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

LECTURE_ ACL #2-Dr. Paul Fadale, MD

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This document is a comprehensive overview of anterior cruciate ligament (ACL) reconstruction, presented by Dr. Paul D. Fadale, an expert in orthopedic sports medicine. ACL reconstruction is a common and growing surgical procedure in the U.S., with over 200,000 cases annually, ranking it as the sixth most performed surgery. However, most surgeons perform fewer than ten ACL surgeries per year, underscoring the need for specialized expertise.<br /><br />Key components for successful ACL reconstruction include understanding anatomy, biomechanics, clinical assessment, surgical techniques (both open and arthroscopic), a variety of implants, and rehabilitation. Indications for surgery focus on symptomatic knee instability, especially in younger or active patients, with the goal of preventing long-term joint damage and meniscal tears.<br /><br />Preoperative preparation (“prehab”) aims to minimize inflammation, restore normal gait and knee range of motion, and educate patients on graft options and postoperative rehabilitation, reducing complications like arthrofibrosis.<br /><br />Surgical goals are to achieve adequate graft strength, anatomically reproduce the ACL footprint through precise femoral and tibial tunnel placement, ensure secure fixation, and facilitate graft maturation. Multiple graft options exist, including bone-patellar tendon-bone (BTB), hamstring tendon, quadriceps tendon autografts, allografts, and emerging biologic methods.<br /><br />Femoral tunnel drilling techniques—trans-tibial, anteromedial portal, and outside-in—each have pros and cons regarding tunnel placement accuracy, ease, and risk of complications. Anatomic tunnel placement is critical to restore knee stability and avoid graft failure. Tibial tunnel placement is similarly crucial to prevent graft impingement.<br /><br />Graft fixation methods include aperture fixation (interference screws) and suspensory fixation (cortical buttons, pins), with ongoing debate about optimal constructs. Proper graft tensioning and fixation ensure stability and graft incorporation.<br /><br />Advanced approaches include double-bundle reconstruction, which may improve objective stability but lacks clear functional superiority, and emerging ACL repair techniques enhanced with biologics.<br /><br />Overall, the presentation emphasizes mastering a few reliable techniques rather than attempting all variants, careful surgical planning, and patient education to optimize outcomes in ACL reconstruction.

Keywords

ACL reconstruction

anterior cruciate ligament

orthopedic sports medicine

graft options

femoral tunnel drilling

tibial tunnel placement

graft fixation methods

preoperative preparation

double-bundle reconstruction

arthroscopic surgery