Anterior Cruciate Ligament
Chapter
Reconstruction via the Anteromedial
47 Portal and Single-Tunnel,
Double-Bundle Techniques 
Benton E. Heyworth and Thomas J. Gill, IV
Anterior Cruciate Ligament
Reconstruction via the
Anteromedial Portal
Use of the anteromedial portal (AMP) for establishment of
the femoral tunnel in anterior cruciate ligament reconstruc-
tion (ACLR) surgery is an area of growing clinical and
research interest. Traditionally, femoral tunnel creation has
been performed by placing instruments through the previ-
ously reamed tibial tunnel. Several studies3-6,8,14,15,26 have sug-
gested that use of the AMP eliminates the constraint in
instrumentation positioning imposed by the transtibial tech-
nique, which can lead to the creation of a more vertical
femoral tunnel or one with a nonanatomic aperture. The
AMP is meant to allow for more anatomic, lower placement
of the femoral tunnel and better re-creation of the native
origins of the anteromedial and posterolateral bundles on
the femoral condyle. However, some reports3,19,20 have under-
scored the technical challenges and steep learning curve asso-
ciated with application of the AMP technique. Complications
that have been described include lateral femoral condyle
back wall blowout, iatrogenic damage to the anterolateral
cartilage of the medial femoral condyle (MFC), bending or
breakage of the guide pin or Beath pin, and difficulty with
graft passage.
Additionally, technical considerations related to graft-
length mismatch, shortening of femoral tunnel length, and
inadequate femoral tunnel fixation can arise with use of the
AMP technique. Because the femoral tunnel angle is typi-
cally smaller, or less steep, than that used with the transtibial
technique, and because the tunnel is directed toward the
lateral cortex, rather than the anterior cortex, of the distal
femur, the length of the femoral tunnel is generally shorter.
With the use of bone-patellar tendon-bone (BPTB) grafts,
either autograft or allograft, shorter femoral tunnel length
can cause the graft to be longer than the overall distance
from the proximal extent of the femoral tunnel to the distal
extent of the tibial tunnel on the anterior cortex of the
tibia—that is, graft-length mismatch. Although this situation
is rarely seen with the technique to be described, detailed
preoperative planning can avoid this pitfall13 and several
approaches can be used to address it when it occurs. Shorten-
ing of the bone plug lengths, seating the distal end of the
femoral bone plug several millimeters deep to the aperture
of the femoral tunnel, use of a free tibial bone block, and
rotation of the tibial bone plug within the tibial tunnel
are all acceptable, well-described techniques for addressing
length issues and should be familiar to surgeons performing
ACLR.34,35
When using soft tissue grafts, there are a number of options
for femoral fixation. The growing popularity of the AMP
technique and its shorter femoral tunnel has increased the
demand for soft tissue fixation constructs with flexibility in
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length. For example, because the commonly used EndoBut-
ton CL (Smith & Nephew, Andover, Mass) uses suspensory
cortical fixation and the construct contains a continuous loop
of suture, with a minimum length of 15 mm, shorter femoral
tunnels may leave a relatively short or unsatisfactory amount
of graft contained within the tunnel. The newer EndoButton
Direct (Smith & Nephew) device allows direct fixation of
the graft onto the button, which maximizes the amount of
graft in the femoral tunnel and may therefore be better suited
for AMP techniques. The ACL Tightrope (Arthrex, Naples,
Fla) is another suspensory fixation option for soft tissue grafts
and allows the doubled-over end of the graft to be advanced
to the most proximal aspect of the femoral tunnel. The
Femoral Intrafix (DePuy Mitek, Raynham, Mass) uses aper-
ture fixation via a sheath and screw construct. Because it
allows for separation of different portions of the graft, thereby
replicating the two bundles,10 it represents the senior author’s
current implant of choice when using the AMP technique
with soft tissue grafts. The AperFix femoral implant (Cayenne
Medical, Scottsdale, Ariz) can also offer aperture fixation.
However, AMP technique with this device requires a slightly
larger portal, because both the implant and all graft limbs
must be passed through the portal, and the smallest length of
the implant is 29 mm, requiring a femoral tunnel length of
at least 30 to 35 mm.
Here we describe our approach for creation of the AMP
for ACLR with a BPTB graft and offer technical tips related
to avoidance of common complications.
Technique
Creation of an appropriately located anteromedial portal is
the most essential, primary step in ACLR surgery that uses
the AMP technique (Fig. 47-1). Although some favor the use
of an accessory AMP, we prefer instead to use a single AMP
that is slightly more inferior than the standard portal in
ACLR. The only exception to this approach is the need to
perform a concomitant procedure that requires standard
portal placement, such as meniscal repair, in which case two
AMP portal incisions may be made. In this scenario, the first
portal is established 1 to 2 mm inferior to the inferomedial
pole of the patella and the second, femoral tunnel–creating
AMP is 1 to 2 mm superior to the superior rim of the tibial
plateau. Arthroscopic visualization of AMP creation from
a standard anterolateral portal (ALP) is advised to avoid
damage to the anterior horn of the medial meniscus, given
the relatively inferior position of the AMP. In addition, some
surgeons have recommended a more medial position of the
portal compared with the AMP placement typically used in
ACLR. However, we have found that damage to the cartilage
of the medial femoral condyle can be a significant complica-
tion that is best avoided with AMP placement 2 to 3 mm
medial to the medial edge of the patellar tendon.
423
424 SECTION 5  Sports Medicine: Ligament Injuries

