Remnant Tensioning Through Pullout Sutures From the Femoral Tunnel During Anatomic Anterior Cruciate Ligament Reconstruction

Abstract

Even after anterior cruciate ligament (ACL) tear, its remnant retains the vascularized synovial sheets, fibroblasts, myofibroblasts, and various mechanoreceptors within it. The aim of preserving the remnant is to retain these components during ACL reconstruction. In the recent past, there has been an increasing trend towards preserving remnants during ACL reconstruction. Although preserving remnants have physiological advantages, cyclops lesion and extension loss were among the most feared complications. Cyclops and loss of extension are due to the fallback of the remnant into the notch. Moreover, the mechanoreceptors present in the remnant are not active when the remnant is lax. These mechanoreceptors are active when the remnant is in tension. Thus, rather than merely preserving the remnant, it is essential to tension it for more physiological functions. Although there are various techniques of remnant tensioning described in the literature, these techniques require tampering of the fixation devices or an extra fixation device adding to the cost of surgery. We describe our modification of the remnant-tensioning method during anatomic ACL reconstruction. In this technique, the sutures holding the remnant are pulled out through the anatomic femoral tunnel and fixed with an interference screw along with the hamstring graft. This technique is cost-effective, reproducible, and does not require tampering with the fixation devices. Moreover, the direction of remnant pull will be the same as that of the reconstructed graft making both the graft and remnant anatomical in orientation. Suture management and visibility of the intraarticular structures during this procedure are a few downsides of this technique. The only prerequisite of this technique is a good quality remnant to hold the sutures.

Modification of Outside-In Technique In Preparing Femoral Tunnel During Anterior Cruciate Ligament Reconstruction—“PL-Portal Outside-In Technique”

“…Despite this, correct assessment of femoral footprints can still be difficult in remnant-preserving ACLR with the outside-in technique. 3 , 5 , 6 Hence, some surgeons have proposed modifications to the viewing portal of the outside-in technique, from the anteromedial portal to the posterior portals, including viewing through a PL portal with a 70° arthroscope, 5 or viewing through a trans-septal portal with a 30° arthroscope. 6 However, most surgeons do not welcome these modifications.…”

“…The working space within the joint may appear crowded in the scenarios of small joints (e.g., pediatric ACLR), or when there is a need to preserve a “big” ACL remnant (e.g., isolated anteromedial [AM] bundle ACLR or isolated posterolateral [PL] bundle ACLR). 3 The visibility is further limited in the AMP technique because of the need for hyperflexion of the knee during femoral tunnel preparation. 3 , 4 This leads to difficulty in assessing the correct intra-articular position of the femoral tunnel aperture.…”

“… 3 The visibility is further limited in the AMP technique because of the need for hyperflexion of the knee during femoral tunnel preparation. 3 , 4 This leads to difficulty in assessing the correct intra-articular position of the femoral tunnel aperture. 3 , 5 , 6 Some surgeons have proposed modifying the viewing portal of the outside-in technique from the AM portal to posterior portals, including viewing through a PL portal with a 70° arthroscope 5 or viewing through a trans-septal portal with a 30° arthroscope.…”

“… 3 , 4 This leads to difficulty in assessing the correct intra-articular position of the femoral tunnel aperture. 3 , 5 , 6 Some surgeons have proposed modifying the viewing portal of the outside-in technique from the AM portal to posterior portals, including viewing through a PL portal with a 70° arthroscope 5 or viewing through a trans-septal portal with a 30° arthroscope. 6 However, these modifications are not popular, probably because of the learning curve involved in adopting posterior portals as the viewing portal.…”