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Anatomic Transtibial Anterior Cruciate Ligament Reconstruction

Dana P. Piasecki, MD,* and Nikhil N. Verma, MD


Although anterior cruciate ligament (ACL) reconstruction remains one of the most successful orthopedic operations, it has become increasingly clear over the past decade that more anatomic reconstructions result in better knee function when compared with less anatomic reconstructions. This has led to increased scrutiny of the most common transtibial technique and the limitations imparted by constraints of drilling the femoral tunnel through the tibial tunnel. Recently, these limitations have led many authors to suggest that alternative approaches should be used instead. Despite this recent scrutiny, a transtibial technique remains the most widely used method of reconstructing the ACL. This article describes modications to the traditional transtibial technique to allow reproducible anatomic ACL reconstruction. Oper Tech Sports Med 21:19-26 2013 Elsevier Inc. All rights reserved. KEYWORDS ACL, reconstruction, transtibial, anatomic, technique

odern endoscopic anterior cruciate ligament (ACL) reconstruction can generally be expected to produce excellent outcomes in most patients. Using a transtibial approach, mean instrumented side-to-side laxity measurements have been reported as negligible in 70%-95%1-7 of patients after reconstruction, with 80% enjoying participation in vigorous cutting/pivoting-type5,8-10 activities, and 90% overall satisfaction with a willingness to undergo the surgery again.1-3,7-9 Despite these favorable historical results, recent investigations have offered an opportunity for still greater improvement. Within the past decade, a number of authors have demonstrated the importance of positioning a graft anatomically with respect to the native ACL insertions. Cadaveric studies have suggested that knee kinematics are optimized when the graft is centered on both the femoral11-13 and tibial14,15 insertions, with recent reports suggesting an association between improved clinical outcomes and anatomic graft position.16,17 It is within this context that a transtibial technique has been the subject of greater scrutiny. When a traditional transtibial tunnel technique is used, the tibial tunnel starting point has traditionally been close to

*Sports Medicine Center, OrthoCarolina, Charlotte, NC. Division of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL. Address reprint requests to Dana P. Piasecki, MD, Sports Medicine Center, 1915 Randolph Road, OrthoCarolina, Charlotte, NC 28207. E-mail: dana.piasecki@orthocarolina.com

the proximal margin of the pes tendons and the intra-articular entrance point is intentionally posteriorized. Anatomic and magnetic resonance imaging studies have suggested that when the femoral tunnel is positioned through this traditional tibial tunnel, the resulting tibial and femoral tunnel positions create a graft that is vertical in both the coronal and sagittal planes.18,19 Biomechanically, this graft position appears to be inferior13 and little different from an ACL-decient knee from a rotational perspective.15 As a result, alternatives have been proposed to a traditional transtibial technique, such as use of an outside-in or accessory anteromedial (AM) portal approach.13,20,21 Unfortunately, the aforementioned studies compare 1 extreme result of a transtibial technique, few authors having considered whether the technique could be modied to achieve a more anatomic graft position. We reasoned that the ideal tibial tunnel would be one closely oriented with a line connecting the centers of both femoral and tibial insertions. Recently, we demonstrated in a cadaveric model that this line exits the tibia much more proximally than a traditional tibial tunnel starting point.19 Use of a tibial tunnel starting point close to this exit point creates a tibial tunnel more colinear with the sagittal and coronal plane orientation of the native ACL, and results in manageable tunnel dimensions whose apertures are centered on both insertions.19 Others have suggested that a modied transtibial approach is comparable biomechanically with an AM portal or outside-in technique.21 Given the familiarity of a transtibial technique to most practicing ACL surgeonsand its demonstrated safety 19

1060-1872/13/$-see front matter 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1053/j.otsm.2012.10.004

20 and success over the many years of its usesimple modications of this method, as described later, may be preferable to more technically challenging and less familiar alternatives.