TT
technique

AMP
technique

Portal
site
TT technique
AMP technique
A

B
Figure 47-1.  A, In some knees, where the anatomic footprint for the femoral tunnel cannot be reached using transtibial (TT) technique,
or in certain revision cases, use of the AMP for guide wire and reamer advancement may allow for optimal tunnel position. B, An
anterior view of the knee demonstrates the angle of the femoral tunnel when the AMP is used to establish the tunnel, relative to the
TT technique.

Following standard diagnostic arthroscopy and débride-
ment of the torn ACL, a notchplasty may be performed, but
we have found this necessary only in the minority of cases
with abnormally narrow notches, less than 15 mm in width.
Given the relatively inferior position of graft placement on
the femoral condyle, compared with traditional transtibial
technique, graft impingement is rarely encountered. The pos-
terior aspect of the soft tissue at the ACL footprint on the
tibial surface is used as a landmark for tibial tunnel creation,
in conjunction with the posterior aspect of the anterior horn
of the lateral meniscus. We prefer to completely débride the
soft tissues and mark the center of the footprint with the
electrocautery device or a small curette prior to insertion of
a standard ACL guide. Following standard tibial tunnel
reaming and use of the motorized shaver to eliminate bony
debris, a reverse chamfer drill is used to smooth the posterior
intra-articular edge of the tibial tunnel to prevent bony abra-
sion of the graft during cyclic knee flexion.
A similar approach as described for the tibial footprint is
used to identify and mark the center of the femoral ACL
footprint. The soft tissues are then completely débrided from
the lateral wall of the intercondylar notch while preserving
the mark for the center of the footprint. An arthroscopic
probe is used to identify the back wall of the femoral condyle
definitively to avoid back wall blowout. The AMP is used to
introduce the offset femoral guide and the guide wire as a unit
past the medial femoral condyle, just as Cain and colleagues8
initially described introduction of the guide wire and reamer
as a unit. The knee must be hyperflexed 110 to 120 degrees
to allow the trajectory of the guide wire directly into the
center of the femoral footprint. Alternatively, flexible guide
pins and reamers have been introduced in an effort to avoid
the need for hyperflexion, minimize articular cartilage damage
on the medial femoral condyle, and allow the length of the
femoral tunnel to be maximized via a more proximally
directed orientation. The guide wire is advanced to the level
of the anterolateral femoral cortex and the offset guide is
removed. A second guide wire is introduced through the
AMP to the femoral footprint, just adjacent and parallel to
the first, to allow for measurement of the approximate length
from footprint to cortex to ensure adequate tunnel length. If
insufficient tunnel length is anticipated, the angle of the
guide wire can be altered to increase tunnel length or other
techniques to address mismatch can be planned, such as slight
shortening of one or both bone plugs, depending on the
estimated length. The second guide wire is removed and the
reamer is then introduced into the notch under arthroscopic
visualization, taking care to avoid damage to the MFC carti-
lage by the edges of the reamer.
Provided the angle of knee flexion is not changed and the
trajectory of the guide wire maintained, we have found the
risk of damage to the cartilage or bending of the guide wire
to be minimal. In addition, the 30-degree arthroscope may
be replaced with a 70-degree arthroscope if adequate visual-
ization of the femoral footprint cannot be achieved with
instrumentation in the notch, although this is not necessary
in most cases. The reamer is advanced 5 to 10 mm into the
femoral ACL footprint and withdrawn slightly to allow for
reassessment of the adequacy of the back wall, with a goal of
1 to 2 mm of intact posterior bone. The reamer is then
advanced to the appropriate depth, which varies according
to graft type and graft length. The guide wire–reamer unit is
removed. A Beath pin with a looped passing suture is intro-
duced through the AMP into the notch, and the knee is again
hyperflexed, with direct assessment of avoidance of contact
between the Beath pin and MFC before advancement into
the femoral tunnel. The pin is passed through the skin of the
anterolateral thigh. The loop of the passing suture is left in
the notch, an arthroscopic grasper is introduced through the
tibial tunnel, and the passing is suture brought out of the
tibial tunnel.
Graft passage is performed in standard fashion, with free
sutures on the femoral side of the graft having been fed
through the looped passing suture. An arthroscopic probe or
grasper is used to orient the femoral bone block of the graft
in the proper trajectory for smooth advancement into the
femoral tunnel. Graft fixation is performed in standard
fashion, with a femoral interference screw passed through the

