About this Book
Why this Book Is Needed
The anterior cruciate ligament (ACL) is one of
the most written about topics in Orthopaedics,
such that it has become very difficult for most
Orthopaedists to stay current through regular
casual reading of the literature. Yet until now
there has not been a comprehensive ACL text.
This book fills that gap. We have attempted
to present the essence of the world’s accumu-
lated clinically relevant ACL-related knowledge
in 81 concise chapters.
About the Associate Editors and
Contributors
The associate editors listed on the cover and the
other contributors are a “dream team” of leading
ACL surgeons and scientists from around the
world who were chosen based on their accom-
plishments and research on the specific topic of
their chapter. Other distinguished surgeons are
being continually added as special contributors
of new “hot topics” for the ACL website.
Fixation Devices and Troubleshooting
Each of the leading ACL reconstruction fixation
devices has its own chapter written by its creator
or one of its most skilled users. Each such chapter
presents scientific rationale, technique, results,
and, most importantly, a troubleshooting section.
Every surgeon encounters technical problems
during cases, but we know of no other source
for the practicing surgeon to find the best way
to get out of them. Most device information
comes to surgeons from company representatives
who do provide a useful service; but the chapters
in this text, along with the many videos, provide
a more in-depth alternative. Through partner-
ship with the leading sports medicine companies,
new devices will be introduced on the website
along with expert orthopaedic evaluations—“peer
reviewed marketing.”
The Technique of ACL Reconstruction
The best techniques for each component of ACL
reconstruction: harvest, fixation, tunnels, notch-
plasty, and so forth, are collected and presented.
This information leads directly to good outcomes.
Choices
After technique, ACL surgery is all about choices:
interference versus cortical fixation, bone–patella
tendon–bone versus hamstring, auto versus allo-
graft, accelerated versus protected rehab, anterior
versus posterior hamstring harvest, metal versus
bio versus osteoconductive, single versus double
bundle, and so on. Information on both sides of
each argument is presented to allow the surgeon
to make each choice a well-informed one.
Related Topics
The expert treatment of related pathology—
cartilage and ligamentous—is essential for the
ACL surgeon, and is presented here. There are also
10 chapters on different types of complications,
much of it probably unfamiliar to many. There is
original research on the incidence of ACL tears,
economics, and stability results. New horizons,
including four double bundle techniques, naviga-
tion, and tissue engineering are also presented, along
with biomechanical information and much more.
vii
 About this Book
The DVD
Dozens of surgical technique videos of the component
techniques that make up ACL reconstruction, and a few
additional topics, comprise the included DVD. Some videos
were created especially for this DVD, others represent
classics from the AAOS and elsewhere. All are the best
we know of on the given topic and form the only such large
collection of ACL videos.
The Website
The dedicated website includes an e edition of the book. At this
writing there are 10 additional chapters not included in the
print version on new “hot topics,” such as quadriceps tendon
ACL reconstruction results, and more will be added as new
advances or controversies emerge. There are also product intro-
ductions in partnership with industry, useful links, course offer-
ings, and much more. The website also includes the “Ask the
Experts” and “ACL Database” features described below.
Ask the Experts
The contributors to this book have all agreed to field
questions from Orthopaedic Surgeons with website pass-
words on their particular topics, or others. These
viii
e-mailed queries are directed to a central question center,
distributed to the appropriate surgeon, and then answered
confidentially to the surgeon who posed the question.
The idea is to assist surgeons everywhere to better treat
their patients by getting help from the best when they
need it.
Staying Current: The ACL Database
The book’s short gestation period has ensured that each
chapter is up-to-date at publication. However, through the
book’s website, significant new ACL-related knowledge is
being added each quarter to keep it that way. This is how it
works: Beginning in January 2007, every month the 50 or so
new ACL-related article references published in the world’s
peer reviewed literature have been appended to the biblio-
graphy for the most relevant chapter(s) or sections of the text
to which they relate. Presentations and even posters from the
major sports medicine meetings are similarly categorized each
month. Thus, the ACL database presents a continually
updated compendium of essentially all the world’s new
ACL-related knowledge as it is being created, organized by
topic. This is an ideal research tool for any ACL-related topic
about which you need to know.

The special contributors listed on the cover of the
book have been involved in this project from the
beginning and have supported its development
with their time and energy simply because they
believed in the worthwhile nature of the project.
There are none brighter or more dedicated. I am
grateful to them and to all the other esteemed con-
tributing authors: the “dream team” of ACL scien-
tists and surgeons described on the preceding
page. I was confident that they would produce
the outstanding works of scholarship that they
have, but I was continually surprised at how easy
to work with these illustrious scientists and sur-
geons all were and how they respected the time
deadlines and constraints of space and organiza-
tional structure of the project. This clearly comes
Acknowledgments
from being passionate about their ideas and
their work and is reflected in the high quality of
the chapters. I would also like to especially thank
one of those contributors, Bert Zarins, for all he
taught me about both sports medicine and life as
my fellowship mentor many years ago.
Kim Murphy and all of the people at
Elsevier have been a great pleasure to deal with.
She showed enthusiasm and creativity for the
project from the beginning and continues to
do so. They have also worked diligently to help
avoid delays so that the book will be up to date
at its publication.
Finally, the staff at our clinic and my fam-
ily have all been wonderful about the time
diverted from them to this book.
ix
 List of Contributors

Keiichi Akita, MD, PhD F. Alan Barber, MD, FACS

Unit of Clinical Anatomy, Fellowship Director,
Graduate School, Plano Orthopedic and Sports Medicine Center,
Tokyo Medical and Dental University, Plano, Texas
Tokyo, Japan Gene R. Barrett, MD
Arturo Almazan, MD Codirector of Knee Service,
Orthopedic Sports Medicine and Arthroscopy Mississippi Sports Medicine and
Department, Orthopaedic Center,
National Institute of Rehabilitation; Jackson, Mississippi
Associate Professor, Guy Bellier, MD
Sports Medicine Residency Program, Cabinet Goethe,
National Autonomous University of Mexico, Institut de l'Appareil Locomoteur
Mexico City, Mexico Nollet,
Andrew A. Amis, PhD, DSc(Eng), FIMechE Paris, France
Professor, Manfred Bernard, MD
Departments of Mechanical Engineering and Priv.-Doz.,
Musculoskeletal Surgery, Klinik Sanssouci,
Imperial College London, Berlin, Germany
London, England Bruce D. Beynnon, PhD
Allen F. Anderson, MD Associate Professor,
Director, McClure Musculoskeletal Research Center,
Lipscomb Clinic Research and Department of Orthopaedics and
Education Foundation, Rehabilitation,
Tennessee Orthopedic Alliance, College of Medicine,
Nashville, Tennessee University of Vermont,
Christian N. Anderson, MD Burlington, Vermont
Resident, Robert H. Brophy, MD
Department of Orthopaedic Surgery, Fellow,
Vanderbilt University Medical Center, Shoulder/Sports Medicine,
Nashville, Tennessee Hospital for Special Surgery,
John C. Anderson, MD New York, New York
Pacific Orthopaedics and Sports Medicine; Charles H. Brown, Jr., MD
Medical Staff, Medical Director,
Portland Adventist Medical Center Abu Dhabi Knee and Sports Injury Centre,
Portland, Oregon Abu Dhabi, United Arab Emirates
xi
 List of Contributors

Taylor D. Brown, MD Lars Ejerhed, MD, PhD

Bone and Joint Center of Houston, Department of Orthopaedics,
Houston, Texas Northern Älvsborg County Hospital,
Anthony Buoncristiani, MD Uddevalla Hospital,
Fellow, Trollhättan Uddevalla, Sweden
Department of Orthopaedic Surgery, Carlo Fabbriciani, MD
University of Pittsburgh Medical Center, Professor and Chairman of Orthopaedics and Traumatology,
Pittsburgh, Pennsylvania Department of Orthopaedics,
David Caborn, MD Catholic University,
Department of Orthopaedic Surgery, Rome, Italy
University of Louisville, Julian A. Feller, FRACS
Louisville, Kentucky Associate Professor,
Guglielmo Cerullo, MD Musculoskeletal Research Centre,
Clinica Valle Giulia, La Trobe University;
Roma, Italy Orthopaedic Surgeon,
Neal C. Chen, MD La Trobe University Medical Centre,
Clinical Fellow, Melbourne, Victoria, Australia
Sports Medicine and Shoulder Service, Mario Ferretti, MD
Hospital for Special Surgery, Research Fellow,
New York, New York Department of Orthopaedic Surgery,
Pascal Christel, MD, PhD University of Pittsburgh Medical Center,
Professor of Orthopaedic Surgery, Pittsburgh, Pennsylvania
Institut de l'Appareil Locomoteur Nollet, Jean Pierre Franceschi, MD
Paris, France Hôpital de la Conception,
Vassilis Chouliaras, MD Marseille, France
Orthopaedic Sports Medicine Center, Ramces Francisco, MD
Department of Orthopaedic Surgery, Orthopaedic Surgeon/Affiliate,
University of Ioannina, Orthopaedic Arthroscopic Surgery International,
Ioannina, Greece Clinica Zucchi,
Massimo Cipolla, MD Milan, Italy
Clinica Valle Giulia, Vittorio Franco, MD
Roma, Italy Clinica Valle Giulia,
Philippe Colombet, MD Roma, Italy
Clinique du Sport de Bordeaux, Stuart E. Fromm, MD
Mérignac, France Black Hills Orthopaedic and Spine Center,
Nader Darwich, MD Rapid City, South Dakota
Deputy Medical Director, Freddie H. Fu, MD, DSc (Hon), DPs (Hon)
Abu Dhabi Knee and Sports Injury Centre, David Silver Professor and Chairman,
Abu Dhabi, United Arab Emirates Department of Orthopaedic Surgery,
Laura Deriu, MD University of Pittsburgh Medical Center,
Department of Orthopaedics, Pittsburgh, Pennsylvania
Catholic University, John P. Fulkerson, MD
Rome, Italy Orthopedic Associates of Hartford, P.C.;
Patrick Djian, MD Clinical Professor and Sports Medicine
Cabinet Goethe, Fellowship Director,
Institut de l'Appareil Locomoteur Nollet, Department of Orthopedic Surgery,
Paris, France University of Connecticut,
Apostolos P. Dimitroulias, MD Farmington, Connecticut
Orthopaedic Surgeon, William E. Garrett, Jr., MD, PhD
University Hospital of Larissa, Duke Sports Medicine Center,
Larissa, Greece Durham, North Carolina
xii
 List of Contributors

Anastasios Georgoulis, MD Stephen M. Howell, MD

Professor of Orthopaedic Surgery; Professor,
Chief, Department of Mechanical Engineering;
Orthopaedic Sports Medicine Center, Member of Biomedical Graduate Group,
Department of Orthopaedic Surgery, University of California at Davis,
University of Ioannina, Sacramento, California
Ioannina, Greece Mark R. Hutchinson, MD
George Giakas, BSc, PhD Professor of Orthopaedics and Sports Medicine,
Department of Sports Science, University of Illinois at Chicago,
University of Thessaly, Chicago, Illinois
Karyes, Trikala, Greece R.P.A. Janssen, MD
Enrico Giannì, MD Orthopaedic Surgeon,
Clinica Valle Giulia, Department of Orthopaedic Surgery and Traumatology,
Roma, Italy Máxima Medical Center,
Thomas J. Gill, MD Veldhoven, Netherlands
Assistant Professor, Timo Järvelä, MD, PhD
Department of Orthopedic Surgery, Department of Orthopaedics and Traumatology,
Harvard Medical School, Tampere City Hospital;
Boston, Massachusetts Tampere University,
Alberto Gobbi, MD Tampere, Finland;
Director, Department of Orthopaedics Surgery,
Orthopaedic Arthroscopic Surgery International, University of Pittsburgh Medical Center,
Clinica Zucchi, Pittsburgh, Pennsylvania
Milan, Italy Markku Järvinen, MD, PhD
Steven Gorin, DO Tampere University;
Institute of Sports Medicine and Orthopaedics, P.A. Department of Trauma, Musculoskeletal Surgery,
Aventura, Florida and Rehabilitation,
Tampere University Hospital,
Tinker Gray, MA, ELS
Tampere, Finland
Research Director,
Shelbourne Knee Center at Methodist Hospital, Don Johnson, MD, FRCS
Indianapolis, Indiana Director,
Sports Medicine Clinic,
Letha Y. Griffin, MD, PhD
Carleton University,
Peachtree Orthopaedic Clinic,
Ottawa, Ontario, Canada
Atlanta, Georgia
Brian T. Joyce, BA
David R. Guelich, MD
Research Coordinator,
Chicago Orthopaedics and Sports Medicine,
Illinois Sports Medicine and Orthopaedic Centers,
Chicago, Illinois
Glenview, Illinois
Yung Han, MD Auvo Kaikkonen, MD, PhD
Resident, Inion Oy;
McGill University Orthopaedic Surgery Residency Tampere University,
Program, Tampere, Finland
Montreal, Canada
Anastassios Karistinos, MD
Michael E. Hantes, MD Assistant Professor,
Consultant Orthopaedic Surgeon, Department of Orthopaedic Surgery,
University Hospital of Larisa, Baylor College of Medicine,
Larisa, Greece Houston, Texas
Aaron Hecker, MA Jüri Kartus, MD, PhD
Bioskills Laboratory Manager, Department of Orthopaedics,
Smith and Nephew, Norra Älvsborg/Uddevalla Hospital,
Mansfield, Massachusetts Trollhättan, Sweden
xiii
 List of Contributors

John F. Keating, BA, MB, BCh, BAO, MPhil, FRCSI, Giuseppe Milano, MD
FRCSEd Associate Professor,
Consultant Orthopaedic Surgeon, Department of Orthopedics,
Department of Trauma and Orthopaedics, Catholic University,
Royal Infirmary of Edinburgh, Rome, Italy
Edinburgh, United Kingdom Mark D. Miller, MD
James Kercher, MD Professor,
Emory School of Medicine, Department of Orthopaedic Surgery,
Emory University, Director of Sports Medicine,
Atlanta, Georgia University of Virginia;
Team Physician,
Petteri Kousa, MD, PhD James Madison University,
Department of Orthopaedics; Charlottesville, Virginia
Department of Surgery, Kai Mithoefer, MD
University of Tampere, Clinical Instructor in Orthopedic Surgery,
Tampere University Hospital, Harvard Medical School;
Tampere, Finland; Harvard Vanguard Orthopedics and Sports Medicine,
Department of Orthopaedics and Rehabilitation, Brigham and Women's Hospital,
McClure Musculoskeletal Research Center; Boston, Massachusetts
Department of Orthopaedics and Rehabilitation,
Tomoyuki Mochizuki, MD, PhD
College of Medicine,
Section of Orthopedic Surgery,
University of Vermont,
Division of Cartilege Regeneration,
Burlington, Vermont
Graduate School,
Jason Koh, MD Tokyo Medical and Dental University,
Northwestern Medical Faculty Foundation, Tokyo, Japan
Chicago, Illinois Anna-Stina Moisala, MD
Michael Kuhn, MD Tampere University,
Clinical Instructor, Surgery, Tampere, Finland
Uniformed Services University, Craig D. Morgan, MD
Bethesda, Maryland; The Morgan-Kalman Clinic,
Fellow, Wilmington, Delaware
Department of Orthopaedic Surgery and Sports Medicine, Constantina Moraiti, MD
New England Baptist Hospital, Department of Orthopaedic Surgery,
Boston, Massachusetts Orthopaedic Sports Medicine Center of Ioannina,
Bert R. Mandelbaum, MD University of Ioannina,
Santa Monica and Orthopaedic and Ioannina, Greece
Sports Medicine Foundation, Takeshi Muneta, MD, PhD
Santa Monica, California Section of Orthopedic Surgery,
Robert G. Marx, MD, MSc, FRCSC Division of Cartilege Regeneration,
Associate Professor of Orthopedic Surgery and Public Health, Graduate School,
Weill Medical College of Cornell University; Tokyo Medical and Dental University,
Attending Orthopedic Surgeon; Tokyo, Japan
Director, Foster Center for Clinical Outcome Research, Brian J. Murphy, MD
Hospital for Special Surgery, Freeworld Imaging,
New York, New York Miami, Florida
Brian P. McKeon, MD Janne T. Nurmi, DVM, PhD
Assistant Clinical Professor of Orthopedics, Inion Oy;
Tufts University; Faculty of Veterinary Medicine,
Head Team Physician, Boston Celtics, Department of Clinical Veterinary Sciences,
Boston Sports and Shoulder Center, University of Helsinki,
Chestnut Hill, Massachusetts Tampere, Finland
xiv
 List of Contributors

Nicholas E. Ohly, MBBS, MRCSEd New England Baptist Hospital,

Specialist Registrar, Boston, Massachusetts
Department of Trauma and Orthopaedics, Andrew Riff, BS
Royal Infirmary of Edinburgh, Medical Student,
Edinburgh, United Kingdom Georgetown University School of Medicine,
Antti Paakkala, MD, PhD Washington, DC
Department of Radiology, Stavros Ristanis, MD, PhD
Tampere University Hospital, Orthopaedic Sports Medicine Center,
Tampere, Finland Department of Orthopaedic Surgery,
Lonnie E. Paulos, MD University of Ioannina,
Professor, Ioannina, Greece
Orthopedic Surgery,
James Robinson, MD
Baylor College of Medicine;
Imperial College of Science,
Codirector,
Technology and Medicine,
The Roger Clemens Institute for Sports Medicine and
London, United Kingdom
Human Performance,
Houston, Texas Julie Rogowski, BS
Professional Education Coordinator,
Hans H. Paessler, MD
Illinois Sports Medicine and Orthopaedic Centers,
ATOS Clinic,
Glenview, Illinois
Center of Knee Surgery,
Foot Surgery and Sports Trauma, Abdou Sbihi, MD
Heidelberg, Germany Hôpital de la Conception,
Marseille, France
Hemant G. Pandit, FRCS (Orth)
North Hampshire Hospital, Sven Ulrich Scheffler, MD
Nuffield Orthopaedic Centre, Sports Medicine and Arthroscopy Service,
Oxford, United Kingdom Department of Orthopaedics and Traumatology,
Center for Musculoskeletal Surgery,
Michael J. Patzakis, MD
Charité, Campus Mitte, University Medicine Berlin,
Professor and Chairman,
Berlin, Germany
Department of Orthopaedic Surgery,
Keck School of Medicine, K. Donald Shelbourne, MD
University of Southern California; Shelbourne Knee Center at Methodist Hospital;
LACþUSC Medical Center, Associate Professor,
Los Angeles, California Department of Orthopaedics,
Indiana University School of Medicine,
Chadwick C. Prodromos, MD
Indianapolis, Indiana
President,
Illinois Sports Medicine and Orthopaedic Centers; Kelvin Shi, MS
Assistant Professor, Statistician,
Orthopaedic Surgery, Forest Labs, Inc.,
Section of Sports Medicine, New York, New York
Rush University Medical Center, Konsei Shino, MD, PhD
Chicago, Illinois Faculty of Comprehensive Rehabilitation,
Giancarlo Puddu, MD Osaka Prefecture University,
Clinica Valle Giulia, Osaka, Japan
Roma, Italy Holly J. Silvers, MPT
Paul Re, MD Director of Research,
Director, Santa Monica Orthopaedic and Sports Medicine
Sports Medicine Emerson Hospital Orthopaedic Affiliates, Research Foundation,
Concord, Massachusetts Santa Monica, California
John Richmond, MD Joseph H. Sklar, MD
Chairman, Assistant Clinical Professor,
Department of Orthopaedics, Tufts University School of Medicine;
xv
 List of Contributors

