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Anterior Cruciate Ligament Reconstruction: All-Inside Reconstruction

Jamie L. Lynch, MD,* and Kyle Anderson, MD


Arthroscopic techniques to reconstruct the anterior cruciate ligament (ACL) are constantly evolving. The treatment of ACL ruptures vary based on the patient, as well as, associated injury and even the surgeons preferred technique. Further attention to the ACL anatomy and attempts to improve the biologic environment for healing have lead to the creation of this all-inside ACL reconstruction. Furthermore, this method utilizes lesser-invasive, cortical-sparing sockets rather than full tunnels. An all-inside ACL reconstruction procedure is fully described below specically detailing the required equipment, implants and technique. Oper Tech Sports Med 21:40-46 2013 Elsevier Inc. All rights reserved. KEYWORDS: ACL, all-inside, graft-link, TightRope, cortical button

n the past decade, orthopaedic sports medicine surgeons have seen considerable modications of the anterior cruciate ligament (ACL) reconstruction. Generally, the goals have been to create a lesser invasive more anatomic reconstruction while attempting to optimize the biological environment for healing. The purpose of this report is to present an all-inside ACL reconstruction, called the graft-link technique, which we believe encompasses all these principles. The proposal of the all-inside ACL reconstruction is not a new concept. In 1995, Morgan et al sought to create an allinside ACL reconstruction using bone-hamstring-bone composite graft xed with metal interference screws.1,2 Stahelin and Weiler described an all-inside technique in 1997.3 The goal of their reconstruction method was developed to improve hamstring tendon xation and facilitate early rehabilitation using biodegradable screws in both the femoral and tibial tunnel, through AM portal and parapatellar incision, respectively.3 Nevertheless, these earlier techniques have been considered technically demanding by some.4 More recently, Lubowitz described a simplied all-inside technique, using a Dual RetroCutter, (Arthrex, Inc, Naples, FL), by way of a transtibial method.4 This allowed for the creation of sockets instead of full tunnels. Unfortunately, potential mal-

*Northeast Orthopaedics and Sports Medicine, LLP, San Antonio, TX. Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, MI. Address reprint requests to Jamie L. Lynch, MD, Northeast Orthopaedics and Sports Medicine, 12709 Toepperwein, Suite 101, San Antonio, TX 78233. E-mail: jlynch@neosm-sa.com

positioning of one or both of the tunnels can occur with a transtibial approach.5,6 The attention to ACL anatomy and knee joint mechanics has resulted in a better appreciation for the proper ACL tunnel position. Purnell et al explained the transtibial error as a mismatch graft position, specically predisposing a graft to pass from the posterolateral aspect of the tibial footprint to the anteromedial (AM) aspect of the femoral footprint.7 Furthermore, femoral tunnels created in a transtibial manner tend to be relatively vertical and have less rotational stability.8-11 Lee et al demonstrated a clinical increased pivot shift in patients with more vertical grafts.12 Multiple authors have demonstrated that nonanatomic femoral tunnel placement is the most common technical error, leading to failure of ACL reconstruction.13,14 Creating an anatomic femoral tunnel can be done with the traditional outside-in (OI) technique that requires dissection over lateral distal femur.15-17 As an alternative, low-prole or exible reamer can be used through the AM portal with the knee in a hyperexed position. There are, however, theoretical and potential pitfalls described by numerous authors based on cadaveric studies. This includes damage to the medial femoral condyle upon reamer entry into the joint, and damage to the posterior lateral femoral condyle, lateral gastrocnemius, lateral collateral ligament, or common peroneal nerve with the guide pin.18,19 Additionally, posterior wall blowout can occur at 90 of exion with AM drilling of a single bundle.20 Farrow and Parker demonstrated decreased risk by drilling the AM bundle in hyperexion of 130 specically decreased distance to the LCL with respect to the PL

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1060-1872/13/$-see front matter 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1053/j.otsm.2012.11.001

