AANA Lab Course 915 - Foundations in Arthroscopy-Graft Selection in ACL Reconstruction

Graft Selection in ACL Reconstruction - David T. Yucha, M.D.

Pdf Summary

This document by Dr. David T. Yucha from Premier Orthopedics and Sports Medicine discusses techniques and important considerations in arthroscopic knee surgery, specifically tendon harvesting and graft preparation for ligament reconstruction.<br /><br />Key tendons involved include the semitendinosus (SemiT), gracilis, and sartorius, located on the medial side of the left knee along with the saphenous nerve and vein. The importance of noting fascial bands is emphasized, as these tendons coalesce at their insertion points. During harvesting, care is taken to clean muscle tissue, measure tendon length accurately, whipstitch graft ends, and assess tension. Proper sizing of the construct is critical, with literature (JBJS 2016, Arthroscopy 2015, AJSM 2016) indicating even a 1mm decrease in diameter can affect outcomes.<br /><br />Special attention is required to release all fascial bands to avoid complications like tendon stripper diversion or graft amputation, which may be indicated by gastroc dimpling under tension. The document contrasts harvesting one versus two tendons and discusses preservation of the thin paratenon and the infrapatellar branch of the saphenous nerve during incisions.<br /><br />Bone plugs (2 x 1cm) can be harvested with precise angled saw cuts to protect the patella from osteotome damage. Grafts can be used with or without bone blocks in single or double bundle reconstructions, noting benefits like decreased donor site morbidity and larger graft size.<br /><br />The document also debates procedural aspects including knee biomechanics, risk of patellar articular cartilage damage, blood loss, graft placement and impingement risks, and visualization of the back wall to avoid the “ridge.” Tools like shavers, burrs, or osteotomes are used to retain the femoral footprint and remove adhesions (“over the top” curette technique).<br /><br />Overall, meticulous surgical technique, anatomical knowledge, and critical decision-making are crucial to successful arthroscopic ligament reconstruction.

Keywords

arthroscopic knee surgery

tendon harvesting

graft preparation

semitendinosus tendon

gracilis tendon

saphenous nerve

fascial bands

ligament reconstruction

bone plugs

knee biomechanics