title: TriLink: Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction.
abstract: Cadaveric and clinical biomechanical studies show improved kinematic restoration using double-bundle anterior cruciate ligament (ACL) reconstruction techniques. These have been criticized in the past for being technically challenging. We present a novel 3-socket approach for anatomic "all-inside" double-bundle reconstruction using a single hamstring tendon fashioned to create a trifurcate graft: the TriLink technique. The semitendinosus alone is harvested, quadrupled, and attached to 3 suspensory fixation devices in a Y-shaped configuration, creating a 4-stranded tibial limb and 2 double-stranded femoral limbs. A medial viewing/lateral working arthroscopic approach is adopted using specifically designed instrumentation. Anatomic placement of the 2 femoral tunnels is performed by a validated direct measurement technique. A single mid-bundle position is used on the tibia. Both femoral and tibial sockets are created in a retrograde manner using outside-to-in drilling. This is a simplified operative technique for anatomic double-bundle ACL reconstruction that maximizes bone preservation. The TriLink construct replicates the 2 bundles of the ACL, conferring native functional anisometry and improving femoral footprint coverage while avoiding the complexities and pitfalls of double-tibial tunnel techniques. Preservation of the gracilis reduces the morbidity of hamstring harvest and allows greater flexibility in graft choice in cases requiring multiligament reconstruction.
authors.affiliation: Hampshire Hospitals NHS Foundation Trust, Basingstoke, England.
authors.forename: Sam K
authors.initials: SK
authors.lastname: Yasen
authors.affiliation: Hampshire Hospitals NHS Foundation Trust, Basingstoke, England.
authors.forename: James S
authors.initials: JS
authors.lastname: Logan
authors.affiliation: Hampshire Hospitals NHS Foundation Trust, Basingstoke, England.
authors.forename: James O
authors.initials: JO
authors.lastname: Smith
authors.affiliation: Hampshire Hospitals NHS Foundation Trust, Basingstoke, England.
authors.forename: Tamara
authors.initials: T
authors.lastname: Nancoo
authors.affiliation: Hampshire Hospitals NHS Foundation Trust, Basingstoke, England.
authors.forename: Mike J
authors.initials: MJ
authors.lastname: Risebury
authors.affiliation: Hampshire Hospitals NHS Foundation Trust, Basingstoke, England.
authors.forename: Adrian J
authors.initials: AJ
authors.lastname: Wilson
references.citation: Sports Med. 1999 Mar;27(3):143-56
references.pmid: 10222538
references.citation: Arthroscopy. 2008 Oct;24(10):1168-77
references.pmid: 19028170
references.citation: Clin Orthop Relat Res. 1987 Jul;(220):162-75
references.pmid: 3594987
references.citation: Arthroscopy. 2007 Jun;23(6):602-9
references.pmid: 17560474
references.citation: Am J Sports Med. 2010 Aug;38(8):1618-25
references.pmid: 20472754
references.citation: Knee Surg Sports Traumatol Arthrosc. 2010 Jan;18(1):43-6
references.pmid: 19585103
references.citation: J Trauma. 1991 Feb;31(2):223-9
references.pmid: 1994082
references.citation: Arthroscopy. 2007 Mar;23(3):278-83
references.pmid: 17349471
references.citation: J Orthop Res. 1997 Mar;15(2):285-93
references.pmid: 9167633
references.citation: Knee Surg Sports Traumatol Arthrosc. 2010 Jan;18(1):64-7
references.pmid: 19847403
