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Anatomic anterior cruciate ligament concept: Single- and double-bundle anterior cruciate ligament reconstruction


OVERVIEW

Chapter synopsis

The goal of anatomic anterior cruciate ligament (ACL) reconstruction is functional restoration of the ACL to its native dimensions and insertion sites. Patient-specific factors, including age, activity level, and future goals are important considerations during preoperative planning. During image review and arthroscopic evaluation, specific measurements should be performed, including the femoral and tibial insertion sites, the intercondylar notch, and the widths of the patella, quadriceps, and hamstrings tendons, to select the appropriate graft tissue that will recreate the patient’s native anatomy during ACL reconstruction. Arthroscopic visualization is key in order to perform an anatomic ACL reconstruction. The ACL femoral and tibial insertion sites should be recreated, and the ACL graft placed with appropriate tension, in order to restore rotatory knee stability. Choosing between single-bundle and double-bundle reconstruction depends on the patient-specific factors, and should be individualized to the patient.

Important points

  • Anatomic ACL reconstruction is key

  • Tailor each procedure to the patient

  • Graft selection based on patient factors, desires, activity level, and age

  • Recreate the native insertion sites

Clinical/surgical pearls

  • Preoperative planning is critical, including measurements on MRI

  • Preserve the ACL remnants on the femoral and tibial sides

  • Visualize tunnel placement through all three portals to ensure anatomic placement

  • Recreate 50%–80% of native tibial insertion site

  • Appropriate graft tension

  • Impingement-free range of motion

Clinical/surgical pitfalls

  • Inadequate visualization

  • Nonanatomic tunnel placement

  • Graft size not individualized to patient

  • Failure to recognize graft impingement on intercondylar notch during knee extension

  • Inappropriate graft tensioning, especially during double-bundle reconstruction

Introduction

The goal of anatomic anterior cruciate ligament (ACL) reconstruction is functional restoration of the ACL to its native dimensions and insertion sites, with consideration given to restoring the anteromedial (AM) and posterolateral bundles (PL). The remnant ACL stumps, as well as identifiable bony landmarks, can be utilized to recreate the patient’s normal anatomy to achieve an anatomic ACL reconstruction. This can successfully be performed through a single-bundle (SB) or double-bundle (DB) ACL reconstruction, depending on the patient’s anatomy measured preoperatively on imaging studies and verified during intraoperative measurements. An individualized approach to anatomic ACL reconstruction should be pursued, which includes restoring the functional bundles of the ACL, anatomic graft placement within the native ACL femoral and tibial insertion sites, appropriate tensioning of each bundle in accordance with native tensioning patterns from full knee extension through flexion, and customizing the surgical approach for each patient.

Preoperative considerations

History

A detailed history should be taken, including mechanism of injury, level of activity, level of sports participation and type of sport played, antecedent pain or feelings of instability in the knee, surgical history on the knee, and patient goals. Additional information to obtain includes prior surgical history on either knee, history of infections and bleeding disorders, risk factors for osteoporosis, personal or family history of hyperlaxity, and history of smoking.

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