1. Quadruple Semitendinosus Graft Construct and Suspensory Button Fixation for Anterior Cruciate Ligament Reconstruction 
Alcindo Silva, M.D., Ricardo Sampaio, M.D. 
Arthroscopy Techniques 
Volume 4, Issue 6, Pages e801-e806 (December 2015)
DOI: /j.eats
Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

2. Fig 1
Graft preparation. (A) Both free ends of the semitendinosus are stitched. Two adjustable-length loop cortical button devices are used: ToggleLoc, for the femur, and ToggleLoc XL Inline, for the tibia. (B) The tendon graft is symmetrically folded over the tibial cortical button loop. (C) The doubled graft is passed through the femoral cortical button loop and is symmetrically folded again. (D) One free end strand of the graft passes through the tibial button loop; both free ends of the graft are tied together with 2 knots. (E) The same sutures are tied over the graft itself with 4 knots. (F) The 4-stranded graft is reinforced on the tibial side with cerclage-type suture and a buried-knot technique.
Arthroscopy Techniques 2015 4, e801-e806DOI: ( /j.eats )
Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

3. Fig 2
Creation of femoral tunnel. (A) Standard medial and lateral portals for arthroscopic visualization are created. (B) By use of a ruler through the anterolateral portal, the length of the anterior cruciate ligament footprint is measured. (C) An appropriate Precision Curved Offset Femoral Guide is selected to reach the center of the femoral anterior cruciate ligament footprint. (D) The guide is introduced through the medial portal. Two alignment rods are inserted in the collar of the guide, one through the coronal hole parallel to the joint line and the other through the trajectory hole to indicate the exit of the flexible guidewire on the lateral femoral cortex. (E) A flexible guidewire is drilled and advanced through the lateral femoral cortex, to exit the skin on the lateral thigh, until the black laser line (arrow) on the flexible guidewire meets the femoral bone in the notch. (F) The length of the femoral tunnel is measured, with the Precision Depth Gauge through the skin until contacting the femoral cortical bone. (G) A Precision Flexible Reamer with the same diameter as the graft is drilled over the guidewire until the desired tunnel depth is reached. (H) A suture is pulled proximally on the flexible guidewire to place the relay suture into the joint space and through the femoral tunnel.
Arthroscopy Techniques 2015 4, e801-e806DOI: ( /j.eats )
Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

4. Fig 3
Bone dowel harvesting and tibial tunnel creation. (A) A guidewire is drilled through the center of the native anterior cruciate ligament footprint. (B) The cortex at the distal end of the tibial tunnel is removed with a reamer. (C) A cannulated plunger is inserted over the K-wire (arrow). (D) The harvesting tube is impacted over the cannulated plunger and the K-wire to the subchondral bone. The harvesting tube is rotated to break the tip of the bone dowel from the subchondral bone, and the harvesting tube is removed from the tunnel.
Arthroscopy Techniques 2015 4, e801-e806DOI: ( /j.eats )
Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

5. Fig 4
Graft passage. (A) The distances on the graft construct are marked, including the length of the total femoral tunnel in the adjustable graft loop and the length of the graft inside the femoral tunnel, measuring from the femoral graft end. (B) The femoral adjustable graft loop is pulled into the femoral tunnel, through the tibial tunnel, until the mark on the graft loop reaches the tunnel aperture. Once the button flips, the femoral pull suture is tensioned to pull the graft up into the femoral tunnel.
Arthroscopy Techniques 2015 4, e801-e806DOI: ( /j.eats )
Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

6. Fig 5
Bone dowel introduction. (A) The bone plug is compacted into the tibial tunnel. (B) Coronal oblique computed tomography scan of bone dowel inside tibial tunnel.
Arthroscopy Techniques 2015 4, e801-e806DOI: ( /j.eats )
Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

7. Fig 6
Tibial fixation. (A) The tibial tensioning sutures are pulled until the button is seated outside the tibial tunnel. (B) Three-dimensional computed tomography scan of ToggleLoc XL Inline in tibia after fixation.
Arthroscopy Techniques 2015 4, e801-e806DOI: ( /j.eats )
Copyright © 2016 Arthroscopy Association of North America Terms and Conditions