AANA Lab Course 915 - Foundations in Arthroscopy-How to do an ACL Reconstructions

How to do an ACL Reconstructions - David T. Yucha, M.D.

Pdf Summary

This document is a comprehensive overview of Anterior Cruciate Ligament (ACL) injury and reconstruction, presented by David T. Yucha, MD, at the AANA Foundations in Arthroscopy in December 2019.<br /><br />ACL injuries often occur via non-contact mechanisms like jumping, cutting, twisting, or deceleration, characterized by a “pop” sensation, knee instability, swelling, and commonly misdiagnosed initially as a sprain.<br /><br />The clinical exam includes comparison of both knees, focusing on hamstring relaxation and specific tests such as the Lachman test (with grading by laxity and endpoint quality) and pivot shift test to assess instability.<br /><br />Imaging evaluation involves careful review of x-rays, MRIs, and awareness of fractures like Segond's fracture, arthritis, growth plate status, and alignment. The surgeon is advised to interpret their own films carefully due to variable accuracy in readings.<br /><br />ACL reconstruction choices have evolved from bone-patellar tendon-bone (BTB) autografts with screw fixation to include hamstring (various configurations), quadriceps tendon, contralateral autografts, allografts, partial bundle repairs, and biologic enhancements. There is no single “gold standard” graft; each has specific pros and cons regarding laxity, failure, and patient outcomes.<br /><br />Surgical technique emphasizes correct patient preparation—consent, anesthesia, nerve blocks, antibiotics, fluoroscopy, and trained assistants. Indications for partial or primary repair depend on proximal tears with good tissue quality.<br /><br />Anatomic graft placement is critical for function and graft longevity. Femoral tunnel placement is especially crucial: anterior placement risks graft rupture due to tightness, central placement offers poor rotational control, and anterior tibial placement risks graft impingement. Tunnel drilling methods have evolved from transtibial to anteromedial (AM) portal and retrograde drilling to improve anatomic accuracy.<br /><br />Femoral tunnels can be drilled transtibially (simpler but potentially nonanatomic), via medial portal (allows independent femoral drilling and better placement), or with flexible/retrograde reamers. Placement must consider landmarks such as the lateral intercondylar ridge and the bifurcate ridge.<br /><br />Fixation methods include cortical suspension devices (buttons) and aperture interference screws, with pros and cons related to strength, graft elongation, tunnel length, and risk of fixation failure.<br /><br />Overall, the presentation underscores the complexity and variety of ACL reconstruction techniques, highlighting the importance of mastering a limited set of reproducible techniques and achieving precise anatomic graft placement to optimize patient outcomes.

Keywords

Anterior Cruciate Ligament

ACL injury

ACL reconstruction

Lachman test

pivot shift test

femoral tunnel placement

bone-patellar tendon-bone autograft

hamstring autograft

anteromedial portal drilling

cortical suspension fixation