references.citation: Am J Sports Med. 2011 Apr;39(4):743-52
references.pmid: 21173191
references.citation: Knee Surg Sports Traumatol Arthrosc. 2009 Aug;17(8):956-63
references.pmid: 19399476
references.citation: Arthroscopy. 2012 Oct;28(10):1504-12, 1512.e1-2
references.pmid: 22739002
references.citation: Knee Surg Sports Traumatol Arthrosc. 2012 Jul;20(7):1289-92
references.pmid: 22095484
references.citation: Arthroscopy. 2009 Jan;25(1):95-101
references.pmid: 19111224
references.citation: Sports Med Arthrosc Rehabil Ther Technol. 2012 Mar 14;4(1):9
references.pmid: 22414219
references.citation: Int Orthop. 2013 Feb;37(2):271-7
references.pmid: 22941098
references.citation: Clin Orthop Relat Res. 1975 Jan-Feb;(106):216-31
references.pmid: 1126079
references.citation: Sports Med Arthrosc Rev. 2010 Mar;18(1):15-9
references.pmid: 20160625
references.citation: Clin Orthop Relat Res. 2007 Jan;454:100-7
references.pmid: 17091015
references.citation: Ann R Coll Surg Engl. 2011 May;93(4):326
references.pmid: 21944810
references.citation: Am J Sports Med. 2011 Feb;39(2):279-88
references.pmid: 21239692
references.citation: J Knee Surg. 2012 Jul;25(3):237-43
references.pmid: 23057143
references.citation: Am J Sports Med. 2012 Feb;40(2):404-13
references.pmid: 22116668
references.citation: J Bone Joint Surg Br. 2011 Oct;93(10):1334-40
references.pmid: 21969431
references.citation: Arthroscopy. 2004 Dec;20(10):1013-4
references.pmid: 15592228
references.citation: Clin Orthop Relat Res. 2007 Jan;454:66-73
references.pmid: 17091011
references.citation: Int Orthop. 2012 Jan;36(1):171-7
references.pmid: 21898038
references.citation: Knee Surg Sports Traumatol Arthrosc. 2012 Apr;20(4):613-20
references.pmid: 22278656
references.citation: Am J Sports Med. 2004 Dec;32(8):1825-32
references.pmid: 15572308
references.citation: Clin Orthop Relat Res. 2007 Jan;454:108-13
references.pmid: 17202919
references.citation: Knee Surg Sports Traumatol Arthrosc. 2007 May;15(5):500-7
references.pmid: 17216271
references.citation: Am J Sports Med. 2011 Dec;39(12):2595-603
references.pmid: 22021585
references.citation: J Bone Joint Surg Am. 2011 Oct 19;93(20):1865-72
references.pmid: 22012523
references.citation: Br J Sports Med. 2010 Jan;44(1):21-5
references.pmid: 19952376
references.citation: J Orthop Res. 2004 Jan;22(1):85-9
references.pmid: 14656664
references.citation: Knee Surg Sports Traumatol Arthrosc. 2010 Sep;18(9):1151-3
references.pmid: 20668836
references.citation: Knee Surg Sports Traumatol Arthrosc. 2008 Jan;16(1):29-36
references.pmid: 17957351
references.citation: Arthroscopy. 2006 Mar;22(3):240-51
references.pmid: 16517306
references.citation: Am J Sports Med. 2010 Jul;38(7):1349-58
references.pmid: 20423987
references.citation: Clin Orthop Relat Res. 2008 Jun;466(6):1467-74
references.pmid: 18404292
references.citation: Am J Sports Med. 2008 Sep;36(9):1675-87
references.pmid: 18490472
references.citation: Arthroscopy. 2011 Sep;27(9):1259-67
references.pmid: 21741796
references.citation: Clin Orthop Relat Res. 2007 Apr;457:203-9
references.pmid: 17195812
references.citation: Am J Sports Med. 2010 Feb;38(2):263-72
references.pmid: 19966094
references.citation: Orthop Traumatol Surg Res. 2011 Oct;97(6 Suppl):S75-9
references.pmid: 21903501
references.citation: Arthroscopy. 2007 Jan;23(1):7-13
references.pmid: 17210421
references.citation: Arthroscopy. 2007 Jul;23(7):771-8
references.pmid: 17637414