ACL reconstruction
bundle in 130 of exion.18 In general, it appears that lateral structures are at less risk with higher knee exion angles.18-21 However, the hyperexed position of the knee associated with AM portal reaming has led to documented breakage of the guide pin.22 The present technique, however, revisits the OI concept, but allows for a small percutaneous incision, with no need for muscular dissection, and aids in direct visualization of the femoral footprint through the AM portal without hyperexion. As there is no need for hyperexion, the knee is able to rest at 90, which is a very familiar position for the surgeon when visualizing the femoral footprint. By and large, the femoral footprint is recreated near the center of the footprint more reproducibly using a tibial tunnelindependent technique, such as OI or AM portal method, but an OI approach results in lower risk to the lateral femoral condyle than the AM portal technique.18,21 Lubowitz and Konicek also point out that AM portal reaming of the femoral tunnel can result in shorter tunnels with respect to OI reaming.23 One hallmark of this technique is that sockets are created rather than full tunnels. The result is that the extra-articular cortices are intact, which can decrease swelling, pain, and possibly synovial uid inltration or ow through the graft bone interface. The conceptual difference is that of potting the graft into a compact bony socket as opposed to pulling a graft through a full-length tunnel. This allows for more complete ll of the aperture and socket with graft collagen and eliminates the need for interference xation, which can displace the graft to one portion of the aperture and can be deleterious to healing by limiting healing interface area, as well as affecting the biological milieu. The described technique later in the text will focus primarily on an anatomic single-bundle ACL reconstruction using autologous hamstring; however, with appropriate adjustments, it can also be used to complete a double-bundle ACL reconstruction. In addition, this cortical button technique can be used for autologous bone-patellar-tendon-bone (BPTB) graft. Most surgeons who use the TightRope (Arthrex, Inc, Naples, FL) with BPTB graft tend to use this xation on solely the femoral side. That being said, the principles of this all-inside technique can be used for the femoral and tibial side of an autograft BPTB. One signicant difference from a standard technique is the size of the graft must be smaller to ensure that it does not bottom out during positioning and tensioning.

41 harvest based on these ndings. If the examination or preoperative data are not entirely clear, the diagnostic arthroscopy can be performed next to conrm the diagnosis before harvesting tissue. This technique focuses on the use of autograft hamstring. However, based on the individual patient, the choice of graft can be altered to include soft-tissue allograft, BPTB autograft, or BPTB allograft.

Graft Harvest
The hamstring graft harvest can be completed through a traditional approach over the pes tendons or through a miniposterior approach as described by Prodromos et al.24 This will allow for an exceptionally cosmetic harvest, as the incision is not visible from anterior aspect of the knee. The graftlink technique uses a closed-loop graft where the tendon is tripled or quadrupled, and can frequently allow for use of a single hamstring tendon.25 The semitendinosus tendon is generally more likely to be adequate for the single-tendon construct. The surgeon must consider patients size, age, and activity demands to best decide the required size for the graft. Magnussen et al recently described the importance of graft size and risk for graft rupture.26 Secondary to this, additional studies, and the authors experience, we prefer our grafts to be 9 mm or larger.27,28 However, we prefer them to be no larger than 12 mm unless it is in the revision setting, in which case, a FlipCutter (Arthrex, Inc, Naples, FL) would not be used.

Graft Preparation and Linkage


The procedure uses a TightRope-Reverse Tensioning (TightRope-RT, Arthrex, Inc, Naples, FL) for the femoral side and either a TightRope-RT or a TightRope Attachable Button Sys-

Technique
Patient Positioning
The patient is placed in the supine position with a post to assist with a valgus moment and a foot and thigh holder to hold the leg at 90 when needed. A tourniquet is applied, but rarely used.

Diagnositic Arthroscopy/Graft Selection


The procedure is initiated with an examination using anesthesia. Many surgeons feel comfortable proceeding to graft
Figure 1 TightRope-RT.

