The Concept of Anatomic Anterior Cruciate Ligament Reconstruction

The Concept of AnatomicAnterior Cruciate Ligament ReconstructionCesar A.Q. Martins, MD, Eric J. Kropf, MD, Wei Shen, MD, PhD, Carola F. van Eck, MD,and Freddie H. Fu, MD, Dsc

Growing interest in double-bundle anterior cruciate ligament (ACL) reconstruction hassparked tremendous research, yielding a better understanding of normal ACL anatomy,kinematics, and function. Recent studies have more accurately defined the size andorientation of the femoral and tibial insertion sites of the anteromedial and posterolat-eral bundles. At our institution, we have identified specific osseous landmarks to betterguide tunnel placement. The goal of anatomic ACL is to use these discoveries, refinetechnique, and reconstruct the ACL in a manner that most closely mimics normalanatomy. Logically, we believe that anatomic ACL reconstruction will lead to morefavorable kinematics and, in turn, improved patient outcomes. This article summarizesour experiences and details our systematic approach to anatomic ACL reconstruction.Finally, we highlight multiple issues with conventional ACL reconstruction to betterillustrate the concept of anatomic ACL reconstruction.Oper Tech Sports Med 20:7-18 © 2012 Elsevier Inc. All rights reserved.

KEYWORDS ACL, anterior cruciate ligament reconstruction, double-bundle technique, rota-
tional stability, sports medicine
dd

sr

The anterior cruciate ligament (ACL) is 1 of 4 majorligaments in the knee, along with the posterior cruci-

ate ligament, medial collateral ligament, and lateral collat-eral ligament. The ACL connects the distal femur to theproximal tibia, preventing excessive anterior translationand rotation of the tibia. Structurally, the ACL comprises 2separate functional bundles named for their tibial inser-tion sites: the anteromedial (AM) and the posterolateral(PL) bundle (Fig. 1).1,2 Both bundles are evident duringfetal development and persist throughout life.3,4 Through-out a functional range of motion, the ACL acts primarily asa restraint to excessive anterior tibial translation. Morerecent studies have also shown that the ACL, specificallythe PL bundle, plays an important role in resistance torotational forces.5,6

Understanding ACL injury mechanisms is a complextask. The typical injury occurs during a noncontact twist-

Reprinted with permission from Martins CAQ, Kropf EJ, Shen W, et al: TheConcept of Anatomic Anterior Cruciate Ligament Reconstruction. OperTech Sports Med 16:104-115, 2008 (© 2008 Elsevier Inc.).

Department of Orthopaedic Surgery, School of Medicine, University of Pitts-burgh, Pittsburgh, PA.

Address reprint requests to Freddie H. Fu, MD, 3471 Fifth Avenue, Suite
p1011, Pittsburgh, PA 15213. E-mail: [email protected]
1060-1872/12/$-see front matter © 2012 Elsevier Inc. All rights reserved.doi:10.1053/j.otsm.2012.03.002

ing mechanism or as the result of a valgus-directed blow tothe knee. Noncontact mechanisms, which comprise morethan 70% of acute ACL injuries, are seen in cutting sportsduring sudden, violent deceleration and change of direc-tion with the knee close to full extension. Contact ACLinjuries occur more often as a result of valgus collapse ofthe knee.7 Complete tears of the ligament produce a pre-

ictable pattern of mechanical instability and a variableegree of functional instability.8

After ACL disruption, ligament reconstruction is generallyaccepted as the most reliable method of re-establishing kneestability. The goal of ACL reconstruction is to return the patientto a previous level of function while preventing later degenera-tion of the knee. The best method to achieve such goals isthrough restoration of normal knee kinematics. Although sin-gle-bundle reconstruction is widely used for ACL reconstruc-tion, recent publications have shown that reconstruction of bothbundles (AM and PL) may better re-establish the normal kine-matics of the knee.9-12 In addition, a recent meta-analysishowed that no more than 60% of the patients would attain fullecovery after single-bundle ACL reconstruction.13 Another

study with midterm follow-up also demonstrates significantlyhigh occurrence rates of osteoarthritis after single-bundle ACLreconstruction.14 Thus, there is still room for continued im-
rovement in ACL reconstruction.
7

mailto:[email protected]

