AANA Lab Course 901 - Foundations in Arthroscopy (Resident/Fellow)-How to Do an Anterior Cruciate Ligament Reconstruction, James P. Leonard, MD

How to Do an Anterior Cruciate Ligament Reconstruction, James P. Leonard, MD

Pdf Summary

This comprehensive lecture by Dr. James Leonard outlines the critical aspects of anterior cruciate ligament (ACL) reconstruction, emphasizing its multidisciplinary nature involving anatomy, biomechanics, clinical evaluation, imaging, surgical technique, and rehabilitation.<br /><br />ACL ruptures typically occur due to noncontact injuries, often with an audible pop and early hemarthrosis, presenting with instability and an inability to return to play. Clinical evaluation includes sensitive tests like the Lachman and highly specific pivot-shift examinations. MRI confirms the diagnosis and assesses associated injuries, since isolated ACL tears are rare; meniscal, cartilage, and collateral ligament injuries frequently coexist.<br /><br />Candidates for reconstruction usually exhibit symptomatic instability affecting active lifestyles, especially in younger patients at risk of further meniscal damage and early osteoarthritis. Preoperative goals include restoring range of motion, reducing swelling, and patient education to minimize postoperative complications like arthrofibrosis.<br /><br />Surgical success hinges on appropriate graft choice—autograft (bone-patellar tendon-bone, hamstring) versus allograft—anatomic tunnel placement, and secure fixation. Techniques for femoral tunnel drilling include transtibial, anteromedial portal, and outside-in, with the latter two yielding more anatomic placement and better stability. Tibial tunnel accuracy is crucial to avoid graft impingement and mismatch.<br /><br />Fixation methods involve cortical buttons and interference screws, with biocomposite screws favored for ease of MRI interpretation and revision. Graft tensioning is performed in full extension with attention to maintaining knee reduction to optimize outcomes.<br /><br />The lecture notes that meticulous execution in each step is paramount since errors compound, complicating succeeding stages. Routine notchplasty is generally discouraged due to lack of demonstrated benefit and risks like extension loss. An examination under anesthesia and diagnostic arthroscopy guide intraoperative decisions, including management of secondary instabilities, which are a significant cause of reconstruction failure.<br /><br />Key technical pearls stress preoperative planning with backups, consistent intraoperative assessments, preference for bony landmarks, and anatomic tunnel positioning, all contributing to restoring native ACL biomechanics and improving patient outcomes.

Keywords

anterior cruciate ligament reconstruction

ACL rupture

noncontact injury

clinical evaluation

MRI diagnosis

meniscal injury

graft choice

femoral tunnel drilling techniques

fixation methods

postoperative rehabilitation