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 CHAPTER 47  Anterior Cruciate Ligament Reconstruction via the Anteromedial Portal and Single-Tunnel, Double-Bundle Techniques  425
AMP over a nitinol wire. Care must be taken to advance the
screw into the tunnel with the knee in the same degree of
hyperflexion that was used during femoral reaming. This
avoids the complication of graft-screw divergence that has
been reported for the AMP technique. Standard cycling of
the graft and tibial interference screw fixation, with the knee
in full extension and maximal manual traction on the graft,
is then performed. A routine approach to wound closure is
used.
Discussion
Use of the anteromedial portal in ACL reconstruction has
the advantage of allowing for placement of a femoral tunnel
in a more anatomic location than that seen with classic
transtibial techniques. It can be particularly useful in revision
surgery, in which the primary surgery may have involved
placement of a more vertical femoral tunnel (e.g., at 11:00 or
1:00 o’clock, if not higher). Not only can a vertical primary
position be responsible for graft failure through retear or
persistent rotational instability, but the more anatomic place-
ment may be performed without significant primary graft or
tunnel débridement, interference screw removal, or bone
grafting. In addition, use of the AMP has gained interest
because of the growing popularity in double-bundle surgery,
in which a more complex tibial tunnel configuration may
warrant great flexibility in femoral tunnel placement, as is
afforded by the AMP technique.
Despite its advantages in revision or double-bundle proce-
dures, use of the AMP may have its greatest role as a new
standard technique in primary ACL reconstruction, given the
increasingly recognized importance of femoral tunnel posi-
tion on restoration of native knee kinematics.10,39,40 Despite
the technical challenges associated with its use, complica-
tions can be avoided by a thorough understanding of the
potential pitfalls and technical principles. Critical to success
with AMP techniques are an understanding of native foot-
print anatomy, appropriate inferior AMP placement, intro-
duction and advancement of instruments into the joint and
notch under arthroscopic visualization, meticulous measure-
ments of graft and tunnel length, and experience with appro-
priate flexion and hyperflexion angles of the knee for the
different portions of the procedure. Although more clinical
outcomes studies related to use of this technique are war-
ranted, early, lower level evidence, cadaveric studies, and
descriptions of its technique have been favorable.4,5,12,14,19
It remains unclear how widespread AMP use will be in the
future, but we believe that it should become a technique
familiar to all surgeons performing ACLR, especially in the
revision setting. One approach favored by many surgeons for
primary ACLR is creation of the tibial tunnel and assessment
of potential femoral tunnel positioning through the trans-
tibial tunnel. Because even minute variations in knee
anatomy and tibial tunnel position can influence the ability
to achieve anatomic placement of the femoral tunnel, this
step allows for use of the AMP technique at this time if the
transtibial approach does not allow for optimal graft place-
ment. In the senior author’s experience, an optimal femoral
