An Anterior Cruciate Ligament Reconstruction

Technique With 4-Strand Semitendinosus Grafts,

Using Outside-In Tibial Tunnel Drilling and
Suspensory Fixation Devices
Philippe Colombet, M.D., and Nicolas Graveleau, M.D.

Abstract: We describe an anatomic single-bundle anterior cruciate ligament reconstruction using a 4-strand semite-
ndinosus graft fixed with 2 Pullup adjustable suspensory fixation systems (SBM, Lourdes, France). Outside-in full tibial
tunnel drilling represents a secure option for length management of the graft. The preferred graft choice is a 4-strand
semitendinosus autologous graft. A special technique is used to stitch the graft with a figure-of-8 stitch to load the 4
strands. The Pullup adjustable loop is equipped with 2 buttons of different sizes: a small button for the standard Pullup
system on the femoral side and a large button for the Pullup XL system on the tibial side. With this method, graft tension is
equally distributed among the 4 strands and the graft cannot bottom out in the tibial tunnel in case of inadequate graft
length.

S ingle-bundle anterior cruciate ligament (ACL)

reconstruction has largely evolved since its original
description.1 Anatomic single-bundle ACL reconstruc-
tion using a 4-strand semitendinosus (4ST) graft is now
widely used, but it is a highly demanding technique.
Choosing the appropriate graft management technique,
approach (all inside, inside out, and so on), and fixation
devices is important when trying to perform an
optimized 4ST ACL reconstruction.
The outside-in technique presented in this report uses
adjustable suspensory fixation on both sides: Pullup and
Pullup XL fixation systems (SBM, Lourdes, France). The
Pullup adjustableeloop length suspensory fixation
consists of 2 loops controlled by a knotless locking
mechanism. Multiple points of friction create resistance
to both displacement and slippage but allow for tight-
ening of the loop. The loops are prolonged by
tensioning sutures (pull sutures) used to reduce the
From Clinique du Sport Bordeaux-Mérignac, Mérignac, France.
The authors report the following potential conflict of interest or source of
funding: P.C. receives royalties from SBM France.
Received February 6, 2015; accepted May 19, 2015.
Address correspondence to Philippe Colombet, M.D., Clinique du Sport, 2
rue Negrevergne, 33700 Mérignac, France. E-mail: philippe.colombet5@
wanadoo.fr
Ó 2015 by the Arthroscopy Association of North America. Open access
under CC BY-NC-ND license.
2212-6287/15118
http://dx.doi.org/10.1016/j.eats.2015.05.014
loop length and a flipping button available in 2 different
sizes: a small button for the Pullup system to be locked
in a small bone tunnel (4.5 mm) and a large button for
the Pullup XL system for larger tunnels measuring up to
11 mm (Fig 1). Comprehensive instrumentation is
provided to optimize this procedure. Planning is
required for graft preparation based on a calculation
table used to anticipate the semitendinosus (ST) tendon
length and predict the length between the femoral
and tibial insertion sites of the native ACL (Table 1,
Video 1).
Surgical Technique
Two factors must be considered for a short graft
technique. First, the native ACL length must be deter-
mined. An intact ACL has a mean length of 38 mm
(range, 25 to 41 mm). Brown et al.2 found a correlation
between ACL length and patient height (Pearson r ¼
0.73, P < .001) but not with other demographic vari-
ables (age, gender, or weight). On the basis of these
findings, they developed a linear regression equation
for predicting the native ACL length: ACL length (in
millimeters) ¼ 0.4606  Patient height (in
centimeters)  41.29. The second important point is
determining the optimal graft length for the 4ST tech-
nique; it has been estimated at 28 cm or at 7 cm once
folded: 2 cm within the femoral tunnel, 3 cm in the
joint space, and 2 cm within the tibial tunnel (Fig 1). A
retrospective study investigated the frequency of

Arthroscopy Techniques, Vol 4, No 5 (October), 2015: pp e507-e511 e507

e508 P. COLOMBET AND N. GRAVELEAU

Fig 1. Anterior cruciate ligament reconstruction by the 4-strand semitendinosus technique is fully dependent on the harvested
graft’s length. Indeed, the graft needs to be around 70 mm long, with 20 mm on the femoral and tibial sides and 27 to 42 mm in
the joint space. An adjustable Pullup cortical suspension device on each side allows the surgeon to adjust the graft length in the
tunnels and to manage graft tension.