New England Orthopaedic Surgeons, Center for Musculoskeletal Surgery,

Springfield, Massachusetts Berlin, Germany
James R. Slauterbeck, MD Tony Wanich, MD
Associate Professor, Orthopaedic Resident,
McClure Musculoskeletal Research Center, Department of Orthopaedic Surgery,
Department of Orthopaedics and Rehabilitation, Hospital for Special Surgery,
College of Medicine, New York, New York
University of Vermont, Russell F. Warren, MD
Burlington, Vermont Professor of Orthopaedics,
James S. Starman, MD Weill Medical College of Cornell University;
Research Fellow, Surgeon-in-Chief,
Department of Orthopaedic Surgery, Hospital for Special Surgery,
University of Pittsburgh Medical Center, New York, New York
Pittsburgh, Pennsylvania Kate E. Webster, PhD
Nicholas Stergiou, PhD Research Fellow,
HPER Biomechanics Laboratory, Musculoskeletal Research Centre,
University of Nebraska at Omaha, La Trobe University,
Omaha, Nebraska Melbourne, Victoria, Australia
Neil P. Thomas, BSC, MB, BS, FRCS Andreas Weiler, MD, PhD
North Hampshire Hospital, Head of Sports Traumatology and
Basingstoke, United Kingdom; Arthroscopy Service,
Hampshire Clinic, Center for Musculoskeletal Surgery,
Wessex Knee Unit, Berlin, Germany
Hampshire, United Kingdom
Kazunori Yasuda, MD, PhD
Fotios Paul Tjoumakaris, MD Professor and Chairman,
Attending Physician, Department of Sports Medicine and
Department of Orthopaedics, Joint Surgery,
Cape Regional Medical Center, Hokkaido University School of Medicine,
Cape May Court House, New Jersey Sapporo, Japan
Harukazu Tohyama, MD, PhD Bing Yu, PhD
Associate Professor, Associate Professor,
Department of Sports Medicine, Division of Physical Therapy,
Hokkaido University School of Medicine, Department of Allied Health Sciences,
Sapporo, Japan The University of North Carolina at Chapel Hill,
Elias Tsepis, BSc, PT, MSc, PhD Chapel Hill, North Carolina
Associate Professor,
Charalampos G. Zalavras, MD
Physical Therapy,
Associate Professor,
Supreme Technological Institution of Patra at Aigio,
Department of Orthopaedic Surgery,
Patra, Greece
Keck School of Medicine,
Frank Norman Unterhauser, MD University of Southern California;
Center for Musculoskeletal Surgery, LACþUSC Medical Center,
Clinic for Trauma and Reconstructive Surgery, Los Angeles, California
Charité, Campus Mitte,
Bertram Zarins, MD
Berlin, Germany
Augustus Thorndike Clinical Professor of
George Vagenas, BSc, PhD Orthopaedic Surgery,
National and Kapodistrian University of Athens, Harvard Medical School;
Faculty of Physical Education and Sport Science, Chief,
Illioupolis, Attiki, Greece Sports Medicine Service,
Michael Wagner, MD Massachusetts General Hospital,
Sports Traumatology and Arthroscopy Service, Boston, Massachusetts
xvi
 PART A ANATOMY, PHYSIOLOGY, BIOMECHANICS, EPIDEMIOLOGY
Anatomy and Biomechanics of the
Anterior Cruciate Ligament
INTRODUCTION
Anterior cruciate ligament (ACL) reconstruction
is the sixth most common procedure performed
in orthopaedics, and it is estimated that between
75,000 and 100,000 ACL repair procedures are
performed annually in the United States alone.1,2
The ACL has therefore been intensively studied,
and outcomes of ACL surgery have received con-
siderable attention. This has included research on
surgical technique factors such as tunnel position,
graft choices, and fixation methods, as well as
postoperative rehabilitation protocols.
Traditional single-bundle ACL recon-
struction has focused on reconstruction of one
portion of the ACL, the anteromedial (AM)
bundle, and although outcomes are generally
good, with success rates between 69% and 95%,
there remains room for improvement.3,4 A pro-
spective study of a cohort of ACL reconstructed
patients 7 years after surgery revealed degenera-
tive radiographic changes in 95% of patients,
and only 47% were able to return to their previous
activity level following ACL reconstruction.5
However, it should be noted that some studies
of long-term follow-up have more encouraging
results. Jarvela et al demonstrated tibiofemoral
degenerative changes in only 18% of patients at
7 years follow-up post ACL reconstruction with
bone–patella–bone grafts.6 In addition, Roe
et al reported on a cohort of patients recon-
structed with bone–patellar tendon–bone grafts
and found an incidence of 45% with degenerative
radiographic changes at 7 years follow-up, as well
1
CHAPTER
as an incidence of 14% with degenerative changes James S. Starman
in a group with hamstring grafts.7
Mario Ferretti
A thorough review of the anatomy and
biomechanics of the normal ACL reveals key Timo Järvelä
points regarding its complex role in stabilization Anthony Buoncristiani
of the knee joint. Improved awareness of the ana- Freddie H. Fu
tomy and biomechanical properties of the normal
ACL may lead to improvements in techniques
for ACL reconstruction and an associated
improvement in outcomes over traditional
results. This chapter describes the normal anat-
omy of the two bundles of the ACL and reviews
the biomechanical contributions of each bundle.
ANTERIOR CRUCIATE LIGAMENT
ANATOMY
Historical Descriptions
One of the earliest known descriptions of the
human ACL was made around 3000 BC, written
on an Egyptian papyrus scroll. During the Roman
era, the earliest description of the ligament using
its modern name was made by Claudius Galen
of Pergamon (199–129 BC), who described the
“ligamenta genu cruciate.” In 1543 the first
known formal anatomical study of the human
ACL was completed by Andreas Vesalius in his
book De Humani Corporis Fabrica Libris Septum.
Two bundles of the ACL were described for
the first time in 1938 by Palmer et al, followed by
Abbott et al in 1944 and Girgis et al in 1975.8–10
Each author described an AM bundle and a
3
 Anterior Cruciate Ligament Injury
posterolateral (PL) bundle, named for the relative location of
the tibial insertion sites of each bundle. More recently, in
1979 and again in 1991, Norwood et al and Amis et al, respec-
tively, described a third bundle of the ACL anatomy, the
intermediate (IM) bundle.11,12 Although it may be said that a
two-bundle description of the ACL anatomy is an oversimpli-
fication of the complete anatomy, many studies have been
based on this functional division, and it has been accepted as
a reasonable way to understand the anatomy and biomechanics
of the ligament. The IM bundle is most similar to the AM
bundle in both anatomical and biomechanical considerations,
and for the purposes of this chapter it is therefore considered
as part of the AM bundle.
Anatomy of the Anteromedial and
Posterolateral Bundles
The ACL is a structure composed of numerous fascicles of
dense connective tissue that connect the distal femur and
the proximal tibia. Histological studies have demonstrated
that a septum of vascularized connective tissue is present that
separates the AM and PL bundles (Fig. 1-1). In addition, it
has been shown that the histological properties of the liga-
ment are variable at different stages in ACL development.
At the time of fetal ACL development, the ACL is
observed to be hypercellular with circular, oval, and fusi-
form-shaped cells. Later, in the adult ACL, the histology
reveals a relatively hypocellular pattern with predominantly
fibroblast cells with spindle-shaped nuclei.13,14
The ligament finds its origin on the medial surface of
the lateral femoral condyle (LFC), runs an oblique course
FIG. 1-1 Fetal anterior cruciate ligament, sagittal cut. Arrows indicate the
septum of vascularized connective tissue dividing the anteromedial (AM)
and posterolateral (PL) bundles.
4
within the knee joint from lateral and posterior to medial
and anterior, and inserts into a broad area of the central tibial
plateau. The cross-sectional area of the ligament varies signi-
ficantly throughout its course from approximately 44 mm2 at
the midsubstance to more than three times as much at both its
origin and insertion.10,15,16 The total length of the ligament is
approximately 31 to 38 mm and varies by as much as 10%
throughout a normal range of motion.17
Anterior Cruciate Ligament Development
ACL formation has been observed in fetal development as early
as 8 weeks, corresponding to O'Rahilly stages 20 and 21.18,19
A leading hypothesis holds that the ACL originates as a
ventral condensation of the fetal blastoma and gradually
migrates posteriorly with the formation of the intercondylar
space.20 The menisci are derived from the same blastoma
condensation as the ACL, a finding that is consistent with
the hypothesis that these structures function in concert.21
Another proposed mechanism of fetal ACL formation is from
a confluence between ligamentous collagen fibers and fibers of
the periosteum.22 Following the initial formation of the liga-
ment, no major organizational or compositional changes are
observed throughout the remainder of fetal development.19
Two distinct bundles of the ACL are present at 16
weeks of gestation (Fig. 1-2). In arthroscopy, the AM and
PL bundles can also be appreciated, particularly with the
knee held in 90 to 120 degrees of flexion (Fig. 1-3). Finally,
cadaveric dissection also reveals two anatomical bundles of
the ACL (Fig. 1-4). In summary, there is a considerable
amount of interindividual variability with respect to the rel-
ative sizes of the AM and PL bundles, as seen in fetal,
arthroscopic, and cadaveric studies; however, all individuals
with an intact ACL have both bundles of ligament.
Insertion Site Anatomy
Anatomical studies have characterized the individual contri-
butions of both the AM and PL bundles to the overall ACL
architecture. Odensten and Gillquist described the femoral
origin of the ACL as an ovoid area measuring 18 mm in
length and 11 mm in width.23 Within this area, the AM
bundle occupies a position located on the proximal portion
of the medial wall of the LFC, and the PL bundle occupies
a more distal position near the anterior articular cartilage
surface of the LFC (Fig. 1-5, A). Harner et al studied the
digitized origin and insertion of the AM and PL bundles
in five cadavers and concluded that each bundle occupies
approximately 50% of the total femoral origin, with cross-
sectional areas of 47  13 mm2 and 49  13 mm2 for
AM and PL, respectively.16
 Anatomy and Biomechanics of the Anterior Cruciate Ligament 1

FIG. 1-2 16-week fetus demonstrating two bundles of the anterior cruciate ligament with the knee in extension
(A, sagittal view with medial femoral condyle removed) and flexion (B, frontal view). AM, Anteromedial; LFC, lateral
femoral condyle; PL, posterolateral.

FIG. 1-3 Arthroscopic view of anteromedial (AM) and posterolateral (PL)

FIG. 1-4 Two distinct bundles of ACL present in cadaveric specimen.
bundles in 14-year-old female. Left knee, 110 degrees flexion. LFC, Lateral
Left knee, 90 degrees flexion. AM, Anteromedial; LFC, lateral femoral
femoral condyle.
condyle; PL, posterolateral.

On the tibia, the insertions of the AM and PL bundles
are located between the medial and lateral tibial spine over a
broad area stretching as far posterior as the posterior root of
the lateral meniscus. The full ACL insertion has been
described as an oval area measuring 11 mm in diameter in the
coronal plane and 17 mm in the sagittal plane.10,15,24 Within
this area the AM bundle insertion can be found in an anterior
and medial position, whereas the PL bundle insertion is located
more posteriorly and laterally (Fig. 1-5, B). Posteriorly, fibers of
the PL bundle are in close approximation to the posterior root
of the lateral meniscus and, in some individuals, may attach to
the meniscus itself (Fig. 1-6). The overall size of the tibial
insertion is approximately 120% of the femoral origin; how-
ever, as is the case with the femoral origin, the two bundles

5
 Anterior Cruciate Ligament Injury
FIG. 1-5 A, Femoral insertion sites of anteromedial (AM) and posterolateral (PL) bundles (right knee, medial
femoral condyle removed). B, Tibial insertion sites of AM and PL bundles (right knee tibial plateau, menisci
removed). Lat men, Lateral meniscus; MM, medial meniscus.
FIG. 1-6 Posterolateral (PL) bundle tibial insertion is located just anterior to
the posterior root of the lateral meniscus (Lat men). Left knee, arthroscopic
view.
share approximately equal tibial insertion site areas: the AM
bundle occupies 56  21 mm2, and the PL bundle occupies
53  21 mm2.16
The size and length of each bundle is also unique.
The AM bundle is approximately 38 mm in length.10,15,17
The PL bundle has been less well studied. Kummer and
Yamamoto measured the PL bundle in 50 cadavers and
determined an average length of 17.8 mm.25 However, the
AM and PL bundles have a similar diameter.
Crossing Pattern
Based on their anatomical positions, the AM and PL bun-
dles change alignment as the knee moves from extension to
6
flexion. The femoral insertion sites are oriented vertically
when the knee is in zero degrees, and the two bundles of
the ACL are oriented in parallel (Fig. 1-7). As the knee
moves into 90 degrees of flexion, the AM bundle insertion
site on the femur rotates posteriorly and inferiorly, in con-
trast to the femoral insertion of the PL bundle, which
rotates anteriorly and superiorly. This change in alignment
of the insertion sites leads to a horizontal plane of insertions
for the AM and PL bundle with the knee in 90 degrees of
flexion (Fig. 1-8). The change in insertion site alignment
causes the two bundles to twist around each other and
become crossed. As the knee is flexed, the PL bundle can
be seen anterior to the AM bundle at its femoral insertion
(Fig. 1-9).
Tensioning Pattern
The change in alignment of the AM and PL femoral insertion
sites allows the ACL to twist around itself as it is moved
through a complete range of motion. Clearly, this crossing
pattern, along with the differences in the length of each bun-
dle, has implications for the tensioning pattern of the overall
ligament and each individual bundle. In a study by Gabriel
et al, forces were measured in each bundle during an anterior
load of 134N over several flexion angles, as well as for a com-
bined rotatory load of 10 Nm valgus and 5 Nm internal tibial
torque.26 The results showed that the PL bundle is tightest in
extension (in situ force of 67  30N) and becomes relaxed as
the knee is flexed, whereas the AM bundle is more relaxed in
extension, and reaches a maximum tightness as the knee
approaches 60 degrees of flexion (in situ forces of 90 
17N).12,26 This tensioning pattern also can be observed
grossly in cadaveric and arthroscopic views of the bundles
(Fig. 1-10). The PL bundle is also observed to tighten during
internal and external rotation.
 Anatomy and Biomechanics of the Anterior Cruciate Ligament 1

FIG. 1-7 Crossing pattern of anteromedial (AM) and posterolateral (PL) bundles. With the knee in extension, the
AM and PL bundles are parallel (A, left knee, medial femoral condyle removed) and the insertion sites are oriented
vertically (B).

FIG. 1-8 Crossing pattern of anteromedial (AM) and posterolateral (PL) bundles. With the knee in flexion, the AM
and PL bundles are crossed (A, left knee, medial femoral condyle removed) and the insertion sites are oriented
horizontally (B).

In summary, the ACL consists of two distinct bun-

dles, the AM and PL bundles, and these bundles contribute
synergistically to the stability of the knee. The alignment of
the insertion sites of AM and PL on the femur allows the
ligament to become crossed as the knee is flexed and can
be observed as a vertical alignment of the femoral insertion
sites during extension and a horizontal alignment of femoral
insertion sites during flexion. We will now turn our atten-
tion to biomechanics for a review of the role of the ACL
and the specific contributions of each bundle.
BIOMECHANICS
Historical Studies
The field of biomechanics has a long history, with the ear-
liest known considerations dating back to Chinese and
Greek literature around 400 to 500 BC. The first modern
work in biomechanics was completed during the 1500s to
1700s by well-known figures such as Galileo, DaVinci, Bor-
elli, Hooke, and Newton. Orthopaedic biomechanics was

7
 Anterior Cruciate Ligament Injury

FIG. 1-9 Arthroscopic view and computer model of anteromedial (AM) and posterolateral (PL) bundle crossing
pattern in extension (top) and flexion (bottom). The PL bundle is obscured in extension but becomes visible in
flexion as it moves anteriorly on the femoral side. LFC, Lateral femoral condyle.

FIG. 1-10 Arthroscopic views of an anterior cruciate ligament (ACL)-injured left knee with an intact posterolateral
(PL) bundle and torn anteromedial bundle (removed). In extension, the PL bundle is tensioned maximally and
appears taut (A), and in 90 degrees flexion, the PL bundle is more relaxed (B).

8

initially advanced during the 1940s and 1950s by the work
of Eadweard Muybridge, Arthur Steindler, Verne Inman,
Henry Lissner, and A. H. Hirsch. Since the 1960s, the
information learned from biomechanical studies in orthope-
dics has been applied to refine clinical treatment approaches.
Anterior-Posterior Translation Control
The dynamic nature of the two bundles of the ACL during
knee flexion demonstrates the complex role of the ACL in
stabilization of the knee joint. However, initial biomechani-
cal studies of the ACL focused mainly on its function of
resisting anterior tibial translation.27,28 From this work we
know that the in situ forces of the ACL vary considerably
during a normal range of motion of the knee joint. With
a 110N anterior tibial load applied, the ACL demonstrates
high in situ forces between 0 and 30 degrees flexion, with
a maximum occurring at 15 degrees. In situ forces are at
their lowest point between 60 and 90 degrees, with a mini-
mum occurring at 90 degrees.
As mentioned earlier, recent studies have also been
completed to evaluate the individual roles of each bundle
of the ACL in anterior-posterior translation. These studies
have shown that the AM bundle has relatively constant
levels of in situ forces during knee flexion, whereas the PL
bundle is more variable, with high in situ forces at 0, 15,
and 30 degrees of flexion but rapidly decreasing in situ
forces beyond this angle.28
Rotational Stability
Clinical experience has suggested that biomechanical con-
siderations of anterior-posterior translation alone do not
correlate with subjective evaluations of knee stability and
that a more complete evaluation of the role of rotational sta-
bility is relevant.29 Therefore, in recent years closer attention
has been given to the rotational stabilizing function of the
ACL.26,30,31 Included in the study by Gabriel et al was an
analysis of a combined rotatory load of 10 Nm valgus and
5 Nm internal tibial torque at 15 and 30 degrees flexion.
For the PL bundle, in situ forces of 21N were recorded at
15 degrees and 14N at 30 degrees. For the AM bundle, in
situ forces were 30N and 35N, respectively. This demon-
strates that the both the AM and PL bundles contribute
to rotational stability of the knee at these angles.
In addition to biomechanical studies, recent studies
using in vivo kinematics analysis have assessed rotational
stability in the ACL during various functional activities such
as walking, running, and cutting.32–34 Andriacchi et al stud-
ied the in vivo kinematics of normal and ACL-deficient
subjects during four phases of walking and determined that
Anatomy and Biomechanics of the Anterior Cruciate Ligament 1
an ACL-deficient knee is positioned differently than a nor-
mal knee. During walking, the intact ACL maintains a bal-
ance of rotation during the interval of swing phase to heel
strike. However, in the ACL-deficient knee, an increased
internal rotation occurs between these phases of walking,
which is maintained through the stance phase.30 A study
of running and cutting in ACL-deficient patients demon-
strated normal anterior-posterior stability during running
but abnormal rotational movements compared with subjects
with an intact ACL.34
Finally, a magnetic resonance imaging (MRI)-based
study of the in vivo kinematics of the normal ACL during
weight-bearing knee flexion has demonstrated that several
components of ACL kinematics change during weight-
bearing knee flexion. First, as the flexion angle increases,
axial rotation (or twist) of the ACL increases as well. At full
extension the ACL is internally twisted by approximately 10
degrees; however, this increases to approximately 20 degrees
when the knee is moved to 30 degrees flexion, and it
increases to approximately 40 degrees with the knee at 60
to 90 degrees flexion. Second, the orientation of the liga-
ment within the joint space changes with the flexion angle.
As the knee flexion angle increases, so does the lateral angu-
lation of the ligament. Therefore, the ligament may possess
a lateral force component, functioning to constrain internal
tibial rotation.32,33
In summary, the ACL provides an important part of
rotational stability during both low- and high-demand
activities by helping to maintain the normal position of
the tibiofemoral contact, a role that is shared by both
bundles of the ligament.
Biomechanics Considerations in Anterior
Cruciate Ligament Surgery
Based on the aforementioned research into the role of rota-
tional stability, work has been completed to assess the ability
of different surgical techniques in restoring both anterior-
posterior translation of the knee and rotational stability. Yagi
et al performed a study comparing a single-bundle reconstruc-
tion with the femoral tunnel placed at the 11- or 1-o'clock
position with anatomical double-bundle ACL reconstruction
and the femoral tunnels placed based on the insertion site
anatomy of the transected ACL.35 In this study, the double-
bundle ACL reconstruction was better able to resist anterior
tibial translation at full extension and 30 degrees flexion,
compared with the single-bundle technique. Additionally,
when a combined internal tibial and valgus torque was applied
at 15 and 30 degrees flexion, the double-bundle ACL recon-
struction had a response closer to the intact ACL compared
with the single-bundle technique.
9
 Anterior Cruciate Ligament Injury
Yamamoto et al compared the double-bundle ACL
reconstruction with a lateral single-bundle reconstruction,
with the femoral tunnel placed approximately at a 10-o'clock
position for the right knee.36 The double-bundle anatomical
reconstruction better restored the anterior tibial translation
at 60 degrees and 90 degrees flexion when compared with
the single-bundle technique.36
Finally, Tashman et al performed an in vivo kinemat-
ics analysis of normal and single-bundle reconstructed
knees.31 Subjects with a normal ACL were compared with
a group of single-bundle ACL reconstructed patients to
evaluate anterior-posterior translation and knee rotation
during downhill jogging. Single-bundle ACL reconstructed
patients had fully restored anterior-posterior translation as
compared with subjects with a normal ACL but were found
to lack normal rotational kinematics.31 Because the single-
bundle reconstruction is an approximation of the position
of the AM bundle, it can be concluded that part of the
rotational stability is derived from the actions of the PL
bundle.
In summary, Yagi et al and Yamamoto et al have
demonstrated that normal anterior-posterior translation
may be restored using traditional single-bundle reconstruc-
tion techniques. However, it is not possible to restore rota-
tional stability using this approach.35,36 In addition,
Tashman et al have shown that single-bundle reconstruction
is not capable of restoring normal rotational kinematics.36
Anatomical double-bundle reconstruction, in contrast,
offers an opportunity to restore both components of normal
knee stability as demonstrated in cadaveric biomechanics
studies, and it is possible that this will soon be demonstrated
in an in vivo kinematics model as well.35,36
CONCLUSION
The anatomy of the ACL shows that the ligament consists
of two distinct and functional bundles, the AM and PL
bundles. These two bundles have unique points of attach-
ment in the knee, and this leads to their complex spatial
relationship throughout knee flexion, as well as their differ-
ent roles in biomechanics and knee stability. It is important
to take the anatomical properties of the ACL into consider-
ation when performing ACL surgery. This may lead to a
more accurate restoration of knee kinematics to the native
state and improvements in long-term outcomes. However,
although the current body of knowledge of the anatomy
and biomechanics of the ACL is extensive, it remains
incomplete. Future work in areas such as in vivo kinematics
will allow for a more complete understanding of rotational
stability and knee motion during complex movements.
10
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4. Freedman KB, D'Amato MJ, Nedeff DD, et al. Arthroscopic
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7. Roe J, Pinczewski LA, Russell VJ, et al. A seven year follow-up of
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ligament. Fibre bundle actions related to ligament replacement and
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15. Arnoczsky SP. Anatomy of the anterior cruciate ligament. Clin Orthop
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16. Harner CD, Baek GH, Vogrin TM, et al. Quantitative analysis of
human cruciate ligament insertions. Arthroscopy 1999;15:741–749.
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cruciate ligament reconstruction. Part 1: biology and biomechanics of
reconstruction. Am J Sports Med 1999;27:821–830.
18. O'Rahilly R. The early prenatal development of the human knee joint.
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21. Galleazzi R. Clinical and experimental study of the semilunar cartilage
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23. Odensten M, Gillquist J. Functional anatomy of the anterior cru-
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24. Petersen W, Tillmann B. Anatomy and function of the anterior cruci-
ate ligament. Orthopade 2002;31:710–718.

