AANA Lab Course 1001 - Foundations in Arthroscopy (Resident/Fellow)-Graft Harvest/Graft Preparation, Notchplasty-James P. Leonard, M.D.

Graft Harvest/Graft Preparation, Notchplasty-James P. Leonard, M.D.

Pdf Summary

This comprehensive document by Dr. James Leonard addresses anterior cruciate ligament (ACL) reconstruction, focusing on graft choices, biomechanics, fixation methods, complications, and surgical techniques.<br /><br />Key goals in ACL reconstruction include replicating native ACL anatomy and biomechanics, achieving rapid biological incorporation, ensuring strong initial fixation, minimizing donor site morbidity, optimizing clinical outcomes, and cost-effectiveness.<br /><br />Graft options are categorized as autografts and allografts. Autografts include Bone-Patellar Tendon-Bone (BPTB), hamstring tendons (quadrupled semitendinosus/gracilis), and quadriceps tendon. Allografts include BPTB, hamstring, quadriceps, Achilles, anterior tibialis, and posterior tibialis tendons. Each graft type varies in tensile strength, stiffness, and cross-sectional area, with hamstring and Achilles allografts showing high strength and stiffness.<br /><br />Healing times differ: autograft BPTB and quadriceps grafts incorporate in 6-12 weeks, hamstring in 12 weeks, while allografts may take up to 6 months. Early rehabilitation requires fixation devices that withstand forces of 450–500 N and minimize micromotion (<3 mm) to ensure graft incorporation. Fixation devices such as interference screws and cortical buttons have variable ultimate failure loads and stiffness.<br /><br />Donor site complications vary by graft: BPTB autografts may cause patellar fracture, tendon issues, tenderness, and numbness; hamstring autografts risk MCL injury and numbness; quadriceps grafts risk hematoma and cosmetic deformity. Anterior knee pain incidence is similar between BPTB autografts and allografts but lower with hamstring and quadriceps grafts.<br /><br />Allografts have low disease transmission risk due to rigorous donor screening and sterilization but possible weakening from sterilization methods, especially gamma radiation.<br /><br />Clinical studies generally show no significant outcome differences between BPTB and hamstring autografts, though BPTB offers increased knee stability and is preferred by many sports physicians despite higher kneeling pain and incisional discomfort.<br /><br />Cost analyses reveal allografts are more expensive with longer supplies costs, while autografts have longer operating times.<br /><br />Graft selection depends on surgeon experience, patient age, activity, occupation, comorbidities, prior surgery, and preferences. Typical indications: BPTB autograft for high-demand young athletes and revisions; hamstring for younger recreational athletes; quadriceps for those with inadequate other tendons; allografts for older, recreational athletes or complex injuries.<br /><br />The document also details surgical principles and technical pearls for harvesting BPTB and hamstring grafts, emphasizing incision placement, graft sizing, bone cuts, tendon exposure, fascial release, and graft preparation to minimize morbidity and optimize graft integrity.<br /><br />Overall, the text provides an expert guide to ACL graft options, biomechanics, complications, fixation, costs, and detailed surgical technique considerations to optimize patient outcomes.

Keywords

ACL reconstruction

graft choices

autografts

allografts

biomechanics

fixation methods

donor site complications

surgical techniques

rehabilitation

clinical outcomes