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TITLE: Ribbon ACL Reconstruction Using Quad Tendon – the preliminary findings of a two-year
follow-up including CT and MRI scans

AUTHOR(S): Śmigielski Robert, MD PhD, Kopko Daniel, MD, Zielińska Aleksandra, MA BSc, Ciszkowska-Łysoń
Beata, MD PhD

INTRODUCTION: The paradigm of anterior cruciate ligament reconstruction (ACL-R) is undergoing changes. There
are several techniques performed by the surgeons around the world, stirring much discussion regarding the pros
and cons as well as the success rate of currently used methods. The objective, now, is to establish anatomy-driven
best practices regarding ACL-R procedures including the optimisation of the reconstruction technique and graft
choice. This work is to present the preliminary results of a 2-year follow-up of the patients who have undergone an
ACL-R using an original method called the “ribbon technique” (ACL-RR) which is based on recent anatomical findings
and clinical observations.
METHODS: Forty patients have undergone a "ribbon" ACL reconstruction with a central band of the quadriceps
femoris (QF) tendon (82,05%) or semitendinosus (17,95%) autograft. In 11 cases a pre-op CT scan was made. All
patients did pre- and post-op MRI scans and bilateral X-Rays. The follow-up included physical examination at 3, 6,
and 12 weeks and then every 3 months up to 1 year. In the second year of the observation, the physical exam took
place every 6 months. Follow-up MRIs were done at every 3 months post-op in the first year, and then every 6
months. In 15 cases post-op CT scans were done (the post-op protocol was extended by a routine CT after a certain
number of cases). The physical examination included: ROM evaluation; oedema / swelling evaluation; pain
(palpation); and instability assessment, including Lachman and anterior drawer tests.
RESULTS: In all cases, the patients returned to their normal level of activity 6 months post-op. Functionally, the
patients restored full range of motion and symmetrical stability in both lower limbs (negative Lachman and
anterior drawer tests). Through customised physical therapy, monitored by the physician-in-charge, patients
achieved good to very good quadriceps femoris contraction 6 months post-op. There were no donor site
morbidities. Structure-wise, there were no complications indicated by imaging diagnostics. A properly healing
anatomical structure was restored with good graft ingrowth (CT&MRI). No anterior subluxation was recorded on
post-op MRIs. Tunnel widening was monitored on CTs, no significant changes were recorded
DISCUSSION: It has been previously assumed that the ACL consists of two bundles. However, more recent
anatomical research concerning knee anatomy, including the author’s own published work, point to a flat, ribbon-
like structure of the ACL midsubstance, with the footprints also acknowledged by many knee experts as
“flattened”; rectangular femoral attachment and C-shaped tibial insertion. The findings of research by Zhao et al.
(2018) suggest that drilling a flattened tunnel during ACL-R could be a favourable surgical approach, capable of
replacing double-bundle ACL-Rs. Their biomechanical tests also showed that flattened tunnel ACL reconstruction
would result in a stronger regenerated tendon–bone interface. Thus, the premise of the newly-established ACL-
RR complies with the anatomical findings and provides ideas how to best perform a truly anatomical procedure,
offering superior functional and structural outcomes - especially with regard to the graft incorporation failure
rate.
CONCLUSION(S): Ribbon technique provides very good outcomes, allowing patients to return to their normal
lifestyle in shorter time with small chance of re-rupture. Though the results are preliminary, combined with
clinical observations of other surgeons using the ACL-RR, the technique may become the new golden standard of
ACL-R around the world.
Suggested reading:

ANATOMY:

Śmigielski R, Zdanowicz, U., Drwięga, M., Ciszek, B., Ciszkowska-Łysoń, B., Siebold, R. Ribbon like appearance of
the midsubstance fibres of the anterior cruciate ligament close to its femoral insertion site: a cadaveric study
including 111 knees. Knee Surg Sports Traumatol Arthrosc. 2015;23 (11):3143-3150.

Śmigielski R, Zdanowicz U, Drwięga M, Ciszek B, Fink C, Siebold R. Variations of the tibial insertion of the anterior
cruciate ligament: an anatomical study. Anterior cruciate ligament reconstruction. Springer; 2014:29-32.

Siebold R, Schuhmacher P, Fernandez F, Śmigielski R, Fink C, Brehmer A, Kirsch J. Flat midsubstance of the
anterior cruciate ligament with tibial “C”-shaped insertion site. Knee Surg Sports Traumatol Arthrosc. 2015;23
(11):3136-3142.

Śmigielski R, Zdanowicz U. A new approach to ACL anatomy: The Ribbon Concept. ASPETAR Sports Medicine
Journal. 2015

Śmigielski R. Zdanowicz U. Anatomy of ACL Insertion: Ribbon. Contreversies in the Technical Aspects of ACL
Reconstruction: An Evidence-Based Medicine Approach. Springer; 2017

BIOMECHANICS:

Kawaguchi Y, Kondo E, Takeda R, Akita K, Yasuda K, Amis AA. The Role of Fibers in the Femoral Attachment of
the Anterior Cruciate Ligament in Resisting Tibial Displacement. Arthroscopy. 2015;31 (3):435-444.

Lord BR, El-Daou H, Zdanowicz U, Śmigielski R, Amis AA. The Role of Fibers Within the Tibial Attachment of the
Anterior Cruciate Ligament in Restraining Tibial Displacement. Arthroscopy. 2019;35 (7):2101-2111.

SURGICAL TECHNIQUE:

Fink C, Smigielski R, Siebold R, Abermann E, Herbort M. Anterior Cruciate Ligament Reconstruction Using a
Ribbon-Like Graft With a C-Shaped Tibial Bone Tunnel. Arthroscopy Techniques. 2020

Domnick C, Herbort M, Raschke MJ, Schliemann B, Siebold R, Śmigielski R, Fink C. Converting round tendons to
flat tendon constructs: Does the preparation process have an influence on the structural properties. Knee Surg
Sports Traumatol Arthrosc. 2017;25 (5):1561-1567.

Zhao F, Hu X, Zhang J, Shi W, Ren B, Huang H, Ao Y. A more flattened bone tunnel has a positive effect on
tendon-bone healing in the early period after ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2019;27
(11):3543-3551.

Śmigielski R, Zdanowicz U, Drwięga M, Ciszek B, Williams A. The anatomy of the anterior cruciate ligament and
its relevance to the technique of reconstruction. Bone Joint J. 2016;98-B (8):1020-1026.