Anatomic anterior cruciate ligament (ACL) reconstruction: a global perspective. Part 1

KNEE

Anatomic anterior cruciate ligament (ACL) reconstruction:a global perspective. Part 1

K. K. Middleton • T. Hamilton • J. J. Irrgang •

J. Karlsson • C. D. Harner • F. H. Fu

Received: 30 September 2013 / Accepted: 10 January 2014

� Springer-Verlag Berlin Heidelberg 2014

Abstract

Purpose In August 2011, orthopaedic surgeons from

more than 20 countries attended a summit on anatomic

anterior cruciate ligament (ACL) reconstruction. The

summit offered a unique opportunity to discuss current

concepts, approaches, and techniques in the field of ACL

reconstruction among leading surgeons in the field.

Methods Five panels (with 36 panellists) were conducted

on key issues in ACL surgery: anatomic ACL reconstruc-

tion, rehabilitation and return to activity following ana-

tomic ACL reconstruction, failure after ACL

reconstruction, revision anatomic ACL reconstruction, and

partial ACL injuries and ACL augmentation. Panellists’

responses were secondarily collected using an online

survey.

Results Thirty-six panellists (35 surgeons and 1 physical

therapist) sat on at least one panel. Of the 35 surgeons

surveyed, 22 reported performing ‘‘anatomic’’ ACL

reconstructions. The preferred graft choice was hamstring

tendon autograft (53.1 %) followed by bone-patellar ten-

don-bone autograft (22.8 %), allograft (13.5 %), and

quadriceps tendon autograft (10.6 %). Patients generally

returned to play after an average of 6 months, with return

to full competition after an average of 8 months. ACL

reconstruction ‘‘failure’’ was defined by 12 surgeons as

instability and pathological laxity on examination, a need

for revision, and/or evidence of tear on magnetic resonance

imaging. The average percentage of patients meeting the

criteria for ‘‘failure’’ was 8.2 %.

Conclusions These data summarize the results of five

panels on anatomic ACL reconstruction. The most popular

graft choice among surgeons for primary ACL recon-

structions is hamstring tendon autograft, with allograft

being used most frequently employed in revision cases.

Nearly half of the surgeons surveyed performed both sin-

gle- and double-bundle ACL reconstructions depending on

certain criteria. Regardless of the technique regularly

employed, there was unanimous support among surgeons

for the use of ‘‘anatomic’’ reconstructions using bony and

soft tissue remnant landmarks.

Level of evidence V.

Keywords Anatomic � ACL reconstruction � Global

perspectives � Summit

Introduction

Anterior cruciate ligament (ACL) injuries are among the

most common knee ligament injuries in the world. It fol-

lows that ACL reconstruction (ACL-R) is one of the most

commonly performed orthopaedic surgeries [10]. The ACL

is comprised of two functional bundles, the anteromedial

(AM) and posterolateral (PL) bundles. Together, they

synergistically provide anterior–posterior and rotational

stability to the knee. Until recently, methods to reconstruct

the ACL focused on using a single graft. Such techniques

have been demonstrated to have high success rates despite

30 % of patients experiencing persistent knee pain and/or

instability [9]. Double-bundle ACL reconstruction methods

K. K. Middleton � T. Hamilton � J. J. Irrgang �C. D. Harner � F. H. Fu (&)

Department of Orthopaedic Surgery, University of Pittsburgh

School of Medicine, Kaufman Medical Building, Suite 1011,

3941 Fifth Avenue, Pittsburgh, PA 15203, USA

e-mail: [email protected]

J. Karlsson

Department of Orthopaedics, Gotenborg University, Goteborg,

Sweden

123

Knee Surg Sports Traumatol Arthrosc

DOI 10.1007/s00167-014-2846-3

were developed to reconstruct both the AM and PL bun-

dles. Some studies have demonstrated superior outcomes

and improved rotational stability with double-bundle

reconstruction compared with single-bundle reconstruc-

tions. However, as of late, there have been reports of no

difference in outcome measures between the two tech-

niques [3, 26], particularly when the reconstruction is

‘‘anatomic’’. Anatomic ACL-R is defined as functional

restoration of the ACL to its native dimensions, collage

orientation, and insertion sites [29]. Anatomic ACL-R

(regardless of technique) has been shown to yield better

clinical and biomechanical results compared with non-

anatomic reconstruction [12].

The evolution of anatomic ACL-R has occurred globally

due to the dissemination of scientific evidence as well as

open communication between surgeons across the world.

In August 2011, nearly 200 orthopaedic surgeons, sports

medicine physicians, and experts in the field of rehabili-

tation representing over twenty countries convened in

Pittsburgh, Pennsylvania, to discuss current concepts in

anatomic ACL reconstructive surgery. Of those in atten-

dance, 36 experts in the field of ACL surgery presented on

panels to discuss current concepts, techniques, advance-

ments, and future directions in the field of anatomic ACL-

R. The purpose of this descriptive study was to present the

responses to panel questions, thus providing a global per-

spective on the current approaches used around the world.

Materials and methods

Panels and panellist profile

Five panels were conducted on the topics of anatomic

ACL-R, rehabilitation and return to activity following

anatomic ACL-R, failure after ACL-R, revision anatomic

ACL-R, and partial ACL injuries and ACL augmentation.

Thirty-four orthopaedic surgeons with extensive expe-

rience in orthopaedic sports medicine and ACL-R partici-

pated in at least one of the five panels. Among the 34

panellists, fifteen represented the USA, three each repre-

sented Brazil and Japan, two each represented Germany

and Australia, and the following countries were each rep-

resented by one surgeon: China, France, Finland, Italy, the

Netherlands, South Africa, South Korea, Sweden, and the

United Arab Emirates. On average, the panellists have been

in practice for 22 ± 10.1 years (range 5–42 years). The

mean total number of ACL reconstructions performed over

the surgeon’s career was 2,143.9 ± 1,857.4 (range

100–7,800 surgeries).

