SURGICAL TECHNIQUE

General anesthesia was administered with the patient in the supine position. After standard sterilization and draping, conventional anteromedial and anterolateral arthroscopic portals were established. Diagnostic arthroscopy was performed to confirm the ACL rupture and to evaluate for concomitant injuries, such as meniscal tears and cartilage lesions. First, a shaver was introduced to debride hypertrophic synovial tissue within the patellofemoral joint space and the anterior compartment of the knee. Hemostasis of the debrided synovial bed was achieved using a radiofrequency ablation electrode (BONSS, BDS313, Jiangsu, China). Second, any torn meniscus was repaired using a meniscal suture device (Smith & Nephew, FastFix 360°, Hertfordshire, United Kingdom). Third, a 3‐cm oblique skin incision was made centered on the intersection of the horizontal line at the level of the tibial tubercle apex and the vertical line along the medial border of the patella. After incising the skin and fascial layer, the semitendinosus and gracilis tendons were identified. Both tendons were bluntly dissected, looped with a tendon harvester, and harvested proximally at their musculotendinous junctions, obtaining the tendons with their periosteal attachments (Figure 1a). The harvested tendons were fashioned into an 8.0‐cm long, 8.0‐mm diameter graft for ACL reconstruction. Both ends of the graft were whipstitched with high‐strength suture over a length of 20 mm each (Figure 1b). Fourth, a suture hook was used to pass a PDS‐II suture (violet) through the proximal one‐third of the ACL remnant (Figure 2a). This PDS‐II suture was then used to shuttle a #5 ETHIBOND suture (Ethicon, Raritan, NJ) (green), which was subsequently employed to create a lasso‐loop configuration around the ACL remnant (Figure 2b). Fifth, the femoral tunnel was established. With the knee flexed at 120°, a 6.0‐mm femoral aimer was positioned at the center of the ACL footprint on the medial femoral condyle (Figure 3a). A 2.0‐mm beaded guide pin was drilled, followed by overdrilling with a 4.5‐mm EndoButton (Smith & Nephew, Andover, MA) cannulated reamer. The total length of the femoral socket was measured as 36 mm using a depth gauge. Subsequently, an 8.0‐mm cannulated reamer was used to create the femoral tunnel to a depth of approximately 20 mm. A PDS‐II suture was then shuttled through the anteromedial portal as a passing suture, traversing the femoral tunnel using the beaded guide pin (Figure 3b). Sixth, the tibial tunnel was established. With the knee flexed at 90°, an ACL tibial aimer was introduced through the anteromedial portal into the joint. The aimer was oriented at approximately 30° relative to the longitudinal axis of the tibia and approximately 50° relative to the tibial plateau. The tunnel entrance was positioned at the center of the native ACL tibial footprint (Figure 3c). A 2.0‐mm Kirschner (K)‐wire was drilled, followed by overdrilling with an 8.0‐mm cannulated reamer, to create the tibial tunnel in an inferomedial‐to‐superolateral direction into the joint cavity. Seventh, a suture retriever was introduced through the tibial tunnel to pull the trailing ends of both the #5 ETHIBOND suture (Ethicon, Raritan, NJ) (used to lasso the ligament remnant) and the PDS‐II passing suture out of the joint cavity and through the tibial tunnel (Figure 3d). The prepared tendon graft was then looped onto an adjustable suspensory fixation device (NATON, 4.4 × 12.2 mm, Beijing, China). Next, the #5 ETHIBOND suture (Ethicon, Raritan, NJ) and the passing suture of the adjustable device were threaded through the loop of the PDS‐II suture. The PDS‐II suture was then pulled to shuttle these suture tails out through the femoral tunnel and the lateral femoral cortex. Eighth, by pulling the passing suture of the adjustable device, the suspensory button was advanced through the femoral tunnel until its flip plate was deployed and seated flush against the outer cortex of the femoral tunnel opening. Subsequently, the white sutures of the adjustable device were alternately tensioned to advance the tendon graft into the femoral tunnel until the graft's marking suture reached the tunnel entrance (Figure 3e). Concurrently, the #5 ETHIBOND suture (Ethicon, Raritan, NJ) tails were pulled to reduce and approximate the native ligament remnant to its femoral footprint. A knot pusher was then used to tie the #5 ETHIBOND suture (Ethicon, Raritan, NJ) to the white sutures of the adjustable device, creating the “suspender‐style” traction effect (Figure 3f). Ninth, after final graft tensioning, the knee was cycled through the full range of motion to ensure the ACL graft was free from impingement or notch compromise (Figure 4a). Maintaining tension on the graft, a 9.0 × 25 mm bioabsorbable interference screw (Smith & Nephew, Hertfordshire, United Kingdom) was inserted into the tibial tunnel for tibial‐side fixation. Finally, the tension and anatomic position of both the native ligament and the tendon graft were assessed arthroscopically (Figure 4b). This completed the modified “suspender‐style” traction‐preservation and native ligament reconstruction procedure (Figure 4c).

