APEX Knee Navigating Pearls and Pitfalls-Optimizing Your ACL (Tunnel Placements, Graft Options, Fixation Choices, and More!)

Optimizing Your ACL (Tunnel Placements, Graft Options, Fixation Choices, and More!)

Video Transcription

Video Summary

The transcript discusses complex ACL revision cases and key decision points in managing instability after multiple failures. The first patient is a 23-year-old airplane mechanic with persistent instability after two prior ACL reconstructions (initial BTB autograft, then failed allograft). Exam shows a positive Lachman and pivot shift. Imaging demonstrates widened tunnels and a markedly increased posterior tibial slope (~18°), raising concern for repeat graft failure risk. Panelists debate thresholds for staged bone grafting (often >12 mm tunnel widening) versus creative fixation strategies, but agree slope correction is critical. The surgeon performs a staged approach: stage 1 includes arthroscopy, meniscus repair, tunnel bone grafting with large allograft dowels (femur ~12 mm, tibia ~16 mm) soaked in bone marrow concentrate, and a supratubercle slope-reducing osteotomy to ~6–7° while preserving a posterior hinge. Stage 2 occurs about three months later: hardware removal, lateral meniscus root repair using an aperture fixation device, revision ACL reconstruction with an all-inside quadriceps soft-tissue graft plus suture tape augmentation, and an added lateral extra-articular tenodesis for added rotational stability.<br /><br />A second case highlights that acute ACL tears can coexist with both medial and lateral meniscus root tears; the discussion emphasizes careful pre-op MRI review, the biomechanical importance of root repairs to protect ACL stability, and thoughtful tunnel/order planning to avoid tunnel convergence.

Asset Caption

Moderator: Patrick A. Smith, M.D.

Keywords

revision ACL reconstruction

posterior tibial slope correction

staged tunnel bone grafting

tunnel widening threshold

meniscus root repair

quadriceps tendon all-inside graft

lateral extra-articular tenodesis