Panellists were asked to prepare a 6-min presentation

answering questions pertaining to practice setting, patient

profile, surgical considerations, current techniques, and

clinical outcomes. For each topic, their responses to the

questions were presented followed by a 30-min question–

answer session. During the question–answer discussion, the

panellists’ responses were tabulated and results were

summarized. Following the summit, responses were sec-

ondarily collected and recorded using an online survey [28]

for final analysis. See ‘‘Appendix’’ for survey questions.

Patient profile

The majority of patients undergoing ACL-R were female

(57 %) and between 19 and 24 years old (Fig. 1). This age

group comprised 30.5 ± 10.6 % of the patient population.

The age group between 25 and 34 years made up

27.9 ± 11 % of the population, followed by the 14–18-

year-old age group (18.2 ± 7.9 %) and the 35–50-year-old

age group (16.4 ± 7.1 %). Less than 8 % of the patients

undergoing ACL-R were under 14 years of age

(2.5 ± 3.4 %) or over 50 years of age (4.6 ± 3.7 %).

Level of sports participation varied among patients who

underwent primary ACL-R: 44.9 ± 19.5 % were recrea-

tional athletes, 20.7 ± 12.3 % were college athletes,

19.8 ± 11.5 % were high school athletes, and 5.2 ± 4.3 %

were professional athletes. Approximately 9 % of the

patients did not participate in athletics at any of the above-

mentioned levels (Fig. 2).

Results

Panel I: Anatomic ACL reconstruction

Criteria for single-bundle ACL-R versus double-bundle

ACL-R

All panellists agreed upon the indications for surgical

management of a torn ACL, whether single or double

bundle. These include a history of trauma or injury

(contact vs. non-contact) resulting from a plant-twist

mechanism; subjective complaints of instability; clinical

examination findings of laxity as evidenced by a positive

pivot shift, Lachman, and or anterior drawer; and con-

firmed disruption of the ACL on magnetic resonance

(MR) imaging.

Four surgeons (13.7 %) reported that they performed

single-bundle reconstructions for ‘‘all ACL tears’’ unless

the patient requested a ‘‘double-bundle’’ reconstruction

or more ‘‘rotational control’’ with surgery, the patient

was a professional athlete requesting a ‘‘double-bundle’’

procedure, or if the patient had a large body habitus

(Fig. 3). One surgeon who performed ‘‘mostly double-

bundle’’ reconstructions elected to perform single-bundle

procedures in patients who were non-athletes, in


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augmentation cases, or if the patient already had evidence

of osteoarthritis.

Fourteen panellists (48.3 %) performed both SB and DB

techniques depending on certain criteria (defined in

Table 1). For one surgeon in particular, the graft choice

dictated his reconstruction technique. For instance, SB

reconstructions were performed whenever a BTB graft was

used, and DB reconstructions were always performed with

hamstring tendons. Other surgeons used criteria that

included graft size, insertion site size and notch size, knee

size and/or body habitus, level of activity prior to surgery,

amount of laxity during the physical examination, and

subjective complaints of rotatory instability.

Preferred technique

Remnant preservation and intraoperative measure-

ments Preservation of the tibial remnant during ACL

reconstruction is believed to help restore the proprioceptive

function of the ACL [1], accelerate revascularization and

ligamentization of the intra-articular graft [7, 23], and

enhance the biological environment for graft healing within

the tibial tunnel [32]. However, some studies have shown

no such benefit [23] and encourage continued studies

evaluating the clinical efficacy of remnant preservation

techniques. Of the 29 surgeons on the panel, 21 (72.4 %)

mentioned preserving ACL remnants with the hopes of

Fig. 1 Patient age distribution

Fig. 2 Patient level of sports

participation

Fig. 3 Panellists’ technique:

single bundle or double bundle.

SB single bundle, DB double

bundle


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providing near or complete restoration of the native func-

tion of the ACL and thus improving surgical outcome.

Twenty-three of 29 surgeons (88.5 %) obtained various

measurements during arthroscopy. Time is an important

consideration for those not commonly using intraoperative

measurements. Of those surgeons who obtained measure-

ments during surgery, five (17.2 %) measure the intra-

articular size of the ACL at its mid-portion. Thirteen

(44.8 %) measure the size of the ACL insertion sites, and

nine (31 %) measure intercondylar notch width. Surgeons

employing arthroscopic measuring devices during surgery

believe that measurements help guide surgical decision-

making and ensure adherence to the anatomic concept.

Three surgeons, in particular, have published articles

demonstrating the process and utilization of intraoperative

measurements [8, 25, 29]. Interestingly, nearly half of the

panellists (13 of 29) also measure tunnel aperture size prior

to passing the graft. Measurement of the tibial tunnel

aperture size is more difficult for those who utilize remnant

preservation techniques. Though soft tissue can obscure the

boundaries of the tunnel, these measurements were said to

help confirm desired tunnel size.

Tunnel placement, femoral drilling, and documentation of

location Anatomic ACL reconstruction is defined as the

functional restoration of the ACL to its native dimensions,

collagen orientation, and insertion sites [29]. Tunnel

placement is deemed ‘‘anatomic’’ if the tunnel dimensions

lie within the native insertion site. For the purposes of this

study, tunnel location was considered anatomic if surgeons

specifically reported ‘‘anatomic’’ placement, one that was

‘‘in the centre of the footprint’’, or a single tunnel located at

the junction ‘‘between the AM and PL insertion sites’’.

Twenty-six of 29 surgeons (89.7 %) reported placing

their femoral tunnels anatomically. Several also mentioned

that if they had to err with respect to femoral tunnel

placement, they would do so towards the AM insertion site.

Many specified that they used ACL remnants, bony land-

marks such as the lateral bicondylar and lateral bifurcate

ridges, and/or estimation of notch wall height (placing the

tunnels ‘‘lower on the lateral side of the notch’’) to help

determine anatomic placement. ACL insertion sites are

depicted in Fig. 4. The three surgeons who did not

explicitly indicate ‘‘anatomic’’ placement described their

femoral tunnel location as such:

• Below the lateral intercondylar ridge, centred posteri-

orly to the middle of the lateral femoral condyle wall.

