Trends in Surgeon Preferences on Anterior Cruciate Ligament Reconstructive Techniques

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Key Points

  • Along with increasing knowledge of anterior cruciate ligament (ACL) anatomy and kinematics as well as clinical experience, orthopedic surgeons have engaged in and witnessed an amazing evolution regarding surgical reconstructive techniques.

  • Today, many surgeons intend to replicate the native ACL as much as possible, aiming at anatomic ACL reconstruction.

  • An outline of the new surgical preferences is starting to form; orthopedic surgeons have shifted their preferences in arthroscopic technique,

Primary Repair and Augmentation

Several clinical attempts of primary repair of the ACL have been tried; but almost all of them report discouraging results, although short-term outcomes are positive.5, 6 These results led orthopedic surgeons onto the path of different augmentation techniques that would theoretically not only promote healing but also prevent elongation and rupture. However, studies on augmentation together with repair revealed high rerupture rates and unfavorable outcomes.7 The incapacity of the ruptured ACL to

Synthetic Grafts

The use of synthetics when reconstructing the ACL is theoretically very appealing, allowing surgeons to use custom made off-the-shelf grafts while also shortening operating time by avoiding time-consuming graft harvest. Accordingly, patients undergoing reconstructive surgery would be free of donor site morbidity, such as muscle weakness and pain. However, more than a century later, through several clinical attempts with silk, silver wire, Teflon (DuPont, Wilmington, Delaware), polyester, carbon

Fixation techniques

For the purpose of understanding the rapid development in graft fixation techniques, one must appreciate that the reconstructed ACL is no stronger than its weakest link, which is the graft fixation, as noted by Kurosaka and colleagues.66 The patellar tendon autograft with an interference screw fixation technique has enjoyed a status of gold standard since the latter part of the twentieth century.4 However, with the emerging world-wide popularity of the hamstring graft and lesser used graft

Summary

There has been an amazing evolution in the knowledge of ACL anatomy and the surgical techniques for ACL reconstruction from open to arthroscopic reconstruction. An outline of the new surgical preferences is starting to form, yet another shift in paradigm is identified, the anatomic reconstructive concept. Today, orthopedic knee surgeons performing ACL reconstruction have a wide array of graft choices and fixation techniques at hand, which enables them to specifically tailor each reconstruction

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References (82)

  • J.H. Lubowitz et al.

    Anterior cruciate ligament femoral tunnel length: cadaveric analysis comparing anteromedial portal versus outside-in technique

    Arthroscopy

    (2010)
  • K. Samuelsson et al.

    Treatment of anterior cruciate ligament injuries with special reference to graft type and surgical technique: an assessment of randomized controlled trials

    Arthroscopy

    (2009)
  • A.W. Murray et al.

    10-16 year results of Leeds-Keio anterior cruciate ligament reconstruction

    Knee

    (2004)
  • K. Franke

    Clinical experience in 130 cruciate ligament reconstructions

    Orthop Clin North Am

    (1976)
  • J.P. Fulkerson et al.

    An alternative cruciate reconstruction graft: the central quadriceps tendon

    Arthroscopy

    (1995)
  • D. Andersson et al.

    Treatment of anterior cruciate ligament injuries with special reference to surgical technique and rehabilitation: an assessment of randomized controlled trials

    Arthroscopy

    (2009)
  • L.A. Pinczewski et al.

    Integration of hamstring tendon graft with bone in reconstruction of the anterior cruciate ligament

    Arthroscopy

    (1997)
  • S.J. Kim et al.

    Anterior cruciate ligament reconstruction: autogenous quadriceps tendon-bone compared with bone-patellar tendon-bone grafts at 2-year follow-up

    Arthroscopy

    (2009)
  • Y. Kocabey et al.

    Endopearl augmentation of bioabsorbable interference screw fixation of a soft tissue tendon graft in a tibial tunnel

    Arthroscopy

    (2004)
  • P. Fauno et al.

    Tunnel widening after hamstring anterior cruciate ligament reconstruction is influenced by the type of graft fixation used: a prospective randomized study

    Arthroscopy

    (2005)
  • A. Harilainen et al.

