AANA Lab Course 902 - Foundations in Arthroscopy (Resident/Fellow)-LAB LECTURE

LAB LECTURE_ ACL #1-Dr. Paul Fadale, MD

Pdf Summary

This comprehensive lecture by Dr. Paul D. Fadale, an orthopedic sports medicine expert, covers anterior cruciate ligament (ACL) graft choice and harvesting techniques. ACL tears have a high and increasing incidence, especially in women, children, and middle-aged populations. The ACL consists of two bundles (anteromedial and posterolateral) with limited blood supply, significant sensory function, and critical roles in knee stability and motion control.<br /><br />Diagnosis involves history (non-contact injury common), physical exam (Lachman and pivot shift tests), imaging (radiographs and arthroscopy), and objective measurements (KT 1000). Hemarthrosis is a key sign of ACL tear.<br /><br />An ideal ACL graft should mimic native anatomy and biomechanics, ensure strong fixation, allow rapid biological incorporation, minimize donor morbidity, and provide good clinical outcomes. No single “gold standard” graft exists, so graft selection depends on individual factors such as patient age, activity, occupation, prior surgeries, comorbidities, and surgeon preference.<br /><br />Graft options discussed include:<br />- Bone-Patellar Tendon-Bone (BPTB) autograft: favored for high-demand athletes, strong with early bone incorporation but more donor site morbidity (anterior knee pain, kneeling pain).<br />- Quadrupled hamstring autograft: less harvest morbidity, reduced anterior knee pain, strongest graft construct but risks hamstring weakness, and healing limitations.<br />- Quadriceps tendon autograft: strong and large diameter, with minimal donor morbidity, though potential for patellar fracture and quadriceps weakness.<br />- Various allografts: no harvest morbidity and faster surgery but concerns about delayed incorporation, disease transmission, mechanical weakening, and higher failure rates in young, active patients.<br /><br />Harvesting techniques, especially for hamstring grafts, emphasize careful fascia release to avoid graft amputation and ensuring proper graft preparation.<br /><br />Recent registry data show higher failure risk for hamstring grafts compared to BPTB, particularly with smaller diameter grafts (<8mm). Techniques like triple semitendinosus or hybrid auto-allograft grafts can augment graft size.<br /><br />Double-bundle reconstructions show better objective stability but no clear functional benefit.<br /><br />Ultimately, graft choice balances biomechanical properties, patient-specific factors, and surgical expertise to optimize ACL reconstruction outcomes.

Keywords

ACL tear

anterior cruciate ligament

graft choice

BPTB autograft

hamstring autograft

quadriceps tendon autograft

allograft

ACL reconstruction

knee stability

harvesting techniques