8 C.A.Q. Martins et al

The Concept ofAnatomic ACL ReconstructionAnatomy is the basis of orthopaedic surgery. Our approach toACL reconstruction surgery is governed by this concept and,thus, strives to closely reproduce the native anatomy of theACL. There are 4 fundamental principles in anatomic ACLreconstruction. The first is to restore the 2 functional bundlesof the ACL. Second, we aim to restore the native insertionsites of the ACL by placing the tunnels in the true anatomicpositions. Tunnel and graft size are tailored to match the sizeof the native ACL insertion sites. The third principle is correcttensioning pattern of each bundle. The AM bundle is tautthroughout knee range of motion, reaching a maximum be-tween 45° and 60°, whereas the PL bundle is tight primarilyin extension (Fig. 2). Therefore, we independently tensionthe AM and PL bundles accordingly to restore their nativetensioning behaviors.

The fourth and final principle is individualized surgery foreach patient. Tunnel diameter and graft size are dictated bynative insertion sites. In addition, single-bundle ACL recon-struction is considered in patients with small native insertionsites (less than 14 mm in length), open growth plates, severe

Figure 1 Cadaveric dissection showing the ACL and its two distinctbundles (AM and PL) from the medial (A) and lateral viewpoint (B).

bone bruising, narrow intercondylar notch width, and mul-

tiligamentous knee injuries. The concept of anatomic recon-struction can also be extended to the revision ACL surgerysetting. Single-bundle (AM or PL) augmentation surgery isroutinely performed when only 1 of the 2 bundles is torn. Wefirmly believe that only when native anatomy is closely re-stored can superior outcomes can be achieved.

To further demonstrate the concept of anatomic recon-struction, a few pitfalls of ACL surgery are discussed here:

The Clock Face ReferenceAlthough the “clock face” reference has been widely ac-cepted in the literature to describe femoral tunnel posi-tioning during ACL reconstruction, it has generated moreconfusion than clarification in helping surgeons to locate

Figure 2 Cadaveric model with the medial femoral condyle removed.(A) The AM bundle is taut in 90° of flexion; (B) the PL bundle is taut
with the knee in extension.

bprto(rtnabt

c

ofag

The concept of anatomic ACL reconstruction 9

the anatomic footprint of the ACL. The clock face refer-ence is based on radiographs of the knee in extension, butACL surgery is typically performed at or near 90° of kneeflexion. Therefore, the orientation of clock face is wrong asthe femoral AM and PL insertion sites move from verticalto horizontal alignment as the knee move from extensionto 90° of flexion (Fig. 3).

Besides, the intercondylar notch is a 3-dimensional (3D)structure. It is inaccurate to simplify the 3D anatomy of theintercondylar notch to a 2-dimensional (2D) clock face. Theclock position varies depending on whether the clock facereferences the anterior versus the posterior aspect of thenotch. Most importantly, the description of the clock facedoes not correlate with any specific anatomic landmarks.Therefore, we see no role for the clock face reference in ana-tomical ACL reconstruction.

Tunnel Mismatch andAnterior Notch ImpingementDuring transtibial ACL techniques, there is often concern for

Figure 3 The clock face concept of describing femoral tunnel posi-tion: cadaveric model with the knee positioned (A) in full extensionand (B) at 90° of flexion.

anterior impingement with the roof of intercondylar notch.

Typically, to avoid impingement, the tibial tunnel is movedposteriorly occupying the native insertion site of the PL bun-dle. The transtibial technique also dictates the femoral posi-tion; typically resulting in the graft being placed in the highAM position on the femoral side. Therefore, a mismatchedand nonanatomical placement of the tibial and femoral tun-nels is expected. In the most commonly encountered clinicalsituation, instead of connecting the tibial AM (PL) to femoralAM (PL), the tibial PL is connected to the femoral AM or eventhe high nonanatomic AM position (Fig. 4).