25. Kummer B, Yamamoto Y. [Funktionelle Anatomie der Kreuzbaen-
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situ loads on the human anterior cruciate ligament. J Orthop Res
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deficient limb during running and cutting. Knee Surg Sports Traumatol
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11
 2
CHAPTER
Mechanisms of Noncontact Anterior
Cruciate Ligament Injuries
William E. Garrett, Jr. As in the prevention of other injuries in sports,
understanding injury mechanisms is a key compo-
Bing Yu
nent of preventing noncontact anterior cruciate
ligament (ACL) injuries.1 The research effort to
determine risk factors of sustaining noncontact
ACL injuries is increasing as the concerns of
increased incidents and cost for treatment, as well
as serious consequences of noncontact ACL
injuries, are growing. Prospective cohort studies
are commonly used in epidemiological research
designs for determining risk factors of injuries
and diseases2 and are being used to determine risk
factors of sustaining noncontact ACL injuries.3
The results of epidemiological studies with cohort
designs, however, are descriptive in nature and
lack cause-and-effect relationship between iden-
tified risk factors and the injury.2 Without a good
understanding of the injury mechanisms, the risk
factors of sustaining noncontact ACL injuries
identified from epidemiological studies could be
misinterpreted and could lead to the selection of
nonoptimal injury prevention programs.
Injuries of the ACL frequently occur in
athletic movements such as stopping or quickly
changing directions. These kinds of movements
often are awkward and off-balance maneuvers.
Video analysis often shows a hard landing with
the knee near full extension in these movements
as the athlete experienced a sensation of the knee
collapsing into a valgus position. The quadriceps
muscles are likely to be the major source of the
anterior shear force that causes the rupture of
the ACL in these movements. However, we have
not been accustomed to considering the fact that
our own muscles can create injuries. Although a
12
valgus moment applied to the knee can create
enough deformation to cause an injury of the
ACL, few noncontact ACL injuries involve seri-
ous injuries to the medial collateral ligament
(MCL) that would occur if the knee sustained
sufficient valgus moment loading to injure the
ACL. This chapter will examine biomechanical
studies relating to ACL injury and explore strains
induced by the quadriceps muscles near full knee
extension and by valgus moment loading.
Mechanically, ACL injury occurs when
an excessive tension force is applied on the
ACL. A noncontact ACL injury occurs when
a person self-generates great forces or moments
at the knee that applied excessive loading on the
ACL. An understanding of the mechanisms of
ACL loading during active human movements,
therefore, is crucial for understanding the
mechanisms of noncontact ACL injuries and
risk factors of sustaining noncontact ACL inju-
ries. Berns et al4 investigated the effects of com-
bined knee loading on ACL strain on 13
cadaver knees. The strain of the anteromedial
(AM) bundle of the ACL was recorded using
liquid mercury strain gauges at 0 and 30 degrees
knee flexion. The results of this study showed
that anterior shear force on the proximal end
of the tibia was the primary determinant of the
strain in the AM bundle of the ACL, whereas
neither pure knee internal-external rotation
moment nor pure knee valgus-varus moment
had significant effects on the strain of the AM
bundle of the ACL. The results of this study
further showed that anterior shear force at the
proximal end of the tibia combined with a knee

valgus moment resulted in a significantly greater strain in
the AM bundle of the ACL than did the anterior shear
force at the proximal end of the tibia alone.
Markolf et al5 also investigated effects of anterior
shear force at the proximal end of the tibia and knee valgus,
varus, internal rotation, and external rotation moments on
the ACL loading of cadaver knees. A 100N anterior shear
force and 10-Nm knee valgus, varus, internal rotation, and
external rotation moments were added to cadaver knees.
The ACL loading was recorded as the knee was extended
from 90 degrees flexion to 5 degrees hyperextension. The
results of this study showed that an anterior shear force on
the tibia generated significant ACL loading, whereas the
knee valgus, varus, and internal rotation moments also gen-
erated significant ACL loading only when the ACL was
loaded by the anterior shear force at the proximal end of
the tibia. The results of this study further showed that the
ACL loading due to the anterior shear force combined with
either a valgus or a varus moment to the knee was greater
than that due to the anterior shear force alone, whereas
the ACL loading due to the anterior shear force combined
with a knee external rotation moment was lower than that
due to anterior shear force alone. The knee valgus and exter-
nal rotation moment loading are elements of dynamic valgus
that many current ACL injury prevention programs are
trying to avoid.3 The results of the study by Markolf et al5
also showed that ACL loading due to the combined knee
varus and internal rotation moment loading was greater than
that due to either knee varus moment loading or internal
rotation moment loading alone and that the ACL loading
due to combined knee valgus and external rotation moment
loading was lower than that due to either knee valgus or
external rotation moment loading alone. Finally, the results
of this study showed that the ACL loading due to the ante-
rior shear force and knee valgus, varus, and internal rotation
moments increased as the knee flexion angle decreased.
Fleming et al6 studied the effects of weight bearing and
tibia external loading on ACL strain. They implanted a
differential variable reluctance transducer to the AM bundle
of the ACL of 11 subjects. ACL strains were measured
in vivo when a subject's leg was attached to a knee loading
fixture that allowed independent application of anterior-
posterior shear force, valgus-varus moments, and internal-
external rotation moments to the tibia and simulation of
weight-bearing conditions. The anterior shear force was
applied on the proximal end of the tibia from 0N to 130N
in 10-N increments. The valgus-varus moments were applied
to the knee from 10 Nm to 10 Nm in 1-Nm increments.
The internal-external rotation moments were applied to the
knee from 9 Nm to 9 Nm in 1-Nm increments. The knee
flexion angle was fixed at 20 degrees during the test. The
results of this study showed that ACL strain significantly
Mechanisms of Noncontact Anterior Cruciate Ligament Injuries 2
increased as the anterior shear force at the proximal end of
the tibia and the knee internal rotation moment increased,
whereas knee valgus-varus and external rotation moments
had little effects on ACL strain under the weight-bearing
condition.
The previously mentioned studies consistently showed
that the anterior shear force at the proximal end of the tibia
is a major contributor to ACL loading, whereas the knee
valgus, varus, and internal rotation moments may increase
ACL loading when an anterior shear force at the proximal
end of the tibia is applied. According to these ACL loading
mechanisms, a small knee flexion angle, a strong quadriceps
muscle contraction, or a great posterior ground reaction
force can increase ACL loading.
Quadriceps muscles are the major contributor to the
anterior shear force at the proximal end of the tibia through
the patella tendon. DeMorat et al7 demonstrated that a
4500-N quadriceps muscle force could create ACL injuries
at 20 degrees knee flexion. Eleven cadaver knee specimens
were fixed to a knee simulator and loaded with 4500-N
quadriceps muscle force. Quadriceps muscle contraction
tests at 400 N (Q-400 tests) and KT-1000 tests were per-
formed before and after the 4500-N quadriceps muscle force
loading. Tibia anterior translations were recorded during the
Q-400 and KT-1000 tests. All cadaver knee specimens were
dissected after all tests to determine the ACL injury states.
Six of the 11 specimens had confirmed ACL injuries (three
complete ACL tears and three partial tears). All specimens
showed increased tibia anterior translation in Q-400 and
KT-1000 tests. The result of this study also showed that
quadriceps muscle contraction caused not only tibia anterior
translation but also tibia internal rotation.
Decreasing knee flexion angle increases the anterior
shear force at the proximal end of the tibia by increasing
the patella tendon–tibia shaft angle. With a given quadri-
ceps muscle force, the anterior shear force at the proximal
end of the tibia is determined by the patella tendon–tibia
shaft angle, defined as the angle between the patella tendon
and the longitudinal axis of the tibia.8 With a given quadri-
ceps muscle force, the greater the patella tendon–tibia shaft
angle, the greater the anterior shear force on the tibia.
Nunley et al8 studied the relationship between the patella
tendon–tibia shaft angle and knee flexion angle with weight
bearing. Ten male and 10 female university students with-
out known history of lower extremity injuries were recruited
as the subjects. Sagittal plane x-ray films were taken for each
subject at 0, 15, 30, 45, 60, 75, and 90 degrees knee flexion,
bearing 50% of body weight. Patella tendon–tibia shaft
angles were measured from the x-ray films. Regression ana-
lyses were performed to determine the relationship between
patella tendon–tibia shaft angle and knee flexion angle and
to compare the relationship between genders. The results
13
 Anterior Cruciate Ligament Injury
showed that the patella tendon–tibia shaft angle was a func-
tion of the knee flexion angle, with the patella tendon–tibia
shaft angle increasing as the knee flexion angle decreased,
and that on average the patella tendon–tibia shaft angle
was 4 degrees greater in females than in males. The rela-
tionship between the patella tendon–tibia shaft angle and
knee flexion angle obtained by Nunley et al8 was consistent
with those from other studies on the patella tendon–tibia
shaft angle under non–weight-bearing conditions.9–11
Decreasing the knee flexion angle also increases ACL
loading by increasing the ACL elevation angle and deviation
angle, defined as the angle between the longitudinal axis of
the ACL and the tibia plateau and the angle between the
projection of the longitudinal axis of the ACL on the tibia
plateau and the posterior direction of the tibia, respectively.12
The resultant force along the longitudinal axis of the ACL
equals the anterior shear force on the ACL divided by the
cosines of the ACL elevation and deviation angles. The
greater the ACL elevation and deviation angles, the greater
the ACL loading with a given anterior shear force on the
ACL. Li et al12 determined the in vivo ACL elevation and
deviation angles as functions of the knee flexion angle with
weight bearing. Five young and healthy volunteers were
recruited as the subjects. The ACL elevation and deviation
angles at 0, 30, 60, and 90 degrees knee flexion with weight
bearing were obtained using individualized dual-orthogonal
fluoroscopic images and magnetic resonance imaging
(MRI)-based, three-dimensional (3D) models. The results
of this study showed that both the ACL elevation and devia-
tion angles increased as the knee flexion angle decreased.
Several studies show that ACL loading increases as
the knee flexion angle decreases. Arms et al13 studied the
biomechanics of ACL rehabilitation and reconstruction and
found that quadriceps muscle contraction significantly
strained the ACL from 0 to 45 degrees knee flexion but did
not strain the ACL when knee flexion was greater than 60
degrees. Beynnon et al14 measured the in vivo ACL strain
during rehabilitation exercises and found that isometric
quadriceps muscle contraction resulted in a significant
increase in ACL strain at 15 and 30 degrees knee flexions
but resulted in no change in ACL strain relative to the relaxed
muscle condition at 60 and 90 degrees knee flexion.
Li et al15,16 investigated the quadriceps and hamstring muscle
loading on ACL loading and showed that the in situ ACL
loading increased as the knee flexion angle decreased when
quadriceps muscles were loaded, regardless of the hamstring
muscle loading conditions.
Literature also shows that individuals at high risk of
sustaining noncontact ACL injuries have a smaller knee
flexion angle during athletic tasks than do individuals at low
risk. Epidemiological studies show that female athletes are
at higher risk of sustaining noncontact ACL injuries than
14
their male counterparts.17–24 Recent biomechanical studies
demonstrated that female recreational athletes exhibited
small knee flexion angles in running, jumping, and cutting
tasks.25,26 Studies also demonstrate that female adolescent
athletes had a sharply increased ACL injury rate after age 13
years.27,28 A recent biomechanical study showed that female
adolescent soccer players started decreasing their knee flexion
angle during a stop-jump task after age 13 years.29 Taken
together, these results suggest that small knee flexion angle
during landing tasks may be a risk factor of sustaining
noncontact ACL injuries.
Increasing peak posterior ground reaction forces dur-
ing athletic tasks increases ACL loading by inducing an
increased quadriceps muscle contraction. A posterior ground
reaction force creates a flexion moment relative to the knee,
which needs to be balanced by a knee extension moment
generated by the quadriceps muscles.30 As previously
described, the quadriceps muscle contraction adds an ante-
rior shear force on the proximal end of the tibia through
the patella tendon. The greater the posterior ground reac-
tion force, the greater the quadriceps muscle force and the
greater the ACL loading.30 Cerulli et al31 and Lamontagne
et al32 recently recorded in vivo ACL strain in a hop-land-
ing task. A differential variable reluctance transducer was
implemented on the middle portion of the AM bundle of
the ACLs of three subjects through surgical procedures.
Subjects then performed the hop-landing task in a biome-
chanics laboratory. Force plate, electromyography (EMG),
and in vivo ACL strain were recorded simultaneously. The
results of this study showed that the peak ACL strain
occurred at the impact peak vertical ground reaction force
shortly after initial contact between foot and ground.
Yu et al30 demonstrated that peak impact vertical and
posterior ground reaction forces occurred essentially at the
same time. Taken together, these results suggest that a hard
landing with a great impact posterior ground reaction force
may be a risk factor of sustaining noncontact ACL injuries.
Literature shows that individuals at a high risk of sus-
taining noncontact ACL injuries have greater peak posterior
ground reaction forces in athletic tasks. Chappell et al26
studied the lower extremity kinetics as well as kinematics
of university-age recreational athletes during landings of
stop-jump tasks. Their results showed that female recrea-
tional athletes had greater peak resultant proximal tibia
anterior shear force and knee joint resultant extension
moment during landings of stop-jump tasks than did male
recreational athletes. Yu et al studied the immediate effects
of a newly designed knee brace with a constraint to knee
extension during a stop-jump task.29–29b Their results
showed that the university-age female recreational athletes
had greater peak posterior ground reaction force during
the landing of the stop-jump task than did their male

counterparts. Yu et al30 showed that the resultant peak
proximal tibia anterior shear force was positively correlated
to the peak posterior ground reaction force.
Hamstring co-contractions protecting the ACL have
been a longstanding clinical concept because hamstring
muscles provide a posterior shear force on the tibia that is
supposed to reduce the anterior shear force on the tibia
from the patellar tendon and thus unload the ACL. Recent
scientific studies, however, did not support this concept.
Li et al15 showed in a cadaver study that hamstring co-
contraction did not significantly decrease tibia anterior
translation when the knee flexion angle was less than 30
degrees. Beynnon et al14 found that the isometric hamstring
co-contraction of the hamstring muscles did reduce in vivo
ACL strain between 15 and 60 degrees knee flexion. Kingma
et al33 found that hamstring muscle activation increased only
1.3 to 2.0 times, whereas knee extension moment increased
2.7 to 3.4 times with a knee flexion angle between 5 and
50 degrees, which did not suggest a hamstring recruitment
pattern to reduce the ACL loading. O'Connor,34 Pandy
et al,35 and Yu et al29 all studied ACL loading using a model-
ing and computer simulation approach and showed that the
hamstring muscles did not reduce ACL loading at all when
the knee flexion angle was small.
Although biomechanical studies showed that the knee
valgus moment was not a major mechanism of ACL loading,
a recent epidemiological study by Hewett et al3 reported that
external knee valgus moment in a vertical drop landing–jump
task was a predictor of ACL injuries. A total of 205 high
school soccer, basketball, and volleyball players were followed
for three competition seasons. Knee flexion and valgus angles
at initial foot contact with the ground and the maximum knee
flexion and valgus angles and maximum moments during
the stance phase of the vertical drop landing–jump task
were recorded prospectively for every subject. A total of nine
subjects sustained ACL injuries after three competition sea-
sons. The results of this study showed that knee abduction
angle at landing was 8 degrees greater in ACL-injured than
in uninjured athletes and that ACL-injured athletes had a
2.5 times greater peak external knee valgus moment and
20% higher peak vertical ground reaction force than did
uninjured athletes. The results further showed that peak
external knee valgus moment predicted ACL injury status
with 73% specificity, 78% sensitivity, and a predictive R2
value of 0.88. The results of this study appear to suggest an
association between knee valgus angle and moment with
ACL injuries.
However, we may have to be cautious when interpret-
ing the association of knee valgus angle and moment with
noncontact ACL injuries observed in the study by Hewett
et al.3 The observed preinjury knee valgus moments of
the nine subjects who suffered ACL injuries in this study
Mechanisms of Noncontact Anterior Cruciate Ligament Injuries 2
were less than 0.12 Nm/body weight/standing height. The
average body weight and stranding height of the injured
subjects in this study were 62 kg and 1.68 m, respectively.
This means that the preinjury knee valgus moments of the
nine injured subjects in this study were less than 12.5 Nm.
These knee valgus moment loadings were similar to those
in the studies by Berns et al,4 Markolf et al,5 and Fleming
et al,6 which demonstrated that knee valgus loading did
not significantly affect ACL loading unless a significant
proximal tibia anterior shear force was applied. Further-
more, several other studies in the current literature demon-
strate that knee valgus moment loading alone cannot
injure the ACL when the MCL is intact. Bendjaballah
et al36 studied the effects of knee valgus-varus moment
loading on cruciate and collateral ligament loadings using
a finite element model. Their results suggest that cruciate
ligaments are not major valgus-varus moment loading bear-
ing structures when collateral ligaments are intact. Matsu-
moto et al37 investigated the roles of the ACL and MCL
in preventing knee valgus instability using cadaver knees.
Their results demonstrate that the MCL is the major struc-
ture to stop medial knee space opening. Mazzocca et al38
tested the effect of knee valgus loading on MCL and
ACL injuries. They found that the response of the ACL
strain to knee valgus moment loading was minimal when
the MCL was intact but significantly increased after the
MCL rupture began due to knee valgus moment loading.
Their results show that the ACL still had about 60% of
its original strength after complete MCL ruptures with
medial knee space openings greater than 15 mm due to knee
valgus moment loading. This study clearly demonstrates
that a complete ACL rupture due to knee valgus moment
loading without a complete MCL rupture (grade III injury)
is unlikely, whereas clinical observations show that the
majority of noncontact ACL injuries do not have significant
MCL injuries. A recent study by Fayad et al39 showed that
only 5 of a total of 84 contact and noncontact ACL injuries
had complete MCL ruptures. Taken together, these studies
suggest that knee valgus moment loading alone is not likely
to be a major ACL loading mechanism that can result in
ACL rupture or a major risk factor of sustaining noncontact
ACL injuries. More scientific studies are needed before we
can confidently interpret the association of knee valgus
angle and moment with noncontact ACL injuries as a sole
risk factor of sustaining noncontact ACL injuries.
In summary, the current literature clearly suggests that
sagittal plane biomechanics are the major mechanism of
ACL loading. Decreased knee flexion angle and increased
quadriceps muscle force and posterior ground reaction force
causing an increased knee extension moment are require-
ments for increased ACL loading. Although the external
knee valgus moment has been demonstrated to be associated
15
 Anterior Cruciate Ligament Injury

