Dr. Garcia’s Updated Quad ACL Reconstruction Technique

This video, presented by orthopedic surgeon Dr. Grant H. Garcia, details an updated technique for an all-soft-tissue Quadriceps Tendon ACL Reconstruction. This modification utilizes adjustable TightRope fixation on both the femoral and tibial sides, combined with an InternalBrace for extra structural reinforcement.

Surgical Breakdown:

• Graft Harvesting & Sizing: The quadriceps tendon graft is harvested through a minimal incision, aiming to keep it partial-thickness off the patella (kneecap) unless a patient's larger size requires full-thickness tissue. On the prep table, a short whip-stitch is applied to hold the graft, and its uniform thickness is verified. Because dual-button fixation is used, the surgeon only needs a length of about 70 mm, avoiding a massive dissection all the way up to the rectus femoris muscle.
• Harvest Site Speed Closure: Before shifting focus to the arthroscopic work inside the knee, the surgeon utilizes a Knee Scorpion suture passer and a pre-linked loop stitch to close the quadriceps muscle defect. This rapid "speed closure" approach shaves about 5 minutes off the overall surgery time and leaves a tiny, flush knot that patients cannot feel externally.
• Tunnel Preparation: Inside the joint, the torn ACL remnants are cleared away. The surgeon uses a minimally invasive half-reamer to create a bone tunnel socket (drilling to a depth of about 25 to 30 mm), followed by a 4.5 mm drill through the outer bone cortex to allow the TightRope button to flip on the outside of the thigh bone. The integrity of the back wall of the bone tunnel is visually verified.
• Pull-Through Delivery Technique: Unlike a standard "all-inside" procedure, this approach uses a fold-through/pull-through technique, making it highly effective for revision ACL surgeries as well. The prepped graft is pulled upward into the femoral tunnel using the adjustable TightRope loop, keeping at least 15 to 20 mm of graft safely tucked inside the bone socket.
• Dual-Button Fixation & Internal Brace: On the lower leg (tibial) side, the graft is anchored using an Attachable Button System (ABS) button. The surgeon feeds a high-strength InternalBrace suture tape directly through this tibial button. With the knee held in full extension and verified free of soft-tissue impingement, the tibial and femoral TightRopes are sequentially cinched down to maximum tension.
• Final Backup Anchor: To provide definitive secondary security for both the adjustable loop and the InternalBrace tape, a SwiveLock anchor is placed directly into the tibial bone with the knee locked in full extension. The resulting construct delivers an exceptionally stable, rigid graft alignment with optimal tension throughout a full range of motion.