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Figure 2 Set desired length of graft, considering femoral and tibial socket length and intra-articular distance.

tem for the tibial side. The TightRope is the second-generation graft loop that is adjustable and assists in suspensory xation using a cortical button. This loop of suture is a knotless locking mechanism that relies on multiple points of friction to create self-reinforcing resistance to slippage under tension analogous to a nger-trap or seatbelt mechanism (Fig. 1).25 The adjustable graft loop decreases in length under tensioning of the free ends, or tensioning strands. The tensioning strands pull the graft into the sockets by shortening the loop of suture through which the graft was passed. This eliminates the need for precise length calculations and proper loop length selection needed in the rst-generation cortical button devices.25 However, graft length remains an important concern in this technique in terms of its relationship with the overall construct length. Satisfactory estimations are 15-20 mm for the femoral tunnel, 20-25 mm for the intra-articular segment, and 25-30 mm for the tibial tunnel. The desired graft length is 5-7 mm shorter than the total length of each of the

sockets plus the intra-articular distance, allowing for some measurement error.4 A major potential pitfall of this technique is graft length mismatch. A short graft will not place enough collagen tissue into the sockets, and a long graft will lead to bottoming out in the socket and inability to properly tension the graft. As a general guideline, a 20-mm femoral socket and a 25-mm tibial socket plus approximately 25 mm of intra-articular distance will safely t a 60- to 65-mm (after pretensioning) graft. Two TightRope-RTs (Arthrex) are placed on the graft preparation station such that their loops are set apart by the desired length of graft (Fig. 2). The graft is passed through the loops of the 2 TR-RTs, with as many passes as possible for the desired length. This will establish the width of the graft (Fig. 3). While maintaining signicant tension on the graft ends, cerclage-type sutures are passed through and around each end of the graft. Care must be taken to include each strand of graft in these sutures. Two cerclage sutures are passed at each end of the graft (Fig. 4). We prefer to place these sutures at a distance from the end of the graft that matches the length of the socketthus at 20 mm on the femoral end and 25 mm at the tibial end. This is helpful during graft passage and tensioning and indicates how much tissue has been seated into each socket. Also, we prefer to start the cerclage sutures from inside so that the knot will be buried into the graft center, which decreases bulk of the graft to aid in graft passage, as well as, minimize suture material at the graft bone interface (Fig. 5). The nal closed-loop graft construct is then attached to a spring-loaded tensioning device to approximately 40 N. We have noted approximately 10% stress relaxation of the graft after pretensioning. In addition, one must account for the few millimeters of the graft tissue within the loops of the TR, as this will add to the ultimate length for the construct. This should be considered when setting the initial distance of the 2 TightRope-RTs (Arthrex). Thus, if a desired nal graft

Figure 3 Triple or quadruple the graft through the two TightRopeRTs (Arthrex).

Figure 4 Cerclage suture at both ends of the graft.

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Figure 5 Place the buried cerclage suture at a known distance from the end of the graft and use as an indicator of the amount of collagen within the socket.

length is 60 mm, we set the initial distance at 50-53 mm. Also, single-tendon grafts may have slightly less stress relaxation than double-tendon grafts. The diameter of the graft should be determined while it is on the tensioning station. This can be done using a measuring block with 0.5-mm increments. The authors determine the graft length prior to creating the femoral and tibial sockets.

Figure 7 Engage the reamer once it has entered the joint.

Femoral Socket Preparation


The joint is inspected, and dbridement of the ACL remnant is performed while preserving the femoral and tibial footprint. Notchplasty is avoided unless signicant narrowing of the notch is observed. The femoral footprint is marked with a radio-frequency probe. The authors prefer to create the ACL femoral socket via an OI approach using the FlipCutter (Arthrex), with arthroscopic visualization from the AM portal with 90 of knee exion. This is preferred because this method creates a more circular precise aperture, with complete freedom of positioning, and there is no risk to the medial femoral condyle. This is as opposed to the more oblique tunnels and limited positioning options of the transtibial reaming or the potential damage to the medial condyle, which can occur with medial portal reaming. After a soft-tissue notchplasty that specically maintains the bers of the ACL, a radio-frequency probe is used to delineate the location of the lateral intercondylar and bifurcate ridges. Both the AM bundle and posterolateral bundle are found posterior to the lateral intercondylar ridge, whereas the bifurcate ridge divides the 2 bundles.29 Ideally,