    Cross-pin femoral fixation versus metal interference screw fixation in anterior cruciate ligament reconstruction with hamstring tendons: results of a controlled prospective randomized study with 2-year follow-up

    Arthroscopy

    (2005)
  • P. Marks et al.

    A pilot clinical evaluation comparing the Mitek bone-tendon-bone cross pin and bioabsorbable screw in anterior cruciate ligament reconstruction fixation, a randomized double blind controlled trial

    Knee

    (2008)
  • D. Sabat et al.

    Tunnel widening after anterior cruciate ligament reconstruction: a prospective randomized computed tomography–based study comparing 2 different femoral fixation methods for hamstring graft

    Arthroscopy

    (2011)
  • O.S. Schindler

    Surgery for anterior cruciate ligament deficiency: a historical perspective

    Knee Surg Sports Traumatol Arthrosc

    (2012)
  • C.F. van Eck et al.

    Systematic review on cadaveric studies of anatomic anterior cruciate ligament reconstruction

    Knee Surg Sports Traumatol Arthrosc

    (2011)
  • C.F. van Eck et al.

    "Anatomic" anterior cruciate ligament reconstruction: a systematic review of surgical techniques and reporting of surgical data

    Arthroscopy

    (2010)
  • J. Karlsson et al.

    Anatomic single- and double-bundle anterior cruciate ligament reconstruction, part 2: clinical application of surgical technique

    Am J Sports Med

    (2011)
  • T. Grontvedt et al.

    A prospective, randomized study of three operations for acute rupture of the anterior cruciate ligament. Five-year follow-up of one hundred and thirty-one patients

    J Bone Joint Surg Am

    (1996)
  • R. Sandberg et al.

    Operative versus non-operative treatment of recent injuries to the ligaments of the knee. A prospective randomized study

    J Bone Joint Surg Am

    (1987)
  • T. Grøntvedt et al.

    Comparison between two techniques for surgical repair of the acutely torn anterior cruciate ligament. A prospective, randomized follow-up study of 48 patients

    Scand J Med Sci Sports

    (1995)
  • D.J. Dandy

    Arthroscopic surgery of the knee

    Br J Hosp Med

    (1982)
  • D.D. Buss et al.

    Arthroscopically assisted reconstruction of the anterior cruciate ligament with use of autogenous patellar-ligament grafts. Results after twenty-four to forty-two months

    J Bone Joint Surg Am

    (1993)
  • S.E. Cameron et al.

    A prospective, randomized comparison of open vs arthroscopically assisted ACL reconstruction

    Orthopedics

    (1995)
  • D.J. Raab et al.

    Comparison of arthroscopic and open reconstruction of the anterior cruciate ligament. Early results

    Am J Sports Med

    (1993)
  • K.D. Shelbourne et al.

    Intraarticular anterior cruciate ligament reconstruction in the symptomatic arthritic knee

    Am J Sports Med

    (1993)
  • T. Hess et al.

    Single-versus two-incision technique in anterior cruciate ligament replacement: influence on postoperative muscle function

    Am J Sports Med

    (2002)
  • T.G. Gerich et al.

    One- versus two-incision technique for anterior cruciate ligament reconstruction with patellar tendon graft. Results on early rehabilitation and stability

    Knee Surg Sports Traumatol Arthrosc

    (1997)
  • S. Brandsson et al.

    Reconstruction of the anterior cruciate ligament: comparison of outside-in and all-inside techniques

    Br J Sports Med

    (1999)
  • J.F. Reat et al.

    One-versus two-incision ACL reconstruction. A prospective, randomized study

    Am J Knee Surg

    (1997)
  • A.S. Panni et al.

    Clinical and radiographic results of ACL reconstruction: a 5- to 7-year follow-up study of outside-in versus inside-out reconstruction techniques

    Knee Surg Sports Traumatol Arthrosc

    (2001)
  • T.D. Zavras et al.

    A comparative study of 'isometric' points for anterior cruciate ligament graft attachment

    Knee Surg Sports Traumatol Arthrosc

    (2001)
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    The authors did not receive any outside funding or grants directly related to the research presented in this article. The Department of Orthopaedic Surgery from the University of Pittsburgh receives funding from Smith and Nephew to support research related to reconstruction of the ACL. The authors state that this article is an original work only submitted to this journal. All authors contributed to the preparation of this work.

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