1. Enhanced Bone-Tendon-Bone Approach for Open Anterior Cruciate Ligament Replacement With Conservation of the Joint Capsule 
Sebastian Gottfried Walter, M.Sc., Tom Sascha Thomas, M.D., Luca Tafuro, M.D., Wolfram Thomas, M.D., Ph.D. 
Arthroscopy Techniques 
Volume 4, Issue 5, Pages e609-e613 (October 2015)
DOI: /j.eats
Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

2. Fig 1
To tighten the patellar tendon, the knee is positioned at 90°. The patellar tendon is exposed, while the skin and fascia are held aside. The desired measurements of the bone-tendon-bone (BTB) graft are marked, and the graft is harvested with a mini-saw (and chisels). To guarantee high tear strength, the BTB graft should be resected following the fiber orientation of the patellar tendon.
Arthroscopy Techniques 2015 4, e609-e613DOI: ( /j.eats )
Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

3. Fig 2
To achieve a good fit, the bone-tendon-bone (BTB) graft is stretched and pulled through a mold with a certain diameter (normally 8 to 9 mm); this will be the diameter of the insertion tunnel as well. In this case a press-fit technique should be avoided because the BTB graft will not pass through the tunnel.
Arthroscopy Techniques 2015 4, e609-e613DOI: ( /j.eats )
Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

4. Fig 3
After resection of the bone-tendon-bone graft, the Hoffa body (yellow) is mobilized and remnants of the anterior cruciate ligament are removed. A jig (gray) is placed exactly onto the original tibial footprint, and a K-wire (red) is inserted. The K-wire now exactly imitates the course of the former ACL and serves as a guidewire for the further steps.
Arthroscopy Techniques 2015 4, e609-e613DOI: ( /j.eats )
Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

5. Fig 4
The previously placed K-wire guides the drilling of the insertion tunnel. The femoral part of the tunnel corresponds to the length of the osseous end of the bone-tendon-bone graft (approximately 20 mm).
Arthroscopy Techniques 2015 4, e609-e613DOI: ( /j.eats )
Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

6. Fig 5
The bone-tendon-bone (BTB) graft (orange) is attached to the K-wire that is pulled out through the femur, thus bringing the graft into its position. The indicated jig (gray) is used for femoral fixation of the BTB graft using Rigidfix pins (blue).
Arthroscopy Techniques 2015 4, e609-e613DOI: ( /j.eats )
Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

7. Fig 6
The bone-tendon-bone (BTB) graft is shown in its final position. Before and after final fixation of the tibial part, range of motion is performed to make small adjustments to the tension of the BTB graft if necessary.
Arthroscopy Techniques 2015 4, e609-e613DOI: ( /j.eats )
Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

8. Fig 7
Final position of the bone-tendon-bone (BTB) graft with a double, parallel fixation through Rigidfix cross-pins (blue) on the femoral part and an interference screw on the tibia. Wound closure has already been performed with single stitches.
Arthroscopy Techniques 2015 4, e609-e613DOI: ( /j.eats )
Copyright © 2015 Arthroscopy Association of North America Terms and Conditions