AANA Lab Course 901 - Foundations in Arthroscopy (Resident/Fellow)-LAB LECTURE_ Graft Harvest_Graft Preparation, Notchplasty, James P. Leonard, MD

LAB LECTURE_ Graft Harvest_Graft Preparation, Notchplasty, James P. Leonard, MD

Pdf Summary

This document, authored by Dr. James Leonard, provides an in-depth overview of Anterior Cruciate Ligament (ACL) reconstruction techniques, graft choices, biomechanics, and surgical pearls. It discusses the goals of ACL reconstruction: to replicate native ACL anatomy and biomechanics, achieve rapid biologic incorporation, ensure strong initial fixation, minimize donor site morbidity, optimize clinical outcomes, and maintain cost-effectiveness.<br /><br />Graft options include autografts (bone-patellar tendon-bone (BPTB), hamstring, and quadriceps tendon) and allografts (BPTB, hamstring, quadriceps, Achilles, anterior and posterior tibialis tendons). Biomechanical properties such as ultimate tensile strength, stiffness, and cross-sectional area vary among graft types, influencing their suitability. For example, allografts tend to have slower incorporation and potential risks of disease transmission despite eliminating donor site morbidity.<br /><br />Early rehabilitation depends critically on graft fixation strength and stiffness, with soft tissue fixation devices differing in resistance to displacement under load. Slippage during the six weeks post-op corresponds to high cycle loading, emphasizing the need for durable fixation.<br /><br />Donor site complications differ by graft: BPTB autografts risk patellar fracture, tendon rupture, anterior knee pain, and numbness; hamstring autografts risk numbness and potential graft truncation; allografts carry theoretical disease transmission risks mitigated by advanced screening.<br /><br />Clinical outcomes comparing BPTB and hamstring autografts show limited differences in function and failure rates, but donor site morbidity and kneeling pain are more common with BPTB. Quadriceps autografts offer larger graft size with less donor morbidity but carry patellar fracture risk.<br /><br />Cost analyses reveal allografts are more expensive with longer incorporation times, while autografts have higher operative time but lower supply costs.<br /><br />Surgical technique sections detail graft harvest and preparation, emphasizing anatomical knowledge and reducing donor site morbidity. Key points include medial incision placement to minimize kneeling pain, careful bone block harvesting for BPTB, and meticulous fascial band release when harvesting hamstring tendons to prevent graft amputation.<br /><br />Graft choice indications depend on patient age, activity level, prior surgery, and surgeon preference: BPTB autografts for high-demand athletes and revisions; hamstring for younger recreational athletes; quadriceps when other tendons are inadequate; and allografts for older or multiligament-injured knees.<br /><br />The document concludes with a suggested operative timeline including diagnostic arthroscopy, notchplasty, graft harvest, tunnel drilling, fixation, and open knee dissection, serving as a comprehensive guide for ACL reconstruction.

Keywords

ACL reconstruction

anterior cruciate ligament

graft choices

autografts

allografts

biomechanics

surgical technique

donor site morbidity

rehabilitation

operative timeline