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16

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17
 3
CHAPTER
Risk and Gender Factors for Noncontact
Anterior Cruciate Ligament Injury
Letha Y. Griffin INTRODUCTION
James Kercher
In the past decade, there has been an increased
emphasis on injury prevention in sports. How-
ever, a significant difficulty with designing pre-
vention programs for anterior cruciate ligament
(ACL) injury is our incomplete understanding
of risk factors and mechanism of injury.
Two different schemes exist for classifying
risk factors. Risk factors can be divided into
intrinsic factors, meaning those unique to the
individual such as anatomy, muscle strength, and
balance, and extrinsic factors, which are external
influences on the body including such factors as
shoe-surface interactions, braces, and weather
conditions. Risk factors can also be categorized
as environmental, anatomical, hormonal, neuro-
muscular, and genetic. The latter classification
scheme will be the basis for this discussion.
ENVIRONMENTAL RISK FACTORS
Many environmental risk factors specific to
ACL injury have been studied, including weather
and playing conditions, shoe-surface interaction,
footwear, and bracing. These variables are impor-
tant because they represent potentially avoidable
risk factors.
The foot plant, the shoe, the surface, and
the shoe-surface interaction are critical factors in
noncontact ACL injuries. Basic physics describes
static and kinetic frictional forces between two
bodies. Energy is dissipated once the static fric-
tional force is overcome, allowing movement. This
18
is termed sliding, which causes a shift from static
to kinetic frictional force that is more readily
overcome. It is logical to assume that during foot
plant, characteristics that increase static frictional
force between the foot and ground will create
higher-energy forces in the lower extremity.
Certain studies have examined surface
conditions relating to ACL injuries. Olsen
et al1 and Torg et al2 both studied team hand-
ball and found an increased risk of ACL injury
while playing on synthetic floors versus tradi-
tional parquet floors. Both believed that the
increased friction of synthetic flooring was the
cause. Orchard et al,3 Heidt et al,4 and Scranton
et al5 all reported higher rainfall and cooler
temperatures were related to decreased ACL
injuries and theorized that dry, hot weather
conditions promote increased frictional forces
on the playing field, thus in turn resulting in
increased injury rates.
Lambson et al6 in a 3-year prospective study
looked at footwear to evaluate torsional resistance
of modern football cleats. They compared four
styles of football shoes and found that the edge
design, a design having longer irregular cleats at
the periphery and many smaller cleats interiorly,
was associated with higher ACL injury rates.
Bracing Pros and Cons
Prophylactic and functional (postreconstructive)
knee bracing has long been a controversial
subject. Over the past 20 years, attitudes have
fluctuated regarding the effectiveness of braces
in preventing knee injury in the uninjured athlete,

the ACL deficient athlete, and the ACL reconstructed ath-
lete. A study by Decoster and Vailas7 on brace prescriptions
patterns noted that there has been a decreasing tendency for
orthopaedic surgeons to prescribe ACL braces. The authors
also noted that a primary factor influencing brace prescription
by orthopaedists was the activity level of the patient.7
Early studies on prophylactic brace wear by Teitz et al8
and Rovere et al9 indicated no benefit to brace wear. These
authors cited increased rates of knee injury in some athletes
using prophylactic knee braces. In contrast, two other
studies—the West Point study by Sitler et al10 involving
1396 cadets at the U.S. Military Academy who played intra-
mural tackle football and the Big Ten Conference study by
Albright et al11 involving 987 NCAA football players—
concluded that prophylactic knee braces were effective in
reducing injury. Since these studies, there has been a paucity
of data to support prophylactic bracing for ACL injury protec-
tion, but it is believed that braces may provide some advantage
to reducing medial collateral ligament (MCL) injury.12,13
Braces are commonly prescribed following ACL injury
or reconstruction; however, little evidence supports their phys-
iological or biomechanical efficacy. In a prospective rando-
mized clinical trial of functional bracing for ACL deficient
athletes, Swirtun et al14 found that subjectively, patients had
initial sense of increased stability, but these investigators were
unable to find objective benefits. In contrast, Kocher et al stud-
ied the use of braces to prevent reinjury in 180 ACL deficient
alpine skiers and found reinjury occurred in 2% of the braced
skiers compared with 13% of the unbraced “control” skiers.15
Risberg et al investigated the effect of knee bracing
after ACL reconstruction in a prospective clinical trial of
60 patients randomized postoperatively (30 braced and 30
without brace) with 2 years of follow-up.16 They found no
evidence that bracing affected knee joint laxity, range of
motion, muscle strength, functional knee tests, patient satis-
faction, or pain in braced athletes compared with athletes
who did not use a brace following ACL reconstruction.
Furthermore, they found prolonged bracing, which they
defined as brace wear 1 to 2 years postoperatively, produced
decreases in quadriceps muscle strength. McDevitt et al in
a prospective, randomized multicenter study of 100 subjects
likewise found no significant differences between braced and
nonbraced subjects following ACL reconstruction.17
It has been theorized that damage to the ACL can
disrupt mechanoreceptors in the knee leading to decreased
proprioception.18 Birmingham et al19 has suggested that
brace wear may help to correct this deficit somewhat, but
benefits do not carry over to more demanding tasks. To
examine knee proprioception, researchers have studied the
threshold for detection of passive knee motion and found
that brace application to the ACL deficient limb does not
improve the threshold to detect passive range of motion.20,21
Risk and Gender Factors for Noncontact Anterior Cruciate Ligament Injury 3
Although the preponderance of evidence would
suggest that braces are ineffective in protecting the ACL
deficient or reconstructed athletic knee, many patients still
wish for a brace because they subjectively report that braces
increase their confidence during sports participation.
ANATOMICAL RISK FACTORS
Recognition of disparities in noncontact ACL injury rates
between men and women has led to much debate on the asso-
ciation of gender-specific anatomical differences as potential
injury risk factors. Proposed anatomical risk factors include
increased quadriceps femoris angle (Q angle), ligamentous lax-
ity in apparent knee valgus, femoral notch size, ACL geometry,
subtalar joint pronation, and body mass index (BMI).
Association Between Q Angle and
Injury Risk
The Q angle, which typically ranges from 12 to 15 degrees,
is formed by the intersection of two lines, one from the
anterior superior iliac spine to the midpoint of the patella
and another from the tibial tubercle to the same reference
point on the patella. It has been proposed that an increased
Q angle may be associated with an increased risk for
knee injury because excessive lateral forces could negatively
influence the knee's mechanical alignment.22,23
Females have been reported to have larger Q angles
than their male counterparts24,25; however, in a trigonomet-
ric evaluation, Grelsamer et al reported a mean difference of
only 2.3 degrees between the Q angles of men and women
and furthermore found that men and women of equal height
demonstrated similar Q angles.26 Shambaugh et al25 studied
the relationship between lower extremity alignment and
injury rates in recreational basketball players and found
larger Q angles in athletes who sustained knee injures. In
contrast, other authors have not been able to relate injury
to Q angle.22,27,28 Guerra et al29 reported that quadriceps
contraction alters Q angle measurements, thus making it
difficult to establish a direct link between static Q angle
measurements and injury.
Notch Width as a Risk Factor
Structural characteristics of the distal femur and femoral
intercondylar notch as well as ACL geometry and the
ACL relationship to the intercondylar notch have been
implicated as anthropometric factors associated with ACL
injury rate disparity between males and females. It has been
postulated that a smaller notch, termed notch stenosis, may
cause impingement to the ACL and put it at increased risk
19
 Anterior Cruciate Ligament Injury
of injury, or possibly a smaller notch may imply a smaller
ACL leading to decreased load to failure. Although these
factors have been heavily studied using plain radiography,30–38
computed tomography (CT),39,40 magnetic resonance
imaging (MRI),41,42 and cadaveric43-45 and in vitro37 analysis,
a lack of consistent measurement techniques and findings has
made it difficult to interpret results. Therefore there is still no
consensus relating morphology of the intercondylar notch to
ACL injury rates. A chronological summary of the data is listed
in Table 3-1.
HORMONAL RISK FACTORS
The increased incidence of ACL injury in women compared
with men has raised interest regarding the influence of
sex hormones on injury occurrence. Fig. 3-1 describes the
menstrual cycle. A normal cycle is typically 28 to 30 days.
The follicular phase (i.e., the stage of the follicle development)
begins with menstruation and ends with ovulation. The latter
lasts approximately 3 to 5 days and, if pregnancy does not
occur, is followed by the luteal phase, which begins with the
involution of the follicle and formation of the corpus luteum.
Estradiol secretion is biphasic, peaking in both the follicular
and luteal stages. Progesterone is produced by the corpus
luteum and therefore occurs in the luteal phase only.
Monthly Distribution of Anterior Cruciate
Ligament Injuries
Initial surveys of injury occurrence throughout the monthly
menstrual cycle revealed that injuries were not equally
distributed throughout the cycle but instead were clustered
either around menstruation or the ovulation period of the
cycle.46–48
However, the reliability of these early data was ques-
tioned because subjects were not frequently controlled for the
use of birth control pills and hormonal assays were not done
Proliferative phase (uterus)
Follicular phase (ovary)
Menstrual phase
LH
FSH
Estrogen
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 1 2
Menses Ovulation
FIG. 3-1 A normal menstrual cycle. FSH, Follicle stimulating hormone; LH, luteinizing hormone.
20
to verify cycle times; instead, athletes recalled or reported their
menstrual history. Repeated studies using radioimmunoassays
on serum, urine, or saliva verified the non–chance distribution
of ACL injuries throughout the menstrual cycle.48–51
Sex Hormones and Laxity
If sex hormone levels do influence injury rates, how this
occurs is not clear. Multiple studies in the past decade have
focused on the influence of sex hormones on knee laxity,
and some investigators have even correlated female sex hor-
mone levels and laxity measures with menstrual cycle phase.
In 1999, Wojtys and Huston52 reported on a series-
controlled study of 12 females and 12 males, in which they
found a decrease in knee laxity on day 12 of the monthly
menstrual cycle in women versus no monthly variation in
knee laxity in men.
In the following year, however, Belanger et al53reported
no significant difference in anterior knee laxity throughout
the monthly cycle in 18 Brown University athletes studied
over 10 weeks. Similarly, Karageanes et al54 reported no sig-
nificant changes in ACL laxity from the follicular to luteal
phases. This research group measured laxity before workouts
in 26 athletes, comparing these data to self-charted menstrual
cycles. Van Lunen et al,55 using a within-subjects linear
model, reported on 12 females tested for knee laxity at the
onset of menses, near ovulation, and on day 23 with hormonal
assays performed on blood drawn on those same days. They
found no association between follicular, ovulatory, or luteal
phase hormone concentrations and ACL laxity measures.
This is in contrast to an earlier study by Heitz et al,56
who not only compared laxity measures taken on days 1, 10,
11, 12, 13, 20, 21, 22, and 23 of a self-reported menstrual
cycle but also compared these data with serum estradiol
and progesterone levels as measured by immunoassays in
seven active females who reported normal 28- to 30-day
menstrual cycles. These investigators found a significant
difference in anterior knee laxity when comparing laxity
Progestational phase (uterus)
Luteal phase (ovary)
ne
te ro
es
og
Pr
Menses
 Risk and Gender Factors for Noncontact Anterior Cruciate Ligament Injury 3
TABLE 3-1 Studies Evaluating Notch Size as an Anterior Cruciate Ligament (ACL) Injury Risk Factor
Year Author Study Design Conclusion Comments

1987 Anderson Analysis of the intercondylar Retrospective study. Compared Significant association between Notchplasty for
et al39 notch by computed bilateral ACL tears, unilateral tears, anterior outlet stenosis and those with
tomography and normal knees in males and unilateral and bilateral ACL tears. documented
females using computed No gender differences found. stenosis
tomography (CT) scan.

1987 Houseworth The intercondylar notch in acute Retrospective study using computer Narrowed posterior arch of the Positive
et al40 tears of the anterior cruciate graphic analysis of notch-view notch may predispose a knee to association
ligament radiographs in 50 patients with an ACL tear. between notch
acute ACL injury and 50 normal and injury but no
knees. comment on
gender
112
1988 Souryal et al Bilaterality in ACL injuries: Retrospective analysis of 1120 NWI was significantly less for Positive
associated intercondylar notch patients with ACL ruptures. Devised bilateral group compared with association
stenosis notch width index (NWI) to unilateral and normal knees. between notch
compare notch widths on and injury but no
radiographs. comment on
gender

1993 Souryal et al38 Intercondylar notch size in ACL
injuries in athletes
Prospective blind study of 902 high Athletes with stenotic notch have Females had
school athletes. ACL injuries were greater risk for noncontact ACL significantly
recorded and correlated with NWI. injury. Limit of “critical stenosis” smaller NWI
was NWI of <0.20 for males and
<0.18 for female subjects.

1993 Schickendantz Predictive value of radiographs Retrospective radiographic study of Size of notch probably a factor in Notch
36
et al in the evaluation of unilateral 250 patients with ACL injuries. ACL injuries, but plain radiographs measurements
and bilateral ACL injuries Compared unilateral ACL injury, cannot be used reliably to should not be
bilateral ACL injury, and noninjured diagnose clinically significant used to predict
subjects. stenosis. potential for ACL
injury

1994 Lund-Hassen Intercondylar notch width and
et al33 the risk for ACL rupture
31
1994 LaPrade et al Femoral intercondylar notch
stenosis and correlation to ACL
injuries
A case-control study of 46 female Notch widths of less than 17 mm NWI is predictive
handball players. were six times more likely to of injury
sustain ACL injury.
Prospective study of 213 athletes. 7 Athletes with a stenotic notch ACL within a
ACL tears (4 male, 3 female). were at significant risk of ACL stenotic notch
rupture. No statistical difference may be coupled
between gender of the athlete and with an inherently
NWI. smaller ACL

1997 Muneta et al44 Intercondylar notch width and A cadaveric knee study. 16 knees (8 Knees with smaller NWI did Impingement may
its relation to the configuration male, 8 female). Notch and ACL contain thinner ACLs. be due to
and cross-sectional area of the dimensions were measured. mismatch
ACL between size of
ACL and notch
volume
continued

21
 Anterior Cruciate Ligament Injury
TABLE 3-1 Studies Evaluating Notch Size as an Anterior Cruciate Ligament (ACL) Injury Risk Factor—Cont'd
Year Author Study
1998 Shelbourne The relationship between
et al37 intercondylar notch width of the measurements were taken on 714
femur and incidence of ACL
tears
2001 Anderson Correlation of anthropometric
et al41 measurements, strength, ACL
size, and intercondylar notch
characteristics to sex differences for body fat analysis, muscle
in ACL tear rates
2001 Rizzo et al45 Comparison of males' and
females' ratios of ACL width to
femoral intercondylar notch
(FIN) width
30
2001 Ireland et al A radiographic analysis of the
relationship between the size
and shape of the intercondylar
notch and ACL injury
2002 Tillman et al41a Differences in three
intercondylar notch geometry
indices between males and
females
42
2002 Charlton et al Differences in femoral notch
anatomy between males and
females
2005 Chandrashekar Sex-based differences in the
et al43 anthropometric characteristics
of the ACL and its relation to
intercondylar notch geometry
22
Design Conclusion Comments
Prospective study. Intraoperative Females have smaller notch Notch but may
widths. After both had reflect smaller ACL
ACL (480 male, 234 female) reconstructions with equally sized
reconstructions. Patients who autografts, there was no difference
subsequently tore their contralateral in graft tear rate. Also found that
ACL or graft were recorded. NWI is not effective for
standardizing people of differing
heights.
Prospective study of 100 matched No statistically significant Notch width did
high school basketball players (50 difference in NWI between sexes. not standardize
males and 50 females). Examined ACL was smaller in females but did equally between
not vary in proportion to notch. No males and females
strength, and magnetic resonance evidence indicating difference in of different sizes
imaging (MRI) of the notch and notch characteristics and sex
cross-sectional area of the ACL. differences in ACL tears.
Cadaveric study. 15 male knees and Significant difference between Females have
11 female knees. male and female ACL widths; ACL: smaller ACL:FIN
FIN width ratio which was smaller ratios
in females.
Retrospective study. Notch-view Smaller notch width and NWI in Smaller notch
radiographs from 108 subjects (55 ACL-injured patients regardless of dimensions at
females, 53 males) with ACL injuries notch shape or gender. A-shaped greater risk of
and 186 with intact ACLs (94 notches were smaller. injury
females, 92 males).
Cadaveric skeletal study of 100 male The intercondylar notch appears ACL geometry
and 100 female skeletons. 3 indices less round in females. may be the cause
of notch geometry were calculated of increased ACL
using digital photographs: NWI, injury in females
notch area index, and notch shape
index.
MRI study of 48 asymptomatic Volume of the ACL located inside Females may have
subjects (20 females, 28 males). the femoral notch was significantly smaller ACLs and
Analyzed notch morphology. smaller in females. Subjects with smaller notches
smaller notch volumes have
smaller ACLs.
Cadaveric study of 20 knees (10 No difference in notch geometry Smaller ACLs in
males, 10 females). Notch and ACL between males and females. ACLs females
were examined using in females were smaller in length,
three-dimensional (3D) imaging. cross-sectional area, volume, and
mass when compared with ACLs in
males.