adequate ST tendon length and proposed an equation
for predicting the ST graft length3: ST length (in
millimeters) ¼ 6.508 þ 0.129  Patient height (in
centimeters). Almost 80% of the population has an ST
tendon length of 28 cm or more, and this length is
greatly correlated with the patient’s height.3,4 To make
these formulas easier to use, we generated the data
presented in Table 2. From these data, graft length can
be deduced and the tendon can be prepared using the
GraftTech table (SBM). Graft preparation is crucial:
When using suspensory fixation, each strand must be
loaded.
The patient is anesthetized and placed in the supine
position, the affected leg is disinfected, and an air tourni-
quet is applied to the limb with a pressure of 300 mm Hg.
The whole tendon must be harvested; using a tendon
harvester (ConMed Linvatec, Largo, FL) is mandatory.
The GraftTech table is then equipped with 2 fixations, a
standard Pullup device on the femoral side and a Pullup
XL device on the tibial side (Fig 2). Graft preparation
begins with a crucial step: The distal part of the graft is
used to make a loop that is passed through the Pullup
loops and secured with a temporary clamp. The graft
goes through the Pullup XL loop and then returns to the
Pullup device; this operation is then repeated to obtain a
4-strand graft. Stitching begins with 2 figure-of-8
stitches to lock the first graft loop (Fig 3, Video 1). It is
important to stitch the entire length of the graft to in-
crease resistance against graft slippage in the fixation
loops. The suture is maintained on the needle and will

Table 1. Surgical Steps, Pearls, and Pitfalls

Surgical Steps
Graft harvesting and preparation
Stitching of graft
Tibial tunnel drilling
Pearls
The semitendinosus is harvested through a small
incision measuring 2.5 cm. A special stripper
(ConMed Linvatec) is required to make sure the
whole tendon is harvested. The tibial end of the
graft must be calibrated to obtain a wide regular
graft.
The figure-of-8 stitch requires adequate
preparation of the first loop of the graft. Fifteen
millimeters of the proximal part of the tendon is
passed through the Pullup loops and secured
with a temporary clamp. Two figure-of-8 stitches
are placed at 5 mm and 10 mm from the
proximal end of the graft. The suture continues
on one edge of the graft and then returns to the
other edge. In this setting, the graft should be
quite flat.
The tibial tunnel length must be as long as possible
to facilitate final tensioning of the graft. A tibial
tunnel aimer is used, and a 65 angulation must
be chosen for its setting.
Pitfalls
Using an open stripper poses the major risk of
cutting the proximal end of the tendon, thus
reducing the tendon length and making the graft
length too short. If the graft is not well calibrated,
the proximal end of the graft can be larger than
the distal end. In this case 2 different tunnel
diameters are mandatory.
Extreme care must be taken with the first figure-of-
8 stitch to avoid going through the Pullup XL
loop’s thread because this would make
tightening the loop impossible. The same
problem can occur at the other graft extremity
with the suture and the Pullup loops.
Before beginning to drill the tibial tunnel, the
surgeon must make sure that the K-wire or drill
does not slip on the tibial cortex because this
would make the tibial tunnel external aperture
higher and the tibial tunnel length shorter.
 ADJUSTABLE SUSPENSORY FIXATION e509