• Eight millimetres vertical above the tibial plateau in the

mid-portion of the notch with the knee in 90� of flexion

and back in the notch, halfway to the posterior over-

the-top position.

• Seven to eight millimetres above the inferior articular

cartilage margin of the intercondylar notch with the

knee in 90� of flexion, slightly deep in the notch to the

bifurcate ridge.

Nearly 70 % of the surgeons utilize the anterior–medial

(AM) portal to drill the femoral tunnel. Five surgeons

(21.7 %) used both the AM portal technique and the tran-

stibial technique to drill the femoral tunnel depending on

whether or not anatomic tunnel placement can be achieved

with the transtibial technique. No surgeon used only the

transtibial drilling technique.

On the tibial side, 25 of 29 surgeons (86.2 %) reported

placing their tibial tunnels anatomically, that is, in the

native footprint. Additionally, five panellists (17.2 %)

reported using bony and soft tissue landmarks to help guide

Table 1 Criteria for single- and double-bundle ACL reconstructions

based on surgeon responses

Single bundle Double bundle

Graft choice: Bone-tendon-bone Graft choice: Hamstring

Normal history and physical

examination findings for an

ACL rupture with AP

translation being the primary

problem

Normal history and physical

examination findings for an

ACL rupture in addition to the

rotatory component being more

dominant problem than AP

translation

Small knee, recreational athlete,

additional procedures required

(e.g. meniscal surgery),

skeletally immature patient

Large knee, professional athlete,

high-grade pivot shift on

physical examination, patient

request

Open physes Big body habitus, those who non-

specifically request or require

more rotatory stability

Insertion site length less than

14 mm, notch width less than

12 mm. Criteria based on the

need of insertion site coverage

and technical feasibility given

anatomic constraints

Insertion sites larger than 18 mm

in length. Either a single- or

double-bundle procedure can

be performed for insertion sites

between 14 and 18 mm in

length

Grade II pivot shift on

examination, smaller insertion

sites, small hamstring grafts

Grade III pivot shift, tibial

insertion greater than 16 mm in

length, femoral insertion site

greater than 18 mm in length,

larger hamstring grafts (PL

bundle graft must be 5.5 mm in

diameter or larger)

Older patients, non-high-

performance athletes

Younger patients, high-

performance athletes

ACL insertion site less than

14 mm in length

ACL insertion site larger than

14 mm in length

Small graft size Subjective complaints of

rotational instability, relatively

high athletic demand

Small knee, thin hamstring

tendons, non-athlete, or

recreational athlete

Large knee, high-level athlete,

athletes involved in pivoting

sports, large hamstring tendons

Criteria table based on individual surgeon responses. ‘‘Insertion site’’

is referring to the tibial insertion site unless specified


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tunnel placement, including the medial tibial eminence,

posterior border of the lateral meniscus, and cartilage of the

medial tibial plateau. The four surgeons who did not spe-

cifically report ‘‘anatomic’’ placement described placing

their tibial tunnels using the following criteria:

• Five to six millimetres anterior to the posterior cruciate

ligament (posterior placement).

• Tunnel position is based on notch size, so as not to

impinge the graft.

• Posterior edge of the anterior horn of the lateral

meniscus.

As with drilling the femoral tunnels, accurate tibial

tunnel placement is not without error. One surgeon men-

tioned that he places his single tunnel in the ‘‘central region

of tibial footprint’’, but that he prefers to ‘‘err posteriorly

rather than anteriorly to avoid impingement’’.

A variety of systems are used to confirm and document

tunnel position intraoperatively, including pictures and

video, radiography/fluoroscopy, navigation, and measure-

ments (Fig. 5). Post-operative determination of tunnel

position can be challenging; however, it serves as a useful

metric to help guide surgical technique, and it also provides

a simple, radiographic measure for objective outcome

evaluation. Five surgeons (17.2 %) used magnetic reso-

nance (MR) imaging, and eight (27.6 %) used computed

tomography (CT) scans after primary reconstructions to

document tunnel location. Three surgeons did not obtain

any radiographic studies to verify tunnel location. Illing-

worth et al. [13] demonstrated that flexion weight-bearing

posterior–anterior radiographs and sagittal magnetic reso-

nance imaging (MRI) can aid in the evaluation of femoral

tunnel position after ACL reconstruction using femoral

tunnel and inclination angles. CT scans are not routinely

performed post-operatively unless there is a clear indica-

tion. To minimize risks associated with radiation, clinical

indications for CT scans (particularly three-dimensional

reconstructions) following ACL surgery include reinjury

and pre-operative planning if revision surgery is necessary

[30].

Graft choice, size, and fixation methods varied between

surgeons. The major graft choices for ACL reconstruction

have evolved over the past decade, with allografts being

prohibited in many countries. Patella tendon autografts

were once the standard of care for all ACL reconstructions.

Now, hamstring autografts, quadriceps tendon autografts,

and Achilles and patella tendon allografts with and without

bone blocks are becoming more popular. Consistent with

these trends, hamstring tendon autografts were used 53 %

of the time, followed by bone-patellar tendon-bone auto-

grafts 23 % of the time (Fig. 6). Allografts are being used

13 % of the time, and quadriceps tendon autograft recon-

structions are being performed 11 % of the time. Though a

variety of graft choices are being used, each of the 29

Fig. 4 Femoral (A) and tibial

(B) ACL insertion sites. Black

line demarcates lateral

intercondylar ridge. Asterisk:

approximate centre of the AM

and PL insertion sites. Of note,

ACL insertion site anatomy and

size vary from individual to

individual

Fig. 5 Documentation of

tunnel location following

primary ACL-R. Surgeons

could have used more than one

method to document tunnel

location. Fluoro fluoroscopy,

XR X-ray, MRI magnetic

resonance imaging, CT

computed tomography


123

panellists clearly has a preferred graft choice. Three sur-

geons use only one graft type (two use only bone-patellar

tendon-bone (BTB) autografts, and only one surgeon uses

hamstring autografts). Nine surgeons use the same graft in

over 90 % of patients, with seven preferring hamstring, one

preferring BTB, and one preferring quadriceps tendon

autografts. Five surgeons use the same graft in 75–85 % of

cases, with four preferring hamstring tendon autografts and

one using quadriceps tendon autografts 80 % of the time.