the guide is placed directly on the bifurcate ridge as described by Purnell and Larson.30 Unfortunately, these ridges are not always visible.29,31 In this situation, different intraoperative methods can be used to determine the correct starting point. In addition, if a notchplasty is necessary and the anatomic attachment of the ACL is no longer evident, one should place the guide pin for the FlipCutter (Arthrex) approximately 40% from the deep cortex relative to the overall length of the femoral condyle with the knee at 90 of exion. Also, note that one should place the height to allow a 2-mm bone bridge from the inferior articular cartilage with the knee exed to 90 (Fig. 6).32 The FlipCutter femoral guide (Arthrex) enters through the anterolateral portal, and the point is placed on the center of femoral footprint. The angle of the guide is set to 100-110. It has a unique graduated trochar guide sleeve with a narrowed tip that measures 7 mm in length. This allows for advancement of the trochar into the bone of the lateral femoral cortex and the AM tibia for stability and accurate socket measurement. The FlipCutter trochar guide sleeve (Arthrex) should enter approximately 1 cm anterior to the posterior border of the iliotibial band and 2.5 cm proximal to the lateral femoral epicondyle.25 A number 11-blade is used to place a small percutaneous incision through the skin and

Figure 6 Arthroscope placed in the AM portal and the femoral guide enters through the anterolateral portal.

Figure 8 A passing wire or suture loop is retrieved from the femoral socket.

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Figure 9 Place guide at the center of the tibial footprint. Figure 10 Pass drill through guide, then remove guide, and position the guide sleeve.

down through the IT band, and the guide is advanced 7 mm into bone. This is a built-in safety mechanism to provide a 7-mm bridge of bone that is protected to prevent overreaming through the cortex. A FlipCutter (Arthrex) of the appropriate diameter is drilled into the joint, and the guide is removed while the guide sleeve is then advanced 7-mm into the bone with a mallet. The FlipCutter (Arthrex) is engaged and drilled retrograde (Fig. 7). For best visualization, an arthroscopic shaver can be used to clear bony debris as the reaming is performed. The FlipCutter (Arthrex) is placed back into the knee, and the reamer is ipped back into its linear position to be removed from the knee, while holding the guide sleeve stable. Next, a coated suture (FiberStick, Arthrex) or passing wire is placed into the guide sleeve and into the joint to be used later as a passer for the sutures from the graft (Fig. 8). The looped suture is then removed from the joint via the AL portal and secured with a clamp on itself. If traditional reaming is preferred, the femoral socket can be created using AM portal with low-prole reamers or exible reamers,33 and a Beath pin can be used to place a suture loop within the femoral socket.

passing suture or wire is placed through the tibial guide sleeve and into the joint.

Graft Passage
Before passing the graft, the surgeon must be certain the AM portal is large enough to pass the graft. To avoid creation of a soft-tissue bridge, we recommend usage of a shoehorn or open-style cannula or a cannula large enough to pass the graft. Also, it is essential that the passing sutures from the femur and tibia do not become entangled. This is simplied by using a large combination retreiver/grasper, the tibial suture is retrieved in the sliding part of the retriever while the femoral sutures are grasped in the grasper portion (Fig. 12). It is often helpful to mark the intraosseous socket distance on the loop of suture at the femoral end of the graft-link construct. This is easily determined by reading the laser marks on the FlipCutter (Arthrex) guide sleeve just as it exits the femoral guide. The distance is measured from the unipped button and marked on the suture loop, which contains the graft. The button will reach the cortex close to the moment the marking on the suture loop reaches the femoral aperture.