Table 2. Estimation of ACL Length and ST Graft Length

Based on Patient Height (According to Brown et al.2 and
Papastergiou et al.3)
Patient Height, cm ACL Length, mm ST Graft Length, mm
140-145 24.3 (23.2-25.5) 24.9 (24.6-25.2)
146-150 26.6 (26.0-27.8) 25.5 (25.3-25.9)
151-155 29.0 (28.3-30.1) 26.2 (26.0-26.5)
156-160 31.3 (30.6-32.4) 26.8 (26.6-27.1)
161-165 33.6 (32.9-34.7) 27.5 (27.3-27.8)
166-170 35.9 (35.2-37.0) 28.1 (27.9-28.4)
171-175 38.2 (37.5-39.3) 28.8 (28.6-29.1)
176-180 40.5 (41.6-43.9) 29.4 (29.2-30.4)
181-185 42.8 (42.1-43.9) 30.1 (29.9-30.4)
186-190 45.1 (44.4-46.2) 30.7 (30.5-31.0)
191-195 47.4 (46.7-48.5) 31.3 (31.1-31.7) Fig 3. The figure-of-8 continuous stitch is a special stitch used
196-200 49.7 (49.0-50.8) 32.0 (31.8-32.3) to lock the first graft loop. This stitch is mandatory to secure
NOTE. Data are presented as mean (range). and load the 4 graft strands. Two figure-of-8 stitches are made
ACT, anterior cruciate ligament length; ST, semitendinosus. with a 5-mm interval, after which the graft is sutured nor-
mally along its full length. (4ST, 4-strand semitendinosus.)
be used at the end to seal the external aperture of the
tibial tunnel. The graft diameter is calibrated along its socket length is precisely controlled arthroscopically
entire length with a special device graduated in half (Fig 4). A 20-mm tunnel length is recommended. A full
millimeters. tibial tunnel is drilled in an outside-in manner using an
The arthroscopic procedure uses a classic anterolateral aimer with 65 of angulation to obtain a long bony
portal for the arthroscope and an anteromedial portal tunnel calibrated to the graft size. The internal aperture
for the instruments. This anteromedial portal is placed of the tibial tunnel is placed in the middle of the re-
just above the medial meniscus anterior root. Notch sidual ACL tibial attachment fibers. The graft is tracked
preparation aims at salvaging the maximum amount of from the tibia to the femur until the graft is locked at
soft tissue, which will be helpful for graft healing. The the end of the femoral socket. Button-flip sutures are
femoral tunnel is drilled with an inside-out approach. A used so that the surgeon can feel the button flip and
complete bone tunnel is drilled using a special 4.5-mm ensure that the button exits the femoral tunnel.
drill, equipped with a top pin to avoid displacement Tensioning sutures are used to tighten the fixation
when the knee is bent in full flexion. Next, a socket is loops and lock the graft within the femoral socket. A
drilled using a router of the same size as the graft. The plastic guide is used inside the empty part of the tibial