D.P. Piasecki and N.N. Verma

Technique
Surgery is performed with the patient supine after administration of preoperative antibiotics and a general anesthetic. Before denitive positioning, the injured knee is carefully examined under anesthesia to grade ACL insufciency and assess potential secondary restraint compromise. A padded tourniquet is then placed on the operative thigh. If a pivot shift is appreciated during the examination under anesthesia, we proceed with graft preparation before diagnostic arthroscopy. If the knee does not demonstrate a denitive pivot, a thorough diagnostic arthroscopy is performed before harvesting the autograft (or thawing the allograft). An initial diagnostic arthroscopy is always performed using standard inferolateral (IL) viewing and inferomedial (IM) instrumentation portals. In the case of allograft or soft-tissue reconstructions, these portals are created through individual portal incisions, but in cases where autograft patellar tendon grafts are harvested rst, the IL and IM portals may be created within the graft harvest incision. Careful attention is paid to the articular surfaces, meniscal status, and the presence or absence of loose bodies. To maximize visualization and subsequent instrumentation of the intercondylar notch, we routinely debride the innermost portion of the fat pad. With the arthroscope in the IL portal, a large shaver is introduced through the IM portal and used to resect the fat pad from the intercondylar notch anteromedially along the medial gutter to include the medial plica sheet and shelf. The arthroscope is then repositioned laterally and the fat pad further excised to the lateral condylar margin, with the shaver placed in the IM portal. Once visualization of the notch is maximized in this way, the ACL stump and status of the posterior cruciate ligament (PCL) can be easily assessed. Intercondylar notch preparation begins with resection of the ACL stump and remnant tissue along the lateral wall and on the tibial side, using a large shaver and radiofrequency ablation. Once complete, one should be able to visualize and easily probethe posterior wall of the notch and lateral border of the PCL, in addition to the osseous tibial insertion of the ACL. Before proceeding, the center of both insertions are scrutinized and marked with cautery (Fig. 1). Bony notchplasty is performed when necessary to improve visualization. Because resection of bone at the level of the ACL insertion can alter graft forces,22 we try to avoid a notch resection, unless visualization of the native femoral insertion is not otherwise possible from accessory portals, or in chronic instability or revision cases where notch overgrowth has created a nonanatomic notch. If performed, we attempt to resect only the most peripheral edge of the notch, given that resection of the back wall has not been shown to improve the accuracy of instrumenting the femur19 and may be expected to signicantly alter graft performance. In such cases, the notchplasty is initiated with a curved osteotome intro-

Figure 1 View of both tibial and femoral insertions (from IM portal). Centers are marked.

duced through the IM portal and used to remove roughly 2-3 mm of bone from the AM portion of the lateral femoral condyle. Bone fragments are removed with a grasper andin autograft patientssaved for later grafting of the patellar and tibial donor sites. A spherical burr is used to smooth this resection and transition it to the anterior edge of the femoral insertion. After notch preparation, the tibial tunnel is created. Our earlier investigation has suggested the ideal tibial tunnel is 1 closely aligned with the oblique orientation of the native ACL, with a starting point 15-20 mm below the joint line.19 In practice, the fact that a large tunnel aperture is created allows use of a starting point slightly more distal than this (20-22 mm), which has the benet of creating a slightly longer tibial tunnel to mitigate graft tunnel mismatch. The ideal starting point is localized by inserting a spinal needle into the joint just above the medial tibial plateau edge and adjacent to the patellar tendon, adjusting the entrance point of the needle until it passes directly over the center of the tibial insertion and intersects the center of the femoral insertion. This is conrmed with the arthroscope in both the IL and IM portals (Fig. 2). Once the needle position is optimizedserving as a reference for anatomic coronal plane orientation of the tunnela tibial tunnel starting point is marked with cautery on the proximal tibia 20-22 mm distal to the medial tibial plateau edge where the needle enters the joint (Fig. 3). Care should be taken to avoid tunnel starting points that are much closer to the medial tibial plateau edge, as this could compromise tibial-sided xation and/or present more challenging graft tunnel mismatch problems. An accessory IM portal is then created with an 11 blade at the entrance point of the spinal needle, and a tibial drill guide (Smith and Nephew, Acufex) then inserted through this portal with the tip of the guide placed at the center of the tibial insertion. This position usually is 2 mm anterior to the posterior edge of the anterior horn of the lateral meniscus.19 We do not choose a set angle of the guide, given that our chief concern is only the creation of a linear tunnel appropriately aligned with the ACL. With the