Multiple studies have demonstrated that nonanatomictunnel placement results in limited range of motion,higher than physiologic graft tension, and ultimately graftfailure.15-18 Also, mismatched ACL graft placement has

een shown to not restore rotational stability when com-ared with the intact ACL and anatomical double-bundleeconstruction.19 In an ongoing study, we have shown thathe PL to high-AM reconstruction does not restore anteri-r-posterior stability, while the anatomic reconstructionAM to AM) procedure provides superior anterior-poste-ior and rotational stability. Another advantage of ana-omic tunnel placement is that the graft is exposed toormal biomechanical stimuli and therefore, a more favor-ble biological environment for healing. This is evidencedy a lesser degree of bony tunnel expansion with the ana-omical reconstruction technique.

The subject of graft impingement is complicated. Classi-ally, Howell and Taylor20 have recommended that the tibial

tunnel lie posterior to the intercondylar roof on a hyperex-tension lateral to prevent impingement. However, Miller andOlszewski21 have refuted this and found that impingement isften overdiagnosed by this simple radiographic measure. Inact, in the ACL-deficient or ACL reconstructed knee subtlenteroposterior subluxation may be seen on the lateral radio-raph and misdiagnosed as graft impingement.22 We should

keep in mind that the native ACL does not impinge. Logi-cally, if we reconstruct the ACL in an anatomic fashion, im-pingement should not occur (Fig. 5). To achieve anatomic

Figure 4 With transtibial techniques, the tibial tunnel is typicallymoved posteriorly mimicking the anatomic PL position and the
femoral insertion is anterior relative to the anatomic AM position.

vbArs


femoral tunnel placement, the anteromedial viewing portalmust be used. The standard anterolateral provides a superiorview of the tibial footprint but does not allow visualization ofthe true anatomic insertion on the femoral side. Drilling ofthe femoral tunnels through an accessory medial portal al-lows the tunnel to be placed independent of the tibial tunnel,in effect granting access to the true anatomic position.

Notchplasty and PCL ImpingementWhen the 3-portal technique is used, notchplasty is un-necessary. The medial wall and the posterior border of thelateral femoral condyle are clearly visualized when view-ing from the anteromedial portal. Because notchplasty isnot routinely performed, the native soft tissue and osseouslandmarks are preserved as essential guides for anatomicACL reconstruction. It cannot be overemphasized that theremnants of the ACL and bony ridges are critical anatom-ical landmarks in identifying the true ACL insertion sites.Our recent publication23 showed that the femoral attach-ment of the ACL is composed of 2 ridges. The lateralintercondylar ridge (previously called “resident’s ridge”)runs from proximal to distal along the entire ACL femoralinsertion. No ACL fibers were found to attach anterior tothe lateral intercondylar ridge. Another bony prominencewas also found to be present in the anterior portion of thefemoral footprint running in an anterior to posterior di-rection, which is referred to the lateral bifurcate ridge (Fig.6). Historically, notchplasty has been advocated as amethod of preventing ACL–PCL impingement. In an effortto create more room for the graft, the native anatomy isdistorted. Therefore, the anatomic ridges are rarely everappreciated.

Anatomic ACL reconstruction is not merely a techniquebut, rather, a fundamental concept. Each individualized casewill present with unique variations of normal anatomy. Thegoal of anatomic ACL reconstruction is to use new techniques

Figure 5 After anatomic double-bundle ACL reconstruction, im-pingement does not occur. The normal relationship between theACL and intercondylar notch roof is maintained.

(accessory medial portal drilling, no notchplasty) to identify

and replicate the native ACL anatomy in each case. Thisconcept can be routinely applied in all cases of ACL recon-struction.

Biomechanical ConsiderationsBiomechanical studies suggest that each bundle (AM andPL) makes a unique kinematic contribution to knee func-tion. The 2 bundles function together, but the AM bundleprovides the major anteroposterior restraint whereas thePL bundle contributes more to rotational stability.24 An inivo kinematics study has shown that conventional single-undle ACL reconstruction, which most closely mimicsM bundle reconstruction, may successfully restore ante-ior-posterior knee stability but does not successfully re-tore rotational stability.12 In addition, cadaveric biome-

chanical studies have shown that double-bundle ACLreconstructions more closely restore knee kinematics thansingle-bundle ACL reconstructions.9

