Anatomic triple-bundle ACL reconstruction using hamstring tendon

Anatomic double-bundle (ADB) anterior cruciate ligament (ACL) reconstruction has been widely performed, but cannot mimic the morphology of the normal ACL. Anatomic triple-bundle (ATB) ACL reconstruction was then developed using three tibial and two femoral tunnels to more closely mimic the normal ACL morphology. The concepts of this procedure are (I) to closely mimic the natural fiber arrangement and the morphology of the normal ACL, (II) to promote biological healing by increasing the contact area between the graft and tunnel walls, and (III) to distribute the stress from the graft at the tibial tunnel apertures. The indication for this procedure applies to all cases with ACL injury, especially for those with problems in the extensor mechanism. As the ATB technique is more effective in restoration of anterior stability the ADB procedure, the initial tension at graft fixation in the ATB procedure can be minimized or almost zero newton. Thus we usually fix grafts with 10-20 N of initial tension in the ATB procedure. However, there are some unsolved issues, including tunnel enlargement, graft rupture, and the long distance between fixations. Breakthroughs are required to resolve these issues.