Transtibial Anterior Cruciate Ligament Reconstruction Using a Synthetic Graft Combined With Remnant Repair: A Hybrid Technique.

The purpose of this technical note is to describe a hybrid arthroscopic technique that combines anterior cruciate ligament reconstruction using a synthetic graft with concomitant remnant repair. Following diagnostic arthroscopy and assessment of remnant quality, tibial and femoral tunnels are created using a transtibial approach with attention to graft isometry. Anterior cruciate ligament remnant fibers are selectively preserved and repaired using a cinch-loop suture followed by an additional encircling stitch to form a sleeve-like construct. A synthetic ligament is then passed through the prepared tunnels, and the repaired remnant is cofixed with the synthetic graft on the femoral side, allowing the remnant to envelop the graft. This technique provides immediate mechanical stability while preserving vascularized native tissue and neuromechanical elements that may support biological integration and proprioceptive preservation.