Prior to surgical reconstruction of the ACL, a thorough examination under anesthesia should be performed by the operating surgeon. Depending on the certainty of the diagnosis and surgeon preference, one may either proceed directly to graft harvest or diagnostic arthroscopy. In the case of allograft reconstruction, graft preparation may be performed prior to the initiation of surgery (Fig. 51-9).
Graft Harvest: Patellar Tendon
An 8 cm long incision is made just medial to the midline centered over the patellar tendon and carried down to just below the tibial tubercle. The incision is carried down to layer 1 of the knee, and full-thickness flaps are developed to expose the patel-
lar tendon in its entirety. The medial and lateral borders of the patellar tendon are identified and the width of the tendon is measured. The central 10 mm of tendon (which generally corresponds with the central one third) is marked out using a sterile marking pen. The tendon is then incised along these lines longitudinally. These incisions are extended along the periosteum of the patella and tibial tubercle for an additional 2.5 cm in each direction. This serves as the guide for osteotomizing the bone plugs.
An oscillating saw is used to create the bone plugs. A trapezoidal bone plug is harvested from the tibial tubercle and a triangular bone plug is harvested from the patella. The bone plugs are then measured and contoured, and drill holes and sutures are passed through the plugs for graft passage (Fig. 51-10).
Graft Harvest: Hamstring Tendon
A 3- to 4-cm incision is made longitudinally along the antero-medial tibial crest, centered over the pes anserine tendons (Fig. 51-11 A). Alternatively, transverse and oblique incisions have been described. This incision is typically approximately three finger breadths below the joint line at the level of the apex of the tibial tubercle and centered equally between the tubercle and the posteromedial aspect of the tibia. The sartorius fascia is identified, and the gracilis and semitendinosis tendon are easily palpable. If visualized, any branches of the infrapatellar branch of the saphenous nerve are preserved. At our institution, we prefer to release the tendons off their insertion on the tibia and use a closed tendon stripper for harvesting. Alternatively, the insertion site can be initially preserved and an open stripper used (Fig. 51-11B).
Once the tendons are identified, an incision is made in the sartorial fascia between the two tendons. The tendons are dissected down to the periosteum of the tibia and then reflected as one sleeve, maximizing length. Each tendon is then identified and tagged with a no. 2 nonabsorbable suture. The gracilis is harvested first. All fascial slips are released and the tendon is harvested with the closed tendon stripper. In a similar fashion, the semitendinosis is harvested. The semitendinosis often has multiple fascial connections to the medial gastrocnemius, and these must be released prior to using the tendon stripper in order to avoid premature graft amputation.33
Muscle remnants on the tendon grafts are removed. Final graft preparation is dependent on the fixation device. Typically, a no. 2 nonabsorbable suture whipstitch is placed in each free end and each graft is doubled over to produce a quadruple-strand construct (Fig. 51-12). Numerous fixation devices exist for both femoral and tibial fixation and are a matter of surgeon preference.
Diagnostic arthroscopy is performed and any intra-articular pathology is addressed. The ACL stump is debrided with a combination of a motorized shaver and electrocautery device. We leave the tibial footprint of the ACL intact for its propriocep-tive and vascular contributions. The intercondylar notch is then prepared with the use of a motorized bur or shaver. We prefer to perform a limited notchplasty, taking just enough bone to expose the "over-the-top" position.
The tibial tunnel is prepared first. Tunnel placement is based on the anatomy of the intact ACL. The tibial attachment is adjacent to the anterior horn of the lateral meniscus. Numerous commercially available guide systems can be used. The tip of the guide is placed in the center of the ACL footprint on the tibia and angled about 30 degrees off the midline. The incision used for harvest of either the patellar tendon autograft or hamstring autograft can be used for the tunnel. If an allograft is used, a separate incision is made centered over the anteromedial aspect of the tibia similar to the incision described for the hamstring
Figure 51-12 Quadruple hamstring graft being prepared for EndoButton (Smith & Nephew, Andover, MA) CL fixation.
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