ClinicalOutcomes and LimitationsRecent prospective, randomized level I and level II studieshave reported favorable clinical outcomes after double-bun-dle ACL reconstructions.25-29 At the University of Pittsburgh,the 2-year follow-up the first 100 double-bundle ACL recon-struction patients has also shown good to excellent short-term results.30 Since the inception of double-bundle ACLreconstruction at our institution in 2003, our knowledge ofACL anatomy and anatomic ACL reconstruction has evolved.We realized that not all “double-bundle” procedures are an-atomically performed. Simply drilling 2 tunnels in the femurand the tibia does not result in an anatomic restoration of thenative ACL. We also acknowledge that the assessment oftunnel position after ACL reconstruction can be extremely

Figure 6 Arthroscopic view of left knee through the anteromedialportal. After the ACL remnant has been gently débrided, the lateralintercondylar ridge (arrows) and the lateral bifurcate ridge (arrow-
head) are easily visualized.


difficult with routine radiography or MRI, as these are 2Drepresentations of a 3D situation. Also, because of variationin surgical technique or position of the operative leg, it caneven be difficult to truly assess tunnel position at the time ofarthroscopy. We believe that 3D computed tomography re-construction represents the future as the best method to eval-uate the position of the tunnels after ACL reconstruction(Fig. 7).

It is also important to note the fact that there is a lack ofreadily available, reliable, and valid clinical outcome mea-sures. Therefore, it is exceedingly difficult to reliably andconsistently compare different ACL reconstruction tech-niques. In the office setting alone, it is difficult to quantifydifferences in anteroposterior and rotational stability inabsolute terms. High speed, biplane radiographic stereo-photogrammetric analysis is a promising research modal-ity to precisely evaluate in vivo knee kinematics duringactivities of daily living, running, and jumping.12 This mo-dality, coupled with high-field magnetic resonance imag-ing to detect the earliest signs of cartilage degeneration,may provide a more reliable means to determine the effectsof different approaches to ACL reconstruction. We believethat with the development of more accurate comprehen-sive outcome measures, anatomic ACL reconstruction willdemonstrate great benefit in restoring the normal struc-

Figure 7 3D reconstruction computed tomography scanning pro-vides an accurate assessment of tunnel position on the femur (A)and on the tibia (B).

ture and function of the knee.

Anatomical Double-BundleACL Reconstruction TechniqueThe patient is placed supine on the operating table and phys-ical examination of both knees is performed under anesthe-sia. The nonoperative leg is well padded and positioned in awell-leg holder. A tourniquet is applied to the operative ex-tremity at a pressure ranging from 250 to 400 mm Hg de-pending on the size of the limb, and the leg is then positionedin a leg holder. With the leg holder setup, the weight of theleg and foot applies a gentle distraction force to the knee jointwhile still permitting free and easy movement of the operatedleg.

With the knee held in 90° of flexion, an anterolateral portalis established just lateral to the patellar tendon (Fig. 8). Thisportal is in a slightly more proximal position with the distalextent of the portal at the level of the inferior pole of thepatella. The high anterolateral portal position minimizes theneed to traverse the fat pad and allows superior visualizationof the tibial insertion sites. A thorough diagnostic evaluationis performed and associated pathology is addressed accord-ingly.

The anteromedial portal is established with 18-gauge nee-dle localization and an 11-blade (Figs. 8 and 9). This portal isjust medial to the midline, off the edge of the patellar tendon,and just above the level of the meniscus. The anteromedialportal provides excellent visualization of the lateral wall ofthe intercondylar notch without need for notchplasty. Whileviewing through the anteromedial portal, the surgeon canlater drill the femoral tunnels through the accessory medialportal under direct visualization.

Needle localization is again used to establish the accessoryanteromedial portal (Figs. 8 and 9 ). This localization is in a

Figure 8 Three-portal technique: the anterolateral portal (AL portal)is established at the level of the inferior pole of patella, and theanteromedial (AM portal) and accessory anteromedial (AAM portal)portals are established via needle localization. The standard incisionis placed midway between the tibial crest and the medial border of
the tibia.


more medial position above the medial meniscus. This portalshould provide direct access to the most distal and anterioraspect of the lateral intercondylar notch where the PL tunnelwill later be drilled. This correct position lies close to themedial condyle and careful attention must be taken to avoidiatrogenic cartilage injury.

