Anatomic Single- and Double-Bundle Anterior Cruciate Ligament Reconstruction Flowchart

doi:10.1016/j.arthro.2009.07.027

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 26, Issue 2, February 2010, Pages 258-268

https://doi.org/10.1016/j.arthro.2009.07.027 Get rights and content

Anatomy is the foundation of orthopaedic surgery, and the advancing knowledge of the anterior cruciate ligament (ACL) anatomy has led to the development of improved modern reconstruction techniques that approach the anatomy of the native ACL. Current literature on the anatomy of the ACL and its reconstruction techniques, as well as our surgical experience, was used to develop a flowchart that can aid the surgeon in performing anatomic ACL reconstruction. We define anatomic ACL reconstruction as the functional restoration of the ACL to its native dimensions, collagen orientation, and insertion sites. A guideline was written to accompany this flowchart with more detailed information on anatomic ACL reconstruction and its pitfalls, all accompanied by relevant literature and helpful figures. Although there is still much to learn about anatomic ACL reconstruction methods, we believe this is a helpful document for surgeons. We continue to modify the flowchart as more information about the anatomy of the ACL, and how to more closely reproduce it, becomes available.

Section snippets

Methods

The current literature on the anatomy of the ACL, as well as our surgical experience, was used to develop a flowchart that takes the surgeon through all the steps of an anatomic ACL reconstruction procedure. A guideline was written to accompany this flowchart with more detailed information and literature support for each step. Figures were added to the guideline where necessary to assist in explaining the steps. The flowchart was designed to be a dynamic document that can be modified as more

Results

The result is the anatomic single- and double-bundle ACL reconstruction flowchart (Appendix Fig 1). All the steps of the flowchart will be extensively discussed in this report, accompanied by relevant literature and figures.

Discussion

Nonanatomic tibial and femoral tunnel placement represents one of the most important causes of ACL graft failure.²⁹ When the tibial tunnels are placed too anteriorly, this may lead to roof impingement, which is associated with loss of extension and abrasion of the graft.³⁰ To prevent this, some surgeons move the tibial tunnel more posteriorly. However, this approach creates tunnel mismatch.³¹ Often, a tibial tunnel positioned at the PL insertion site is combined with an AM or high AM femoral

Conclusions

Anatomic ACL reconstruction intends to replicate normal anatomy, restore normal kinematics, and protect long-term knee health. We use a systematic approach to each case; normal anatomy and injury pattern are identified first, and then ACL reconstruction is tailored to closely replicate the native anatomy of the patient. However, this type of anatomic ACL reconstruction is a complex and detailed surgical procedure that has many pitfalls. Therefore a flowchart was developed that can help

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Cited by (253)