measures at baseline estrogen levels with peak levels of
estrogen and when comparing laxity at baseline progester-
one levels with that of peak progesterone levels. These
results are similar to a series-controlled Japanese study57
involving 16 women and 8 men, which found no statistical
difference in anterior displacement over time in men but
did find variation in anterior knee laxity in women between
the follicular and ovulatory phases and between the follicular
and luteal phases at 89N displacement. Furthermore, Shultz
et al58 obtained daily knee laxity measures as well as assayed
daily serum samples for estradiol, progesterone, and testos-
terone in 25 females throughout one complete menstrual
cycle and concluded that changes in sex hormones mediated
changes in knee laxity across the menstrual cycle. Moreover,
these investigators found a variable knee laxity response
among females, with some females experiencing significant
variation in knee laxity across the monthly cycle and others
experiencing very little.
Even if an association can be demonstrated among sex
hormones, menstrual phase, and increased laxity, an increase
in knee laxity has not been reliably associated with an
increased risk of ACL injury.59–62
Sex Hormones and Ligament Biology
Female sex hormones have been found in animal and human
studies to have a direct effect on growth and development of
bone, muscle, and connective tissue. In 1996, Liu et al63
reported receptor sites for estrogen and progesterone in the
human ACL, and in 2005, Lovering and Romani reported
androgen receptors in the female ACL as well, suggesting
that these sex hormones could have a direct effect on the
structure and composition of the ACL.64
In fact, in 1997, Liu et al reported a significant
reduction in procollagen synthesis by ACL fibroblasts and
in fibroblast proliferation with increasing estradiol concentra-
tions.65 Similarly, Slauterbeck et al66 found that high-dose
17b-estradiol significantly decreased the tensile strength of
the ACL in ovariectomized rabbits compared with the tensile
strength of the ACL in ovariectomized rabbits not supple-
mented with estrogen. Seneviratne et al67 reported that
despite the presence of estrogen receptors on ovine ACL
fibroblasts, there was no significant difference in ACL fibro-
blast proliferation or collagen synthesis when cells in culture
were exposed to 17b-estradiol at physiological concentra-
tions. In 2003, Strickland et al,68 in a controlled laboratory
study of 38 matured ewes, found that estrogen or a selective
estrogen receptor agonist at physiological levels did not result
in a change in the mechanical properties of the sheep's knee
ligament. Arendt et al69 mechanically tested ACLs of 26
young rhesus monkeys (14 ovariectomized and 12 sham-
operated) and concluded that estrogen had no effect on the
Risk and Gender Factors for Noncontact Anterior Cruciate Ligament Injury 3
mechanical or material properties of the ACL in these
primates.
Sex Hormones and Other Concerns
Perhaps sex hormones influence ACL injuries not by a
direct effect on the mechanical properties of the ligament
but on other injury-associated parameters such as balance,
muscle response time, mood, and focus.70,71 Estrogen and
progesterone have been found to influence the cardiovascu-
lar system, blood pressure, heart rate, minute ventilation,
substrate metabolism, thermal regulation, resting O2 con-
sumption, and other factors.72,73 Variable results regarding
anaerobic performance and the menstrual cycle have been
reported, with some researchers claiming no change in
anaerobic ability across the cycle and others claiming greater
anaerobic capacity and peak power during the luteal phase.74
Wojyts and Huston52 investigated the variations in
strength, endurance, and time to peak torque in 12 women
on days 1, 12, and 24 of a complete cycle and found no signifi-
cant variation in any of these factors across the menstrual cycle.
Schultz et al have made the thoughtful statement that
although we do not know how the impact of the menstrual
cycle affects noncontact ACL injuries, the preponderance of
evidence favors the idea that the incidence of noncontact
ACL injuries does vary throughout the monthly cycle and
does not occur by chance alone. Therefore, one has to ques-
tion the validity of data accumulated in women regarding
other risk factors for ACL injury that do not take into account
the time of the monthly menstrual cycle during which the data
were obtained.75 In summary, research in the area of sex
hormones' effects on ACL injury rates has been intense in
the last several years, but many questions remain unanswered.
NEUROMUSCULAR RISK FACTORS
The majority of ACL injuries occur without direct contact
made to the player's knee. Players may describe a bump or a
hit to another body area that throws them off balance
(a perturbation), but in more than 70% of ACL injuries,
a noncontact mechanism has been identified.27,47,76–78 More-
over, interviews with players and analysis of injury videotapes
from basketball, soccer, football, and volleyball have revealed
that most injuries occur with decelerating, as when stopping,
cutting, changing directions, or landing a jump.79–81
However, the exact mechanism—that single action or
cascade of events that ultimately results in an ACL injury—
is still largely unknown. Markolf et al,82 using fresh frozen
cadavers, applied combined loads to the tibia and measured
the effects on the ACL through a wide range of motion
angles. These researchers found that a combination of
23
 Anterior Cruciate Ligament Injury
internal rotation and anterior tibial force resulted in the high-
est load to the ACL. Earlier, Markolf et al had reported that
the ACL experienced large loads when the knee was near
straight (i.e., at angles between 0 and 20 degrees of flexion).83
The most detailed analysis of the mechanism of ACL
injury has been in alpine skiing, where videotape analysis of
ACL injuries has revealed two potential mechanisms of
injury.84,85 The most common is the so-called “phantom
foot mechanism” that occurs when the skier falls or sits
backwards, catching the inside edge of the tail of the ski,
which results in internal rotation of the tibia with the knee
flexed well beyond 90 degrees. The second injury mecha-
nism in skiing occurs with a hard, off-balance landing. In
this scenario, the skier's boot “pushes” the tibia forward on
landing, increasing the load on the ACL.
Garrett has suggested that a large eccentric quadriceps
contraction with the knee in slight flexion can result in suf-
ficient force to tear the ACL; in other words, the quadriceps
could be the intrinsic force in a noncontact ACL injury.85a
This theory was investigated in a laboratory study by
DeMorat et al86 using 13 fresh frozen potted knees held
in 20 degrees of flexion. A 4500N quadriceps force ante-
riorly displaced the tibia, resulting in damage to the ACL
in 11 knees and gross disruption of this ligament in 6 of
these 11 knees. Two knees sustained tibial plateau fractures.
It is known that joint stability is provided not only by
the static ligament restraints but also by dynamic muscle
contraction. In fact, Markolf reported that patients who
were not athletes could increase varus and valgus knee stiff-
ness by twofold to fourfold with isometric contraction of the
hamstrings and quadriceps.87 Women have been found to
be less able to stiffen their knees through muscle contraction
than men, a factor that may place women at greater risk for
ACL injury when compared with men.88–90
A study by Wojtys et al90 employing 23 volunteers
(10 men and 13 women who were selected to participate
because they had healthy but “loose knees” [i.e., a manual
maximal anterior arthrometric laxity measurement of at least
6 mm]) found that maximal co-contraction of the knee
significantly decreased mean anterior tibial translation in all
volunteers, but the percent increase in sheer stiffness of the
knee was greater in men (P ¼ 0.003). This same research
group earlier studied 10 elite female athletes and 10 elite male
athletes with sex-matched, nonathlete controls and reported
that female athletes compared with male athletes took longer
to generate maximal hamstring muscle torque during
isokinetic testing and contracted their quadriceps, rather than
their hamstrings, as an initial response to anterior tibial
translation. Overall, females had less strength and endurance
than males and had greater anterior tibial laxity.91
Not only do women demonstrate variations in strength,
laxity, and muscle recruitment, but a number of researches
24
have reported that women perform cutting maneuvers and
land jumps in a more upright posture—a posture shown by
Markolf et al to put greater strain on the ACL.82,83,92–98 In
contrast, in 1996 Hewett et al99 reported no difference in knee
flexion angles on landing between males and females, and
Fagenbaum and Darling evaluated eight females and six male
varsity collegiate basketball players and reported that women
landed with increased knee flexion angles.100
Recently, several research groups have used three-
dimensional (3D) kinematics to evaluate landing and cutting
movements.101–105 McLean et al evaluated side-stepping
in 10 male and 10 female collegiate athletes and found women
had significant larger normalized knee valgus moments than
males.103 These findings are consistent with other resear-
chers who reported larger knee valgus motions in women
compared with men performing side-step cutting man-
euvers96 and are also consistent with greater valgus motion
reported in women doing jump-landing tasks.106,107
Researchers have also emphasized the relationship of
knee position to neuromuscular control of the hip. They
believe that knee valgus moments are related to hip flexion
and internal rotation on contact during side-stepping,102 a
relationship previously emphasized by Kibler.108
Ford et al,109 using 3D kinematic analysis of 81 high
school basketball athletes (47 females and 34 males) perfor-
ming a drop–vertical jump maneuver, reported that females
landed with greater total valgus knee motion and a greater
maximal valgus knee angle than male athletes. Moreover, this
same group of researchers prospectively examined 205
female soccer, basketball, and volleyball players performing a
jump-landing task and reported that of these 205 subjects,
9 sustained an ACL injury during the time of the study.107
These 9 subjects had a knee abduction angle on landing of
8 degrees greater (P > 0.05) than uninjured athletes and a
2.5 times greater knee abduction moment (P < 0.001) and
20% higher ground reaction force (P < 0.05) than those who
did not sustain an ACL injury. Three-dimensional kinematic
and kinetic analysis was used for the study.
Increased valgus knee movements in female recrea-
tional athletes during the landing phase of vertical and back-
ward jumping were also reported by Chappell et al,92 but
this research group found no difference in the magnitude
of the knee varus-valgus moments between genders. These
researchers also reported that female recreational athletes
had an increased proximal tibial anterior sheer force during
the landing phase in a stop-jump task compared with male
recreational athletes.
In their investigation of gender differences in 3D hip
and knee joint mechanics in college athletes performing five
randomly cued cutting trials, Pollard et al found no gender
differences in selected peak hip and knee joint kinematics
and movements, except in peak hip abduction, where

females demonstrated significantly less peak hip abduction
than did males.105
The variable responses reported by investigators with
regard to neuromuscular risk factors in female athletes may
be related to the relatively small cohort size in many studies,
variations between recreational and elite athletes, or age
group variations in the athletes tested. Moreover, most
researchers compared gender differences, and perhaps the
differences or variations in neuromuscular parameters exist
among members of the same gender, not merely between
genders. Further clarification is needed through additional
research efforts.
FAMILIAL TENDENCY TO NONCONTACT
ANTERIOR CRUCIATE LIGAMENT INJURY
In a retrospective study published in 1994, Harner et al110
compared 31 patients who sustained bilateral ACL injuries
with 23 matched control subjects (i.e., no history of ACL
injury) and reported a significant increase (P < 0.01) in the
ACL incidence rate among immediate family members of
the 31 ACL-injured patients compared with the controls.
Similarly, Flynn et al111 compared 171 ACL-injured subjects
with 171 matched controls and found that ACL-injured
patients were twice as likely to have relatives who had sustained
an ACL injury compared with the controls (adjusted odds
ratio ¼ 2.00; 95% confidence interval, 1.19–3.33).
SUMMARY
Despite the plethora of research on gender-specific risk factors
for ACL injury over the past several decades, there remains
no conclusive evidence of a direct cause-and-effect relation-
ship. It is known that females have increased ACL injury rates.
Perhaps this represents the interplay of several risk factors
resulting in a cumulative effect. Further research is warranted.
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27
 4
CHAPTER
The Incidence of Anterior Cruciate
Ligament Injury as a Function of Gender,
Sport, and Injury-Reduction Programs
Chadwick C. Prodromos INTRODUCTION
Yung Han
Although many studies have examined the inci-
Julie Rogowski dence of anterior cruciate ligament (ACL) tears
Brian T. Joyce
for given populations, an overall understanding
Kelvin Shi of the real incidences is difficult to ascertain due
to the breadth of the data and the disparate man-
ner in which it is reported. The overall number
of ACL tears appears to be increasing. This is
caused in part by the increased participation of
females in high-risk sports, as females clearly have
an overall higher incidence of ACL tears than
males. This realization has spawned the creation
of training programs designed to decrease the inci-
dence of ACL tears in females. The increase in
ACL tears is also fueled by the increase in sports
participation, from seasonal to yearlong, by ath-
letes of both genders. This results in an increased
number of exposures per year above that which
was present for single-sport athletes in the past.
Some sports appear to have higher risks of ACL
tears than others, but these differences have not
been well understood. Knowing the relative and
absolute risks of ACL tear as a function of these
parameters serves to focus attention on preventive
strategies, where it is most needed. It also allows
athletes and parents to understand the risks of
participation in various sports.
PURPOSE
Our purpose was to acquire and review all of the
relevant peer-reviewed published data on the
28
incidence of ACL tears for the purpose of com-
paring the incidence of ACL tears in the fol-
lowing ways:
1 Among sports
2 Between females and males
3 Between those who have completed a
program to decrease the incidence of ACL
tears and those who have not
METHODS
A computerized search of all papers in the peer-
reviewed literature that had a possibility of dealing
with the incidence of ACL tears was performed
using a variety of indexing terms. Searches were
then carried out by individual sports. This pro-
duced 793 articles that had some relation to knee
or ACL injuries. These articles were reviewed,
and bibliographies were cross-referenced for other
papers, which were also reviewed for the purpose
of identifying studies that had actual numerical
incidences of complete ACL tears; this eliminated
the overwhelming majority of papers. However,
33 papers were found that did have such quantita-
tive data, and they form the basis for this chapter.
Of these 33 papers, 25 had data that either used,
or could be converted into, the preferred ACL
injury incidence reporting method, namely: “ACL
tears/1000 exposures.” An exposure is defined as
either a practice or a game. These studies are listed
in Table 4-1. They are divided by sport and then
subdivided by level of competition, gender, and
 TABLE 4-1 ACL Tear Rate by Sport, Gender, and Injury Training*
Sport Level Subgroup Author Male and ACL Exposures Female ACL Exposures Male ACL Exposures Female/Male
Female Tears Tears Tears

Basketball Professional WNBA Trojian22 0.20 9 45,036

{ 23 0.21
Professional NBA Lombardo 15 70,185

College NCAA Mihata15 0.17 1393 8,068,016 0.28 1061 3,733,209 0.08 332 4,334,807 3.50

NCAA Agel13 0.18 682 3,889,954 0.29 514 1,797,730 0.08 168 2,092,224 3.63

The Incidence of Anterior Cruciate Ligament Injury as a Function of Gender, Sport, and Injury-Reduction Programs
Collegiate Harmon36 0.18 359 1,972,170 0.30 275 925,501 0.08 84 1,046,669

NCAA Arendt 14 0.17 238 1,375,974 0.30 189 639,898 0.07 49 736,076 4.29

Naval: collegiate Gwinn17 0.28 6 21,734 0.48 5 10,452 0.09 1 11,282 5.33

Naval: intramural Gwinn17 0.14 5 35,226 0.00 0 1360 0.15 5 33,866 0.00

Naval: all levels Gwinn17 0.19 11 56,960 0.42 5 11,812 0.13 6 45,148 3.23

High school Gomez25 0.13 11 84,341.66

Messina24 0.05 15 290,636 0.09 11 120,751 0.02 4 169,885 4.50

Untrained Pfeiffer19 0.11 2 18,076

Trained 0.48 3 6302

Untrained Hewett 21 0.29 3 10,370

Trained 0.42 2 4757

{ 20 0.65
Soccer Adults German national Faude 11 16,830
league

Adults Competitive: Soderman21a 0.18 4.0 22,134

trained

Adults Competitive: 0.04 1.0 27,846

untrained
{ 0.07
Adults Recreational Bjordal18 131 1,837,455.83

College NCAA Mihata15 0.21 1295 6,283,785 0.32 871 2,736,615 0.12 424 3,547,170 2.67

NCAA Agel13 0.21 586 2,840,568 0.33 394 1,208,994 0.12 192 1,631,574 2.75

continued
29

4
30

Anterior Cruciate Ligament Injury

TABLE 4-1 ACL Tear Rate by Sport, Gender, and Injury Training*—Cont'd
Sport Level Subgroup Author Male and ACL Exposures Female ACL Exposures Male ACL Exposures Female/Male
Female Tears Tears Tears

Collegiate Harmon36 0.20 317 1,605,004 0.32 194 604,430 0.12 123 1,000,574

NCAA Arendt14 0.19 178 934,971 0.31 97 308,748 0.13 81 626,223 2.38

Naval: collegiate Gwinn17 0.32 6 18,916 0.77 5 6508 0.08 1 12,408 9.63

Naval: intramural Gwinn17 0.46 12 26,204 2.70 2 742 0.39 10 25,462 6.92

Naval: all levels Gwinn17 0.40 18 45,120 0.97 7 7250 0.29 11 37,870 3.34

High school Untrained Mandelbaum16 0.49 67 137,448

Trained 0.09 6 67,860

Untrained Pfeiffer19 0.11 1 9357

Trained 0.00 0 5913

Untrained Hewett21 0.22 2 9017

Trained 0.00 0 4517

Alpine All ages General Deibert12 0.40 1448 3,641,041

skiing population

Adults General Warme11 0.63 1615 2,550,000

population

Employees Oates9 0.02 19 1,196,496

Employees Viola10 0.04 31 726,836 0.04 10 227,766 0.04 21 499,070 1.0

Lacrosse College NCAA Mihata15 0.18 315 1,783,903 0.18 146 799,611 0.17 169 984,292 1.06

American Adults Professional Scranton37 0.07 61 895,908

football

High school} DeLee28 0.11 37 331,561

Handball Adults|| Elite athletes Myklebust31 0.33 28 84,690 0.56 23 40,799 0.11 5 43,891 5.09

Adults Recreational Seil32 0.24 5 20,462.67

Adults} Untrained Petersen30 0.86 5 5815

Trained 1.60 1 625

Young Competitive Wedderkopp38 0.09 4 42,442.42

#
adults
continued
 TABLE 4-1 ACL Tear Rate by Sport, Gender, and Injury Training*—Cont'd
Sport Level Subgroup Author Male and ACL Exposures Female ACL Exposures Male ACL Exposures Female/Male
Female Tears Tears Tears

Australian Adults Professional: Orchard33 0.82 83 100,820

{
football 2001

The Incidence of Anterior Cruciate Ligament Injury as a Function of Gender, Sport, and Injury-Reduction Programs
Rugby College Collegiate Levy29 0.36 21 58,296

Naval: collegiate Gwinn17 0.22 7 31,263 0.35 3 8475 0.18 4 22,788 1.94

Volleyball High school Untrained Pfeiffer19 0.00 0 11,229

Trained 0.00 0 5739

Untrained Hewett 21 0.00 0 3751

Trained 0.00 0 7938

Wrestling College Naval: collegiate Gwinn 17 0.25 3 11,888 0.77 1 1,306 0.19 2 10,582 4.05

Indoor All ages** General Lindenfeld26 2.78 10 3600 5.21 8 1536 0.97 2 2064 5.37
soccer population
{{ 5.30 5.0 1.04
All ages General Putukian27 1 190 2 600
population

*Incidences are expressed as complete ACL tears/1000 exposures.