After diagnostic arthroscopy is complete and associatedchondral or meniscal injury has been addressed, we carefullydetermine the rupture pattern of the AM and PL bundles(midsubstance, femoral or tibial sided, or combined injury)(Fig. 10).31 The remnant ACL stump is then carefully dis-sected with the use of a shaver and thermal device to exposeand mark the anatomic insertion sites of the AM and PLbundles on the femur and tibia (Fig. 11). The lateral inter-condylar ridge and lateral bifurcate ridge that we described

Figure 9 Arthroscopic view left knee from the anterolateral viewingportal. Two 18-gauge spinal needles are inserted just above the levelof the meniscus. The trajectory of the anteromedial (AM portal) andaccessory anteromedial (AAM portal) portals is depicted.

Figure 10 ACL injury pattern is determined in all cases. In this caseviewed through the anterolateral portal (AL portal), the PL bundleappears in continuity but hemorrhagic and stretched out. Thestump of the AM bundle is typical of a midsubstance or femoral
sided AM bundle rupture.
previously should be looked for as landmarks for femoraltunnel placement. Both the bony ridges and soft tissue rem-nant of the torn ACL serve as important landmarks to identifythe anatomic insertion sites. In chronic cases, where the ACLstump has already been resorbed or only fibrous tissue re-mains, the PCL, intermeniscal ligament and the lateral me-niscus attachment provide important intra-articular cues fortibial tunnel positioning. It is important to note the distancebetween the PCL and the center of the ACL footprint variesamong patients. Based on our anatomic study, the maximaldistance reaches around 14 mm.

After the insertion sites are defined, a metallic ruler isinserted through the anteromedial portal with the scope inthe lateral portal (Fig. 12). We measure the length and widthof each insertion site on the tibia and femur. To accuratelymeasure the femoral insertion sites, the scope must be movedto the accessory medial portal while the ruler is kept in the

Figure 11 The anterolateral viewing portal provides superior visual-ization of the tibial insertion sites. In this arthroscopic view of a leftknee, the AM and PL insertion sites have been traced back andmarked with a thermal device.

Figure 12 With the arthroscope in the anterolateral portal, a ruler isplaced through the anteromedial portal and the native ACL inser-
tions sites are measured and recorded.


anteromedial portal (Fig. 13). On the basis of the measuredvariations of the native anatomy, we individualize the tunnelsize and graft size for each bundle.

The femoral insertion sites are marked with a Steadmanawl (Fig. 14) and a guide pin is then tapped into place at theanatomic PL bundle position. With the knee held in 110° offlexion, the PL femoral tunnel is drilled first through theaccessory anteromedial portal, typically around 6 to 7 mm indiameter and 20 to 22 mm in length. The trajectory of instru-ments passed through the accessory medial portal is closer tothe medial condyle than is usually encountered with the con-ventional anteromedial portal. Care must be taken to avoiddamage to the articular cartilage. We use a drill bit with flutesat the tip only for added safety.

Attention is then turned to creation of the tibial tunnels. Adirect ACUFEX drill guide (Smith & Nephew Endoscopy,Andover, MA) is set at 45° and 55° for the PL and AM tunnelsrespectively (Fig. 15). A 3-cm incision is made sharply down

Figure 13 With the arthroscope in the accessory anteromedial portal,the femoral insertion sites are measured with a ruler insertedthrough the anteromedial portal.

Figure 14 With the scope in the anteromedial portal, a Steadman awlis inserted through the accessory anteromedial portal and the center
of the AM and PL insertion sites are marked.
to the level of the anteromedial tibial cortex. The PL bundletunnel should be placed distal and posteromedial on the tibiarelative to the AM tunnel entry point. During the PL tunneldrilling, care should be taken because the tibial drill startsjust anterior to the superficial medial collateral ligament fi-bers. Two separate 2.5-mm guidewires are sequentially firedthrough the ACUFEX guide into the stumps of the PL and AMtibial footprints. At this point, the distance between PL andAM pins is measured with the ruler to further confirm ana-tomic positioning (Fig. 16). A single lateral fluoroscopic im-age is also obtained with a mini-C-arm with the knee held in

Figure 15 Creation of the tibial tunnels. (A) An ACUFEX tip guide isused and set at 45° for the PL tunnel and 55° for the AM tunnel. (B)In the coronal plane, a 1- to 2-cm bone bridge on the anteromedialtibia must separate the tunnels.

extension to confirm the satisfactory positioning of both pins


(Fig. 17). Then, the tibial tunnels are drilled with the appro-priately sized compaction drill bits for the PL and AM tunnels(Fig. 18).