The remaining surgeons used multiple grafts, but still had a

predominant graft type.

The median graft size for single-bundle reconstructions

was 8.0 mm in diameter (ranging from 6 to 10 mm;

Fig. 7), which is important given the findings of recent

clinical studies suggesting that graft size can predict ACL

failure [18, 24]. Though grafts 8.0 mm and larger are

recommended based on the above studies, one can argue

that there is no ‘‘ideal’’ graft size, only an ‘‘average’’, since

graft size varies depending on the size of the native ACL

insertion site size and the patients’ needs. Three surgeons

indicated that they base their graft size on the native

insertion site size and that the goal of ACL-R is to

‘‘maximally occupy the native ACL footprint’’.

Graft fixation is variable and depends on graft type,

femoral versus tibial tunnel, and surgeon preference. For

graft fixation in the femoral tunnel, suspensory fixation was

the primary method (39 %) followed by interference

screws (bioabsorbable 21 %; metal 3 %). Five of 29 sur-

geons (18 %) varied their fixation method depending on

graft type. An interference screw was mostly used for BTB

reconstructions, and a suspensory device or transfix was

used for hamstring reconstructions. The most commonly

used fixation device on the tibial side was a bioabsorbable

screw. Fifteen of 29 surgeons (51.7 %) preferred this

method. Four surgeons (13.8 %) used multiple methods

depending on the type of graft and skeletal maturity of the

patient. For instance, one surgeon preferred use of a bio-

absorbable interference screw for hamstring grafts and used

a metal interference screw for all BTB grafts; another

preferred suture mini-discs for hamstring grafts and

Fig. 6 Primary ACL-R graft

choice. BTB, bone-patellar

tendon bone, HS hamstrings,

Quad quadriceps tendon

Fig. 7 Distribution of typical

single-bundle graft sizes. The

type of hamstring graft

(quadruple semitendinosus vs.

semitendinosus and gracilis)

utilized was not specified


123

bioabsorbable interference screws for BTB grafts. For

patients with open physes, pneumatic staples were used by

one surgeon. The remaining ten surgeons used metal

interference screws, peek screws, staples, suture mini-

discs, a fixation post, or two methods combined to further

ensure stable fixation (e.g. use of a bioabsorbable inter-

ference screw and staple, or a bioabsorbable interference

screw with a spike and washer).

Surgical outcomes

A large majority of panellists reported closely following

their patients after surgery. Though follow-up protocols

varied between surgeons, the average number of post-

operative visits during the first 12 months was 5.0 ± 1.2.

Fourteen of 29 surgeons (48.3 %) re-examine their patients

within one week of surgery, with many surgeons requiring

that patients see them at least three times during the first

year. Fifteen surgeons (51.7 %) continued following their

patients annually.

With respect to evaluating clinical outcomes, all 29

surgeons reported using ROM during physical examination

as an assessment tool. Twenty-six of 29 surgeons (89.7 %)

also used manual and/or instrumented assessment of laxity

to evaluate clinical outcomes. Many surgeons also used

imaging to assess clinical outcomes. Twenty-five surgeons

(86.2 %) consistently used post-operative radiographs, nine

(31 %) occasionally used magnetic resonance (MR)

imaging, and eight (27.6 %) occasionally used CT scans.

Additional methods used for outcome evaluation included

ultrasound when needed, functional hop tests, and robotic

knee testing. Twenty-six of 29 surgeons (89.7 %) consid-

ered patient-reported outcome measures; however, these

were never the sole determining factor in assessing surgical

outcome.

Eighty-seven perscent of all pooled surgical cases were

complication free. In other words, the complication rate for

all reported surgeries was 13 %. The majority of compli-

cations were related to graft failure greater than 6 months

after surgery (5.2 %); 2.3 % of the reported complications

were related to stiffness or scar tissue. Other reported

complications were infection (1 %), DVT (0.9 %), graft

failure less than 6 months after surgery (1.1 %), or a

combination of factors (2.3 %).

Panel II: Return to activity after anatomic ACL

reconstruction

Patients generally return to sports (starting with practice)

after an average of 6 months (range 3–9), with return to

full competition after an average of 8 months (range 4–12).

At 12 months following surgery, the panellists reported

that 75.3 % of their patients had returned to full sports

participation to a pre-injury level of activity.

The most recent study by the same group of researchers

found that 31 % of 187 athletes returned to their pre-injury

level of sport at 12 months and suggested that this low

return to competitive sports was likely influenced by psy-

chological factors [4]. Of the panellists’ patients who had

not returned to full activity at 12 months, 34.8 % of the

patients reported a fear of reinjury or a lack of confidence.

Just over a third (34.7 %) of the patients had problems

related to the knee (persistent instability, pain and/or

swelling, and rerupture) that kept them from achieving

their pre-injury level of activity and 30.5 % of the patients

simply changed their lifestyle due to family/work obliga-

tions or lost interest in active sports.

Panel III: Failure after ACL reconstruction: How

do you define it and what is your rate?

Ten of 12 panellists see their patients in the office for a

1-year post-operative visit and then on a yearly basis. Half

also reported using a yearly survey (in office or phone call)

as a part of their evaluation of surgical outcomes. Close

follow-up of patients is critical when evaluating long-term

outcomes. Just as important is the use of a consistent def-

inition of ‘‘failure’’ following ACL reconstruction, since no

strict definition of failure currently exists.

