is cycled, andif necessary, the TightRopes can be retensioned beforefinally removing excess suture (Video 1). This all-insideapproach is a modification of our original translateraltechnique. In thefirst-generation technique, a traditional

tibial tunnel was drilled and tibial fixation was achievedwith an interference screw.

DiscussionThere are many advantages to the translateral all-

inside technique. The instruments allow all femoralpreparation to be carried out through a single modifiedAL portal with the knee at 90� of flexion. This includessoft-tissue debridement and identification and markingof the center of the ACL footprint, together with crea-tion of the femoral retrosocket.Bird et al.17 previously described the ruler technique

with themidbundle position being located halfway alonga line measured on the lateral intercondylar wall fromthe deep articular cartilage margin to the most shallowposition. Anatomic placement of the femoral tunnel isachieved while avoiding the pitfalls of the AM portaltechnique identified by Lubowitz.12 The most notableof these is the need for hyperflexion, which can leadto disorientation, a short femoral tunnel, malpositioningof the femoral aiming jig, “portal tightening,” iatrogenic

Fig 5. Arthroscopic view of directmeasurement of medial aspect of lateralfemoral condylewithmarking/measuringtool. All the arthroscopic images are ofa left knee in 90� of flexion throughthe AM portal. (A) Measuring deep toshallow. (B) Measuring shallow articularcartilage to center of femoral footprint.This point lies halfway between thedeep and shallow articular cartilage. (C)Measuring from low articular cartilagealong line of bifurcate ridge. The height ofthe center of the femoral tunnel is 2 mmplus the radius of the femoral tunnelabove the low articular cartilage.

Fig 6. Caliblator curved RF device. (A)Measuring deep to shallow. (B) Mea-suring shallow articular cartilage tocenter of femoral footprint, which lieshalfway between deep and shallowarticular cartilage. (C) Measuring fromlow articular cartilage along line ofbifurcate ridge. The height of the centerof the femoral tunnel is 2 mm plus theradius of the femoral tunnel above thelow articular cartilage.

TRANSLATERAL ALL-INSIDE TECHNIQUE e103

damage to the articular cartilage of the medial femoralcondyle, and increased fat pad ingression.12 In ourpractice, anatomic femoral socket placement usingthe accessory medial portal has been complicated byinstrument crowding.We have shown that, with the useof specifically designed instrumentation, the translateraltechnique provides a facile approach to anatomic ACLreconstruction, dispensing with the requirement for anaccessory medial portal or hyperflexion of the kneeduring femoral socket preparation.The all-inside modification of the translateral tech-

nique requires only isolated harvesting of the semite-ndinosus tendon, which has previously been shown topreserve postoperative hamstring strength,16 and allowsthe remaining hamstring to function as a secondarystabilizer or to be used as a graft for further ligamentreconstructions. The use of bicortical suspensory fixation

Fig 7. Arthroscopic images of femoraltunnel preparation. Images show a leftknee at 90� of flexion through the AMportal. (A) Aiming jig in position atanatomic midbundle point. This can beconfirmed by the calibrations on thejig arm. (B) View of femoral tunnel.(C) Confirming tunnel position withmeasuring tool.

of the graft has also been shown to withstand higherforce to failure over conventional interference fixationdevices (data on file at Arthrex).The quadrupled semitendinosus graft has consistently

provided a good graft diameter in our series, 8.6 mmmean.However, inadvertentharvestingof thegracilis canoccur. In this event, a quadrupled gracilis can be used ifthis graft is of a suitable diameter. In cases in which thegraft is of insufficient girth, a quadrupled semitendinosusand gracilis composite graft can be used to form a “mega-GraftLink.” GraftLink preparation can be more time-consuming and technically challenging than traditionalwhipstitching. A competent assistant is required. Despitethese caveats, this new technique has significant advan-tages with specifically designed instrumentation thatpermits a facile approach, namely, all work is carried outthrough the lateral portal with all viewing through the

e104 A. J. WILSON ET AL.

medial portal anda single quadrupledhamstring graft canbe readily used with cortical fixation at both the femoraland tibial tunnels.

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