Anatomic transtibial ACL reconstruction

21 bone-tendon-bone (BTB) graftsand given the normal tibial insertion dimensions of roughly 9- to 10-mm diameterwe usually use a 10- or 11-mm reamer, whichever appears to most closely reproduce the patients anatomy (Fig. 4). Smaller reamers may be used in cases of soft-tissue reconstruction, although the smaller diameter tunnel may make it more difcult to access the center of the femoral insertion. Care is taken to avoid excess over-reaming of the back edge of the tunnel to prevent an effective posteriorization of the graft.19,23 Once bony debris are lavaged from the joint, attention is turned to the femoral tunnel. Because the tibial tunnel created above closely reproduces the normal course of the native ACL, accessing the center of the femoral insertion is possible through this tunnel. Although we have shown this is manageable using rigid linear instrumentation,19 we prefer use of exible instrumentation (Stryker, Kalamazoo, MI), given the even greater ease of wire positioning and subsequent reaming. This also allows a slightly more distal tibial starting point, whichas noted earlierimproves tibial tunnel length. Currently, we use a standard 7-mm offset aimer, which is introduced retrograde through the tibial tunnel, the lip of the guide placed along the posterior wall of the notch and its handle externally rotated (if necessary) to bring the inserted pin to the center of the native femoral insertion (Fig. 5). A straight wire is introduced briey to pierce the notch cortex roughly 3-4 mm, and begin a path for the exible wire. Once the rigid wire is removed, a exible guide wire is inserted through the guide and drilled out the distal lateral thigh. We have found that posterior cortical breakthrough is exceedingly uncommon if the wire exits the thigh above the midline, when the thigh is viewed

Figure 2 Spinal needle used to reference anatomic coronal plane alignment of anterior cruciate ligament, for identication of the ideal tibial tunnel starting point. Once the needle passes over both the tibial and femoral insertions (when viewed from both IL and IM portals; shown is an IL portal view), it is considered a good reference for this anatomic alignment.

angle of the guide left free, the trocar is advanced to the marked starting point and then the angle setting tightened (usually between 45 and 50), corresponding with the normal orientation of the ACL in the sagittal plane.18 A guide pin is then drilled through the guide into the joint, and is anchored in the roof of the notch. A straight reamer is then passed over the wire to create the tibial tunnel. Because our preference tends to be the use of

Figure 3 A starting point on the proximal tibia is then marked 20-22 mm below the medial tibial plateau edge at the point where the spinal needle (Fig. 2) enters the joint. Notice the more distal level of the pes tendons (white, dashed line) where a traditional tibial tunnel would typically start.

22 from the side (Fig. 6). Should the wire exit too far posteriorly, it should be repositioned until the back wall is considered safe. Once inserted, a exible reamer (Stryker, Kalamazoo, MI) of chosen diameter (usually 9 or 10 mm) is advanced over the wire and used to ream the femoral tunnel to the outer cortex (Fig. 7). Whether exible or rigid reamers are used, we recommend care in passing the reamer through the tibial tunnel. Multiple authors have demonstrated that blind passage of the reamer over the femoral guide pin will tend to inadvertently remove bone from the posterior aspect of the tibial tunnel, because of the wires eccentric position.19,23,24 This is one reason we favor use of a exible system, as it allows easy passage of the reamer to the notch wall. Alternatively, if a rigid linear system is used, a half uted reamer can be used to allow atraumatic passage through the tibial tunnel without additional posterior bone removal. Our typical femoral tunnel depth is 38-40 mm (Fig. 8). While we have not encountered signicant curvature of the femoral tunnel with exible instrumentation, for BTB grafts, we will occasionally pass a rigid acorn reamer of identical diameter over the wire at this point to ensure ease of BTB graft passage. Final inspection of the femoral tunnel is performed by passing the arthro-