The femoral AM tunnel is then drilled through 1 of 3different approaches (ie, transtibial AM, transtibial PL, andaccessory anteromedial portal). The determining factor is al-ways the ability of the surgeon to recreate the true anatomiclocation. If a transtibial guidewire can reach the previouslymarked anatomical position, the transtibial technique is pre-ferred because it creates a longer and divergent tunnel rela-tive to the femoral PL tunnel. If this is not possible, theaccessory anteromedial portal should be used to place thefemoral AM tunnel. Once the appropriate technique is deter-mined, the far cortex of the AM femoral tunnel will bebreached with a 4.5-mm EndoButton drill (Smith & NephewEndoscopy, Andover, MA), and the depth gauge will be usedto measure the distance to the far cortex.

Our preferred graft choice is double-stranded anterior orposterior tibialis allograft. Among many other advantages,these grafts are 24 to 30 cm in length and, after they arefolded, we can obtain a 12 to 15 cm graft length. The grafts

Figure 16 After the tibial pins are fired, confirmatory measures areagain taken. (A) The distance between the center of the AM and PLtunnels is measured and (B) the distance from the PCL to the center
of the PL tunnel is also measured (12 mm in this case).
are thawed on the back table, rinsed in antibiotic solution,trimmed of excess or loose tissue, and doubled over. The endsof each graft are baseball stitched with #2 Ticron sutures for alength of 2.5 cm. The PL graft is passed first, followed by AMgraft passage secondly. On the femoral side, an EndoButton CL(Smith & Nephew Endoscopy) is used for femoral-sided fix-ation. In some cases, when the PL femoral tunnel is shorterthan 25 mm, Endobutton Direct (Smith & Nephew Endos-copy) is used to maximize the amount of graft in the tunnel.

Figure 17 Fluoroscopic depiction of tunnel pin placement in cadav-eric model. In clinical cases, after the tibial guide pins have beenpositioned, a single lateral C-arm image is taken to further confirmanatomic positioning.

Figure 18 The femoral tunnels are shown here after drilling and thedilators are left in the tibial tunnels to better illustrate tibial tunnel
position.


On the tibial side, a Bioabsorbable screw that is the samediameter as the drilled tunnel is used for each bundle. Pre-conditioning of the grafts is performed by flexing and extend-ing the knee through a range of motion from 0° to 120°approximately 25 times. The final fixation of the graft is doneat 45° and 0° of flexion for the AM and PL bundles, respec-tively. A final arthroscopic inspection is performed to con-firm correct position and tensioning of the grafts and theabsence of graft impingement (Fig. 19).

AnatomicSingle-Bundle ReconstructionThe anatomic reconstruction concept and associated princi-ples also can be applied to single-bundle ACL reconstruc-tions. By understanding insertion site anatomy and sizes, thesurgeon will realize that an anatomical approach that tailorsthe tunnel size and matches the tunnel position on femoraland tibial insertion sites will more consistently restore theanatomy of the native ACL (Appendix 1). There are severalinstances when an anatomic single-bundle reconstruction isperformed (30% of ACL reconstructions in the senior authorspractice). If the ACL insertion site is less than 14 mm in sizea double-bundle ACL reconstruction becomes technicallydifficult and an anatomic single bundle reconstruction is con-sidered. In addition, in patients with open growth plates,severe arthritic changes, multiple ligament injuries, or severelateral femoral condyle bone bruising anatomic single bundlereconstruction is routinely performed.

Postoperative RehabilitationOur rehabilitation protocol is the same for the anatomicalsingle- and double-bundle ACL reconstruction, as previouslypublished.32 The essential features include early emphasis on

Figure 19 Graft impingement does not occur after anatomic double-bundle ACL reconstruction. In this clinical case, the AM and PLbundles are visualized. The space between the ACL and PCL isevident in the superior intercondylar notch.

control of pain and swelling and the early restoration of full

passive knee extension symmetrical to the noninvolved knee.During rehabilitation, attention must be paid to maintainingpatellar mobility, regaining quadriceps control and protectedweight bearing.

