Enveloping of periosteum on the hamstring tendon graft in anterior cruciate ligament reconstruction

Tendon-bone incorporation of a tendon graft within the bone tunnel is a major concern when using tendon graft for ligament reconstruction. Periosteum consists of multipotent mesodermal cells to form all varieties of connective tissue, including osteogenic and chondrogenic tissues. From our histologic and biomechanical studies in animals, a superior healing process and stronger healing strength can be achieved when periosteum is sutured onto the tendon inserted within a bone tunnel. We applied this idea to anterior cruciate ligament reconstruction to enhance tendon-bone healing. A quadruple-stranded hamstring tendon graft is used. A piece of periosteum, 3 x 3 cm, harvested from the anterior cortex of proximal tibia, is split into 2 rectangle flaps (1.5 x 3 cm each). The periosteum flaps are wrapped and sutured around the tendon graft at the portions near the femoral and tibial tunnel openings. The cambium layer is faced outside to the bone tunnel. Periosteum is easy to harvest from proximal tibia, where is a routine incision for harvesting hamstring tendons. Besides the potential for enhancement of tendon-bone healing, periosteum may be able to seal off the intra-articular opening in a very early period to avoid synovial fluid reflux into the tunnel.