ACL ST 4 inside  (PULLUP®)                            Courtesy of Dr. David Dejour

1.  Graft harvesting

Harvest the ST with a open or close tendon stripper.

2. Graft preparation

Enlarge the white braids loops and install the 2 Pul-lup® devices on the GraftTech® preparation station.   


The ST has to be quadrupled around the Pullup® loops.

Remove the green sutures from the Pullup® plates. They can be used later for the graft passage.

Once the graft is loaded in linkage with Pullup® loops, the graft free ends are crossed and wrapped around with a POWERTEX® suture. 

Each stich must cross all the 4 bundles, with the knots preferably positioned inside the graft. 

Be aware of not passing thru the Pullup® loops with the needle.

Calibrate and measure the graft (55 to 60 mm depending on the patient’s size).

A distance of 15 mm is marked on both graft free ends with a sterile pen, corresponding to the graft position at the socket entries. 

The graft is pre tensioned on the GraftTech® .

3 Tunnels drilling

Outside-in femoral guide is positioned (45° coronal plane; 30° proximally - distally), thus the femoral pin is positioned in the center of ACL anatomic footprint. 


A complete tunnel (4,5 mm) is drilled. 

Complete tunnel at 4.5 mm:

Tibial guide is positioned (55°- 65° coronal plane; 25° sagittal plane), then the tibial pin is positioned in the center of ACL anatomic footprint. 

A complete tunnel (4,5 mm) is drilled. 

Tibial and femoral socket drilling:

Insert the retrograde drill with the same diameter of the graft in the tibial tunnel.

Open the retrograde drill with the proper device. 

Manual retrograde drill tibial socket (20-25 mm) has to be performed. The tunnel length depends on the graft size; it is advised to drill 3 mm more than the graft length to optimize the intra-articular graft ten-sion and position. 

Repeat this procedure for the femoral socket.

4 Graft Passage

Insert 2 pulling suture via the antero-medial arthros-copic portal; fi rst in the femur and then in the tibia. 


The green sutures removed earlier from the plates can be used to achieve this surgical step.

Introduce the graft via the antero-medial arthrosco-pic portal pulling on the white/blue traction suture; the tibial part fi rst and then the femoral one. 


The pen marks help the surgeon to optimize the pro-perly graft position in the bone tunnels

5 Graft tensioning and fixation

Femoral fixation

With the knee fl exed to 80°, alternately pull on the braid sutures with one hand and then with the other until the plate is contact with the femoral shaft. Visual confi rmation of the plate-to-bone contact is possible through the full-thickness incision with or without the scope.  

Graft cycling by pulling on the tibia white/blue traction suture.

Tibial fixation

With the knee fl exed at 10°, the graft is tensioned and the anterior tibial translation is reduced by ap-plying a posterior drawer; fi nally, the tibial fi xation is performed using the same method described above for the femur.

Cut the Pullup® sutures by leaving 2 mm on each plate.

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