tunnel can often be achieved transtibially, and the transtibial
approach can be used for the single-tunnel, single-bundle
technique and the single-tunnel, double-bundle technique,
as will be described.
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Anterior Cruciate Ligament
Reconstruction via Single-Tunnel,
Double-Bundle Technique
Although a number of clinical outcomes studies have dem-
onstrated good results using single-bundle ACLR,2,23,29 several
long-term studies have shown unsatisfactory rates of osteoar-
thritis and knee pain following this technique.* Therefore,
double-bundle ACLR has gained increasing interest based
on clinical and biomechanical evidence suggesting that
re-establishment of the separate anteromedial (AM) and pos-
terolateral (PL) bundles may more closely restore native knee
joint stability and kinematics.9-11,21,22,31,36-38 However, double-
bundle reconstruction techniques involving the creation of
two tibial tunnels, and either one or two femoral tunnels, are
more technically challenging, with longer operative times
and more bone loss, thereby potentially increasing complica-
tion rates and making revision surgery more difficult. In addi-
tion, clinical and biomechanical studies have been performed
that fail to demonstrate improved outcomes.28,32
Here we describe a technique of single-tunnel, double-
bundle (STDB) ACLR that was developed in our laboratory.
It takes advantage of the potential biomechanical advantage
of separate AM and PL bundles while avoiding the technical
challenges and pitfalls associated with the creation of two
bony tunnels.
Technique
Knee arthroscopy is performed through standard anterome-
dial and anterolateral portals to confirm the ACL tear, and
the ACL remnant is débrided with a motorized shaver. A
notchplasty is performed only if necessary. The lower extrem-
ity is then exsanguinated and a thigh tourniquet inflated to
280 mm Hg. The semitendinosus and gracilis tendons are
harvested in standard fashion through a 2- to 3-cm incision
in the skin overlying the pes anserinus insertion on the
anteromedial surface of the proximal tibia. The harvested
grafts are pretensioned on a graft preparation board (DePuy
Mitek) with 20 lb of force while the tibial and femoral tunnels
are prepared in standard fashion. If optimal anatomic posi-
tioning of the femoral tunnel cannot be achieved through a
transtibial technique, an anteromedial portal technique is
used to centralize the tunnel on the femoral ACL footprint,
as described earlier.
Two different femoral fixation devices, with slightly differ-
ent techniques, may be used to achieve a STDB soft tissue
graft construct, depending on surgeon preference. The first
STDB technique involves use of the Femoral Intrafix (DePuy
Mitek) device. This has the dual advantage of aperture fixa-
tion using a femoral sheath and interference screw construct,
while maximizing biologic healing, via compression of the
graft against cancellous bone throughout the length of the
tunnel. The semitendinosus and gracilis tendons are looped
over a single strand of suture and only the AM bundle is
colored on the proximal end of the graft to identify the
bundle easily. To achieve the desired anatomic position for
the AM and PL bundles, a graft-positioning tool from the
Intrafix set is used. The graft is placed in the fork of the
*References 1, 16, 17, 24, 25, and 27.
426 SECTION 5  Sports Medicine: Ligament Injuries

