TriLink: Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction

Abstract

Cadaveric and clinical biomechanical studies show improved kinematic restoration using double-bundle anterior cruciate ligament (ACL) reconstruction techniques. These have been criticized in the past for being technically challenging. We present a novel 3-socket approach for anatomic "all-inside" double-bundle reconstruction using a single hamstring tendon fashioned to create a trifurcate graft: the TriLink technique. The semitendinosus alone is harvested, quadrupled, and attached to 3 suspensory fixation devices in a Y-shaped configuration, creating a 4-stranded tibial limb and 2 double-stranded femoral limbs. A medial viewing/lateral working arthroscopic approach is adopted using specifically designed instrumentation. Anatomic placement of the 2 femoral tunnels is performed by a validated direct measurement technique. A single mid-bundle position is used on the tibia. Both femoral and tibial sockets are created in a retrograde manner using outside-to-in drilling. This is a simplified operative technique for anatomic double-bundle ACL reconstruction that maximizes bone preservation. The TriLink construct replicates the 2 bundles of the ACL, conferring native functional anisometry and improving femoral footprint coverage while avoiding the complexities and pitfalls of doubleetibial tunnel techniques. Preservation of the gracilis reduces the morbidity of hamstring harvest and allows greater flexibility in graft choice in cases requiring multiligament reconstruction.

Biomechanical comparison of graft structures in anterior cruciate ligament reconstruction

“…The femoral attachment site has the most effect on ACL graft isometry and tension with knee flexion [ 16 , 27 , 41 ], so a simplified graft construct which covers most of the femoral ACL attachment is attractive. Therefore, the purpose of this study was to examine the relative merits of a three-socket (3S) construct, with a V-configuration graft located into a single tibial tunnel and double femoral ACL graft tunnels [ 49 ]. Unlike previous work, the present study evaluated ACL reconstructions using cortical suspensory fixation, enabling different tensioning angles for each graft bundle.…”

ACL double-bundle reconstruction with one tibial tunnel provides equal stability compared to two tibial tunnels

“…A number of biomechanical [6,14,29,36] and clinical studies [1,4,17,18,22,23,26,37,39] with different techniques have been published. Improved results were reported for the double-bundle reconstruction with one tibial tunnel compared to a single-bundle reconstruction, particularly for the simulated pivot shift, but also in anterior tibial translation [6,23,36].…”

Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction with Hamstring Tendon Autograft through Single Femoral Tunnel and Single Branched Tibial Tunnel

“…Other modified techniques were limited by difficulty, graft/suture entanglement, 32 graft length <22 cm, femoral footprint diameter <16 mm, 33 and difficulty in passing the graft through the anteromedial portal except after its widening and removal of the ACL remnant. 34 …”