D.P. Piasecki and N.N. Verma

Figure 5 Transtibial instrumentation of the femur. Because the tibial tunnel is oriented closely with the native anterior cruciate ligament orientation, it is not difcult to instrument the center of the femoral insertion through this tunnel (yellow dot indicates center of femoral insertion).

scope retrograde through the tibial tunnel, allowing nal conrmation that the posterior wall is intact, that there is no intratunnel blowout, and that a small rim of posterior cortex remains. Once soft tissue is cleared from the tibial tunnels metaphyseal entrance, the chosen graft is taken from the back table and shuttled through the tibial tunnel and into the femoral socket. With BTB grafts, we typically use a pull-through technique (Fig. 9) and a 20- to 22-mm femoral bone plug to

Figure 4 Tibial insertion pre- and post-reaming. Note that the tunnel aperture enters with good coverage of nearly the entirety of the tibial insertion.

Figure 6 If the guidewire exits the thigh above the mid-lateral line (marked), it is highly unlikely that the posterior cortex will be breached. If the wire exits at or below the line, it is advisable to reposition the wire.

Anatomic transtibial ACL reconstruction

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Figure 7 Femoral reaming is performed with use of a exible reamer. This avoids any eccentric reaming of the posterior aspect of the tibial tunnel, and allows a slightly more perpendicular trajectory to the face of the intercondylar notch.

Figure 9 Graft passage is typically with a pull-through technique, recessing the femoral plug (BTB graft shown) 5-10 mm to offset grafttunnel mismatch. This results in near-aperture xation on the tibial side (purple markings on tibial end of graft mark the bone plug).

mitigate grafttunnel mismatch. It is not uncommon to encounter 5-10 mm of graft tunnel mismatch with this technique, predominantly owing to the shorter tibial tunnel. With our typical femoral tunnel depth of 35 mm, this is almost always manageable by simply recessing the graft on the femoral side, although we have encountered greater mismatch with BTB grafts whose patellar tendons exceed 50 mm. Additional options for management of mismatch include shortening of the tibial plug to a 15-mm length, rotation of the graft, or choice of alternative xation method for the tibial side. Alternatively, the surgeon may prefer to start with a more distal tibial tunnel starting position (to improve tunnel length), converting to use of an AM portal technique if anatomic positioning is not later possible on the femur. We always place the cancellous portion of the femoral plug anteriorly, and nd it helpful to place a exible nitinol wire into the anterior plugtunnel interface (through the acces-

sory AM portal) before fully recessing the femoral plug. Once the graft is recessed to an appropriate depth to optimize mismatch on the tibial side, a cannulated 7 25-mm metal interference screw is inserted over the nitinol wire. A graft protector sleeve is inserted through the AM portal to prevent the screw from engaging the soft-tissue portion of the graft, and the knee is exed to 110 to optimize parallelism of the screw trajectory and the femoral tunnel (Fig. 10). Once inserted to the level of the femoral plug, the screwdriver and wire are removed. For soft-tissue reconstructions, a cortical xation button is typically used on the femoral side, and once the graft is passed, we conrm cortical apposition of the button with mini C-arm.

Figure 8 Final femoral tunnel location is highly anatomic with respect to the native femoral insertion. Shown are both tibial and femoral tunnel apertures with the exible guidewire still in position.

Figure 10 Femoral xation is performed with a 7 25-mm cannulated interference screw through the accessory AM portal (localized where the reference spinal needle entered the joint). A graft protector sleeve allows the screw to be inserted without catching on the soft-tissue portion of the graft.

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D.P. Piasecki and N.N. Verma


we prefer tibial xation with either an expandable tunnel sleeve or a spiked-screw and washer. Once the graft is xed on the tibial side, a Lachman test and pivot shift test are performed as a nal conrmation of knee stability. Final graft appearance is then conrmed arthroscopically, and should mirror the normal ACLs anatomy with respect to its tibial and femoral insertions. An anatomically placed graft will mimic the normal triangle of space between the ACL and PCL (Fig. 10). In autograft reconstructions, bone graft collected from the BTB preparation, tibial tunnel reaming, and femoral tunnel reaming are packed into the distal patellar and tibial tubercle defects before closure. In autograft cases, the central patellar tendon defect is loosely reapproximated with the knee in exion to minimize shortening of the extensor mechanism. The paratenon is then closed over the tendon, followed by interrupted dermal sutures and a running subcuticular stitch. Simple sutures are used for portal closure, and local anesthetic (bupivacaine, 0.5%) is routinely injected into the joint and all incisions.

