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During reconstruction of the anterior cruciate ligament, graft preparation is an essential step. The semitendinosus tendon is most frequently used, usually with a 4-strand graft and endobutton fixation. Our lasso-loop technique for tendon fixation is rapid and without sutures, providing a graft with a regular diameter, with no weak points and satisfactory primary stability.
The video shows a 4-stranded semitendinosus graft between 2 endobuttons (Arthrovims Button; Arena-alpha), first with a traditional technique in which both ends of the tendon are held with a clamp and then using the lasso-loop technique, which simplifies graft preparation and improves primary stability.
Technique Video
See video under supplementary data.
Intra-articular anterior cruciate ligament (ACL) reconstruction using a 4-strand semitendinosus graft is increasingly frequent. This requires the use of 1 or 2 systems of cortical fixation to the tibia and the femur. These systems include a closed loop that prevents tendon fixation through an opening at its end. Thus, 2 clamps and a traction device must be used for graft preparation, creating 2 areas of apposition between the strands and the tendon (Fig 1). These are weak, uneven areas that may make advancement of the graft in bone tunnels difficult (Table 1).
Fig 1In the absence of fixation of one end on the endobutton (Arthrovims Button; Arena-alpha), the tendon must be held with 2 clamps while the graft is being prepared. The clamps that remain attached to the graft after it has been advanced make it difficult to suture the ends. Moreover, the areas of graft apposition at the ends of the graft are sources of irregularity, which may make advancement in the bone tunnels difficult (arrows).
Table 1Advantages and Disadvantages of the Lasso-Loop Technique
Advantages
Disadvantages
No graft irregularity that may occur due to the placement of the large distal end of the tendon on the other strands, increasing the diameter of the graft and making advancement in the bone tunnels difficult (Fig 1)
The tendon is 1 cm shorter because of tissue used to form the loop
Traction on a single strand of the graft, improving control of the tension applied to the graft (Fig 5)
Risk of tearing of the end of the tendon if excessive tension is applied or if the tendon is fragile. In this case, a simple nonabsorbable suture of the end of the tendon will remedy it, without any consequence for the rest of the procedure (Fig 6).
Prevents the need for 2 hands to assist, possibly in the surgical field, which can make it difficult to visualize graft preparation (Fig 1, Fig 5)
Good primary stability that does not depend only on the sutures, which may be loosened when the graft is advanced through the tunnels
Our technique creates a lasso at the end of the tendon so that it can be attached to a closed loop (Fig 2).
Fig 2The lasso-loop technique creates stable graft fixation on the loop of the endobutton (Arthrovims Button; Arena-alpha) by passing the tendon through a buttonhole created at the end (arrow).
Harvesting of the semitendinosus is usually performed with a stripper. Its distal end is detached at the tibial insertion at the pes anserinus. The remnants of muscle fiber are removed before or after detachment. The tendon is placed flat on the table and a longitudinal 0.5-cm incision is made at the distal end. The incision is made with a No. 11 scalpel placed in the tendon with the sharp edge facing toward the proximal end, and then the tendon is pulled upward along the blade (Fig 3).
Fig 3The buttonhole is created 0.5 cm from the distal end of the tendon, by pressing the end of the blade of the No. 11 scalpel (red arrow), with the cutting edge faced toward the proximal end of the tendon (1). The incision is performed along the axis of the fibers (red arrow) by pulling the tendon upward (black arrow) (2).
The nonincised proximal end of the tendon is then placed into a loop device (Arthrovims Button; Arena-alpha) and then into the incision. The lasso is tightened by placing traction on the tendon (Fig 4).
Fig 4The lasso is created by passing the proximal end of the tendon (red arrow) into the fixation system and then into the buttonhole at the distal end (black arrow) (1). The lasso (red arrows) is tightened on the endobutton (Arthrovims Button; Arena-alpha) by placing traction (black arrow) on the tendon (2, 3).
The proximal end of the tendon is then threaded into each loop (Arthrovims Button; Arena-alpha) until a 4-strand graft is obtained. Finally, each end of the graft is sutured with nonabsorbable suture with a straight needle (nonabsorbable No. 1 Ethibond suture; Ethicon) (Fig 5).
Fig 5After it has been folded 3 times, the end of the tendon (red arrow), held by the clamp, is placed on the 4-strand graft (1). Suturing with a nonabsorbable suture and a straight needle (nonabsorbable No. 1 Ethibond suture; Ethicon) stabilizes both ends of the graft (black arrows).
The incision is made 0.5 cm from the end of the tendon (Fig 3), the necessary length to tighten the lasso. It must not be further in, to avoid reducing the length of the remaining tendon. To avoid tearing when the loop is tightened, the incision is made at the distal end of the tendon, which is the most resistant and fleshy portion (Table 1).
In the event of a tear in the end of the tendon, a simple nonabsorbable suture (nonabsorbable No. 3-0 Ethibond suture; Ethicon) will remedy it, without any consequence for the rest of the procedure (Fig 6).
Fig 6In the event of a tear in the end of the tendon during traction (green arrow) (1), a suture (nonabsorbable No. 3-0 Ethibond suture; Ethicon) of the distal end of the tendon (black arrow) allows the tear to be closed (2) and the loop of the lasso to be made normally (red arrow) (3).
The technique described here can be used to attach a tendon to any loop system. For example, we also use it to attach the semitendinosus to the gracilis for continuous intra- and extra-articular reconstruction (Fig 7).
Fig 7The lasso-loop technique may also be used to attach one tendon to another, as seen here where the semitendinosus is attached to the gracilis tendon with a lasso loop to create a autologous hamstring tendon graft combined with anterolateral ligament reconstruction.
The video shows a 4-stranded semitendinosus graft between 2 endobuttons (Arthrovims Button; Arena-alpha), first with a traditional technique in which both ends of the tendon are held with a clamp and then using the lasso-loop technique, which simplifies graft preparation and improves primary stability.
References
Barbosa N.C.
Guerra-Pinto F.
Cabeleira C.
Beja da Costa P.
Hamstring graft biological preparation for anterior cruciate ligament reconstruction.
The author reports no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
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