Clinical failure has generally been defined as an MRI-

documented ACL graft failure and a need for revision, or a

combination of a positive Lachman and pivot shift tests,

and/or a KT-1000 side-to-side difference of 5 mm or

greater. On this panel, ten of 12 surgeons reported using ‘‘a

need for revision’’ to define failure in the most general

sense. Regarding the indications for revisions, all 12 sur-

geons were in agreement, citing patient-reported episodes

of instability and pathological laxity on clinical examina-

tion. Eleven of 12 surgeons also used MRI evidence of a

ruptured or absent ACL graft to define failure.

The average percentage of ACL reconstructions per-

formed by the panellists that met their definition of failure

was 6.2 % (ranging from 2 to 13 %). Of these failures, the

panellists ultimately revised 4.6 % (ranging from 2 to

10 %). The 1.6 % discrepancy between the cases that met

criteria for failure and those that were actually revised

demonstrates the importance of considering multiple fac-

tors when evaluating failure, not only the need for revision.

Of the failure cases experienced by the panellists,

41.1 % were thought to be due to technical error. Another

28.3 % were related to a traumatic event or knee reinjury;

5.3 % of the cases failed because of poor graft healing and/

or incorporation; and 25.3 % of the failures resulted from a

combination of factors.


123

Panel IV: Revision anatomic ACL reconstruction

With the number of ACL reconstructions growing annu-

ally, revision ACL surgery is also increasing and continues

to pose a challenge for all surgeons. In accordance with the

surgeons on Panel III, the surgeons of this panel attributed

the majority of their failures (39.2 %) to technical error.

Another 31.2 % were thought to be caused by a traumatic

event or knee reinjury, 7.9 % were attributed to failure of

graft healing and/or incorporation, and 21.7 % of the cases

failed due to a combination of factors.

The success of revision surgery depends on pre-opera-

tive planning. When considering revision surgery, all 12

panellists perform a thorough history and physical exami-

nation and obtain radiographs and MRI for pre-operative

planning. Nine (75 %) also use previous surgical reports,

and ten (83.3 %) obtained CT scans with or without three-

dimensional (3D) reconstructions for further characteriza-

tion of previous tunnels. One surgeon also occasionally

used a bone scan.

Surgeons preferred a one-stage revision surgery 83.7 %

of the time. Of the 12 panellists, one clearly preferred two

stages to one (4:1). Two surgeons performed both proce-

dures at comparable rates, preferring the one-stage proce-

dure slightly more than half the time. The remaining nine

surgeons performed one-stage revisions 90–100 % of the

time.

Graft choice for revisions is highly variable, even

among individual surgeons. On average, allograft was used

33.8 % of the time. Three surgeons did not use allografts at

all for revision cases. Those who did use allografts selected

from a variety of choices including bone-patellar tendon

bone, quad tendon soft tissue, Achilles tendon, tibialis

anterior, tibialis posterior, peroneus longus, and semiten-

dinosus. BTB and hamstring autografts were used 29 and

27.8 % of the time, respectively, from either the contra-

lateral leg or the ipsilateral leg if not used.

With respect to the technique used for ACL revisions,

82.2 % of the panellists’ cases are revised using a single-

bundle technique. Double-bundle techniques were utilized

17.8 % of the time. Concomitant knee injuries are com-

monly associated with ACL graft failure. Hence, many

additional procedures are performed during ACL revision.

As demonstrated in Fig. 8, nearly one-third (29.1 %) of all

revision cases require meniscectomy, 16.3 % require a

meniscal repair, and 2.6 % require meniscal transplant.

Articular cartilage procedures were performed in 16.4 % of

the cases, collateral ligament surgery in 6.8 % of the cases,

posterolateral corner reconstruction in 5 % of the cases,

and osteotomies in 6 % of the cases on average.

Panel V: Partial ACL injuries and ACL augmentation

Because only seven panellists presented on this panel, they

will remain anonymous

Six of seven surgeons define partial ACL injuries as an

isolated injury of the AM bundle or PL bundle—the other

being intact—resulting in clinical symptoms and episodes

of instability. Specific definitions used by each surgeon are

reported in Table 2. Interestingly, one surgeon ‘‘does not

believe in a true partial rupture’’. He suggests that diag-

nosed partial injuries are actually ‘‘peel-off injuries that

have partially healed’’. Under the consensus definition,

however, partial ACL tears are identified in 8.4 % of the

patients who undergo ACL reconstruction by the panel of

surgeons. This is a slightly lower rate of partial ACL injury

than that reported in the literature (10–20 % of all ACL

injuries) [22, 27, 33].

Regarding the preferred technique for isolated bundle

reconstruction, all seven surgeons agree that the femoral

tunnel for the bundle being reconstructed should lie in the

centre of the native insertion site of that bundle. They used

anatomic landmarks such as the intercondylar ridge, lateral

bifurcate ridge, and soft tissue remnants. On the tibial side,

the surgeons again place the isolated bundle graft in the

centre of the native insertion site. Landmarks used include

Fig. 8 Percentage of ACL

revisions that require additional

procedures


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123

the soft tissue stump, the medial and lateral tibial spines,

and the posterior root of the lateral meniscus. All but one

surgeon preserve the remnants of the isolated bundle being

reconstructed.

When drilling the femoral tunnel, six surgeons prefer

using the accessory medial portal. One surgeon also

occasionally uses an inside-out technique. Six of seven

used intraoperative pictures to document tunnel location.

Four surgeons use intraoperative measurements to confirm

and document femoral tunnel location, and three are doing

the same for the tibial tunnel location. Only one uses

intraoperative radiographs (fluoroscopy) to document

femoral and tibial tunnel location, and no one is using

computer navigation. Post-operatively, five use standard

lateral and anterior–posterior knee radiographs for tunnel

documentation. Three use post-operative CT scans, and

one uses post-operative MRI.