{
Games only.
{
Assumed 1.5 games and 2.25 practices.
}
Data was converted by information given by the author.
||
Assumed 2.25 practices.
}
Per hour, we assumed an exposure for team handball to be 2 hours combined practices and games.
#
Assumed season: 1 year; games; 50 minutes.
**
Games only: games were 45 minutes, so total player hours were divided by 0.75.
{{
Games only: exposure is player hours then multiplied the incidence by 1000.
31

4
 Anterior Cruciate Ligament Injury
whether an ACL injury-reduction training program had been
applied. The ratio of injury of females versus males is also listed
for studies in which there were cohorts for both genders. These
data form the basis for the analyses present in this chapter.
Table 4-2 aggregates like subgroups from Table 4-1
and provides mean injury rates weighted according to the
number of exposures. Table 4-3 lists the remaining studies,
which use methods other than “tears/1000 exposures”1–8.
Table 4-4 aggregates the like populations from studies that
compared incidences by gender. Table 4-5 lists all the stud-
ies that involved training regimens designed to reduce ACL
tear incidence.
EXPOSURES
In all of these studies it is important to remain cognizant of the
number of exposures in the given study. The variance in the
number of exposure between the studies is very large. The
largest study has more than 8 million exposures and the
smallest has only 600, a difference of more than 10,000 to 1
in the statistical power of the studies. These differences are so
important that we have highlighted all the studies with expo-
sures of more than 100,000 to make it easier for the reader to
recognize those incidence studies of greatest statistical power.
DATA CONVERSIONS
A number of studies report their incidence by dividing the
number of ACL tears by hours of participation instead of prac-
tices. In these studies the hourly incidence was therefore used to
calculate an incidence per 1000 exposures by converting hours
to practices or games and adjusting the incidence accordingly.
Doing so allowed these series to be used in the comparative
analysis with the other studies, which used the tear per exposure
methodology. Without this method, a large number of useful
studies would have been lost from the analysis. If an exact
practice length was not listed, we assumed a practice length
of 2.25 hours. In the study by DeLee,28 the data were presented
in tears per hour, but exact data were given on number of
practices and games and their lengths, so the data could be
directly transformed into tears per 1000 exposures.
INDIVIDUAL SPORTS
Alpine Skiing
The alpine skiing data are notable for the large disparity in
incidence between ski lodge employees, who are assumed
to be expert skiers, and recreational skiers. The two studies
of ski lodge employees by Oates and Viola show rates of
32
0.02 and 0.04, respectively.9,10 The two general population
studies by Warme and Deibert show tenfold higher rates
of 0.63 and 0.40, respectively.11,12 Although the rate for
the expert skiers is the lowest for any of the high-risk sports
studied, the rate for the recreational skiers is overall one of
the highest (P < 0.001). It is remarkable that this huge
disparity is produced by two independent studies in each
group, each with a very large number of exposures.
These observations are thus of high reliability and statistical
power.
The lower risk among the expert skiers is presumably
a combination of increased skill and increased fitness in this
group. The expert group is also remarkable for being one of
only two cohorts for which the rate of injury is the same for
males and females.
The lack of a gender difference in the large study by
Viola10 is also remarkable. Aside from lacrosse, alpine skiing
is the only sport studied with a large enough number of
exposures to generate reliable numbers to find this lack of
a gender difference.
Soccer
The soccer data are dominated by the three extremely large
studies of Mihata, Agel, and Arendt.13–21 These data are
remarkable for their amazing similarity. The female rates in
the Mihata, Agel, and Arendt studies are 0.32, 0.33, and
0.31, respectively; the male rates are 0.12, 0.12, and 0.13,
respectively. The female–male ratios are all also in the 2.5 to
1 range. The overall female to male difference was highly
significant (P < 0.0001). Soccer is also notable in that in all
three high school studies with ACL injury-reduction training
program cohorts, the programs were apparently successful.
(These studies were carried out only in females.) In other
words, the trained athletes had significantly lower ACL injury
rates (P ¼ 0.0001) than the untrained athletes. These data are
dominated by the landmark Mandelbaum et al study,16 which
showed a 24% reduction in ACL tear incidence. It should be
noted that the one adult study showed no reduction in ACL
tear incidence with training.21a
Basketball
As was the case with soccer, the basketball rates are domi-
nated by the three large studies of Mihata, Agel, and
Arendt.* Also similar to soccer, the basketball numbers are
amazingly similar among the studies. The female rates are
0.28, 0.29, and 0.30. The male rates are 0.08, 0.08, and
0.07. The female to male ratios are 3.5, 3.6, and 4.2. The
overall difference in rate between females and males was
*References 13–15, 17, 19, 21–25.
 The Incidence of Anterior Cruciate Ligament Injury as a Function of Gender, Sport, and Injury-Reduction Programs 4
TABLE 4-2 Weighted Means for Groups*
Sport Level Male and ACL Exposures Female ACL Exposures Male ACL Exposures Total
Female Tears Tears Tears Exposures

Basketball Professional 0.20 9 45,036 0.21 15 70,185

Collegiate 0.17 2694 15,420,034 0.29 2049 7,119,962 0.08 645 8,300,072

High school: 0.10 27 233,538.66 0.02 4 169,885

untrained

High school: trained 0.45 5 11,069

Soccer German National 0.65 11 16,830 15,949,747.66

League

Adult competitive: 0.04 1 27,846

untrained

Adult competitive: 0.18 4 22,134

trained

Adult recreational 0.07 2412 11,754,568

Collegiate 0.21 2412 11,754,568 0.32 1570 4,873,287 0.12 842 6,881,281

High school: 0.45 70 155,822

untrained

High school: trained 0.08 6.0 78,290

13,892,945.83

Alpine Employees 0.03 50 1,923,332 0.04 10 227,766 0.04 21 499,070

skiing 0.49
General population 3063 6,191,041

8,114,373

Lacrosse Collegiate 0.18 315 1,783,903 0.18 146 799,611 0.17 169 984,292

1,783,903

American Professional 0.07 61 895,908

football 0.11
High school 37 331,561

1,227,469

Handball Elite athletes 0.33 28 84,690 0.56 23 40,799 0.11 5 43,891

Adult recreational: 0.86 5 5815 0.24 5 20,462.67

untrained

Adult recreational: 1.6 1 625

trained

Young adults 0.09 4 42,442.42

154,035.09

Australian Professional 0.82 83 100,820

football 100,820

Rugby Collegiate 0.22 7 31,263 0.36 24 66,771 0.18 4 22,788

89,559

continued

33
 Anterior Cruciate Ligament Injury

TABLE 4-2 Weighted Means for Groups*—Cont'd

Sport Level Male and ACL Exposures Female ACL Exposures Male ACL Exposures Total
Female Tears Tears Tears Exposures

Volleyball High school: untrained 0.00 0.00 14,980

High school: trained 0.00 0.00 13,677

28,657

Wrestling Collegiate 0.25 3 11,888 0.77 1 1306 0.19 2 10,582

11,888

Indoor General population 2.78 14 3600 5.21 9 7126 1.88 5 2664

soccer

4390

*Incidences are expressed as complete ACL tears/1000 exposures.

highly significant (P < 0.0001). Interestingly, and unlike the
case with soccer, the two studies that included a cohort in
which athletes had completed a program to diminish the
ACL tear incidence showed no reduction in ACL tear rate
as a result of training. In fact, the trained athletes in both
studies showed increased ACL tear rates versus the untrained
athletes, although this difference was not significant.
Indoor Soccer
The two studies of indoor soccer are included for the sake of
completeness, but with only about 3600 total exposures,
they have negligible statistical power by comparison to the
more than 10 million soccer exposures by the three large
studies cited earlier for outdoor soccer.27,28 Thus the very
high female incidence of 5.2 tears per 1000 exposures, more
than 10 times the outdoor rate, should be interpreted with
caution, although the difference between females and males
was statistically significant (P ¼ 0.04). Nonetheless it is of
interest that two separate studies arrived at almost iden-
tically high rates. If these increased rates were real, there
would be two obvious potential causes: first, the fact that
this study included only games, not practices, implying a
higher risk with competition. Second, the fact that indoor
soccer is played on artificial turf, whereas outdoor soccer is
played on grass, may upwardly influence the injury rate.
Volleyball
The two volleyball studies have only 28,000 exposures, again
too small to make reliable incidence conclusions.19,21 How-
ever, it is remarkable that no ACL tears were recorded in
either study. Basketball and soccer are often included with
volleyball as high-risk sports for females. The rates of the
six cohorts for basketball and soccer from each of the three
large cited studies are all clustered between 0.28 and 0.33.
If the average rate of 0.30 is applied to the 28,000 volleyball
exposures, about 9 ACL tears would be expected. The fact
that none were recorded may support a lower incidence of
ACL tears in volleyball than in soccer and basketball.
Football
The one large football study, all in high school males, produced
an injury rate of 0.11.29 This is very similar to the male rate
found in college soccer (0.12) and basketball (0.08). With more
than 331,000 exposures, this study is of high statistical power.
Rugby
The 0.35 and 0.36 rates for women and the 0.18 rate for men
from the two published studies are very similar to the 0.32 rate
for women and 0.12 rate for men found in soccer.17,30 This is
not unexpected given the similarities of the sports, which
involve running and pivoting on a grass surface. It is of interest
that the higher level of contact in rugby did not produce a
higher ACL tear rate. The 89,000 total exposures are a
significant number, although far less than the soccer exposure
numbers. Further supporting the validity of the data, however,
is the fact that two separate rugby studies produced almost
identical ACL tear incidences.
Wrestling
With just under 12,000 exposures, the one wrestling study is
of low power.17 It showed a rate of 0.77 in females and 0.19
in males.
Lacrosse
There is one published study with usable data for our anal-
ysis.15 The 0.17 rate of ACL tear for men is similar to that

34
 TABLE 4-3 Studies not Expressed in ACL Tears/1000 Exposures
Basketball Basketball Basketball Soccer Handball Handball Handball Handball American American Australian Australian
Football Football Football Football

Author Deitch6 Deitch6 Deitch6 Heidt4 Myklebust31 Myklebust31 Myklebust31 Myklebust31 Lambson7 Powell1 Orchard8 Orchard8

Year 2006 2006 2006 2000 2003 1997 1997 1997 1996 1992 2001 1999

Level NBA & NBA WNBA High school Amateur/semi- Amateur/semi- Amateur/semi- Amateur/semi- High school NFL AFL AFL

The Incidence of Anterior Cruciate Ligament Injury as a Function of Gender, Sport, and Injury-Reduction Programs
WNBA professional professional professional professional

Details 1996–2002 1997–2002 14- to 18- 1998–1999; 1989–1991 1989–1991 1989–1991 1989–1991, 1980– 1992–2000 1992–1998
(minus strike- seasons year-old females, upper seasons; two seasons; two seasons; two 3 years 1989, 10
shortened females (1 division, seasons, three seasons, three seasons, three seasons
1998–1999) year, Norway, one upper divisions in upper divisions in upper divisions in
2 seasons) season Norway Norway Norway

Criteria for Did not Did not Did not Not specified Arthroscopy Arthroscopy Arthroscopy Arthroscopy Arthroscopy ACLR ACL
ACL injury specify specify specify required required
definition

Sex M&F M F F F M&F M F M M M M

Total ACL 36 22 14 8 29 87 33 54 42
injury

Game ACL 19 10 9 23 29 114 74 78

injury

Practice ACL 17 12 5 6 13
injury

Total 1145 702 443 258 942 3392 1696 1696 3119 2238
number of
participants

Years 6 6 6 1 1 2 2 2 3 9 7
continued
35

4
36

Anterior Cruciate Ligament Injury

TABLE 4-3 Studies not Expressed in ACL Tears/1000 Exposures—Cont'd
Basketball Basketball Basketball Soccer Handball Handball Handball Handball American American Australian Australian
Football Football Football Football

Total player 516 942 6784 3392 3392

seasons

Total player 15,447 123,156

game hours

Total player 193,389

practice
hours

Total player 208,836

game and
practice
hours

Number of 1757 2280

games

Total player 93,400 70,420 22,980 15,547 123,156

games

ACL injury/ 31.4 31.3 31.6 31.0 30.8 25.6 19.5 31.8 13.5
1000 players

ACL injury/ 5.2 5.2 5.3 31.0 30.8 12.8 9.7 15.9 4.5
1000 player
years

ACL injury/ 42.1 34.8

1000 games

ACL injury/ 1.49 0.93 5.0

1000 player
game hours
continued
 TABLE 4-3 Studies not Expressed in ACL Tears/1000 Exposures—Cont'd
Basketball Basketball Basketball Soccer Handball Handball Handball Handball American American Australian Australian
Football Football Football Football

The Incidence of Anterior Cruciate Ligament Injury as a Function of Gender, Sport, and Injury-Reduction Programs
ACL injury/ 0.031 34.2
1000 player
practice
hours

ACL injury/ 0.14

1000 player
game and
practice
hours

ACL injury/ 0.20 0.14 0.39 1.49 0.93

1000 player
games

ACL injury/ 15.5 30.8 12.8 9.7 15.9

1000 player
seasons
37

4
 Anterior Cruciate Ligament Injury

TABLE 4-4 Ratios of Female to Male ACL Tear Rates*

Sport Level Subgroup Author Female ACL Exposures Male ACL Exposures Female/ P Value
Tear Tear Male

Basketball College NCAA Mihata15 0.28 1061 3,733,209 0.08 332 4,334,807 3.50

NCAA Agel13 0.29 514 1,797,730 0.08 168 2,092,224 3.63

36
Collegiate Harmon 0.30 275 925,501 0.08 84 1,046,669 3.75

NCAA Arendt14 0.30 189 639,898 0.07 49 736,076 4.29

17
Naval: collegiate Gwinn 0.48 5 10,452 0.09 1 11,282 5.33

Naval: intramural Gwinn17 0.00 0 1360 0.15 5 33,866 0.00

17
Naval: all levels Gwinn 0.42 5 11,812 0.13 6 45,148 3.23

Mean 0.29 0.08 3.63

24
High Messina 0.09 11 120,751 0.02 4 169,885 4.50
school

Mean 0.28 0.08 3.50 <0.0001

Soccer College NCAA Mihata15 0.32 871 2,736,615 0.12 424 3,547,170 2.67

NCAA Agel13 0.33 394 1,208,994 0.12 192 1,631,574 2.75

Collegiate Harmon36 0.32 194 604,430 0.12 123 1,000,574 2.67

NCAA Arendt14 0.31 97 308,748 0.13 81 626,223 2.38

Naval: collegiate Gwinn17 0.77 5 6508 0.08 1 12,408 9.63

Naval: intramural Gwinn17 2.70 2 742 0.39 10 25,462 6.92

17
Naval: all levels Gwinn 0.97 7 7250 0.29 11 37,870 3.34

Mean 0.32 0.12 2.67 <0.0001

10
Alpine skiing Employees Viola 0.04 10 227,766 0.04 21 499,070 1.00 0.91

Lacrosse College NCAA Mihata15 0.18 148 799,611 0.17 169 984,292 1.06

Mean 0.18 0.17 1.05 0.59

Handball Adults Elite athletes Myklebust31 0.56 23 40,799 0.11 5 43,891 5.09 <0.0001
17
Rugby College Naval: collegiate Gwinn 0.35 3 8475 0.18 4 22,788 1.94 0.36

Wrestling College Naval: collegiate Gwinn17 0.77 1 1306 0.19 2 10,582 4.05 0.25
26
Indoor All ages General Lindenfeld 5.21 8 1536 0.97 2 2064 5.37
soccer population

General Putukian27 5.20 1 190 5.00 3 600 1.04

population

Mean 5.21 1.88 2.77 0.04

*Incidences are expressed as complete ACL tears/1000 exposures.

of soccer, rugby, and basketball. The female rate of 0.18,
however, is substantially lower than the female rates for
these three sports. With 1,783,903 exposures, this study is
of high statistical power. Lacrosse stands as the only
sport aside from alpine skiing for which the rates for males
and females are roughly the same. There is no obvious
explanation. The argument has been made that the carrying
of the stick is ACL tear protective and may be at least part
of the reason for the lower injury rate in females. However,
if this were true there would be no obvious explanation for
the fact that such an effect does not serve to lower the rate
in males compared with other similar sports.

38
 The Incidence of Anterior Cruciate Ligament Injury as a Function of Gender, Sport, and Injury-Reduction Programs 4
TABLE 4-5 Effect of ACL Reduction Training Program on Tear Rate*
Sport Level Author Subgroup Female ACL Exposures Subgroup Female ACL Exposures Change P
Tear Tear (T–UT) Value

Basketball High school Hewett21 Untrained 0.29 3 10,370 Trained 0.42 2 4767 13%

Pfeiffer19 Untrained 0.11 2 18,076 Trained 0.48 3 6302 37%

Mean 0.18 0.45 0.15

Soccer Competitive Soderman21a Untrained 0.04 1 27,846 Trained 0.18 4 22,134 14%
adults

High school Hewett21 Untrained 0.22 2 9017 Trained 0.00 0 4517 –22%

Mandelbaum 16
Untrained 0.49 67 137,448 Trained 0.09 6 67,860 –40%

Pfeiffer19 Untrained 0.11 1 9357 Trained 0.00 0 5913 –11%

Mean 0.45 0.08 –24% 0.0001

Volleyball High school Hewett21 Untrained 0.00 0 3751 Trained 0.00 0 7938 0%
19
Pfeiffer Untrained 0.00 0 11,229 Trained 0.00 0 5739 0%

Mean 0.00 0.00

Handball equally, if not more, important. The proliferation of club

The two published female cohorts both have very high
incidences of 0.56 and 0.86.30,31 The two male cohorts of
0.24 and 0.11 are relatively unremarkable.31,32 The gender
difference is significant (P < 0.0001).
Australian Rules Football
The one large published study with usable data showed a quite
high ACL tear rate of 0.82 per 1000 exposures (games only in
this study).33 This is quite high in relation to other sports for
males. The 100,000 exposures represent a substantial
number, although not as large as some studies. It is interesting
to note that the indoor soccer study, which was also a games-
only study, also had an unusually high tear rate of 0.97. This
suggests the possibility that games have a higher risk of
ACL tear than practices, although there are far too little data
to make this conclusion. If this is not a contributing factor,
other explanations would include an intrinsically high rate
for Australian Rules football or that the rate is high due to
chance in this modest-sized study.
THE OVERALL RISK OF ANTERIOR CRUCIATE
LIGAMENT TEAR
This chapter has focused on the rate per exposure in deter-
mining ACL risk. However, the number of exposures is
teams for high-risk sports, especially soccer, thus combines
a relatively high-incidence sport with a high yearly number
of exposures, leading to an overall high risk. The year-round
club soccer player's ACL tear risk will be much higher
than the now nearly extinct three-sport athlete of years
past, many of whom would have engaged in at least one
lower-risk sport such as softball, baseball, tennis, or swim-
ming during the year. Hewett's prospective study,34 for
example, found a 4.4% 1-year chance of ACL tear in girls
engaged in high-risk sports. For the injury rate of about
0.3 seen in girls' basketball and soccer, a 5% yearly ACL risk
would be seen after 167 yearly exposures–not an excessive
number for a year-round player.1 Equipped with the
incidence contained in this chapter, one need only plug in
a putative number of yearly exposures to generate an
approximate risk of yearly ACL tear.
FEMALE–MALE INJURY RISK RATIO
The female–male ratio for the five sports for which there are
reliable data is as follows: basketball, 3.5; soccer, 2.67;
rugby, 2.0; lacrosse, 1.05; expert alpine skiers, 1.0. Soccer
and basketball dwarf the other sports in level of participation
and are the sports usually thought of when this topic is dis-
cussed. For these two sports, the increased risk versus males
is overall about 3 to 1. This is obviously a higher rate of
ACL tear in females versus males but is much less than
the rates of 6 or even 8 to 135 that are sometimes cited.