Tibial Socket Preparation


Accurately placed tibial socket is important for proper global alignment of an ACL reconstruction. Based on work by Harner et al, the tibial footprint is 120% of the femoral footprint.34 Our previous teaching stressed using intra-articular guides for tunnel placement, specically 7 mm anterior to the posterior cruciate ligament and at the posterior edge of the anterior horn of the lateral meniscus.35 Currently, the goal is to place the tunnel using the bers of the tibial footprint. Therefore, a shaver is used to gently dbride the soft tissue using the radio-frequency probe to mark the center of the footprint. The tibial socket is created with tibial FlipCutter tibial guide (Arthrex) passed through the AM portal while visualizing with the arthroscope in the AL portal (Figs. 9 and 10). The guide angle will measure approximately 55-60. In the same manner as the femoral socket, a FlipCutter (Arthrex) will be used to create the tibial socket while using a shaver to clear debris (Fig. 11). Once the socket is created, a

Figure 11 Engage FlipCutter (Arthrex).

ACL reconstruction

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Figure 13 ACL reconstruction after nal tensioning.

Figure 12 Tibial suture loop in the sliding portion and the femoral suture loop in the graspers portion.

Alternatively, the loop of suture, which contains the graft, can be lengthened and the arthroscope can be placed through the AM portal. This allows direct arthroscopic visualization of the button and its sutures being passed up through the cortex of the femur while the graft is still outside the knee. Then, the scope can be repositioned in the anterolateral portal. The tensioning sutures are alternately pulled, and the graft slowly positioned into the jont until it reaches the femoral aperture. One pitfall of this all-inside technique can be inadvertent ipping of the button beyond the femoral cortex over the IT band or even the skin during advancement of the femoral TightRope-RT (Arthrex). The aforementioned measures can help avoid this pitfall. One must be certain that the button directly opposed to the femur without soft-tissue interposition or xation will be compromised. Dissection of lateral soft tissues may be required to assure that the button rests on the cortex, if it was pulled pass the iliotibial band. In initial cases, use of intraoperative uoroscopy may be useful in conrming position of the button. Once the femoral end of the graft is positioned at the femoral aperture, the tibial button and its sutures are pulled into the joint, through the tibial socket until the button passes out of the AM cortex of the tibia. This step can also be observed arthroscopically. Again, it is very important that the button be advanced along its long axis or it can become lodged in soft tissue in the AM portal.

cut at the skin level, or an arthroscopic suture cutter can be used to cut suture closer to the button. A square knot is tied at the tibial button to help prevent inadvertent cutting of suture at the spliced segment. Refer to Table 1 for a list of pearls for this procedure.

Postoperative Care
A sterile dressing is applied, and the patient is tted for a brace if deemed appropriate by the surgeon.

Postoperative Rehabilitation
The postoperative rehabilitation is similar to other reconstructive techniques and is primarily dependent on surgeon preference. The authors preference is to allow, but not force, motion as tolerated. Weight bearing is also advanced as tolerated unless there is an associated meniscal repair or articular cartilage restoration. We tend to use a postoperative hinged brace until there is good quadriceps activity and voluntary contraction.

Outcome
Although anecdotal at this point, we have observed a substantial decrease in pain and swelling in the early postoperative period (rst 3 weeks). The acquisition of knee range of motion seems to be easier and often faster than with autograft BPTB. At 2-3 months, the reconstructions appear to be equivalent.

Table 1 Pearls for the All-inside ACL Reconstruction Mark interosseous length of the femoral socket on femoral loop sutures (distance from button) Lengthen the TightRope loop on the femoral end to allow visualization (via the AM portal) of passage of the femoral button into the femoral socket and out of the cortex Adjust the amount of graft in femoral tunnel and tibial tunnel by sequentially tensioning each side Final tensioning should occur in full extension and after cycling the knee through a full range of motion Tie a square knot over the tibial button before cutting the sutures to protect the spliced segment

Graft Tensioning
At this point, both ends of the graft should be at their respective socket apertures. The femoral and tibial tensioning sutures are tightened in an alternating manner so that each end of the graft is gradually advanced into its socket and neither end is abruptly fully seated. If this occurs, the amount of tissue in the opposite socket may be compromised. Next, the knee is taken through a range of motion to ensure no need for further tensioning. The knee is brought out into full extension for nal tensioning (Fig. 13). The femoral suture can be