For ACL augmentation surgery, allografts are used only

11 % of the time by the seven surgeons surveyed. Com-

monly used allografts include semitendinosus, tibialis

anterior, tibialis posterior, peroneus longus, and Achilles

tendon. Of all autografts, hamstring tendons are the most

commonly used (72.7 % of the time) followed by bone-

patellar tendon bone (14.6 %) and quadriceps tendon

(1.7 %).

The surgeons report that the complications following

ACL augmentation surgery are the same as those of pri-

mary ACL reconstruction (e.g. DVT, stiffness). In fact,

four of seven surgeons reported that they have yet to

experience any complications following augmentation, but

are currently collecting data given the increasing number of

augmentation procedures performed. Regarding outcomes,

59 % of the pooled cases have ‘‘very good’’ results and

33 % have ‘‘good’’ results. Only 8 % of the cases resulted

in ‘‘fair’’ (5 %) or ‘‘poor’’ (3 %) outcomes. No cases have

resulted in ‘‘very poor’’ (wore than post-injury) outcomes.

Discussion

The panther global summit provided a unique opportunity

for orthopaedic surgeons, physical therapists, and sports

medicine specialist to discuss current concepts, approa-

ches, and techniques in anatomic ACL reconstruction

surgery with representative perspectives from around the

world. ‘‘Anatomic’’ tunnel placement, graft choice, revi-

sion surgery, and return to sports were among the key

topics discussed.

Nearly half of the orthopaedic surgeons on Panel I

perform both single- and double-bundle techniques based

on certain patient characteristics and criteria, including

insertion site sizes, notch size, and graft size. Regarding

tunnel positioning, many surgeons use bony landmarks

such as the intercondylar ridge and the native soft tissue

insertion site on the femoral side and the medial tibial

eminence, posterior border of the lateral meniscus, and

cartilage of the medial tibial plateau on the tibial side.

Accurate femoral and tibial tunnel placement is not without

error. Some surgeons reported erring posteriorly for the

tibial footprint to reduce the risk of impingement. A recent

study by Matsubara et al. [20] evaluated the incidence of

roof impingement after anatomic placement of an ACL

graft in hyperextensible knees compared with the native

ACL in hyperextensible knees using virtual anatomic sin-

gle- and double-bundle ACL reconstructions on 3D mag-

netic resonance imaging bone models. They found that the

native ACL bows posteriorly, resulting in contact with the

intercondylar notch when the knee is hyperextended, sug-

gesting that the anterior–medial bundle roof impingement

may be unavoidable when the knee is hyperextended. The

authors supported the use of a centre-centre single-bundle

ACL reconstruction. However, other studies have demon-

strated no risk of impingement against the intercondylar

roof of the graft after anatomic double-bundle placement

[14, 15]. Furthermore, a graft in the anatomic position may

be able to remodel to account for contact with the interc-

ondylar notch, circumventing the risk for impingement.

As demonstrated by Panel II results, the time to return to

sports varied slightly among surgeons and was dependent

on individual patient progress. Panellists reported that at

12 months post-operative, 75 % of their patients returned

to full sports participation at a pre-injury level of activity.

Interestingly, Ardern et al. in a study of 503 patients who

participated in a competitive level of sports found that

67 % of patients attempted some form of sports activity by

12 months post-operatively; however, only one-third

attempted sports at a competitive level [5].

One of the most conversed issues in ACL reconstruction

surgery is the definition of failure, which is strongly

influenced by the degree of patient follow-up. Some sur-

geons closely follow patients and employ objective means

of evaluating outcomes to define ACL ‘‘failure’’. The

average percentage of failed ACL reconstructions of the

surgeons on panel III was 6.2 %, with 4.6 % of these

failures requiring revision.

The majority of the surgeons on Panel IV preferred

single-staged revisions. However, there have been no sig-

nificant differences reported—clinically or radiographi-

cally—between the two procedures [19]. Complications

such as tunnel widening, improper tunnel position, limited

range of motion, or existent hardware may necessitate a

two-stage procedure. Though clinical outcomes following

revision ACL surgery have been shown to be inferior to

those for primary ACL reconstruction [2, 11, 31], an

average of 82.2 % of the revision cases had ‘‘very good’’ or

‘‘good’’ clinical outcomes per the surgeons on Panel IV.


123

Only 12.6 % of the revisions resulted in ‘‘fair’’ outcomes

with ‘‘no change clinically from the reinjury condition’’,

and 5.3 % resulted in ‘‘poor’’ or ‘‘very poor’’ outcomes

reflecting a clinical outcome ‘‘worse than the reinjury

condition’’.

On average, the surgeons of Panel V perform 9.7

(ranging from 5 to 20) primary AM bundle augmentations

or PL bundle reconstructions and 7.3 (ranging from 3 to 15)

primary PL bundle augmentations or AM bundle recon-

structions, annually. Only two surgeons perform revision

PL bundle augmentations: one and two per year, respec-

tively. ACL augmentation surgery is gaining in popularity

with increasing knowledge of partial injuries, more

advanced radiographic methods to detect individual bundle

tears including special oblique MRI sequences, and

research findings supporting the preservation of one intact

ACL bundle and stump for increased biomechanical sta-

bility, strength, and function; revascularization; proprio-

ceptive innervation; and graft healing, incorporation, and

remodelling [1, 6, 16, 17, 21].