39
 Anterior Cruciate Ligament Injury
ANTERIOR CRUCIATE LIGAMENT TEAR-
PREVENTION PROGRAMS
The published data have shown ACL injury-prevention
programs to be effective in high school soccer. The data in
this study, however, have shown no significant benefit in
other sports. In this regard, Pfeiffer et al speculate that sig-
nificant benefit may require strength and possibly flexibility
training in addition to landing and agility training.19
IMPLICATIONS FOR FUTURE ANTERIOR
CRUCIATE LIGAMENT INJURY-REDUCTION
RESEARCH
The most striking finding in this study is the 16-fold reduc-
tion in alpine skiing injury rate in expert versus recreational
skiers, with no difference between males and females. This,
combined with the success of female ACL tear reduction
programs and the lack of a difference in tear rates in
lacrosse, indicates that biological differences between males
and females are probably far less important than proper
technique. It also squarely highlights basketball as the major
sport with both the largest gender disparity, at 3.5 females
to 1 male, and the only one that thus far has not proven
amenable to reduction of the female rate. Additional study
of technical factors contributing to female basketball ACL
tears should thus be a high priority for future research.
CONCLUSIONS
The following conclusions can be made:
1 Females have a roughly 3.5 times greater risk of ACL tear
than males in basketball and 2.7 times greater risk in soccer–
not the six to eight times increased risk sometimes cited.
2 ACL tear reduction programs have thus far only proven
effective in high school soccer but not in basketball.
3 Recreational alpine skiers have a 16-fold higher incidence
of tears than expert skiers.
4 Expert alpine skiers and lacrosse players are the only
studied athletes in whom females do not have a higher
incidence of ACL tears compared with males.
5 For males, the incidence of ACL tear is similar in
football, soccer, and basketball.
6 Volleyball may be a low-risk sport, not high-risk as
previously thought, for ACL tear.
7 The approximate yearly risk for ACL tear can be
calculated from the data in this chapter. The risk for a
40
year-round female club soccer player would appear to be
roughly 5% per year.
References
1. Powell JW, Schootman M. A multivariate risk analysis of selected
playing surfaces in the national football league: 1980 to 1989. Am J
Sports Med 1992;20:686–694.
2. Myklebust G, Engebretsen L, Braekken IH, et al. Prevention of
anterior cruciate ligament injuries in female team handball players.
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3. Mykelbust G, Maehlum S, Engebretsen L, et al. Registration of cruciate
ligament injuries in Norwegian top level team handball. A prospective
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injuries with preseason conditioning. Am J Sports Med 2000;28:659–662.
5. Orchard J, Seward H, McGivern J, et al. Rainfall, evaporation and the
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6. Deitch JR, Starkey C, Walters SL, et al. Injury risk in professional
basketball players. Am J Sports Med 2006;10:1–7.
7. Lambson RB, Barnhill BS, Higgins RW. Football cleat design and
its effect on anterior cruciate ligament injuries. Am J Sports Med
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8. Orchard J. The AFL penetrometer study: work in progress. Aust J Sci
Med Sport 2001;4:220–232.
9. Oates KM, Van Eenenaam PV, Briggs K, et al. Comparative injury
rates of uninjured, anterior cruciate ligament-deficient, and recon-
structed knees in a skiing population. Am J Sports Med
1999;27:606–610.
10. Viola RW, Steadman JR, Mair SD, et al. Anterior cruciate ligament
injury incidence among male and female professional alpine skiers.
Am J Sports Med 1999;27:792–795.
11. Warme WJ, Feagin JA, King P, et al. Ski injury statistics, 1982 to
1993, Jackson Hole Ski Resort. Am J Sports Med 1995;23:597–600.
12. Deibert MC, Aronsson DD, Johnson RJ, et al. Skiing injuries in chil-
dren, adolescents, and adults. J Bone Joint Surg Am 1998;80A:25–32.
13. Agel J, Arendt EA, Bershadsky B. Anterior cruciate ligament injury in
national collegiate athletic association basketball and soccer. Am J
Sports Med 2005;33:524–531.
14. Arendt E, Dick R. Knee injury patterns among men and women in
collegiate basketball and soccer. Am J Sports Med 1995;23:694–701.
15. Mihata LC, Beutler AI, Boden BP. Comparing the incidence of ante-
rior cruciate ligament injury in collegiate lacrosse, soccer, and basket-
ball players. Am J Sports Med 2006;34:899–904.
16. Mandelbaum BR, Silvers HJ, Watanabe DS, et al. Effectiveness of a
neuromuscular and proprioceptive training program in preventing the
incidence of anterior cruciate ligament injuries in female athletes. Am
J Sports Med 2005;33:1–7.
17. Gwinn DE, Wilckens JH, McDevitt ER, et al. The relative incidence
of anterior cruciate ligament injury in men and women at the United
States Naval Academy. Am J Sports Med 2000;28:98–102.
18. Bjordal JM, Arnoy F, Hannestad B, et al. Epidemiology of
anterior cruciate ligament injuries in soccer. Am J Sports Med
1997;25:341–345.
19. Pfeiffer RP, Shea KG, Roberts D, et al. Lack of effect of a knee liga-
ment injury prevention program on the incidence of noncontact ante-
rior cruciate ligament injury. J Bone Joint Surg 2006;88:1769–1774.
20. Faude O, Junge A, Kindermann W, et al. Injuries in female soccer
players. Am J Sports Med 2005;33:1694–1700.
21. Hewett TE, Lindenfeld TN, Riccobene JV, et al. The effect of neuro-
muscular training on the incidence of knee injury in female athletes.
Am J Sports Med 1999;27:699–706.
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21a. Soderman K, Werner S, Pietila T, et al. Balance board training:
Prevention of traumatic injuries of the lower extremities in
female soccer players? Knee Surg Sports Traumatol Arthrosc
2000;8:356–363.
22. Trojian TH, Collins S. The anterior cruciate ligament tear rate varies
by race in professional women's basketball. Am J Sports Med
2006;10:1–4.
23. Lombardo S, Sethi PM, Starkey C. Intercondylar notch stenosis is not
a risk factor for anterior cruciate ligament tears in professional male
basketball players. Am J Sports Med 2005;33:29–34.
24. Messina DF, Farney WC, DeLee JC. The incidence of injury in
Texas high school basketball. Am J Sports Med 1999;27:294–299.
25. Gomez E, DeLee JC, Farney WC. Incidence of injury in Texas girls'
high school basketball. Am J Sports Med 1996;24:684–687.
26. Lindenfeld TN, Schmitt DJ, Hendy MP, et al. Incidence of injury in
indoor soccer. Am J Sports Med 1994;22:364–371.
27. Putukian M, Knowles WK, Swere S, et al. Injuries in indoor soccer.
Am J Sports Med 1996;24:317–322.
28. DeLee JC, Farney WC. Incidence of injury in Texas high school foot-
ball. Am J Sports Med 1992;20:575–580.
29. Levy AS, Wetzler MJ, Lewars M, et al. Knee injuries in women col-
legiate rugby players. Am J Sports Med 1997;25:360–362.
30. Petersen W, Braun C, Bock W, et al. A controlled prospective case
control study of a prevention training program in female team
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handball players: the German experience. Arch Orthop Trauma Surg
2005;9:614–621.
31. Myklebust G, Maehlum S, Holm I, et al. A prospective cohort study
of anterior cruciate ligament injuries in elite Norwegian team handball.
Scand J Med Sci Sports 1998;8:149–153.
32. Seil R, Rupp S, Tempelhof S, et al. Sports injuries in team handball.
Am J Sports Med 1998;26:681–687.
33. Orchard J, Seward H, McGivern J, et al. Intrinsic and extrinsic risk
factors for anterior cruciate ligament injury in Australian footballers.
Am J Sports Med 2001;29:196–200.
34. Hewett TE, Myer GD, Ford KR, et al. Biomechanical measures of
neuromuscular control and valgus loading of the knee predict anterior
cruciate ligament injury risk in female athletes. Am J Sports Med
2005;33:492–501.
35. Toth AP, Cordasco FA. Anterior cruciate ligament injuries in the
female athlete. J Gend Specif Med 2001;4:25–34.
36. Harmon KG, Dick R. The relationship of skill level to anterior cruci-
ate ligament injury. Clin J Sport Med 1998;8:260–265.
37. Scranton Jr. PE, Whitesel JP, Powell JW, et al. A review of selected
noncontact anterior cruciate ligament injuries in the National Football
League. Foot Ankle Int 1997;18:772–776.
38. Wedderkopp N, Kaltoft M, Lundgaard B, et al. Injuries in young
female players in European team handball. Scand J Med Sci Sports
1997;7:342–347.
41
 5
CHAPTER
Analysis of Anterior Cruciate Ligament
Injury-Prevention Programs for the
Female Athlete
Holly J. Silvers INTRODUCTION
Robert H. Brophy
The anterior cruciate ligament (ACL) is a crucial
Bert R. Mandelbaum stabilizer of the tibiofem oral joint, preventing
anterior translation of the tibia on the femur during
weight-bearing activities. The ACL works collec-
tively with the posterior cruciate ligament (PCL)
to stabilize the knee during dynamic movement.
The PCL is attached to the posterior portion of
the intercondylar eminence of the tibia and passes
forward to attach to the medial condyle of the
femur. The medial collateral ligament (MCL) is
attached to the medial femoral condyle and the
medial surface of the tibia. The lateral collateral
ligament (LCL) is attached to the lateral femoral
condyle and the lateral portion of the head of the
fibula. The MCL and the LCL are extracapsular
ligaments and provide stability to the knee joint
in the frontal plane during varus and valgus loads.
Since the passage of the Title IX Educa-
tional Amendment, there has been an exponential
increase of female participation in sports at both
the collegiate (fivefold increase over the last 30
years)1 and high-school (tenfold increase over the
last 30 years)2 levels. Although participation in
organized sports has many physical and psycho-
logical benefits, including decreases in obesity,
hypertension, diabetes mellitus, and coronary heart
disease, this increase has subsequently led to an
increase in sports-related injuries.3 While identify-
ing risk factors with regard to sports-related injury,
researchers have found an increased rate of liga-
mentous knee injuries, especially of the ACL, in
female athletes compared with their male
42
counterparts participating in similar activities.4–9
Among athletes in pivoting and jumping sports,
adolescent females face a fourfold to sixfold
increased risk of ACL injury compared with their
male counterparts.6,10,11
The ACL is at risk for injury during activ-
ities that require pivoting, decelerating, or landing
from a jump, such as soccer, basketball, volleyball,
and team handball, as well as American football
and downhill skiing.12 An estimated 80,000 to
250,000 ACL injuries occur annually in the
United States alone.12,13 The highest incidence
of these injuries occurs typically in young athletes
between the ages of 15 to 25, which constitutes
nearly 50% of all reported ACL injuries.3 Further-
more, the incidence among female athletes
exceeds their male counterparts by a twofold to
eightfold frequency12,13,14 Arendt and Dick
examined the increased incidence of ACL injury
among NCAA Division I athletes participating
in basketball and soccer over a 5-year period.15
These two sports were chosen due to the fact that
there is a strong similarity between the men's and
women's games with regard to rules, training and
development, style of play, type of playing surface,
and the intensity of the competition. The injury
rate was recorded and analyzed per athlete-expo-
sure, where one practice session or game was
defined as one exposure. The average ACL injury
rate was 0.31 per 1000 athlete-exposures for
female soccer and 0.29 per 1000 athlete-exposures
for female basketball, compared with 0.13 for male
soccer and 0.07 for male basketball per 1000
athlete-exposures. These epidemiological data for
 Analysis of Anterior Cruciate Ligament Injury-Prevention Programs for the Female Athlete
ACL injury rates statistically signify the blatant discrepancy
that exists between genders.6
ACL rupture is a severe ligamentous knee injury, leading
to functional instability in the short term and degenerative joint
disease in the long term. Injury to the ligament can lead to pro-
longed absence from both work and sport and can initiate the
early onset of degenerative osteoarthritis.15,16 Although ACL
reconstructive procedures are readily available, the injury is
painful and costly and can be debilitating. In the United States,
at least 50,000 ACL reconstructions are performed each year at
a cost of about $17,000 per procedure.14,17 The direct medical
cost for reconstructive surgeries alone is just under $1 billion
per year ($850,000,000). This figure does not include initial
treatment costs of all ACL injuries, the rehabilitation costs
after reconstruction, or the costs of conservative treatment
and rehabilitation of those injuries that are not repaired.18
Complete ACL injuries can lead to chronic knee pathology,
including instability, secondary injury to the menisci and artic-
ular cartilage, and an early onset of osteoarthritis. Approxi-
mately 66% of all patients with complete ACL injury incur
damage to the menisci and the articular cartilage of the femur,
patella, and/or tibia. This injury, coupled with the risk of sec-
ondary injury, can significantly decrease the ability of patients
to complete their activities of daily living and affect their quality
of life. The surgical reconstruction of a ruptured ACL can
significantly reduce the risk of secondary injury. Seitz et al18a
noted that 65% of ACL deficient patients sustained a second-
ary meniscal injury within 2.5 years of the initial date of injury.
Data show that despite surgical treatment of this
injury, patients frequently develop posttraumatic arthritis
of the knee.* Despite the most earnest efforts of orthopaedic
surgeons to preserve the integrity of the knee joint during
ACL reconstructive surgery, ACL reconstructed individuals
continue to report with early onset of osteoarthritis. Loh-
mander et al completed a 12-year longitudinal study to fol-
low up on female athletes who previously underwent ACL
reconstruction after sustaining an injury while playing
soccer.10 They found that 55 women (82%) had radio-
graphic changes in their index knee and 34 (51%) fulfilled
the criterion for radiographic knee osteoarthritis. The mean
age for the subjects involved with this study was 31.
Gillquist et al noted that the prevalence of radio-
graphic knee gonarthrosis is significantly higher in the
injured knee compared with the unaffected contralateral
limb.16 The implications of this research are ominous—
hence the increased need for the prevention of these injuries
from occurring in the first place.7
A multidisciplinary meeting was held in Hunt Valley,
Maryland, in 1999 involving biomechanists, physicians,
certified athletic trainers, and physical therapists to delineate
*References 4, 5, 10, 15, 16, 19–21.
5
specific risk factors thought to be directly correlated to the
increased incidence of ACL injuries in the female athlete.5
The identified risk factors included anatomy, hormones,
environment, and biomechanics. This meeting spurred the
development of various ACL injury-prevention programs
and led to increased interest and financial funding in this
area of research. This group of researchers reconvened
in Atlanta, Georgia, in January 2005 to reevaluate the
identified risk factors and to determine what progress has
been made since the inaugural meeting in 1999.
ANTERIOR CRUCIATE LIGAMENT INJURY-
PREVENTION STUDIES
A growing number of injury-prevention programs targeted
at reducing the risk of ligamentous knee injury in general
and ACL injury in particular have been reported in the
literature. Although a number of risk factors for ACL injury
have been proposed, only the biomechanical risk factors
have been examined in sufficient depth to support the
design and evaluation of prevention interventions.2,14
During passive motion, tension in the ACL decreases
from 0 to 35 degrees and then increases again with further
flexion.5 Thus, a combination of maximal ACL tension and
anterior tibial translation force occurs with quadriceps firing
and joint compressive loading at or near full extension.
Contraction of the hamstrings decreases ACL strain in all
positions. However, co-contraction of the hamstrings is not
enough to overcome the strain produced by the quadriceps.7
As the knee moves into extension, female athletes take a
significantly longer time to activate their hamstrings than do
their male counterparts.8,9 At initial contact, males take
approximately 150 ms to achieve their peak flexion angle
compared with females, who take approximately 200 ms.
Landing from a jump, in-line deceleration, and pivoting all
involve eccentric contraction of the quadriceps to prevent the
extended knee from collapsing into flexion. In laboratory
studies, multiple authors4–6 have demonstrated significant
anterior translation of the tibia with quadriceps contraction,
particularly at 0 to 45 degrees of flexion. This anterior transla-
tion force is even greater when the quadriceps contraction is
combined with a joint compressive force.4 These findings are
the basis for ACL prevention strategies that emphasize proper
biomechanics to address proper landing kinematics (hip and
knee flexion while avoiding genu valgum), increase peak
flexion angles, and improve hamstring activation and strength.
Most prevention programs attempt to alter dynamic
loading of the tibiofemoral joint through neuromuscular and
proprioceptive training. The studies to date that focused on
biomechanical modifications have resulted in the reduction
of lower-extremity injuries in athletes. However, the studies
43
 Anterior Crucite Ligament Injury
vary widely both in their approach to injury prevention and
the validity of the study design. Most studies to date have
been nonrandomized, and very few have been conducted as
randomized, controlled trials.
Nevertheless, a number of common elements tie these
programs together. Most include one or more of the following:
traditional stretching, strengthening, awareness of high-risk
positions, technique modification, aerobic conditioning,
sports-specific agility, proprioceptive and balance training,
and plyometrics. The relation of these components to specific
risk factors for ACL injury has been summarized in Table 5-1.
Results of Studies Published to Date
In an attempt to analyze existing ACL prevention programs,
the studies are grouped and reviewed by their approach to
injury prevention, beginning with the more global interven-
tions and working up to the more comprehensive programs.
Ettlinger et al25 looked at the effectiveness of an educational
program to prevent ACL injury among downhill skiers by
increasing awareness of injury mechanism and avoidance.
Several studies have looked at the effect of isolated proprio-
ception training on ACL injury risk, whereas a slightly
more involved approach included neuromuscular training
in landing and cutting techniques. Another pair of studies
looked at the efficacy of technique training coupled with
strengthening. Several more studies used a combination
of neuromuscular training modalities. Finally, a number of
studies have used a comprehensive approach to prevention
of ACL injury, working on strength, flexibility, and agility
as well as proprioception and plyometric training. The studies
to date are summarized in Table 5-2.
Education
25
Ettlinger et al used a relatively simple approach to preven-
tion of ACL injury in downhill skiers, attempting to modify
high-risk–related behavior through education and increased
TABLE 5-1 Potential Biomechanical Deficits and Suggested Interventions
Position Intervention Strategy
Extended knee at initial contact Knee flexion
Extended hip at initial contact Hip flexion
Knee valgus with tibial-femoral Address dynamic control, decrease dynamic
loading valgus
Balance deficits Proprioception drills
Skill deficiency Improve agility
44
awareness. In this prospective nonrandomized trial, 4000
on-slope alpine ski instructors and patrollers in 20 ski areas
completed training and reporting requirements during the
1993–1994 ski season. The training kit included a 19-min-
ute ACL awareness training videotape that showed 10
recorded ACL injuries sustained by alpine skiers of various
levels, as well as various written materials. The videotape
used guided discovery, allowing viewers to visualize carefully
selected stimuli and incorporate this information into their
skiing to avoid high-risk behavior and manage high-risk
situations to reduce the risk of ACL injury. Participants
also underwent an awareness training session that
included proper body positioning, understanding of the
phantom-foot ACL injury mechanism, and strategies to
avoid high-risk positions as well as effective reaction
strategies.
The two seasons prior to the intervention season served
as historical controls, and area employees had sustained an
average of 31 serious ACL sprains per season. During the
intervention season, employees sustained 16 serious ACL
sprains, 6 in the untrained group and 10 in the trained
group, which was a 62% reduction compared with the
normalized expected number of 26.6 ACL injuries in
the trained individuals (P < 0.005).
This study demonstrates that educational efforts and
visual aids to increase awareness effectively reduce the
number of significant ACL injuries in an alpine skiing
population. A significant aspect of this study was the lack
of physical biomechanical intervention. Based on the success
of other intervention studies, it would be interesting to look
at the effect of a similar awareness program combined with
specific biomechanical training for alpine skiers.
Isolated Strengthening and Conditioning
Cahill and Griffith26 looked at the effect of incorporating
weight training into preseason conditioning for high-school
American football teams. Over the 4 years of the study, they
Method of Intervention
Concentric hamstring control and soft landing
Iliopsoas and rectus femoral control and soft landing
Lateral hip control upon landing
Dynamic balance training
Agility drills to address deceleration techniques and core
stability
 TABLE 5-2 Summary of Anterior Cruciate Ligament Prevention Studies
STUDY DESIGN SPORT N GENDER TRAINING MODALITIES RESULTS

Int Control Education Strength Proprio Plyo Agility Flex
ACL Injuries/Injury Rate

Ettlinger, 1995 P/NR/C Skiing 4000 na M/F
62% #

Isolated

Cahill, 1978 P/NR American football 1227 1254 M
63% # surgical knee injuries 86% # concomitant ACL & MCL

Caraffa, 1996 P/NR S 300{ 300{ M
87% # noncontact

Soderman, 2000 P/R S 121 100 F
No change (intervention group 4/5 ACL injuries)
Type of Intervention Program

Hening, 1990 P/NR BB na na F

89% # noncontact

Combination

Wedderkopp, 1999 P/R/C TH 111 126 F


No ACL specific data

Analysis of Anterior Cruciate Ligament Injury-Prevention Programs for the Female Athlete
Pfeiffer, 2004 P/NR S/VB/BB 577 862 F

No change

Hewett, 1999 P/NR S/VB/BB 366 463 F*



72% #

Myklebust, 2003 P/NR TH 855 942 F



Elite players 62% #

Heidt, 2000 P/R S 42 258 F




No significant change

Comprehensive

Olsen, 2005 P/R/C TH 958 879 M/F




80% # knee ligament injury

Mandelbaum, 2005 P/NR S 1041 1905 F




88% # year 1, 74% # year 2

Gilchrist, 2004 P/R/C S 575 854 F




72% #

P, Prospective; R, randomized; NR, nonrandomized; C, controlled; S, soccer; VB, volleyball; BB, basketball; TH, team handball.
*Study also included male controls.
{
Estimate.
45

