1. Anterior Cruciate Ligament Reconstruction with a Four- Strand Hamstring Tendon Autograft by Riley J. Williams, Jon Hyman, Frank Petrigliano, Tamara Rozental, and Thomas L. Wickiewicz JBJS Essent Surg Tech Volume os-87(1 suppl 1):51-66 March 1, 2005 ©2005 by The Journal of Bone and Joint Surgery, Inc.

2. The distal ends of the gracilis and semitendinosus tendons are isolated at the pes anserinus through the use of an obliquely oriented incision along the Langer lines made medial and inferior to the tibial tubercle. Riley J. Williams III et al. J Bone Joint Surg Am 2005;os- 87:51-66 ©2005 by The Journal of Bone and Joint Surgery, Inc.

3. The ends of the tendons are isolated within the sartorius expansion with use of an angled clamp; the distal ends of the tendons are not detached. Riley J. Williams III et al. J Bone Joint Surg Am 2005;os- 87:51-66 ©2005 by The Journal of Bone and Joint Surgery, Inc.

4. A tendon harvester is gently advanced up the gracilis or semitendinosus tendon with the operative limb held in the “figure-of-four” position. Riley J. Williams III et al. J Bone Joint Surg Am 2005;os- 87:51-66 ©2005 by The Journal of Bone and Joint Surgery, Inc.

5. The harvester is advanced with steady pressure. Riley J. Williams III et al. J Bone Joint Surg Am 2005;os- 87:51-66 ©2005 by The Journal of Bone and Joint Surgery, Inc.

6. Countertraction on the distal end of the tendon is maintained with use of an angled retractor or clamp. Riley J. Williams III et al. J Bone Joint Surg Am 2005;os- 87:51-66 ©2005 by The Journal of Bone and Joint Surgery, Inc.

7. The authors' current method of femoral (cross-pin) and tibial (screw-sleeve) fixation for anterior cruciate ligament reconstruction with a hamstring tendon autograft. Riley J. Williams III et al. J Bone Joint Surg Am 2005;os- 87:51-66 ©2005 by The Journal of Bone and Joint Surgery, Inc.

8. The gracilis and semitendinosus are separated and individually prepared by the placement of nonabsorbable interlocking sutures along the free end of each tendon. Riley J. Williams III et al. J Bone Joint Surg Am 2005;os- 87:51-66 ©2005 by The Journal of Bone and Joint Surgery, Inc.

9. The position of the knee for anterior cruciate ligament reconstruction: the patient is in a slight Trendelenburg position, the knee is flexed to approximately 90°, and a bump is placed beneath the knee. Riley J. Williams III et al. J Bone Joint Surg Am 2005;os- 87:51-66 ©2005 by The Journal of Bone and Joint Surgery, Inc.

10. Arthroscopic photograph demonstrating a metal probe that is placed at the so-called over-the- top position on the posterior aspect of the lateral femoral condyle as visualized through a completed lateral femoral notchplasty in a right knee. Riley J. Williams III et al. J Bone Joint Surg Am 2005;os- 87:51-66 ©2005 by The Journal of Bone and Joint Surgery, Inc.

11. A commercial guide is used to advance a guidewire from the anteromedial aspect of the tibia to the anterior cruciate ligament footprint. Riley J. Williams III et al. J Bone Joint Surg Am 2005;os- 87:51-66 ©2005 by The Journal of Bone and Joint Surgery, Inc.

12. The tibial tunnel is created with use of a power reamer. Riley J. Williams III et al. J Bone Joint Surg Am 2005;os- 87:51-66 ©2005 by The Journal of Bone and Joint Surgery, Inc.

13. A second guidewire is then placed in the eleven o'clock position (for the left knee) or the one o'clock position (for the right knee), and the femoral tunnel is created with use of a power reamer to a depth of 25 to 30 mm. Riley J. Williams III et al. J Bone Joint Surg Am 2005;os- 87:51-66 ©2005 by The Journal of Bone and Joint Surgery, Inc.

14. A 4.5-mm reamer is then used to further extend the femoral tunnel through the anterior aspect of the lateral femoral cortex to facilitate placement of the Endobutton. Riley J. Williams III et al. J Bone Joint Surg Am 2005;os- 87:51-66 ©2005 by The Journal of Bone and Joint Surgery, Inc.

15. The Endobutton CL (Smith and Nephew) shown with the number-2 and number-5 sutures placed to facilitate advancement of the graft construct through the bone tunnels. Riley J. Williams III et al. J Bone Joint Surg Am 2005;os- 87:51-66 ©2005 by The Journal of Bone and Joint Surgery, Inc.

16. The completed four-strand tendon autograft, with use of the Endobutton CL, immediately prior to graft insertion. Riley J. Williams III et al. J Bone Joint Surg Am 2005;os- 87:51-66 ©2005 by The Journal of Bone and Joint Surgery, Inc.

17. The four-strand hamstring construct is created by placing the hamstring tendons through the Endobutton loop. Riley J. Williams III et al. J Bone Joint Surg Am 2005;os- 87:51-66 ©2005 by The Journal of Bone and Joint Surgery, Inc.