AANA/SOMOS Course Materials (August 2021)-‘Perfect ACL’(does not exist….but we can try)

‘Perfect ACL’(does not exist….but we can try)

Pdf Summary

This presentation by John D.A. Kelly IV, Professor and Director of Shoulder Sports Medicine at Penn Perelman School of Medicine, discusses the complexities of achieving a "perfect" anterior cruciate ligament (ACL) reconstruction, noting that while perfection isn't attainable, optimal outcomes can be pursued.<br /><br />Key points emphasize the importance of operating on the right patient, preserving the menisci, minimizing harm to the knee, and careful graft selection and placement. Meniscal repair is beneficial but not perfect; repaired menisci heal with some scar tissue and may shrink slightly. Lateral meniscal root tears (up to 12%) influence knee stability and should be identified. Minimizing notchplasty is advised to avoid promoting arthritis or damaging graft placement.<br /><br />The surgeon’s technique is critical—proper femoral tunnel placement affects knee kinematics and graft success. Anatomic placement reduces abnormal tibial rotation and shear stresses, though some studies show varying clinical outcomes between anteromedial (AM) and anatomic approaches.<br /><br />Graft choice discussion highlights bone-patellar tendon-bone (BTB) grafts as preferred for athletes due to better stability and lower revision rates compared to hamstring autografts, with quadriceps tendon grafts showing intermediate revision rates. Allografts, especially nonirradiated ones, have a reputation for higher failure but recent data indicate comparable outcomes to autografts in selected patients. Irradiated allografts show higher failure rates.<br /><br />Lateral augmentation techniques may be considered in revision cases, large pivot injuries, or with anatomical risk factors like increased tibial slope. The role of biologic augmentation remains promising experimentally but unproven clinically.<br /><br />In summary, the "perfect ACL" does not exist, but surgeons can optimize outcomes by careful patient selection, preserving tissue, choosing appropriate grafts (BTB favored for performance athletes), precise graft placement, and considering adjunct procedures like lateral augmentation when necessary. Nonirradiated allografts may be acceptable in some patients. Ultimately, kindness to the knee joint and judicious decisions yield the best results.

Keywords

ACL reconstruction

anterior cruciate ligament

meniscal repair

graft selection

bone-patellar tendon-bone graft

hamstring autograft

allografts

femoral tunnel placement

lateral meniscal root tears

lateral augmentation