# Simultaneous Tunnel Grafting and Anterior Cruciate Ligament Reconstructions Revision Using Double Suspensory Fixation: A Single-Stage Solution

## TL;DR

This paper introduces a single-stage surgical method for revising ACL reconstructions by combining tunnel grafting and double suspensory fixation to improve efficiency and recovery.

## Contribution

A novel single-stage revision technique for ACLR using simultaneous tunnel grafting and double suspensory fixation is proposed.

## Key findings

- The new method eliminates reliance on metaphyseal bone stock for graft fixation.
- The procedure may reduce costs and recovery time by avoiding a second surgery.
- Secure graft fixation is achieved using adjustable loop cortical buttons.

## Abstract

The anterior cruciate ligament (ACL) is often vulnerable to sports-related injuries, leading to numerous ACL reconstructions (ACLRs) annually in the United States. Although largely successful, these procedures face the risk of recurrent instability due to graft failure. ACLR failures are typically attributed to technical errors and patient-related factors, with improper positioning of the tibial and femoral tunnels as the most common technical mistake. Current 2-stage revision techniques involve primary bone grafting followed by secondary tendon graft placement, resulting in increased costs and extended rehabilitation times. This article proposes a single-stage revision strategy involving simultaneous tunnel grafting and ACLR revision. The method employs double suspensory fixation by adjustable loop buttons, thereby eliminating the dependence on metaphyseal bone stock for stable graft fixation. This new procedure may offer a more efficient and cost-effective approach, reducing the need for a second surgery and potentially allowing patients to return to normal activities more quickly.

Video 1A detailed demonstration of our surgical technique for tunnel reaming and graft insertion for anterior cruciate ligament reconstruction. The patient is placed in the supine position and prepped with a tourniquet and intravenous antibiotics. Key locations for various portal insertions are marked and the surgical site is prepared. This is followed by careful graft selection and preparation, including attaching adjustable-length loop cortical buttons to both ends of the graft and tensioning. The arthroscopic technique is used to identify, overdrill, and ream the femoral tunnel. Attention is then directed to the tibial bone to select a new tunnel location, which is then reamed and thoroughly cleared of any remnants from the previous tibial tunnel. The graft is carefully inserted through both femoral and tibial tunnels, showing secure fixation. The final steps involve restoring the tibial bone defect with a cylindrical cancellous bone allograft, checking the stability of the fixation, and closing the wound using monofilament absorbable sutures.

A detailed demonstration of our surgical technique for tunnel reaming and graft insertion for anterior cruciate ligament reconstruction. The patient is placed in the supine position and prepped with a tourniquet and intravenous antibiotics. Key locations for various portal insertions are marked and the surgical site is prepared. This is followed by careful graft selection and preparation, including attaching adjustable-length loop cortical buttons to both ends of the graft and tensioning. The arthroscopic technique is used to identify, overdrill, and ream the femoral tunnel. Attention is then directed to the tibial bone to select a new tunnel location, which is then reamed and thoroughly cleared of any remnants from the previous tibial tunnel. The graft is carefully inserted through both femoral and tibial tunnels, showing secure fixation. The final steps involve restoring the tibial bone defect with a cylindrical cancellous bone allograft, checking the stability of the fixation, and closing the wound using monofilament absorbable sutures.