How to avoid the risk of intraoperative cartilage damage in anatomic four tunnel double bundle anterior cruciate ligament reconstruction

Double bundle (DB) anterior cruciate ligament (ACL) reconstruction is technically demanding. In order to create four anatomical anteromedial (AM) and posterolateral (PL) bone tunnels many surgeons adopt new ways of tibial and femoral bone tunnel drilling. From surgical experience, these technical changes might increase the risk for intraoperative pitfalls. An intraoperative articular cartilage damage to the medial femoral condyle or the medial tibial plateau could be disastrous for the patient. It may be caused by an insufficient anteromedial portal technique for femoral AM and PL bone tunnel drilling or flat tibial AM or PL bone tunnel reaming. Potential pitfalls may be avoided by small modifications to the surgical technique. In this present technical note, a sequence of surgical steps are described, which may help to avoid articular cartilage damage to the medial femoral condyle and medial tibial plateau in anatomical four tunnel DB ACL reconstruction.