Can patient anthropometry predict the anterior cruciate ligament footprint dimensions? - An MRI-based observational study on north Indian population
2024, Journal of Clinical Orthopaedics and Trauma
Anterior Cruciate Ligament (ACL) reconstruction is one of the most common surgeries being currently done. As we usher into the era of Individualized Anatomic Reconstruction, it is very important to understand the native anatomy of ACL. We aimed to assess the ACL footprint dimensions in our patients and correlate it with anthropometric variables, which can help in preoperative decision making.
A total of 143 eligible patients with suspected ACL injury presented during the study period. Out of which 92 were included in the study. Data on patient's age, sex, height, weight and body mass index (BMI) was recorded. The length and area of both the tibial and femoral footprints were measured on MRI. The footprint dimensions were correlated with the recorded anthropometric data.
The ACL tibial footprint length and area, and femoral footprint length and area were found to be 13.3 ± 2.23 mm, 142.6 ± 26.16 mm², 11.2 ± 1.97 mm, 125.8 ± 28.75 mm² respectively. Footprint in males was significantly larger than females. A weak (ρ- 0.21 to 0.4) correlation with weight and moderate (ρ- 0.41 to 0.6) correlation with height was observed. Multivariate linear regression analysis yielded height to be the only significant predictor of footprint dimension from which predictive equations were drawn.
Height was found to be the most significant predictor of footprint dimensions in our patients. The predictive equations and graphs can aid in preoperative surgical decision making resulting in a more anatomical ACL reconstruction and improve the post-operative results.
Comparative study of functional outcomes of arthroscopic anterior cruciate ligament reconstruction using anteromedial portal and translateral all-inside technique
2023, Medical Journal Armed Forces India
Anterior Cruciate Ligament (ACL) injuries are common in the active population of the Armed Forces. Symptomatic instability prompts individuals to seek a cure or a sheltered appointment. Despite the increasing numbers of ACL reconstructions performed, the outcomes have not been so spectacular with only a meager percentage of our patients returning to preinjury levels of activity. With the premise that an all-inside ACL reconstruction is likely to result in better functional outcomes, the aim of this study was to compare the short-term functional outcomes of a large consecutive series of patients undergoing ACL reconstruction using the translateral all-inside ACL reconstruction technique (AI) and standard anteromedial portal technique (AM) with a minimum follow-up of one year.
A total of 240 patients with isolated ACL tear underwent ACL reconstruction via the AI or AM technique. Their preoperative and postoperative scores were compared to look for any significant differences in functional outcomes.
The two groups were matched for age, BMI, mechanism of injury, and interval from injury to surgery. There was no difference in their preoperative scores. Postoperatively, although there were significant improvements across both groups, there was no significant difference between the groups at any point of time.
The AI technique has garnered interest in recent literature in addressing ACL injuries. This study found no discernible benefit of the AI technique when compared to the AM technique in terms of functionality following an ACL reconstruction at any point of time up to 1 year following surgery.
Anatomic Arthroscopic Primary Repair of Proximal Anterior Cruciate Ligament Tears
2023, Arthroscopy Techniques
Within the last decade, various highly diverse anterior cruciate ligament (ACL) preservation techniques have been proposed, as contemporary selective arthroscopic ACL preservation experienced a resurgence. Among surgical techniques, there are a variety of suturing, fixation, and augmentation methods, whereas a common thread, considering essential anatomic and biomechanical properties, is missing. This technique aims to anatomically reapproximate both the anteromedial (AM) and posterolateral (PL) bundles to their respective femoral footprints. Additionally, a PL compression stitch is performed to increase the ligament-bone contact area and recreate the anatomic vectors of the native bundles, therefore, creating a more anatomic and biomechanical construct. This technique is a minimally invasive procedure, with no graft harvesting nor tunnel drilling, which leads to decreased pain levels, earlier return of full range motion (ROM), and faster rehabilitation, while failure rates seem to be comparable to that of ACL reconstruction. We present an updated surgical technique of anatomic arthroscopic primary repair with suture anchor fixation for patients with proximal ACL tears.
Combined Lateral Extra-Articular Tenodesis or Combined Anterolateral Ligament Reconstruction and Anterior Cruciate Ligament Reconstruction Improves Outcomes Compared to Isolated Reconstruction for Anterior Cruciate Ligament Tear: A Network Meta-analysis of Randomized Controlled Trials
2023, Arthroscopy - Journal of Arthroscopic and Related Surgery
To conduct a network meta-analysis (NMA) comparing the results of randomized controlled trials (RCTs) among patients who underwent either isolated anterior cruciate ligament (ACL) reconstruction or combined lateral extra-articular tenodesis (LET) or anterolateral ligament reconstruction (ALLR).
RCTs that compared isolated ACL reconstruction and combined LET or ALLR were included with minimum 12 months follow-up. Studies that used the double-bundle technique were excluded. Outcome assessment included the number of positive pivot shifts, amount of anterior tibial translation, and International Knee Documentation Committee (IKDC) subjective, Tegner, and Lysholm scores. Bayesian NMA and the surface under the cumulative ranking area (SUCRA) were evaluated.
A total of 1,077 patients from 11 RCTs were enrolled in this study. In NMA, the odds ratios (ORs) of positive pivot shift were significantly lower in ACL + ALLR (OR: 0.17; 95% CI: 0.027–0.67) than isolated ACL reconstruction, but no difference between ACL + ALLR and ACL + LET. There were no significant differences in anterior tibial translation among the techniques, but the IKDC subjective and Lysholm scores of ACL + ALLR and ACL + LET were significantly higher than isolated ACL reconstruction. ACL + ALLR were the most preferred in terms of residual pivot shift, anterior tibial translation, and IKDC subjective scores (SUCRA = 88.2%, 86.4%, and 93.1%, respectively). Additional lateral procedures resulted in significantly lower risk of graft failure (OR: 0.27; 95% CI: 0.1–0.71) than isolated ACL reconstruction.
ACL + ALLR were found to have significantly better outcomes in terms of knee rotational stability and graft failure rate than isolated ACL reconstructions, but the clinical outcomes were uncertain after a minimum 12 months follow-up. Considering the greatest probability of obtaining better knee rotational stability in this NMA, ACL + ALLR was found to be the most preferred technique for patients with ACL injury.
Level II, network meta-analysis and systematic review of Level I and II studies.
Rebranding the ‘anatomic’ ACL reconstruction: Current concepts
2023, Journal of ISAKOS
The anterior cruciate ligament (ACL) is a complex ribbon-like structure, which is approximately 3.5 times larger at the tibial and femoral insertions than at the midpoint. Accordingly, it is impossible to recreate with a single cylindrical graft. However, this has not stopped surgeons from using the term “anatomic” to describe multiple ACL reconstruction techniques inserting at a number of different locations within the original ACL footprint, causing confusion. The term “anatomic” should be discarded and replaced by an anatomic description of the tunnel placements on the tibia and femur. Current ACL reconstruction techniques cite anatomical studies that identified “direct and indirect fibres” of the ACL. The “direct fibres” bear 85–95% of the load and provide the main resistance to both anterior tibial translation and internal rotation/pivot shift. On the femur, these fibres insert in a line just posterior to the intercondylar ridge and comprise the portion of the ACL that surgeons should strive to restore. Placement of the graft just posterior to the intercondylar ridge creates a line of placement options from the anteromedial bundle to the “central” position and finally to the posterolateral bundle position. The authors prefer placing the femoral tunnel in the isometric anteromedial position and addressing a high-grade pivot shift at the IT-band with a lateral extra-articular tenodesis. As with the femoral tunnel, the native ACL footprint on the tibia is much larger than the ACL graft and thus can be placed in multiple “anatomic” locations. The authors prefer placement of the tibial tunnel in the anterior most position of the native footprint that does not cause impingement in the femoral notch. Additional research is needed to determine the ideal tunnel positions on the femur and tibia and validating the technique with patient outcomes. However, this cannot be accomplished without describing tunnel placement with specific anatomical locations so other surgeons can replicate the technique.
Anatomic anterior cruciate ligament reconstruction: Freddie Fu's paradigm
2023, Journal of ISAKOS
Anterior cruciate ligament (ACL) reconstruction techniques have evolved over the past four decades. There is evidence that non-anatomic reconstruction techniques, such as traditional transtibial drilling, fail to recreate the native anatomy of the ACL, which can lead to increased rotatory knee instability, revision risk, and post-traumatic osteoarthritis. Anatomic ACL reconstruction has emerged as the gold standard, with the goal of restoring the patient's native anatomy and knee kinematics. This review will summarise the relevant anatomy, modern anatomic ACL reconstruction techniques, and literature supporting anatomic ACL reconstruction as the new paradigm.
Level V, review article.