Conclusions

This article summarizes the results of five panels on ana-

tomic ACL reconstruction from the 2011 panther global

summit on anatomic ACL reconstruction held in Pitts-

burgh, Pennsylvania. The data presented reflect the opin-

ions and experiences of panellists from 13 different

countries, providing an overarching global perspective on

current topics in ACL reconstruction. Though a large

majority of surgeons are performing anatomic ACL

reconstruction, variation exists for preferred technique

(single vs. double bundle), femoral and tibial tunnel posi-

tion, femoral tunnel drilling technique, and graft selection

and fixation in primary, revision, and ACL augmentation

surgery. Based on the results of this study, the majority of

surgeons prefer ‘‘anatomic’’ graft placement with tunnels

drilled in the centre of the individual bundle footprints or

between the two bundles when using a single-bundle

technique. However, a few surgeons mention that they

would place tibial tunnels slightly posterior to obviate the

risk of graft impingement on the intercondylar notch. For

primary reconstructions, most surgeons preserve ACL

remnants and the most popular graft choice is hamstring

(quadrupled semitendinosus or semitendinosus and graci-

lis) autografts. Allograft was used nearly one-third of the

time for revision surgeries, and most revision surgeries

were carried out using a single-bundle technique.

Continued prospective randomized controlled trials will

ultimately determine whether and how the controversial

topics addressed play a significant role in the long-term

outcomes following anatomic ACL reconstruction,

revision, and ACL augmentation surgery. We conclude that

symposia such as this will help further advance research,

stimulate development of solutions to common problems in

our field, and facilitate collaboration between researchers,

surgeons, and physical therapist around the world to better

serve the respective patient populations.

Acknowledgments We gratefully acknowledge each and every

panellist for their participation in this endeavour, including their

participation at the Panther Global Summit and their verification of

the data presented in this article. We would also like to acknowledge

the efforts of all University of Pittsburgh Sports Medicine research

fellows who assisted in data collection and Sara Herold for her

assistance with statistics. Finally, we would like to thank Dr. Pau

Golano for the femoral and tibial ACL insertion site dissections.

Appendix: Panel and survey questions

All responses were open ended unless specified.

General information

Demographic survey

1. Surgeon information:

a. Name

b. Company

c. City/Town

d. State/Province

e. Country

f. E-mail address

2. Total years of experience?

3. Total years of experience with primary ACL

reconstructions?

4. Total number of ACL reconstruction performed over

career?

5. Total number of ACL reconstructions performed per

year?

6. Total number of anatomic single-bundle ACL recon-

structions performed per year?

7. Total number of anatomic double-bundle ACL recon-

structions performed per year?

8. Patient demographic characteristics:

a. Age: percent in each of the following categories.

(total 100 %)

i. \14 years

ii. 14–18 years

iii. 19–24 years

iv. 25–34 years

v. 35–50 years

vi. [50 years


123

b. Gender: percent in each of the following catego-

ries. (total 100 %)

i. Female

ii. Male

c. Level of sports participation: percent in each of the

following categories. (total 100 %)

i. High school athlete

ii. College athlete

iii. Professional athlete

iv. Recreational athlete

v. Non-athlete

d. List specific criteria for single-bundle ACL

reconstruction

e. List specific criteria for double-bundle ACL

reconstruction

Panel I: Anatomic ACL reconstruction

1. List specific indications for anatomic single and dou-

ble-bundle ACL reconstruction.

2. Preferred technique:

a. List specific criteria for location of femoral

tunnel(s).

b. List specific criteria for location of tibial tunnel(s).

c. Do you perform the following intraoperative

measurements?

i. ACL mid-substance size? Yes/no

ii. ACL insertion site size? Yes/no

iii. Intercondylar notch width? Yes/no

iv. Tunnel aperture? Yes/no

v. I do not perform any intraoperative

measurements.

d. Do you preserve ACL remnants? Yes/no

e. Do you use the following methods to create your

femoral tunnel:

i. Accessory medial portal? Yes/no

ii. Transtibial drilling? Yes/no

iii. Both techniques? Yes/no

f. Do you use the following methods to document

femoral tunnel location:

i. Intraoperative pictures/video? Yes/no

ii. Intraoperative radiographs/fluoroscopy? Yes/

no

iii. Intraoperative measurements? Yes/no

iv. Navigation? Yes/no

v. Post-operative radiographs? Yes/no

vi. Post-operative MRI? Yes/no

vii. Post-operative CT scan? Yes/no

g. Do you use the following methods to document

tibial tunnel location:

i. Intraoperative pictures/video? Yes/no

ii. Intraoperative radiographs/fluoroscopy? Yes/

no

iii. Intraoperative measurements? Yes/no

iv. Navigation? Yes/no

v. Post-operative radiographs? Yes/no

vi. Post-operative MRI? Yes/no

vii. Post-operative CT scan? Yes/no

h. What percentage of the time do you use: (total

100 %)

i. Allograft?

1 Please specify type.

ii. Autograft bone patellar tendon bone?

iii. Autograft hamstring?

iv. Autograft quad tendon?

i. What is a typical graft size you use?

j. How do you fix the graft on the femoral side?

k. How you fix the graft on the tibial side?

l. What biological methods do you use to enhance

graft healing?

i. None.

ii. PRP.

iii. Fibrin clot.

iv. Other. Please specify.

3. Results:

a. How often and when do you routinely see patients

for follow-up? List the time from surgery for all

office visits.

b. Of all surgical complications, what percentage is

due to: (total 100 %)

i. Infection.

ii DVT.

iii. Stiffness or arthrofibrosis.

iv. Graft failure at a time point less than

6 months.

v. Graft failure at a time point greater than

6 months.

vi. Other. Please specify.

vii. Percent of surgeries without complications.

c. Do you use the following methods to assess

outcome?

i. Range of motion? Yes/no

ii. Manual/instrumented laxity? Yes/no


123

iii. Radiographs? Yes/no

iv. MRI? Yes/no

v. CT scan? Yes/no

vi. Patient reported outcomes? Yes/no

vii. Other? Please specify.

Panel II: Rehabilitation and return to activity: When

do you allow your athletes to return to sports?

1. Do you use the following criteria to determine readi-

ness for return to sports activity?

a. Time from surgery? Yes/no

b. Absence of pain and swelling? Yes/no

c. Range of motion? Yes/no

d. Laxity upon examination? Yes/no

e. Strength? Yes/no

f. Functional testing? Yes/no

g. Other. Please specify.