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struction: Endoscopic versus two-incision technique. Arthroscopy 10:502-512, 1994 Marchant BG, Noyes FR, Barber-Westin SD, et al: Prevalence of nonanatomical graft placement in a series of failed anterior cruciate ligament reconstructions. Am J Sports Med 38:1987-1996, 2010 Abebe ES, Moorman CT, Dziedzic TS, et al: Femoral tunnel placement during anterior cruciate ligament reconstruction: An in vivo imaging analysis comparing transtibial and 2-incision tibial tunnel-independent techniques. Am J Sports Med 37:1904-1911, 2009 Farrow LD, Parker RD: The relationship of lateral anatomic structures to exiting guide pins during femoral tunnel preparation utilizing an accessory medial portal. Knee Surg Sports Traumatol Arthrosc 18:747753, 2010 Nakamura M, Deie M, Shibuya H, et al: Potential risks of femoral tunnel drilling through the far anteromedial portal: A cadaveric study. Arthroscopy 25:481-487, 2009 Basdekis G, Abisa C, Christel P: Inuence of knee exion angle on femoral tunnel characteristics when drilled through the anteromedial portal during anterior cruciate ligament reconstruction. Arthroscopy 24:459-464, 2008 Gadikota HR, Sim JA, Hosseini A, et al: The relationship between femoral tunnels created by the transtibial, anteromedial portal, and outside-in techniques and the anterior cruciate ligament footprint. Am J Sports Med 40:882-888, 2012 Milankov MZ, Miljkovic N, Ninkovic S: Femoral guide breakage during the anteromedial portal technique used for ACL reconstruction. Knee 16:165-167, 2009 Lubowitz JH, Konicek J: Anterior cruciate ligament femoral tunnel length: Cadaveric analysis comparing anteromedial portal versus outside-in technique. Arthroscopy 26:1357-1362, 2010 Prodromos CC, Han YS, Keller BL, et al: Posterior mini-incision technique for hamstring anterior cruciate ligament reconstruction graft harvest. Arthroscopy 21:130-137, 2005 Lubowitz JH, Ahmad CS, Anderson K, et al: All-inside anterior cruciate ligament graft-link technique: Second-generation, No-incision anterior cruciate ligament reconstruction. Arthroscopy 27:717-727, 2011 Magnussen RA, Lawrence JT, West RL, et al: Graft size and patient age are predictors of early revision after anterior cruciate ligament reconstruction with hamstring autograft. Arthroscopy 28:526-531, 2012 Bickel BA, Fowler TT, Mowbray JG, et al: Preoperative magnetic resonance imaging cross-sectional area for the measurement of hamstring autograft diameter for reconstruction of the adolescent anterior cruciate ligament. Arthroscopy 24:1336-1341, 2008 Maeda A, Shino K, Horibe S, et al: Anterior cruciate ligament reconstruction with multistranded autogenous semitendinosus tendon. Am J Sports Med 24:504-509, 1996 Ferretti M, Ekdahl M, Shen W, et al: Osseous landmarks of the femoral attachment of the anterior cruciate ligament: An anatomic study. Arthroscopy 23:1218-1225, 2007 Purnell ML, Larson AI: Mini-incision patellar tendon harvest and anterior cruciate ligament reconstruction using critical bony landmarks. Sports Med Arthrosc 17:234-241, 2009 Steiner M: Anatomic single-bundle ACL reconstruction. Sports Med Arthrosc 17:247-251, 2009 Bird JH, Carmont MR, Dhillon M, et al: Validation of a new technique to determine midbundle femoral tunnel position in anterior cruciate ligament reconstruction using 3-dimensional computed tomography analysis. Arthroscopy 27:1259-1267, 2011 Harner CD, Honkamp NJ, Ranawat AS: Anteromedial portal technique for creating the anterior cruciate ligament femoral tunnel. Arthroscopy 24:113-115, 2008 Harner CD, Baek GH, Vogrin TM, et al: Quantitative analysis of human cruciate ligament insertions. Arthroscopy 15:741-749, 1999 Morgan CD, Kalman VR, Grawl DM: Denitive landmarks for reproducible tibial tunnel placement in anterior cruciate ligament reconstruction. Arthroscopy 11:275-288, 1995