View all citing articles on Scopus

: The authors report no conflict of interest.

Note: To access the videos accompanying this report, visit the February issue of Arthroscopy at www.arthroscopyjournal.org.

View full text

Level V Evidence With Video IllustrationAnatomic Single- and Double-Bundle Anterior Cruciate Ligament Reconstruction Flowchart

Section snippets

Methods

Results

Discussion

Conclusions

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Oper Tech Sports Med

Arthroscopy

Arthroscopy

Arthroscopy

Orthop Clin North Am

ACL reconstruction: A meta-analysis of functional scores

Clin Orthop Relat Res

The effectiveness of reconstruction of the anterior cruciate ligament with hamstrings and patellar tendonA cadaveric study comparing anterior tibial and rotational loads

J Bone Joint Surg Am

Biomechanical analysis of an anatomic anterior cruciate ligament reconstruction

Am J Sports Med

Single-and double-incision double-bundle ACL reconstruction

Clin Orthop Relat Res

Double-bundle versus single-bundle anterior cruciate ligament reconstruction: A prospective, randomized clinical study

Knee Surg Sports Traumatol Arthrosc

Prospective clinical comparisons of anatomic double-bundle versus single-bundle anterior cruciate ligament reconstruction procedures in 328 consecutive patients

Am J Sports Med

Double-bundle ACL reconstruction can improve rotational stability

Clin Orthop Relat Res

Level V Evidence With Video Illustration
Anatomic Single- and Double-Bundle Anterior Cruciate Ligament Reconstruction Flowchart