2. Do you consider graft healing when making the return

to play decision? Yes/no

3. If yes, how do you determine graft healing? Check all

that apply.

a. Time from surgery.

b. Laxity.

c. Graft appearance on MRI.

d. Other. Please specify.

4. When do you allow your athletes to return to the

following activities? Respond in months.

a. Running?

b. Jumping, cutting, and pivoting?

c. Practice?

d. Competition?

e. Physical work/labor?

5. At 12 months after surgery, what percentage of your

patients return to: (total 100 %)

a. Full participation?

b. Partial participation?

c. No participation at 12 months?

6. For those patients who do not return to full activity,

what is the reason? (total 100 %)

a. Problems related to the knee?

b. Fear of re-injury/lack of confidence?

c. Personal choice: changes in lifestyle due to family

or work obligations?

d. Other. Please specify.

Panel III: Failure after anatomic ACL reconstruction

1. Do you use the methods below to follow your patient’s

to evaluate your rate of failure after primary anatomic

ACL reconstruction?

a. Yearly survey or phone call? Yes/no

b. Yearly office visit? Yes/no

c. Recommendations to return to the office as

needed? Yes/no

2. Do you use the following criteria to identify failure

after anatomic ACL reconstruction?

a. Complaints of instability? Yes/No

b. Pathological laxity? Yes/No

c. MRI evidence of graft failure? Yes/No

d. Need for revision? Yes/No

e. Other. Please specify.

3. What is your definition of ACL reconstruction ‘‘fail-

ure?’’ Please be specific.

4. What percentage of your own anatomic ACL recon-

structions meets your definition of failure?

5. What percentage of your own anatomic ACL recon-

structions do you revise?

6. Of all failure cases that you see, what percentage is due

to: (total 100 %)

a. Technical error?

b. Trauma or re-injury?

c. Failure of graft healing/incorporation?

d. Combination of above factors?

Panel IV: Revision anatomic ACL reconstruction

1. Do you consider the following factors in preoperative

planning?

a. History and physical exam? Yes/no

b. Prior operative report? Yes/no

c. Radiographs? Yes/no

d. MRI? Yes/no

e. CT Scan? Yes/no

f. Other. Please specify.

2. What percentage of your revisions is: (total 100 %)

a. One staged?

b. Two staged?

3. What percentage of the time do you use: (total 100 %)

a. Allograft?


123

i. Please specify type.

b. Autograft bone patellar tendon bone?

c. Autograft hamstring?

d. Autograft quad tendon?

4. What percent of revisions are: (total 100 %)

a. Single-bundle?

b. Double-bundle?

5. What percent of your ACL reconstruction require:

(total does not have to be 100 %)

a. Meniscectomy?

b. Meniscus repair?

c. Meniscal transplant?

d. Collateral ligament surgery?

e. Posterolateral corner surgery?

f. Articular cartilage procedure?

g. Osteotomy?

h. Other: please specify.

6. What complications have you observed with revision

ACL reconstruction?

7. How would you qualify your outcomes? (total 100 %)

a. Very good (like pre-primary injury condition)?

b. Good (same as pre-re-injury condition)?

c. Fair?

d. Poor (no change from re-injury condition)?

e. Very poor (worse than re-injury condition)?

Panel V: Partial ACL injuries and ACL augmentation

1. What is your definition of a partial ACL injury?

2. Explain how you make your diagnosis using each of

the modalities below:

a. History and Physical exam.

b. MRI.

c. Arthroscopy.

3. What percentage of patients undergoing ACL surgery

has a partial ACL injury?

4. How many of the following ACL augmentation types

do you perform a year?

a. Primary augmentation of the AM bundle (PL

reconstruction)?

b. Primary augmentation of the PL bundle (AM

reconstruction)?

c. Revision augmentation of the AM bundle (PL

reconstruction)?

d. Revision augmentation of the PL bundle (AM

reconstruction)?

5. List your specific criteria for location of femoral

tunnel(s).

6. List your specific criteria for location of tibial

tunnel(s).

7. Do you use the following intraoperative

measurements?

a. ACL mid-substand size? Yes/no

b. ACL insertion site size? Yes/no

c. Intercondylar notch width? Yes/no

d. Tunnel aperture? Yes/no

e. I do not use intraoperative measurements.

8. Do you preserve ACL remnants? Yes/no

9. Do you preserve the ACL stump? Yes/no

10. Do you use the following methods to create the

femoral tunnel?

a. Accessory medial portal? Yes/no

b. Transtibial drilling? Yes/no

c. Both techniques? Yes/no

11. Do you use the following methods to document

femoral tunnel location:

a. Intraoperative pictures/video? Yes/no

b. Intraoperative radiographs/fluoroscopy? Yes/no

c. Intraoperative measurements? Yes/no

d. Navigation? Yes/no

e. Post-operative radiographs? Yes/no

f. Post-operative MRI? Yes/no

g. Post-operative CT scan? Yes/no

12. Do you use the following methods to document tibial

tunnel location:

a. Intraoperative pictures/video? Yes/no

b. Intraoperative radiographs/fluoroscopy? Yes/no

c. Intraoperative measurements? Yes/no

d. Navigation? Yes/no

e. Post-operative radiographs? Yes/no

f. Post-operative MRI? Yes/no

g. Post-operative CT scan? Yes/no

13. Please specify your tunnel location and method for

creating tunnels.

14. What percentage of the time do you use: (total

100 %)

a. Allograft?

i. Please specify type.

b. Autograft bone patellar tendon bone?

c. Autograft hamstring?

d. Autograft quad tendon?


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15. What complications have you encountered?

16. How would you qualify your outcomes? (total

100 %)

a. Very good (like pre-primary injury condition)?

b. Good (same as pre-re-injury condition)?

c. Fair?

d. Poor (no change from re-injury condition)?

e. Very poor (worse than re-injury condition)?

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Documents

Anatomic anterior cruciate ligament (ACL) reconstruction: a global perspective. Part 1