FIGURE 1: Graft preparation. (a) The harvested semitendinosus tendon (approximately 27 cm in length) and gracilis tendon (approximately 26 cm in length). (b) The prepared quadruple‐stranded tendon graft, looped onto an adjustable suspensory fixation device, measuring 8 cm in length and 8 mm in diameter.

FIGURE 2: Suturing of the native ACL remnant. (a) A suture hook is used to pass a PDS‐II suture (violet) through the proximal one‐third of the ACL remnant. (b) The PDS‐II suture is then used to shuttle a #5 ETHIBOND suture (Ethicon, Raritan, NJ) (green), creating a lasso loop around the remnant for subsequent traction and reduction to the femoral footprint. (ACL, anterior cruciate ligament.)

FIGURE 3: Surgical steps for tunnel creation and graft passage. (a) Through the anteromedial portal, a 6.0‐mm femoral aimer is positioned at the center of the ACL footprint on the medial femoral condyle. The femoral socket is then created sequentially using a 2.0‐mm beaded guide pin, a 4.5‐mm EndoButton (Smith & Nephew, Andover, MA) cannulated reamer, and an 8.0‐mm cannulated reamer. (b) A PDS‐II suture is shuttled through the femoral tunnel via the beaded guide pin to serve as a passing suture. (c) Through the anteromedial portal, a tibial aimer is positioned at the center of the native ACL tibial footprint. The tibial tunnel is created using a 2.0‐mm K‐wire followed by an 8.0‐mm cannulated reamer. (d) A suture retriever is introduced through the tibial tunnel to pull the tails of both the #5 ETHIBOND suture (Ethicon, Raritan, NJ) and the PDS‐II passing suture out of the joint, which will be used to shuttle the #5 ETHIBOND suture (Ethicon, Raritan, NJ) and the adjustable suspensory fixation device through the femoral tunnel. (e) The white sutures of the adjustable suspensory device are alternately tensioned to advance the tendon graft into the femoral tunnel. (f) A knot pusher is used to secure the #5 ETHIBOND suture (Ethicon, Raritan, NJ) to the white sutures of the adjustable device, achieving the “suspender‐style” traction‐reduction effect. (ACL, anterior cruciate ligament.)

FIGURE 4: Final arthroscopic assessment. (a) With the knee in full extension, viewing from the anterolateral portal. The knee is cycled through a full range of motion to check for graft impingement within the intercondylar notch. (b) With the knee flexed to 90°, viewing from the anterolateral portal. Arthroscopic view showing the final tension and anatomic position of both the reduced native ligament and the tendon graft. (c) With the knee flexed to 90°, viewing from the anterolateral portal. Final arthroscopic overview on the completion of the modified “suspender‐style” traction‐preservation and native ligament reconstruction procedure. (ACL, anterior cruciate ligament.)