All-Inside Primary Anterior Cruciate Ligament Reconstruction Using a Combined Polyester Synthetic Graft and Gracilis Tendon Autograft: Modified Technique of a Hybrid 4 × 2 Graft Preparation.

Anterior cruciate ligament reconstruction is a frequently performed procedure in arthroscopic surgery, with rising rates paralleling the incidence of anterior cruciate ligament ruptures worldwide. Synthetic grafts, especially hybrid constructs combining artificial devices with autologous tissue, offer biomechanical advantages and potential faster recovery. This article describes a modified technique for primary all-inside anterior cruciate ligament reconstruction using a 4 × 2-strand hybrid graft composed of a tubular synthetic device combined with the gracilis tendon. This technique aims to deliver a stronger graft, optimizing stability while preserving bone and reducing operative time. The step-by-step surgical method, graft preparation, tunnel creation, and fixation are detailed, with emphasis on biomechanical and clinical benefits for professional athletes and high-demand patients.