Conclusions
The authors have presented an all-inside ACL reconstruction that allows for a more anatomic and a less invasive reconstruction that maintains the biological environment. The FlipCutter (Arthrex) OI method results in small percutaneous incisions to create sockets as opposed to tunnels. Secondgeneration ACL cortical suspensory xation devices with adjustable graft loop length (ACL TightRope-RT, Arthrex) place the collagen of the graft in direct contact with the socket without need for interference xation, which can alter relative graft position and compromise healing interface. With attention to anatomy and adherence to techniques described earlier in the text, this all-inside technique is reproducible and reliable.
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References
1. Morgan CD: The All-Inside ACL Reconstruction. Operative Technique Manual. Naples, FL, Arthrex Inc, 1995 2. Morgan CD, Kalmam VR, Grawl DM: Isometry testing for anterior cruciate ligament reconstruction revisited. Arthroscopy 11:647-659, 1995 3. Sthelin AC, Weiler A: All-inside anterior cruciate ligament reconstruction using a semitendinosus tendon and soft threaded bio-degradable interference screw xation. Arthroscopy 13:773-779, 1997 4. Lubowitz JH: No-tunnel anterior cruciate ligament reconstruction: The transtibial all-inside technique. Arthroscopy 22:900.e1-11, 2006 5. Howell SM, Gittins ME, Gottlieb JE, et al: The relationship between the angle of the tibial tunnel in the coronal plane and loss of exion and anterior laxity after anterior cruciate ligament reconstruction. Am J Sports Med 29:567-574, 2001 6. Steiner ME: Independent drilling of tibial and femoral tunnels in anterior cruciate ligament reconstruction. J Knee Surg 22:171-176, 2009 7. Purnell ML, Larson AI, Clancy W: Anterior cruciate ligament insertions on the tibia and femur and their relationships to critical bony landmarks using high-resolution volume-rendering computed tomography. Am J Sports Med 36:2083-2090, 2008 8. Scopp JM, Jasper LE, Belkoff SM, et al: The effect of oblique femoral tunnel placement on rotational constraint of the knee reconstructed using patellar tendon autografts. Arthroscopy 20:294-299, 2004 9. Pearle AD, Shannon FJ, Granchi C, et al: Comparison of 3-dimensional obliquity and anisometric characteristics of anterior cruciate ligament graft positions using surgical navigation. Am J Sports Med 36:15341541, 2008 10. Behrendt S, Richter J: Anterior cruciate ligament reconstruction: Drilling a femoral posterolateral tunnel cannot be accomplished using an over-the-top step-off drill guide. Knee Surg Sports Traumatol Arthrosc 18:1252-1256, 2010 11. Moisala AS, Jrvel T, Harilainen A, et al: The effect of graft placement on the clinical outcome of the anterior cruciate ligament reconstruction: A prospective study. Knee Surg Sports Traumatol Arthrosc 15: 879-887, 2007 12. Lee MC, Seong SC, Lee S, et al: Vertical femoral tunnel placement results in rotational knee laxity after anterior cruciate ligament reconstruction. Arthroscopy 23:771-778, 2007 13. MARS Group, Wright RW, Huston LJ, et al: Descriptive epidemiology of the multicenter ACL revision study (MARS) cohort. Am J Sports Med 38:1979-1986, 2010 14. Greis PE, Johnson DL, Fu FH: Revision anterior cruciate ligament surgery: Causes of graft failure and technical considerations of revision surgery. Clin Sports Med 12:839-852, 1993 15. Harner CD, Marks PH, Fu FH, et al: Anterior cruciate ligament recon-

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