ACL reconstruction is a surgical procedure to replace a torn Anterior Cruciate Ligament (ACL) with a graft taken from another part of the body. While the specific techniques can vary from surgeon to surgeon. This is just a general information about ACL reconstruction.

Graft Harvesting

The graft is typically harvested from either the patient’s own body (autograft) or a donor (allograft).

• Hamstring Tendon Autograft: This is a common choice. The semitendinosus and gracilis tendons are harvested from the back of the thigh.
• Patellar Tendon Autograft: This involves harvesting the patellar tendon and a small piece of bone from the kneecap.
• Quadriceps Tendon Autograft: Less commonly used, this involves taking the patellar tendon and a portion of the quadriceps tendon.
• Allograft: This is tissue from a deceased donor. Tendon or bone-patellar tendon-bone grafts are options.

The graft is prepared to the appropriate length and diameter for ACL reconstruction.

Arthroscopic Procedure

The ACL reconstruction is performed arthroscopically, meaning small incisions are made, and a camera and surgical instruments are inserted into the knee joint.

1. Portal Establishment: Small incisions are made to introduce the arthroscope and surgical instruments into the knee joint.
2. Joint Preparation: The knee joint is thoroughly cleaned and inspected for any additional damage, such as meniscus tears or cartilage damage.
3. Femoral Tunnel Drilling: A precise guide is used to drill a tunnel in the femur where the ACL’s original femoral attachment was located. This tunnel should be anatomically positioned to restore proper knee mechanics.
4. Tibial Tunnel Drilling: Similarly, a tunnel is drilled in the tibia to mimic the original ACL’s tibial attachment.
5. Graft Preparation and Insertion: The harvested graft is prepared and inserted through the tibial tunnel and then guided through the femoral tunnel.
6. Graft Fixation: The graft is secured in both the femur and tibia using various fixation techniques.

Graft Fixation

Several options exist for securing the graft in the bone tunnels:

• Interference Screws: These are metal screws inserted into the bone tunnel. The graft is pulled through the eye of the screw and tightened, creating friction between the graft and the screw.
• Endobutton Fixation: This involves inserting small metal buttons into the bone tunnels. The graft is secured to these buttons using sutures.
• Screw-Anchor Fixation: A combination of a screw and an anchor is used to secure the graft.
• Washer-Screw Fixation: A washer is placed over the graft before inserting the screw, providing additional support.
• Suspensory Fixation: This involves using a suspensory device to anchor the graft within the bone tunnel.

The choice of fixation method depends on factors such as the surgeon’s preference, the type of graft used, and the patient’s specific needs.

New developments

LET (Lateral Extra-Articular Tenodesis)

LET is a surgical procedure that complements ACL reconstruction. It involves tightening the lateral side of the knee to enhance stability.

• How it works: A tendon, usually from the iliotibial (IT) band, is secured to the shinbone (tibia) to provide additional support.
• Benefits:
  • Improves knee stability
  • Reduces rotational forces on the knee
  • May decrease the risk of ACL graft failure
• Ideal candidates: Patients with significant rotational instability or those at high risk for ACL reinjury.

Internal Bracing

Internal bracing is a relatively new technique used to reinforce the repaired ACL.

• How it works: A strong, flexible material (like polyethylene) is woven through the repaired ligament and anchored to the bone. This acts as an internal splint, providing extra support during the healing process.
• Benefits:
  • Promotes faster healing of the repaired ACL  
  • Reduces the risk of graft failure
  • May allow for earlier return to sports
    • Anterior Cruciate Ligament Repair with Internal Brace Ligament Augmentation – PubMed pubmed.ncbi.nlm.nih.gov
• Ideal candidates: Patients with complete ACL tears that are suitable for repair rather than reconstruction.

Combined Approach

In some cases, surgeons may combine LET and internal bracing for optimal results. This approach can be particularly beneficial for patients with complex knee injuries or those at high risk for complications.

All inside ACL RECON

Classical ACL reconstruction involves creating tunnels through the bone to anchor the graft.This typically requires larger incisions, leading to more pain, swelling, and recovery time.  

All-inside ACL reconstruction is a minimally invasive technique. It involves creating smaller sockets within the bone to secure the graft. This method results in:  

• Smaller incisions: Less pain, scarring, and swelling.  
• Quicker recovery: Patients often return to normal activities faster.  
• Reduced bone loss: Less bone is removed compared to the classical method.  
• Improved cosmetic results: Smaller incisions lead to less visible scarring.
• While both methods aim to restore knee stability, the all-inside technique offers several advantages in terms of patient comfort and recovery time.

Important Considerations

• Not everyone is a candidate: These procedures are not suitable for all patients. A thorough evaluation by an orthopedic surgeon is essential.
• Rehabilitation is crucial: Regardless of the surgical technique, proper rehabilitation is vital for a successful outcome.
• Long-term outcomes: While early studies show promising results, long-term data on these techniques is still being collected.

Important Note: The information provided here is a general overview and should not replace professional medical advice. Always consult with a qualified orthopedic surgeon for any concerns or questions about ACL reconstruction.