positioning tool with one bundle on either side of the fork.
When the passing suture is used to pull the graft into the
tunnel, the graft positioning tool is advanced through the
tibial tunnel until it reaches the aperture of the femoral
tunnel, at which time the AM and PL bundles are rotated by
rotating the positioning tool. When the desired positions of
the two bundles are achieved, the construct is then fully
advanced into the femoral tunnel. The keel of a sheath trial
is then placed between the strands to maintain the separation
of the two bundles within the single tunnel. The femoral
Intrafix sheath is then inserted into the tunnel, taking care
not to alter the position of the two bundles. The graft is
secured by the Intrafix screw into the sheath. Tibial tunnel
fixation involves placement of the tibial Intrafix sheath with
the AM and PL bundles placed in two opposite quadrants of
the sheath at their anatomic insertion sites on the tibial
plateau. A 40-N graft tension is applied to the graft while the
tibial Intrafix screw is advanced with the leg in full
extension.
An alternative STDB construct that may be used, provided
that femoral tunnel length is adequate (>30 to 35 mm), is
the AperFix (Cayenne Medical, Scottsdale, Ariz) femoral
implant. In this technique, the semitendinosus and gracilis
tendons are passed through the device and looped to form
four strands (Fig. 47-2B). Because the device allows for isola-
tion of the separate tendons of the hamstrings, the two strands
of the semitendinosus tendon are used to represent the AM
bundle and the two gracilis tendon strands represent the
PL bundle (Fig. 47-3A). The implant is passed through the
tibial tunnel into the femoral tunnel. Before deployment,
the two bundles are positioned inside the femoral tunnel in
the native ACL bundle positions. The semitendinosus limbs
of the graft construct are placed in a slightly deeper and
higher position on the femoral condyle, with the knee in the
flexed position, and the gracilis limbs of the graft construct
are placed in an anteroinferior position on the femoral
condyle. The implant is then deployed in standard fashion,
with the deployment knob expanding the teeth of the implant

Femoral
implant AMB

PLB

Tibial
implant

A B

Figure 47-2.  Schematic representation of single-bundle (A) and STDB (B) ACL reconstruction. AMB, Antermedial bundle; PLB, postero-
lateral bundle. (From Gadikota HR, Seon JK, Kozanek M, et al: Biomechanical comparison of single-tunnel-double-bundle and single-bundle
anterior cruciate ligament reconstructions. Am J Sports Med 37:962–969, 2009.)

PLB Tibial implant

AMB

Femur
AMB
Femoral implant
A PLB B
Figure 47-3.  Schematic illustration of the femoral implant and separation of the two bundles in the femoral tunnel (A) and the tibial
implant and separation of the two bundles in the tibial tunnel (B). AMB, Anteromedial bundle; PLB, posterolateral bundle. (From Gadikota
HR, Seon JK, Kozanek M, et al: Biomechanical comparison of single-tunnel-double-bundle and single-bundle anterior cruciate ligament recon-
structions. Am J Sports Med 37:962–969, 2009.)