Once full weight-bearing activity is permitted, patientsprogress to open and closed chain progressive resistance ex-ercises as tolerated. Balance and proprioceptive activities arethen initiated. Approximately 4 to 6 months after surgery,running is initiated until quadriceps strength is 75 to 80% ofthe noninvolved side. Functional training in a brace begins at7 months, with an expected return to sport at 9 months.

Technical Pearls and PitfallsIn this section, we list several pearls and pitfalls that may beof use to the surgeon:

● Anatomical double-bundle ACL reconstruction surgeryshould be performed with attention directed to the in-dividual patient’s anatomy. This requires assessment,measurement and recreation of the native insertion sites.

● Correct portal placement cannot be overemphasized.Care and needle localization should be used to create themedial and accessory medial portals as they are in closeproximity to the medial meniscus and medial femoralcondyle.

● Avoid using the “clock face” method to create the fem-oral ACL tunnels. With the scope in the anteromedialportal, identify and mark the native AM and PL femoralinsertion sites and then recreate these positions whentunnels are drilled.

● The use of a single lateral view fluoroscopic image canhelp to confirm correct placement of the PL and AMtunnels on tibia.

ConclusionAnatomic double-bundle ACL reconstruction intends to rep-licate normal anatomy, and in turn restore normal kinematicsand knee function. We use a systematic approach to eachcase. Normal anatomy and injury pattern are identified first,and then ACL reconstruction is tailored to most closely rep-licate native anatomy (Appendix 2). Controlled laboratoryand short term clinical studies are promising, but obviously,long-term clinical studies are necessary to determine clinicalimpact.

References1. Petersen W, Tretow H, Weimann A, et al: Biomechanical evaluation of

two techniques for double-bundle anterior cruciate ligament recon-struction. Am J Sports Med 35:228-234, 2007

2. Mochizuki T, Muneta T, Nagase T, et al: Cadaveric knee observationstudy for describing anatomic femoral tunnel placement for two-bun-dle anterior cruciate ligament reconstruction. Arthroscopy 22:356-361, 2006

3. Chhabra A, Starman JS, Ferretti M, et al: Anatomic, radiographic, bio-mechanical, and kinematic evaluation of the anterior cruciate ligamentand its two functional bundles. J Bone Joint Surg Am 88:2-10, 2006(suppl 4)

4. Ferretti M, Levicoff EA, Macpherson TA, et al: The fetal anterior cruci-

1

1

1

1

1

1

1

1

1

1

2

2

2

2

2

2

2

2

2

2

3

3

3


ate ligament: An anatomic and histologic study. Arthroscopy23:278-283, 2007

5. Girgis FG, Marshall JL, Monajem A: The cruciate ligaments of the kneejoint. Anatomical, functional and experimental analysis. Clin OrthopRelat Res 106:216-231, 1975

6. Zantop T, Herbort M, Raschke M, et al: The role of the anteromedialand posterolateral bundles of the anterior cruciate ligament in anteriortibial translation and internal rotation. Am J Sports Med 35:223-227,2007

7. Boden BP, Dean GS, Feagin JA, Jr., et al: Mechanisms of anterior cru-ciate ligament injury. Orthopedics 23:573-578, 2000

8. Viskontas DG, Giuffre BM, Duggal N, et al: Bone bruises associated withACL rupture: Correlation with injury mechanism. Am J Sports Med36:927-933, 2008

9. Yagi M, Wong EK, Kanamori A, et al: Biomechanical analysis of ananatomic anterior cruciate ligament reconstruction. Am J Sports Med30:660-666, 2002

0. Yagi M, Kuroda R, Nagamune K, et al: Double-bundle ACL reconstruc-tion can improve rotational stability. Clin Orthop Relat Res 454:100-107, 2007

1. Tashman S, Kolowich P, Collon D, et al: Dynamic function of theACL-reconstructed knee during running. Clin Orthop Relat Res 454:66-73, 2007

2. Tashman S, Collon D, Anderson K, et al: Abnormal rotational kneemotion during running after anterior cruciate ligament reconstruction.Am J Sports Med 32:975-983, 2004

3. Biau DJ, Tournoux C, Katsahian S, et al: ACL reconstruction:Ameta-analysis of functional scores. Clin Orthop Relat Res 458:180-187, 2007

