AANA Lab Course 1001 - Foundations in Arthroscopy (Resident/Fellow)-How to Do an Anterior Cruciate Ligament Reconstruction-James P. Leonard, M.D.

How to Do an Anterior Cruciate Ligament Reconstruction-James P. Leonard, M.D.

Pdf Summary

This comprehensive document by Dr. James Leonard provides an expert overview of anterior cruciate ligament (ACL) reconstruction encompassing anatomy, biomechanics, clinical evaluation, imaging, surgical techniques, graft choices, fixation methods, and postoperative considerations.

Key points include:

- <strong>ACL Injury Presentation:</strong> Most ACL tears result from noncontact injuries with an audible pop and early hemarthrosis. Clinical exams prioritize the Lachman test (most sensitive) and pivot-shift test (most specific).

- <strong>Diagnostic Imaging:</strong> Knee radiographs exclude fractures, while MRI confirms ACL tears and detects common associated injuries, as isolated ACL tears are rare. Meniscus, cartilage, and bone injuries frequently co-occur.

- <strong>Indications for Reconstruction:</strong> Symptomatic instability in young, active patients predisposes to meniscal tears and osteoarthritis. Criteria include minimal effusion, normal gait, 0-120° knee motion, and ability to perform straight leg raises by three weeks post-injury to minimize arthrofibrosis.

- <strong>Graft Choices:</strong> Autografts (bone-patellar tendon-bone [BPTB], hamstring, quadriceps tendon) are preferred in young, high-demand athletes and revision cases. Allografts suit older, recreational athletes or multiligament injuries. Each graft has technical nuances affecting fixation and graft passage.

- <strong>Surgical Techniques:</strong> Femoral tunnel drilling methods—transtibial, anteromedial, and outside-in—vary in anatomical accuracy, ease, and complication risks. Anatomic tunnel placement is critical to restore native ACL function and reduce graft impingement. Notchplasty is generally not recommended routinely.

- <strong>Fixation Methods:</strong> Femoral fixation options include metallic or biocomposite screws and cortical buttons; tibial fixation is often the weakest link due to bone density. Proper graft tensioning at full extension with the tibia reduced on the femur minimizes complications.

- <strong>Technical Considerations:</strong> Preoperative planning, consistent intraoperative examination, and attention to surgical steps are vital as errors accumulate, increasing procedural difficulty. Soft tissue and bony landmarks guide tunnel placement, with graft passage easier through transtibial tunnels and more challenging through anteromedial or outside-in approaches.

- <strong>Common Causes of Failure:</strong> Secondary instabilities such as posterolateral corner injuries and meniscal root detachments necessitate thorough intraoperative assessment and management.

In summary, successful ACL reconstruction demands a multidisciplinary understanding, meticulous surgical technique with anatomical tunnel placement, appropriate graft selection, secure fixation, and structured rehabilitation to optimize outcomes and reduce failure risks.

Keywords

ACL reconstruction

anterior cruciate ligament

ACL injury

Lachman test

pivot-shift test

MRI knee imaging

graft choices

surgical techniques

femoral tunnel drilling

postoperative rehabilitation