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 CHAPTER 47  Anterior Cruciate Ligament Reconstruction via the Anteromedial Portal and Single-Tunnel, Double-Bundle Techniques  427
into the femoral cancellous bone. With the graft now secured
at the femoral end, the distal end of the graft is rotated
by 90 degrees in a clockwise direction for the left knee
(counterclockwise for the right knee), giving rise to the
native anatomic relationship of the AM and PL bundles as
they pass into the tibial tunnel in the location of the ACL
footprint (see Fig. 47-3B). This degree of rotation is based on
the in vivo biomechanical study performed by Jordan and
associates18 that demonstrates approximately 80 degrees of
ACL rotation as the knee flexes from 0 to 120 degrees. After
cycling the knee five times, the graft is tensioned under
maximal manual axial graft tension, with the knee in full
extension, using the AperFix tensioning device. The graft is
secured on the tibial side using the AperFix sheath and inter-
ference screw.
In either technique, the skin incisions at the two portal
sites are repaired using 4-0 monofilament sutures, and the
incision at the tibial footprint is approximated at the deep
dermal layer by 2-0 braided suture and then by a running
subcuticular monofilament suture. The postoperative reha-
bilitation protocol involves 50% partial weight bearing with
the use of crutches for the first 6 weeks. An unlocked hinged
knee brace is used for weight bearing, but removed for therapy,
which includes the use of a continuous passive motion
machine. Strength and stretching exercises are advanced
according to standard post-ACL reconstruction principles.
Discussion
Although interest in double bundle ACL reconstruction con-
tinues to grow, there is also increasing evidence that its pur-
ported advantages may not be replicated in clinical outcomes
or patient satisfaction. Interestingly, a cadaveric study by Rue
and coworkers26 has demonstrated that a well-oriented, later-
ally angled tibial tunnel in single-bundle, single-tunnel
surgery allows for re-creation of the femoral footprints of both
the AM and PL bundles, bringing into question the need for
double tunnels at all. A separate clinical study with 2-year
follow-up32 failed to show any difference in the functional
outcomes of two cohorts of 19 patients undergoing single-
bundle, single-tunnel versus double-tunnel, double-bundle
reconstructions, respectively.
To date, few clinical studies have been published regarding
the use of a STDB construct for ACL reconstruction. Caborn
and Chang7 have described their technique, in which a tibi-
alis anterior allograft is folded over to replicate the AM and
PL bundles, which are separated in single femoral and tibial
tunnels and secured with interference screws. However, their
technique does not involve rotation of the graft limbs prior
to tibial fixation, as described for our technique (see earlier).
Shino and associates30 have described several alterations in
the reaming for and positioning of a BPTB autograft, which
therefore causes different portions of the graft to mimic the
two bundles of the native ACL, but the authors do not
support this interpretation with biomechanical or clinical
data. Takeuchi and coworkers33 have reported on a technique
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involving a bone-hamstring-bone composite graft, in which
a bone block is removed from the tibia at the pes insertion,
divided in two, and sutured to the ends of a standard ham-
string autograft. This composite graft allows for separation of
the limbs of the semitendinosus and gracilis autograft, similar
to our technique. They reported ultimate fixation strength in
their composite graft superior to that of a standard BPTB
autograft.
Two biomechanical cadaveric studies from our institution
have investigated the AperFix and Intrafix STDB techniques
described earlier. In 2009, Gadikota and colleagues11 showed
that the STDB approach with the AperFix reduces anterior
tibial translation at all flexion angles, compared with the
ACL-deficient state. Interestingly, when compared with
ACL-intact specimens, knees with STDB reconstructions
showed comparable anterior tibial translation at low flexion
angles, but decreased translation at 60 and 90 degrees, sug-
gesting slight overconstraint. However, the maximum differ-
ence was less than 3 mm in all cases. A second 2010 study
investigating femoral interference screw fixation with soft
tissue grafts demonstrated that the STDB technique restores
anterior knee stability better when compared with a conven-
tional single-bundle reconstruction.10 The advantage of both
techniques is that they represent technically simple methods
of re-creating double-bundle anatomy without introducing
many of the technical challenges and risk of complications
inherent in the technique.
KEY REFERENCES
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Gadikota HR, Wu JL, Seon JK, Sutton K, Gill TJ, Li G, et al: Single-tunnel
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 CHAPTER 47  Anterior Cruciate Ligament Reconstruction via the Anteromedial Portal and Single-Tunnel, Double-Bundle Techniques  427.e1
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