Figure 11 Final graft appearance (IL portal view). Roughly 90% coverage of both femoral and tibial insertions is accomplished.

Graft position is then evaluated (Fig. 11), the knee brought through a range of motion to conrm the absence of roof impingement or graft abrasion against the notch. Attention is then directed toward tibial xation. This is typically performed with the knee in extension after tensioning the tibial side of the graft. For BTB grafts, we externally rotate the cancellous portion of the plug posteriorly and position a 9 20-mm metal interference screw within the posterior plug tunnel interface. Because the tibial tunnel is shorter than in a traditional transtibial approach (usually roughly 30 mm), the tibial plug is usually close to the tibial aperture in the joint. Placement of an interference screw in this scenario usually achieves something close to aperture xation (Fig. 12), with the soft-tissue portion of the graft fully spanning the anterior posterior length of the native insertion. For soft-tissue grafts,

Postoperative Regimen
All patients are placed in a hinged drop-lock knee brace at the time of surgery, begin immediate active range of motion exercises, and are encouraged to bear weight as tolerated with the brace locked in extension. To protect the donor site, BTB autograft reconstructions are braced until 6 weeks postoperatively, but bracing can be discontinued in allograft or softtissue reconstructions at 7-10 days. Closed-chain strengthening is initiated as soon as patients can comfortably bear weight on the operative limb. A strong emphasis is placed on rapidly achieving full knee extension, with supervised patellar mobilization, passive range of motion, and prone heel hangs. At 6 weeks, motion (typically 0-120 or greater) and

Figure 12 Final radiograph, demonstrating near aperture-xation on the tibial side. Note the proximal tibial tunnel starting position and the greater sagittal plane obliquity of this tunnel on the lateral view.

Anatomic transtibial ACL reconstruction


closed-chain strengthening are advanced. Jogging is permitted at 12 weeks, followed by agility, plyometric, and sportspecic activities at 4 months, and a return to sport in 6-9 months.