4. Freedman KB, D’Amato MJ, Nedeff DD, et al: Arthroscopic anteriorcruciate ligament reconstruction: A metaanalysis comparing patel-lar tendon and hamstring tendon autografts. Am J Sports Med 31:2-11, 2003

5. Allen CR, Giffin JR, Harner CD: Revision anterior cruciate ligamentreconstruction. Orthop Clin North Am 34:79-98, 2003

6. Jaureguito JW, Paulos LE: Why grafts fail. Clin Orthop Relat Res 325:25-41, 1996

7. Johnson DL, Swenson TM, Irrgang JJ, et al: Revision anterior cruciateligament surgery: Experience from Pittsburgh. Clin Orthop Relat Res325:100-109, 1996

8. Harner CD, Giffin JR, Dunteman RC, et al: Evaluation and treatment ofrecurrent instability after anterior cruciate ligament reconstruction. In-
str Course Lect 50:463-474, 2001
9. Zantop T, Diermann N, Schumacher T, et al: Anatomical and nonana-tomical double-bundle anterior cruciate ligament reconstruction: im-portance of femoral tunnel location on knee kinematics. Am J SportsMed 36:678-685, 2008

0. Howell SM, Taylor MA: Failure of reconstruction of the anterior cruci-ate ligament due to impingement by the intercondylar roof. J Bone JointSurg Am 75:1044-1055, 1993

1. Miller MD, Olszewski AD: The appearance of roofplasties on lateralhyperextension radiographs. Am J Sports Med 27:513-516, 1999

2. Almekinders LC, Chiavetta JB, Clarke JP: Radiographic evaluation ofanterior cruciate ligament graft failure with special reference to tibialtunnel placement. Arthroscopy 14:206-211, 1998

3. Ferretti M, Ekdahl M, Shen W, et al: Osseous landmarks of the femoralattachment of the anterior cruciate ligament: An anatomic study. Ar-throscopy 23:1218-1225, 2007

4. Zantop T, Herbort M, Raschke MJ, et al: The role of the anteromedialand posterolateral bundles of the anterior cruciate ligament in anteriortibial translation and internal rotation. Am J Sports Med 35:223-227,2007

5. Yasuda K, Kondo E, Ichiyama H, et al: Clinical evaluation of anatomicdouble-bundle anterior cruciate ligament reconstruction procedure us-ing hamstring tendon grafts: Comparisons among 3 different proce-dures. Arthroscopy 22:240-251, 2006

6. Yagi M, Kuroda R, Nagamune K, et al: Double-bundle ACL reconstruc-tion can improve rotational stability. Clin Orthop Relat Res 454:100-107, 2007

7. Järvelä T: Double-bundle versus single-bundle anterior cruciate liga-ment reconstruction: A prospective, randomize clinical study. KneeSurg Sports Traumatol Arthrosc 15:500-507, 2007

8. Aglietti P, Giron F, Cuomo P, et al: Single-and double-incision double-bundle ACL reconstruction. Clin Orthop Relat Res 454:108-113, 2007

9. Muneta T, Koga H, Mochizuki T, et al: A prospective randomized studyof 4-strand semitendinosus tendon anterior cruciate ligament recon-struction comparing single-bundle and double-bundle techniques. Ar-throscopy 23:618-628, 2007

0. Fu FH, Shen W, Starman JS, et al: Primary anatomic double-bundleanterior cruciate ligament reconstruction: A preliminary 2-year pro-spective study. Am J Sports Med 36:1263-1272, 2008

1. Zantop T, Brucker PU, Vidal A, et al: Intraarticular rupture pattern ofthe ACL. Clin Orthop Relat Res 454:48-53, 2007

2. Irrgang JJ, Enseki KR: Rehabilitation following ACL reconstruction. FuFH, Cohen S (eds): Current Concepts in ACL Reconstruction. Thoro-
fare, NJ: Slack, Inc., 2008, p 377

y matched single-bundle ACL reconstruction.


Appendix 1 The principle of anatomicall


Appendix 2 Anatomic single- and double-bundle ACL reconstruction flowchart.

Documents

The Concept of Anatomic Anterior Cruciate Ligament Reconstruction