ACL

Reconstruction:
Techniques and
Avoiding Pitfalls

Timothy Hosea, MD
University Orthopaedic
Associates
Liberally “borrowed” images from the internet
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 Questions to be Answered
• What is the unique anatomy and function of the
Anterior Cruciate Ligament (ACL) and how do today’s
reconstruction techniques attempt to recreate it?
• What is the history of ACL reconstruction and its
evolution?
• What is a current technique of an ACL reconstruction
and what is its rationale?
• What are possible technical complications
associated with the reconstruction?
• What are my personal preferences in reconstructing
the ACL?
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Of course: Based on Current Literature

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 What is our Goal?
• To restore normal knee
kinematics
– Possible source of
osteoarthritis if lost
(Carmont, 2011)
• Provide a pain free stable
knee
• To provide an expedient
return to previous level of
function

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 Timing of ACL Surgery
• Time interval is not as important as the condition
of the knee at the time of surgery
• Elective procedure (Shelbourne, AJSM, 1991)
– Full ROM
– Minimal effusion
– Minimal pain
– Mentally prepared for the reconstruction and rehab
• AVOID ARTHROFIBROSIS AT ALL COSTS
– Cosgarea, 1995; Shelbourne, 1997; Magit,2007
 ACL function
• Anterior translation of • Prevent anterio-lateral
the tibia with respect to rotation
the femur

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Embryology
45 Days gestation

Bechler, Hosea 1991

 ACL Double bundle

• Anterior Medial Bundle

– Anterior stability
– Taut in flexion
• Posterior Lateral Bundle
– Rotational stability
– Taut in extension
ACL Anatomy
Double Bundle

Kopf, Fu 2012
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 ACL Reconstruction Techniques
• Until the 1970s, there was a significant
controversy about the functional importance of
the ACL
• 1970s: ACL repair
– Not universally successful
• Early 1980s: Repair with augmentation
• Complete replacement of the ACL with a graft
– Clancy: Bone Patella Tendon Bone (vascularized)
• JBJS, 1982
 ACL Techniques
• Non anatomic
• 1990s Transtibial • Quick reproducible
Technique • Femoral tunnel drilled
with offset guide through
the tibial tunnel.

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 ACL Technique
• 2000s
– Anatomically placed tunnels better restore normal knee
kinematics
• Tashman, 2004, 2007
– Non anatomic transtibial techniques result in high
percentage of OA
• Biau, 2007; Fithian, 2005; Simon, 2015
– Postulated that initial trauma (articular cartilage damage)
and tunnel placement may contribute to the onset of OA
• Kopf, Fu, 2012

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 ACL Technique
• Double Bundle
– Attempts to reproduce the
normal ACL anatomy
• Fu etal
– Superior anterior and rotational
stability
• Clinical implications still unknown
• NIH clinical trails in progress
– Not indicated:
• Small, native ACL (<14 mm)
• Open physes
Vyas, Fu 2010
• Narrow notch (<13 mm)
• Severe bone bruising
• Multiple ligament injuries
– Fu, 2012

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 ACL Technique
• Double bundle issues
– Increased operating time
• Double the number of
tunnels
• Complexity of passing and
securing the 2 grafts
• Possibility of large bony
voids in the lateral femoral
condyle if revision necessary
• 6% rerupture rate
– (Carmont, 2011)
• Anatomic single bundle
– Awareness of the
importance of anatomic
placement
• Increased failure of an ACL
reconstruction with non
anatomic placement
– Anatomic tibial tunnel
placement
– Femoral tunnel placed
independent of the tibial
tunnel
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ACL technique

Kopf, Fu 2012

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 Technical Aspects of
ACL Reconstruction
• Position of the ACL graft is the most critical
surgical variable
– Direct effect on knee biomechanics and clinical
outcome
 Graft Options
• Bone Patella Bone
• Hamstring
• Allograft

• Advantages
– Lower rate of graft failure
– Sufficient strength
– Bone plug to bone tunnel
fixation
• Disadvantages
– Increased anterior knee pain
– Small risk patella fractures
• Freedman, Bach, 2003
 Graft Options
• Bone Patella Bone
• Hamstring
• Allograft

• Advantages
– Adequate strength
– Little donor morbidity
• Disadvantages
– Higher rate of graft failure
• Freedman, Bach 2003
• Gifstad, 2014
– Increased laxity , functionally
similar
• Feller, 2002

Frank, JBJS, 1997

 Graft Pearl
• Size matters
– Hamstring < 8mm
• Increased failure rate
– Magnussen, 2012
Surgical Technique
 Femoral Notchplasty
• Femoral notch stenosis
associated with ACL tears
– LaPrade, 1994, Souryal,
1988
• Increased visualization of
the ACL footprint and the
posterior condylar wall
 Tibial Tunnel Site
• Tibial insertion:
– 15 mm behind anterior
border of articular
surface
– Medial to attachment of
anterior horn of lateral
meniscus
Insertion sites

• Femoral attachment:
– Posteriorlateral aspect
of the intercondylar
notch on lateral femoral
condyle
 Femoral Tunnel Placement

Non Anatomic Single Bundle Anatomic Single Bundle

Vertical Graft
Passing the Graft
 Graft Fixation

• Fixation is the weak link during the early stages

of healing
• Fixation Goal
– Obtain biologic incorporation of the graft at the
anatomic attachment of the ACL and restore the
transition from soft tissue to fibrocartilage to calcified
cartilage to bone
 Fixation Choices
• Interference Screw
– Most popular
– Avoid divergence away
from bone plug
• Divergence >15 deg
decrease in pullout
strength
• Clinical studies: few
failures
– Blunted screw threads
for soft tissue grafts
– Bioabsorbable screws
 Fixation Choices
• Endobutton
• Screw and washer
• Cross pin fixation
• Rigid Fix
Anatomic ACL Reconstruction
 Poor Surgical Technique
Non-anatomic Single Bundle
• Vertical tunnels: poor rotational control
 Poor Surgical Technique
• Anterior femoral tunnel: Graft failure in flexion

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Epiphyseal sparring ACL
reconstruction

Kocher, 2006, 2007

 Graft Healing
• BPTB grafts:
– Heal by bone plug incorporation and resembled the normal
insertion of the normal ACL
• Hamstring grafts:
– Heal by fibrils of the graft penetrating the bone directly and
result in the a fibrous insertion of the tendon
• Allografts:
– Slower rate of incorporation
– Greater decrease in structural properties
– Prolonged inflammatory response
 Bone Tunnel Widening
• More frequent with
allograft and hamstring
reconstruction
– Associated with accelerated,
brace free rehabilitation
protocol (Vadala, 2007)
– Associated with fixation
points not close to the joint
(Fauno, 2005)
• No study confirms that
tunnel widening has an
adverse effect on ACL
results
– Revision is more difficult
ACL Complications
• 60-80% are surgical /
technical errors
– Femoral tunnel
placement
– Fixation failure or
mismatch
– Untreated or
unrecognized secondary
insufficiencies
• Morgan, 2012
 Summary: ACL Reconstruction
• Anatomic tunnel placement
• Gold Standard Graft
– B-PT-B
• Hamstring graft with open
growth plates or
patellofemoral issues
– Semitendinosis
– Gracilis
• Always repair the meniscus