Fig 2. The GraftTech graft

preparation table is an essential
tool to prepare the graft with an
adjustable suspensory fixation
required on each side, attached
by brackets. The harvested
semitendinosus tendon is then
passed through the Pullup loops
to constitute a 4-strand graft and
is equally tensioned on the 4
strands.
e510 P. COLOMBET AND N. GRAVELEAU
Fig 4. Final assembly of graft in tunnels. First, with the inside-
out technique, the femoral tunnel is drilled with a 4.5-mm
diameter (1). Second, a femoral socket with a length of 20
mm is drilled with a diameter corresponding to the graft’s
diameter (2). Finally, a full tibial tunnel with the same
diameter as the graft (2) is drilled using the outside-in
technique.
tunnel to control the displacement of the large button
of the Pullup XL device, which is placed at the top of the
tibial tunnel external aperture. With the knee flexed at
20 , the tensioning sutures are pulled to tighten and
lock the graft into place.
Discussion
ACL reconstruction using a 4ST graft is now a com-
mon technique.5,6 It preserves the gracilis and reduces
the significant weakness of the hamstring muscle.7
However, it is a highly demanding technique
compared with the classic hamstring tendon graft
(gracilis and ST), which is now the most common
technique used to reconstruct the ACL all over the
world. Management of graft length and diameter is
related to the technique and type of fixation device.
When an all-inside technique is performed, if the graft
is too long, the graft could bottom out in the tibial
socket during final graft tensioning,8 which would
result in a slack graft. That is why a complete tibial
tunnel is used in the described outside-in technique. In
case the graft does not allow the minimum distance (5
mm) to tension the Pullup XL system, a supplementary
interference screw can be used. The use of suspensory
fixation provides adequate constant fixation whatever
the quality of cancellous tibial bone is. The 4ST graft
also ensures an appropriate graft diameter adapted to
the patient’s morphologic type. In case the ST is too thin
and the final graft diameter measures less than 8 mm,
the gracilis can be harvested and the same process of
graft preparation is applied. In such a case, a 6-strand
graft should be enough to obtain a correct graft diam-
eter and the tendons are cut 2 cm after the last passage
through the Pullup system. Whip-stitching remains the
same.
The main difficulty in such a technique is perfectly
preparing the graft, especially the 2 ends of the tendon.
In some 4ST graft configurations, only 2 strands are
loaded. This significantly weakens the graft, which
could result in breakage. Knee flexion angulation is
very important to tighten the graft. No more than 20 of
flexion is required. Suspensory fixation devices are very
rigid; therefore, if perfect anatomic graft positioning is
not achieved, a knee extension deficit can occur
immediately. Should this occur, the suture bridge must
be cut over the button to release the fixation, and an
interference screw must be used. The Pullup and Pullup
XL loops are initially set at 40 mm in length. This length
can easily be changed and adjusted according to the
patient’s anatomy and tunnel length during surgery,
especially on the femoral side. When full flexion is
limited (in patients with a high body mass index or a
very large thigh muscle), the femoral tunnel should be
very long. In this case the 2 Pullup loop lengths must be
increased by pulling on the loops on 1 side only. If the
loops are not enlarged, the button cannot be flipped
because it will not emerge out of the femoral tunnel.
When the patient is thin or young, the loop lengths
must be reduced because pulling too hard could cause
the button to go through the fascia and not be applied
against the femoral cortex. Some authors recommend
graft pre-tensioning at 500 N,5 but it has been shown
that high initial tension affects the mechanical proper-
ties of the graft9; this is why we recommenddas do
other authorsdmanual tensioning at around 40 N.6
References
1. Chambat P, Guier C, Sonnery-Cottet B, Fayard J-M,
Thaunat M. The evolution of ACL reconstruction over the
last fifty years. Int Orthop 2013;37:181-186.
2. Brown JA, Brophy RH, Franco J, et al. Avoiding allograft
length mismatch during anterior cruciate ligament recon-
struction: Patient height as an indicator of appropriate graft
length. Am J Sports Med 2007;35:986-989.
3. Papastergiou SG, Konstantinidis GA, Natsis K,
Papathanasiou E, Koukoulias N, Papadopoulos AG. Ade-
quacy of semitendinosus tendon alone for anterior cruciate
ligament reconstruction graft and prediction of hamstring
graft size by evaluating simple anthropometric parameters.
Anat Res Int 2012;2012:424158.
4. Schwartzberg R, Burkhart B, Lariviere C. Prediction of
hamstring tendon autograft diameter and length for
 ADJUSTABLE SUSPENSORY FIXATION
anterior cruciate ligament reconstruction. Am J Orthop
(Belle Mead NJ) 2008;37:157-159.
5. Collette M, Cassard X. The tape locking screw tech-
nique (TLS): A new ACL reconstruction method using a
short hamstring graft. Orthop Traumatol Surg Res
2011;97:555-559.
6. Lubowitz JH, Ahmad CS, Amhad CH, Anderson K. All-
inside anterior cruciate ligament graft-link technique:
Second-generation, no-incision anterior cruciate ligament
reconstruction. Arthroscopy 2011;27:717-727.
7. Tashiro T, Kurosawa H, Kawakami A, Hikita A, Fukui N.
Influence of medial hamstring tendon harvest on knee
e511
flexor strength after anterior cruciate ligament recon-
struction. A detailed evaluation with comparison of single-
and double-tendon harvest. Am J Sports Med 2003;31:
522-529.
8. Lubowitz JH. All-inside anterior cruciate ligament graft
link: Graft preparation technique. Arthrosc Tech 2012;1:
e165-e168.
9. Katsuragi R, Yasuda K, Tsujino J, Keira M, Kaneda K.
The effect of nonphysiologically high initial tension on
the mechanical properties of in situ frozen anterior
cruciate ligament in a canine model. Am J Sports Med
2000;28:47-56.