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don allograft: Minimum 2-year follow-up. Am J Sports Med 33:284-292, 2005 Bach BR Jr, Levy ME, Bojchuk J, et al: Single-incision endoscopic anterior cruciate ligament reconstruction using patellar tendon autograft. Minimum two-year follow-up evaluation. Am J Sports Med 26:30-40, 1998 Bach BR Jr, Tradonsky S, Bojchuk J, et al: Arthroscopically assisted anterior cruciate ligament reconstruction using patellar tendon autograft. Five- to nine-year follow-up evaluation. Am J Sports Med 26: 20-29, 1998 Grntvedt T, Engebretsen L, Benum P, et al: A prospective, randomized study of three operations for acute rupture of the anterior cruciate ligament. Five-year follow-up of one hundred and thirty-one patients. J Bone Joint Surg Am 78:159-168, 1996 Noyes FR, Barber-Westin SD: Reconstruction of the anterior cruciate ligament with human allograft. Comparison of early and later results. J Bone Joint Surg Am 78:524-537, 1996 Peterson RK, Shelton WR, Bomboy AL: Allograft versus autograft patellar tendon anterior cruciate ligament reconstruction: A 5-year follow-up. Arthroscopy 17:9-13, 2001 Shaieb MD, Kan DM, Chang SK, et al: A prospective randomized comparison of patellar tendon versus semitendinosus and gracilis tendon autografts for anterior cruciate ligament reconstruction. Am J Sports Med 30:214-220, 2002 Chang SK, Egami DK, Shaieb MD, et al: Anterior cruciate ligament reconstruction: Allograft versus autograft. Arthroscopy 19:453-462, 2003 Harner CD, Olson E, Irrgang JJ, et al: Allograft versus autograft anterior cruciate ligament reconstruction: 3- to 5-year outcome. Clin Orthop Relat Res 324:134-144, 1996 Otto D, Pinczewski LA, Clingeleffer A, et al: Five-year results of singleincision arthroscopic anterior cruciate ligament reconstruction with patellar tendon autograft. Am J Sports Med 26:181-188, 1998 Loh JC, Fukuda Y, Tsuda E, et al: Knee stability and graft function following anterior cruciate ligament reconstruction: Comparison between 11 oclock and 10 oclock femoral tunnel placement. 2002 Richard OConnor award paper. Arthroscopy 19:297-304, 2003 Markolf KL, Jackson SR, McAllister DR: A comparison of 11 oclock versus oblique femoral tunnels in the anterior cruciate ligament-reconstructed knee: Knee kinematics during a simulated pivot test. Am J Sports Med 38:912-917, 2010 Steiner ME, Battaglia TC, Heming JF, et al: Independent drilling outperforms conventional transtibial drilling in anterior cruciate ligament reconstruction. Am J Sports Med 37:1912-1919, 2009 Bedi A, Maak T, Musahl V, et al: Effect of tibial tunnel position on stability of the knee after anterior cruciate ligament reconstruction: Is the tibial tunnel position most important? Am J Sports Med 39:366373, 2011 Kondo E, Merican AM, Yasuda K, et al: Biomechanical comparison of anatomic double-bundle, anatomic single-bundle, and nonanatomic single-bundle anterior cruciate ligament reconstructions. Am J Sports Med 39:279-288, 2011 Alentorn-Geli E, Samitier G, Alvarez P, et al: Anteromedial portal versus transtibial drilling techniques in ACL reconstruction: A blinded crosssectional study at two- to ve-year follow-up. Int Orthop 34:747-754, 2010 Sadoghi P, Krp A, Jansson V, et al: Impact of tibial and femoral tunnel position on clinical results after anterior cruciate ligament reconstruction. Arthroscopy 27:355-364, 2011 Bowers AL, Bedi A, Lipman JD, et al: Comparison of anterior cruciate ligament tunnel position and graft obliquity with transtibial and anteromedial portal femoral tunnel reaming techniques using high-resolution magnetic resonance imaging. Arthroscopy 27:1511-1522, 2011 Piasecki DP, Bach BR Jr, Espinoza Orias AA, et al: Anterior cruciate ligament reconstruction: Can anatomic femoral placement be achieved with a transtibial technique? Am J Sports Med 39:1306-1315, 2011 Gadikota HR, Sim JA, Hosseini A, et al: The relationship between femoral tunnels created by the transtibial, anteromedial portal, and out-

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Results
Referencing a number of large recent series at an average 5-year follow-up, modern endoscopic transtibial ACL reconstruction can generally be expected to produce good-to-excellent results in 80%-90% of patients. Subjectively, 90% of patients note satisfaction after ACL reconstruction and/or report a willingness to undergo the surgery again.1-3,7-9 Postoperative giving-way episodes are reported in a minority of 6-8,10 cases (0%-8% ), with 90% of patients enjoying participation in vigorous5 and/or cutting/pivoting-type5,8-10 activities after surgery. Objectively, most series report 85%-90% or more of patients with less than grade 2 postoperative Lachman and/or pivot shift examinations,1-4,6-8,25-29 and mean instrumented postoperative laxity (KT-1000) measurements 5 mm in 85%-100%1,2,6-9,25,26,28,30 and 3 mm in 70%95%.1-7 Normal or nearly normal ipsilateral knees are noted in 80% of patients postoperatively.1,10,26,28,29,31 Signicant improvements,2,3 near restoration of preinjury scores,3 and mean absolute postoperative Tegner scores, which are good to excellent,4,6,13,27,28 have also been reported in a number of series, as have 82%-97% good-toexcellent Lysholm scores,1-4,6-8,10,28,29 87%-90% good-toexcellent Hospital for Special Surgery scores2,3 and 85%-90% good-to-excellent Cincinnati scores.2,3,9,32 Although no long-term clinical studies exist regarding our described modication of the traditional transtibial technique, our technique has demonstrated anatomic overlap of the native insertions,19 which has been shown superior to a traditional transtibial approach13 in a cadaveric model. Likewise, the association between more anatomic tunnel position and improved clinical outcomes17 would suggest that our modied transtibial approach can be expected to perform at least as wellif not betterthan a traditional approach.

