Anatomic double-bundle anterior cruciate ligament reconstruction with hamstrings

Maurilio Marcacci, Alessandro Paladini Molgora, Stefano Zaffagnini, Alberto Vascellari, Francesco Iacono, M. Lo Presti

Research output: Contribution to journalArticlepeer-review


This article describes a double-bundle gracilis and semitendinosus technique that guarantees a more anatomic anterior cruciate ligament (ACL) reconstruction and allows the surgeon to avoid the use of hardware for graft fixation. The tendons are harvested maintaining their tibial insertion. Sutures are tightened at the free proximal tendon ends to obtain a sufficient strength to traction. The tibial tunnel is located in the medioposterior part of the ACL tibial insertion. For the femoral tunnel, the knee is flexed around 130° and the guide pin is advanced until it passes the femoral cortex. The exit point in the lateral aspect of the femur should be immediately above the end of the lateral femoral condyle. After the lateral incision, the tendons are passed over the top. The correct placement is found by palpating the posterior tubercle of the lateral femoral condyle with a finger. The stitches on the free end of the tendons are tied onto the passing suture that is pulled through the knee joint into the over-the-top position. A suture loop is introduced into the joint through the anteromedial portal using a suture passer and then pulled into the femoral tunnel under the arthroscopic view. The stitches on the free end of the tendons are looped again onto the passing suture, which is pulled through the femoral tunnel, knee joint, and tibial tunnel to retrieve the graft from the tibial incision. The combined gracilis and semitendinosus tendons are then tensioned and secured with a transosseus suture knot. This technique attempts to reproduce the kinematic effect of both anteromedial and posterolateral bundle of the ACL with a 4-bundle reconstruction with a better performance from the anatomic and functional point of view.


  • ACL
  • Arthroscopy
  • Gracilis
  • Graft
  • Semitendinosus
  • Surgical technique

ASJC Scopus subject areas

  • Orthopedics and Sports Medicine
  • Surgery


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