Current Techniques in Anatomic Anterior Cruciate Ligament Reconstruction

Purpose: The aim of this report is to summarize several techniques that are currently performed to reconstruct the anterior cruciate ligament (ACL) via an anatomic approach restoring the anteromedial (AM) bundle and posterolateral (PL) bundle separately. Methods: A survey containing questions about technique and rehabilitation protocol and a picture of an anatomic specimen, where study participants were asked to locate the tunnels, was created. This was sent to surgeons identified either through an Internet-based search via the National Library of Medicine or who have presented clinical studies about anatomic ACL reconstruction at international meetings. The questions were presented in an open-fashioned way in an Excel-based data file (Microsoft, Redmond, WA) and addressed the profile of the panelists, number of total and anatomic ACL reconstruction per year, graft choice, graft fixation, advantages and disadvantages of anatomic ACL reconstruction, and rehabilitation protocol. Results: One of the most common techniques used 2 femoral and 2 tibial tunnels with a soft-tissue graft. All but 1 panelist used a hamstring graft. A great variance in tunnel placement of the PL bundle was noted. Most surgeons prefer a transtibial technique for the AM bundle. Of the study participants, 67% start by placing a tunnel at the tibial insertion of the ACL. All of the surgeons who started at the femoral insertion with the PL bundle used an accessory medial portal technique. Conclusions: Anatomic reconstruction of the ACL remains a technically demanding procedure. Hamstring grafts are the most commonly used graft; an extracortical flip button technique is used at the femoral site, and a hybrid technique is used at the tibial site. The femoral tunnel placement of the PL bundle tunnel is statistically different from the AM bundle tunnel, and the same rehabilitation protocols as for single-bundle ACL reconstructions are used. Clinical Relevance: Knowledge of the pitfalls and current techniques used for an anatomic approach restoring both bundles of the ACL may provide important information for surgeons considering this technique. Level of Evidence: Level V, expert opinion.