Bone-on-Bone Anatomic Patellar Tendon Graft Anterior Cruciate Ligament Reconstruction: A Reproducible Technique Combining Press-Fit and Extracortical Fixation

Scientific interest in optimizing outcomes after anterior cruciate ligament (ACL) reconstruction is ongoing, and some recent developments have focused on graft shape as one of the most important factors of anatomic graft placement. The double-bundle or fanlike structure of the native ACL seems to more closely restore normal function and control of rotational stability of the knee with implant-free or press-fit techniques, creating a favorable situation in terms of direct graft-tunnel healing. The ACL reconstruction technique presented in this article enables safe, reproducible, and anatomic fixation of the patellar tendon autograft, providing the biological and biomechanical benefits of direct bony integration of the ribbonlike bone–patellar tendon–bone graft. Because press-fit fixation represents a technically challenging surgical procedure, the goal of the described technique is to enable direct bone-to-bone healing by using secondary extracortical femoral and tibial fixation without the need for a true press-fit situation. Safe and anatomic femoral tunnel drilling is achieved with an outside-in technique (retrograde drilling), hence providing advantages in the routine clinical setting in terms of applicability and time effort. To reduce donor-site morbidity caused by bone block harvesting, refilling of the harvest sites with autologous material is performed.