Recently, ACL reconstructive procedures such as endoscopic anatomical double bundle technique using hamstring graft which are passed through two tibial and two femoral bone tunnels have improved and reported excellent outcome . Moreover, in Bedi's report, an altered rotational axis resulted in significantly greater translation of the lateral compartment in the anatomical center-center single bundle ACL reconstruction compared with anatomical double bundle ACL reconstruction . On the other hand, patients with ACL deficient knees that were treated with hamstring graft showed tunnel widening [10, 11]. BTB is one of the popular grafts used for ACL reconstruction. The advantages of using the BTB graft include strength, ready availability, strong bone to bone fixation, and prompt healing of the bone plugs. However, sometimes, over 10 mm graft is not suitable for patients, especially small Asian people and females. For these patients, 10 mm graft is bigger than one third of patella tendon width .
The present procedure is anatomical graft route double bundle reconstruction using 7 mm BTB graft for anteromedial bundle. BTB with a bone block at the both ends of graft is applied to minimize tunnel enlargement. The disadvantage and limitation of present procedure is not only harvesting the gracilis tendon, but also the BTB, which thus increases the risk of harvest site morbidity. However, the Sartorius and semitendinosus tendons will function well and that graft site morbidity can be minimized if the gracilis tendon alone is harvested. In terms of the tension load for soft tissue graft in double bundle ACL reconstruction, manual maximum does not recommended . However, the tension load for BTB graft in double bundle technique is still controversial. In the present procedure, BTB graft is applied with maximum manual traction according to Hara's method . After an average 15 months follow-up of sixteen Asian patients (thirteen males and three females) treated using this technique, the preliminary post-operative clinical results showed no definite laxity. The bone tunnel enlargement was not observed at radiological examination. However, in the future, long term clinical and radiological studies as well as a biochemical study will be required.
There have been several reports on reconstructing techniques using BTB and hamstring for the ruptured ACL [17, 18]. However, these procedures did not represent an anatomical reconstruction in a tunnel position or routes strictly. Moreover, 10 mm BTB graft is bigger than one third of patella tendon width of Asian patient. To solve these problems, an anatomical double bundle ACL reconstructive procedure using BTB and gracilis composite autograft was modified and improved.