Anterior Cruciate Ligament (ACL) Reconstruction Overview
Surgical reconstruction of the anterior cruciate ligament (ACL) is indicated for patients with unstable knees who desire to remain active. We reconstruct the ligament with a sterilized donor bone-patellar tendon-bone graft. When followed with an intense, rehabilitation program that is individually-designed for each patient, more than 90% of our patients are able to return to full sports with a stable knee.
 

ACL Reconstruction Patient Experience

ACL Reconstruction Graft Material
The choice for ACL reconstruction graft material is usually the patient’s own patellar tendon with bone attached at each end. This is called bone-patellar tendon-bone (BTB) and is used approximately 65% of the time worldwide. The patient’s own hamstring tendons are used approximately 20% of the time and allograft (cadaver-donated tissue) is used approximately 15% of the time in the U.S. 

The BTB tissues have the advantage of the bone healing to bone in the drill holes and stronger interference-fit fixation devices. This can translate into an earlier return to full activity, which is important for many athletes. 

However, there is the cost of pain and weakness from the harvest site if the patient's own tissue is used. 

Hamstring tendons have the advantage of not weakening the patellar tendon but the disadvantage of weakening the flexor tendons that bend the knee. The fixation devices for hamstring tendons have generally been weaker than those for the bony attachments of the BTB but this is improving rapidly. 

Sterilized donor allografts have had equal results to autogenous tissues and higher patient satisfaction with less anterior knee pain, and newer techniques of sterilizing allografts reduce the risk of disease transmission. For these reasons, we choose to reconstruct the ACL using a sterilized donor bone-patellar tendon-bone graft.
 

ACL Reconstruction Surgical Procedure

	Early examination and magnetic resonance imaging  produce an accurate diagnosis.
	Bone-patellar tendon-bone graft.
	First, the patient is prepared for surgery in a sterile manner. Arthroscopic portals are established to allow for visualization of the procedure and insertion points for the instruments. The entire knee joint, including the ACL, PCL, meniscus, and cartilage are visualized to determine the extent of injury and confirm what was seen on MRI. If the ACL is deemed irreparable, the surgeon will proceed with reconstruction.
	Precise placement is necessary for a successful reconstruction. The anatomic insertion site on the femur for the original ACL is identified. A drill hole is initiated using a gaff to place a rear-entry guide, and is then drilled from outside in. The hole is cleared out and the edges are chamfered (rounded) to avoid damage to the graft. Next, the insertion site of the ACL on the tibia, on the tibial plateau, is identified, and a drill hole is initiated using a triangle-guide, again drilling from outside in. The hole is cleared out and the edges chamfered in a similar manner. The graft tissue, which usually is a bone-patellar tendon-bone allograft, is brought through the now continuous tunnel running from the femur through the knee joint and through the tibia. The tissue is secured in place using an extra large endobutton on the femur and a resorbable 10 x 23 mm screw on the tibia.
	The knee is finally brought through a full range of motion to visualize for any impingement of the graft and to ensure proper placement. The instruments are removed and incision sites are closed. The patient is able to return home later the same day. X-rays are taken to ensure proper placement of fixation devices. Rehab exercises start immediately at home and in our Clinic the next morning.