Introduction: Anatomic anterior cruciate ligament (ACL) reconstruction is a reasonable approach to restore knee stability without loss of motion. Because a normal ACL can be divided into three bundles, anatomic triple-bundle ACL reconstruction with the use of a hamstring tendon graft was developed. In this procedure, two crescent-shaped femoral tunnels are created inside the ACL insertion site and three C-shaped tibial tunnels are created inside the ACL insertion site via an outside-in technique, after which cortical fixation is performed. This video shows the rationale for, technique for, and results of anatomic triple-bundle ACL reconstruction with the use of a hamstring tendon graft.

Surgical procedure: No notchplasty is required for the procedure. For exact arthroscopic identification of the ACL attachment areas, the residual stumps are excised. To identify the femoral attachment area, the upper cartilage margin, the posterior cartilage margin, and the resident’s ridge are used as landmarks. Identification of the residual stump of the ACL, the medial intercondylar ridge, and the anterior horn of the lateral meniscus is helpful to clarify the tibial insertion. Two round femoral tunnels and three round tibial tunnels are created inside the attachment areas with the use of drill guides and the off-set pin guide. Using a single semitendinosus tendon, two limb grafts and a single folded graft are prepared. After femoral fixation with the use of EndoButtons, the graft is pretensioned in situ via repetitive strong manual pulls at 15° to 20° of flexion for a few minutes, monitoring graft tension via a tensioning boot with tensioners installed. Final tibial fixation is achieved with the use of two double-spiked plate and screws with a predetermined tension of 10 to 20 N.

Postoperative Rehabilitation: The knee is immobilized in a brace for 2 weeks postoperatively. Full–weight bearing is allowed at 4 weeks postoperatively. Running is recommended at 3 months postoperatively. Strenuous activity is allowed at 6 to 8 months postoperatively.

Results: Two-year follow-up results are available for 88 recent patients who underwent anatomic triple-bundle ACL reconstruction with the use of a hamstring tendon graft. International Knee Documentation Committee subjective scores demonstrated normal or nearly normal results in 99% of the patients. Physical examination revealed no swelling in any of the patients, and only one patient had a 5° loss of flexion. Based on manual laxity examination, most of the patients had no Lachman sign or pivot shift. A mild Lachman sign was noted in four patients, and a mild pivot shift was noted in 17 patients. KT-1000 arthrometer testing performed at manual maximum force demonstrated a side-to-side difference between -1 mm and +2 mm in 93% of the patients.

Conclusions: Anatomic triple-bundle ACL reconstruction with the use of a hamstring tendon graft can be used to mimic the triple-bundle structure of the native ACL in any patient. The procedure leads to satisfactory outcomes in more than 90% of patients.