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Conclusions
Despite recent criticism of the transtibial technique, it continues to be the most familiar method of ACL reconstruction and with a proven track record of excellent results. Given the comfort level most surgeons have with this approach, we feel simple modications of this traditional technique may be safer and more reliable for many surgeons than adoption of more unfamiliar methods. Assuming the aforementioned technique is carefully followed, the surgeon can expect to reconstruct roughly 90% of both tibial and femoral ACL insertions with a well-positioned single-bundle graft, normalizing both the Lachman and pivot shift tests and producing consistently excellent clinical results with a low failure rate.

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References
1. Bach BR Jr, Aadalen KJ, Dennis MG, et al: Primary anterior cruciate ligament reconstruction using fresh-frozen, nonirradiated patellar ten20.

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side-in techniques and the anterior cruciate ligament footprint. Am J Sports Med 40:882-888, 2012 Sim JA, Gadikota HR, Li JS, et al: Biomechanical evaluation of knee joint laxities and graft forces after anterior cruciate ligament reconstruction by anteromedial portal, outside-in, and transtibial techniques. Am J Sports Med 39:2604-2610, 2011 Markolf KL, Hame SL, Hunter DM, et al: Biomechanical effects of femoral notchplasty in anterior cruciate ligament reconstruction. Am J Sports Med 30:83-89, 2002 Bedi A, Musahl V, Steuber V, et al: Transtibial versus anteromedial portal reaming in anterior cruciate ligament reconstruction: An anatomic and biomechanical evaluation of surgical technique. Arthroscopy 27:380-390, 2011 Silva A, Sampaio R, Pinto E: ACL reconstruction: Comparison between transtibial and anteromedial portal techniques. Knee Surg Sports Traumatol Arthrosc 20:896-903, 2012 Aglietti P, Buzzi R, DAndria S, et al: Arthroscopic anterior cruciate ligament reconstruction with patellar tendon. Arthroscopy 8:510-516, 1992 Aglietti P, Buzzi R, Giron F, et al: Arthroscopic-assisted anterior cruciate ligament reconstruction with the central third patellar tendon. A 5-8-year follow-up. Knee Surg Sports Traumatol Arthrosc 5:138-144, 1997

D.P. Piasecki and N.N. Verma


27. Beynnon BD, Johnson RJ, Fleming BC, et al: Anterior cruciate ligament replacement: Comparison of bone-patellar tendon-bone grafts with two-strand hamstring grafts. A prospective, randomized study. J Bone Joint Surg Am 84:1503-1513, 2002 28. Kleipool AE, Zijl JA, Willems WJ: Arthroscopic anterior cruciate ligament reconstruction with bone-patellar tendon-bone allograft or autograft. A prospective study with an average follow up of 4 years. Knee Surg Sports Traumatol Arthrosc 6:224-230, 1998 29. Wu WH, Hackett T, Richmond JC: Effects of meniscal and articular surface status on knee stability, function, and symptoms after anterior cruciate ligament reconstruction: A long-term prospective study. Am J Sports Med 30:845-850, 2002 30. Levitt RL, Malinin T, Posada A, et al: Reconstruction of anterior cruciate ligaments with bone-patellar tendon-bone and achilles tendon allografts. Clin Orthop Relat Res 303:67-78, 1994 31. Shelbourne KD, Gray T: Results of anterior cruciate ligament reconstruction based on meniscus and articular cartilage status at the time of surgery. Five- to fteen-year evaluations. Am J Sports Med 28:446-452, 2000 32. Aune AK, Holm I, Risberg MA, et al: Four-strand hamstring tendon autograft compared with patellar tendon-bone autograft for anterior cruciate ligament reconstruction. A randomized study with two-year follow-up. Am J Sports Med 29:722-728, 2001

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