5
 Anterior Crucite Ligament Injury
noted a reduction in reported knee injuries and knee injuries
that required surgery in the intervention group.
Isolated Proprioceptive Training
Two studies have looked at the effect of isolated propriocep-
tive training on ACL injury risk, both in soccer players.
Caraffa et al27 conducted a nonrandomized prospective study
with 600 semi-professional and amateur soccer players in
Umbria and Marche, Italy. Twenty teams (10 amateur and
10 semi-professional teams; Group A) underwent proprio-
ceptive preseason training in addition to their regular training
session. The control group (Group B) consisted of 20 teams
(10 amateur and 10 semi-professional teams) and continued
training in their usual fashion. The intervention group (A)
was subjected to a five-phase progressive balance training
program consisting of the following: no balance board, rect-
angular balance board, round balance board, combination
(rectangular/round), and a biomechanical ankle platform
system (BAPS) board (Camp Jackson, MI). The duration/
frequency was 20 minutes per day for 2 to 6 days per week,
including a minimum of 3 times per week during the season.
The groups were followed for 3 years, and the senior author
evaluated all players with a potential knee injury.
Group A (intervention) reported 10 arthroscopically
confirmed ACL injuries over three seasons (0.15 ACL inju-
ries per team/season) compared with Group B (control),
which reported 70 such injuries (1.15 ACL injuries per
team/season) (P < 0.001). Unfortunately, no differentiation
was made between contact and noncontact ACL injuries.
Soderman et al28 conducted a randomized, prospective
controlled trial looking at the effectiveness of a balance board
training program to reduce injuries in female soccer players.
A total of 13 teams in the Swedish second and third division
participated in the study, with seven teams (N ¼ 121 players
enrolled, 62 completed) in the intervention group and six teams
(N ¼ 100 players enrolled, 78 completed) in the age- and
skill-matched control group through one outdoor season.
The intervention consisted of a 10- to 15-minute balance board
training program in addition to regularly scheduled games and
practices. The players were instructed to complete the program
daily for 30 days and continue with three sessions per week
thereafter. Injuries were assessed with regard to number,
incidence, type, and location.
The intervention group had more major injuries (8)
compared with the control group (1) (P ¼ 0.02) and a total
of four ACL injuries were reported in the intervention
group compared with one in the control group. Although
a major limitation of this study was the 37% dropout rate,
balance board training alone did not decrease the incidence
of ACL injury in this cohort.
Based on these two studies, the role for isolated pro-
prioceptive training in efforts to prevent ACL injury is
46
unclear. A major concern is that the training methods used
in both of these studies involve a large commitment both in
terms of training time and financial cost of equipment,
which may decrease compliance with regard to large-scale
injury-prevention efforts.
Neuromuscular Training: Technique
Injury prevention has also been considered with the design of
a neuromuscular training program to modulate existing ath-
letic technique. Henning29 implemented a prevention study
in two NCAA Division I female basketball programs over
the course of 8 years. Henning proposed that the increased
rate of ACL injury in female athletes was primarily functional,
being related to knee position and muscle action during
dynamic movement. In knee extension, the quadriceps exerts
a significant anterior translational force on the tibia, thus
imparting a shear force on the ACL. Conversely, as the knee
moves into flexion, the anterior translational force on the tibia
is decreased, thereby decreasing the torque on the ACL
secondary to the contraction of the hamstrings. In order to
decrease the risk of ACL injury, Henning proposed that
the athletes cut, land, and decelerate with knee and hip
flexion. In addition, he proposed a rounded cut maneuver
instead of a sharp or more acute angle during the cut
cycle. He also proposed that a one-step stop deceleration
pattern should be avoided and a three-step quick stop be
instituted instead. This intervention program was geared at
changing player technique, stressing knee flexion upon
landing, using accelerated rounded turns, and decelerating
with a multistep stop. This protocol was completed on the
basketball court without any additional equipment
requirements.
The intervention group was noted to have an 89%
reduction in the rate of occurrence of ACL injuries.29 Sadly,
Dr. Henning's death in 1991 prevented the publication of
this research. However, his research served as the crucial
foundation of numerous prevention programs that ensued.
Neuromuscular Training: Technique and
Strengthening
Henning's concept of athletic modulation has been widely
accepted and expounded. Wedderkopp et al31 tested a
program including functional strengthening and balance
training (use of an ankle disc for 10 to 15 minutes at all
practice sessions). Teams were randomized into two groups,
with a total of 11 teams (N ¼ 111) in the intervention group
and 11 teams (N ¼ 126) in the control group.
The group using the ankle disc incurred 14 injuries
compared with 66 injuries in the control group (P < 0.01).
The control group had a lower rate of injury during practice
(0.34 per 1000 hours versus 1.17 per 1000 hours; P < 0.05)
and games (4.68 per 1000 hours versus 23.38 per 1000
 Analysis of Anterior Cruciate Ligament Injury-Prevention Programs for the Female Athlete
hours; P < 0.01). The intervention group suffered two knee
injuries whereas the control group incurred eight knee inju-
ries. No data specific to ACL injury was provided.
Pfeiffer et al32 developed the Knee Ligament Injury-
Prevention (KLIP) program, involving 15 minutes of strength-
ening and plyometric activities, for female high-school soccer,
volleyball (VB), and basketball (BB) players. In the first season
of a 2-year, nonrandomized prospective study, 43 schools par-
ticipated in the program (17 BB: N ¼ 191; 11 soccer: N ¼ 189;
15 VB: N ¼ 197) and 69 schools served as the control group
(28 BB: N ¼ 319; 14 soccer: N ¼ 244; 27 VB: N ¼ 299).
The study design included a training session for the coaches
and athletic trainers and weekly compliance checks for athlete
participation for both games and practices. No significant dif-
ference between the two groups was found after one season:
there were three arthroscopically confirmed ACL injuries
reported in the intervention athletes (incidence rate 0.167)
compared with four (incidence rate 0.078) in the control group.
Anecdotally, there were no noncontact ACL injuries in the
intervention soccer and volleyball players; all of the injuries in
the intervention group occurred among basketball players.
Possible explanations for the lack of impact include the
abridged duration of this intervention program (9 weeks) and
the fact that the program was conducted post-training. Neuro-
muscular fatigue at the end of training may directly affect bio-
mechanical technique of the athlete and limit any potential
protective benefit of ACL injury-prevention programs.
Neuromuscular Training: Varied
Other studies have incorporated additional dimensions of
neuromuscular training into ACL prevention efforts. The
Cincinnati Sportsmetric includes flexibility, strengthening
(through weight training), and plyometric activities over a
duration of 60 to 90 minutes. Hewett et al33 researched the
effect of this program on the incidence of knee injury in high
school–age soccer, volleyball, and basketball athletes. Forty-
three teams (N ¼ 1263 athletes), including 15 female teams
(N ¼ 366), implemented the program, and 15 additional
female teams (N ¼ 463) served as the same-sex untrained
control. Thirteen male sports teams (N ¼ 434) served as the
male control group. Coaches and trainers implemented
the program based on a videotape and manual. The program
was performed 3 days per week on alternate days. Seventy
percent of the intervention athletes (248/366) completed the
entire 6-week program, and the remainder completed at
least 4 weeks of training to be included in the study.
The incidence of serious knee injuries (N ¼ 14) in the
female control group was 0.43 per 1000 player-exposures,
compared with 0.12 in the female intervention group
(P ¼ 0.05) and 0.09 in the male control group. The inter-
vention group also had a lower rate of noncontact injuries
(P ¼ 0.01) and noncontact ACL injuries (P ¼ 0.05). The
5
incidence of noncontact knee injury was 0.35 per 1000
player-exposures in the control group, compared with 0 in
the intervention group and 0.05 in the male control group.
When the data were stratified according to sport, no
ACL injuries were reported in volleyball players. Among
the soccer athletes, there were five ACL injuries reported
among the female control athletes (0.56 per 1000 player-
exposures), none among the female intervention athletes,
and one among the male control group (0.12 per 1000
player-exposures). Among the basketball players, eight
ACL injuries were reported; five among the female control
athletes (0.48 per 1000 player-exposures), two among the
trained athletes (0.42 per 1000 player-exposures), and one
among the male controls (0.08 per 1000 player-exposures).
When the data were stratified with regard to sport,
the distribution of athletes varied widely. The intervention
female group included 185 volleyball players, 97 soccer
players, and 84 basketball players. The control female group
included 81 volleyball players, 193 soccer players, and 189
basketball players. The male control group included 209
soccer players and 225 basketball players. The discrepancy
within gender and respective sport cohorts weakens the
strength of the study's conclusion. In addition, the number
of ACL injuries reported throughout this prospective study
was lower compared with historical controls.2,5,34
ACL injuries have also been problematic for European
team handball players. Myklebust et al35 conducted a nonran-
domized prospective study looking at 900 Divisions I–III com-
petitive female handball players over a 3-year period in Norway.
Sixty teams (942 players in the 1998–1999 season) served as
the control athletes (CAs), and 58 teams (855 players in
the 1999–2000 season) and 52 teams (850 players in the
2000–2001 season) served as the intervention athletes (IAs).
The intervention consisted of a 15-minute program focused
on landing, cutting, and planting technique with 5 minutes
spent on each of three exercise components: floor, balance
mat, and wobble board. The program was 5 weeks long, with
different exercises introduced each week. The program was to
be completed three times per week during the first 5 to 7 weeks
and then once per week during the season. A physical therapist
was designated to each team to assess compliance during
the second intervention season (2000–2001). Special equip-
ment included an instructional videotape, a poster delineating
the tasks to be completed, six balance mats, and six balance
boards.
Teams were required to conduct a minimum of 15
training sessions over the 5- to 7-week period with a
minimum of 75% player participation. Only 15 (26%) of the
58 teams from season 2 and 15 (29%) of the 52 teams from
season 3 completed the necessary number of sessions,
although compliance was higher among the elite division
teams (42% and 50%, respectively).
47
 Anterior Crucite Ligament Injury
Overall, there were 29 ACL injuries during the control
season, 23 injuries during the first intervention season (odds
ratio [OR], 0.87; confidence interval [CI], 0.50–1.52; P ¼
0.62) and 17 injuries during the second intervention season
(OR, 0.64; CI, 0.35–1.18; P ¼ 0.15). However, during the
second intervention season, 14 ACL injuries occurred in
players with no training (2.2%) compared with 3 ACL
injuries in the players who completed training (1.1%)
(P ¼ 0.31). In the elite division alone, 4 ACL injuries occurred
in the players with no training (8.9%) compared with 1 ACL
injury in those who completed training (0.6%) (P ¼ 0.0134).
This intervention included elements of plyometric
activities, proprioception, and agilities but did not include
any elements of strength. Limitations of the study include
nonrandomization of the subjects, insufficient power, and
control data that were collected during an earlier season.
Strengths of the study include measures of compliance by
a medical clinician (physical therapist) and the use of an
educational videotape and poster. The study suggests that
the inclusion of a neuromuscular balance–based training
program may impart some protective benefit to the ACL.
Neuromuscular Training: Comprehensive
A number of comprehensive ACL injury programs have been
proposed in the literature. These programs incorporate a full
range of neuromuscular training, including strengthening, flex-
ibility, agility, proprioception, and plyometrics. Heidt et al34
developed the Frappier Acceleration Program (FAP) as a
7-week preseason training program to address ACL injuries
in the high-school–age female soccer population. Three hun-
dred female soccer players were followed over the course of 1
year (one high-school season and one club/select season).
The control group included 258 athletes, whereas the inter-
vention group included 42 athletes. The Frappier Acceleration
Program consisted of sports-specific aerobic conditioning,
plyometrics, sports cord resistance drills, strength training, and
flexibility that was individually customized by sport, player
position, and specific deficits. The plyometric progression
was from unidirectional to bidirectional to multidirectional
and vertical challenge (2-inch increments using foam obsta-
cles). Injuries were defined as a player missing practice or a
game, and athletic exposures were not recorded in this study.
Although there was a significant reduction in injuries,
from 91 (37%) in the control group to 7 (14%) in the interven-
tion group (P < 0.01), there was no significant difference in
terms of ACL injury: 8 (3.1%) in the control group compared
with 1 (2.4%) in the intervention group. Given the small sam-
ple size of the intervention group, the study was not sufficiently
powered to find significant differences. As with the Cincinnati
Sportsmetric Program, the FAP was designed as a preseason
protocol with no in-season continuation. In addition, because
of the complicated equipment requirements (i.e., treadmill,
48
plyometric box), the training has to be completed in a facility,
and compliance could potentially be inhibited by cost.
Olsen et al36 studied a program designed to prevent
lower limb injury in youth team handball. European team
handball clubs (120 teams; intervention ¼ 61 teams, 958
players; control ¼ 59 teams, 879 players) participated in an
8-month intervention program that consisted of four sets of
exercise lasting 15 to 20 minutes. The training consisted of
warm-up exercises (jogging, backward running, forward
running, sideways running, and speed work), technique
(plant, cut, and jump shot landing), balance (passing, squats,
bouncing, perturbation), and strength and power (squats,
bounding, jumps, hamstrings). Each club was instructed on
how to perform the program and was issued a training hand-
book, five wobble boards (Norpro, Norway), and five balance
mats (Airex, Switzerland). The program focused on proper
biomechanics during landing, core stability, and inter-rater
feedback between team members. The intervention teams
consisted of 16- to 17-year-old males and females who
completed 15 consecutive training sessions at the start of
the season, followed by 1 training session per week for the
remainder of the season.
There were 66 (6.9% of players) lower limb injuries
reported in the intervention group (IG) compared with 115
(13.1%) in the control group (CG) (relative risk, 0.51; 95%
CI, 0.36–73; P < 0.001). A total of 19 acute knee injuries
(2.0%) were recorded in the IG compared with 38 (4.3%) in
the CG (relative risk, 0.45; 95% CI, 0.25–0.81; P ¼ 0.007).
There were 3 knee ligament injuries reported in the IG
compared with 14 in the CG (relative risk, 0.20; 95% CI,
0.06–0.70; P ¼ 0.01). All three knee ligament injuries in the
IG were ACL injuries, whereas 10 of the 14 reported knee
injuries in the CG were ACL injuries. A commendable 87%
compliance rate was reported with the study.
Many of these intervention programs require special
equipment, specialized training, or significant time commit-
ment. In 1999 an expert panel convened by the Santa
Monica (California) Orthopedic and Sports Medicine Research
Foundation designed the ACL “PEP Program: Prevent Injury
and Enhance Performance.” This prevention program consists
of warm-up, stretching, strengthening, plyometrics, and
sport-specific agilities to address potential deficits in the
strength and coordination of the stabilizing muscles around
the knee joint. It was designed as an alternative warm-up so that
the desired activities could be performed on the field during
practice without specialized equipment for ease of implementa-
tion. The program consists of an educational videotape or DVD
that demonstrates proper and improper biomechanical tech-
nique of each prescribed therapeutic exercise. An entire team
can complete the 19 components in less than 20 minutes.37
An early nonrandomized study among highly competi-
tive 14- to 18-year-old female club soccer players using the
 Analysis of Anterior Cruciate Ligament Injury-Prevention Programs for the Female Athlete
program demonstrated promising results.37 During the first
year of the study (2000), 1041 female club soccer players
(52 teams) performed the PEP program, and 1902 players
(95 teams) served as the age- and skill-matched controls. There
were 2 ACL tears (0.2 ACL injuries per athlete-exposure) in
enrolled subjects versus 32 ACL tears (1.7 ACL injuries per
athlete-exposure) in the control group—an 88% decrease in
ACL ligament injury. In year 2 (2001) of the study, four
ACL tears were reported in the intervention group, with an
incidence rate of 0.47 injuries per athlete-exposure. Thirty-five
ACL tears were reported in the control group, with an
incidence rate of 1.8 injuries per athlete-exposure. This corre-
sponds to an overall 74% reduction in ACL tears in the inter-
vention group compared with an age- and skill-matched
control group in year 2.
The limitations of this study include nonrandomiza-
tion of the subjects, no consistent direct oversight of the
intervention, and compliance measurements that were only
completed in a small subset of intervention teams.
The strengths of the PEP Program include the fact that
it is an on-field warm-up program that requires only traditional
soccer equipment (cones and soccer ball). It is completed two to
three times per week over the course of the 12-week soccer sea-
son and is 20 minutes in duration. It includes progressive
strength, flexibility, agility, plyometric, and proprioceptive
activities to address the deficits most commonly demonstrated
in the female population. Deceleration patterns are addressed,
stressing the multistep deceleration pattern and proper landing
technique, and it encourages knee and hip flexion while landing
on the ball of the foot and avoiding genu valgum by using
the abductors and lateral hip musculature. In addition, because
the program is designed as a warm-up, compliance rates are
higher and the element of neuromuscular fatigue does not
affect the performance of the therapeutic exercises.
This aforementioned study was followed by a rando-
mized controlled trial using the PEP Program in Division I
NCAA women's soccer teams in the 2002 fall season.38 Sixty-
one teams with 1429 athletes completed the study, with 854
athletes participating on 35 control teams and 575 athletes par-
ticipating on 26 intervention teams. No significant differences
were noted between intervention and control athletes with
regard to age, height, weight, or history of past ACL injuries.
After using the PEP Program during one season, there
were 8 ACL injuries in the intervention athletes (IA) (rate of
0.14) versus 18 in control athletes (CA) (rate of 0.25)
(P ¼ 0.15). There were no ACL injuries reported in IA dur-
ing practices versus 6 in CA (0.10) (P ¼ 0.01). During game
situations, the difference was nonsignificant (IA, 7; CA, 12;
P ¼ 0.76). Noncontact ACL injuries occurred at more than
three times the rate in CA (N ¼ 10; 0.14) than in IA
(N ¼ 2; 0.04) (P ¼ 0.06). Control athletes with a prior history
of ACL injury suffered a reoccurrence five times more
5
frequently than the IA group (0.10 versus 0.02; P ¼ 0.06); this
difference reached significance when limited to noncontact
ACL injuries during the season (0.06 versus 0.00; P < 0.05).
There was a significant difference in the rate of ACL injuries
in the second half of the season (weeks 6–11; IA, 0.00; CA,
0.18) (P < 0.05). This would support the concept that it
takes approximately 6 to 8 weeks for a biomechanical
intervention program to impart a neuromuscular effect.
Overall, these studies provide evidence that preven-
tion-training programs have a quantifiable effect on ACL
injury risk. This has been demonstrated in male and female
athletes from various sports and across different age groups.
Only three of the reviewed studies showed no effect of
training on ACL injury risk; two of them were significantly
underpowered and the third implemented the prevention
program post-training and for a relatively short duration
(9 weeks). Eight studies demonstrate a significant decrease
in ACL injury risk for some or all of the study population.
Prospective studies of comprehensive prevention programs
in large cohorts have been particularly encouraging. Never-
theless, a number of important questions remain.
AREAS FOR FURTHER RESEARCH
Program Specifics
Practically, a cost-benefit analysis needs to be considered prior
to initiating an injury-prevention program on a large scale.
First, what equipment, if any, is necessary, and at what cost?
Extensive and more expensive equipment is necessary for
programs such as the Frappier Acceleration Program,34 the
Cincinnati Sportsmetric program,33 and the various programs
using some form of a balance board.30,31,34,35 Other successful
programs such as PEP37,38 and the Henning program29 do not
have such prohibitive requirements. Secondly, what is the
minimal time commitment needed to provide adequate
protection? How long and how frequent should training
sessions be? When should these programs be introduced?
What is the minimum duration of an injury-prevention
program, or does it need to be continued, perhaps at a lesser
frequency throughout the course of the season? When initiat-
ing a neuromuscular intervention program, it takes approxi-
mately 4 to 6 weeks to impart a benefit onto the athlete.
Most of the programs studied to date have a relatively intense
start-up period for 4 to 6 weeks followed by less frequent, and
in some cases, no additional training.
Timing of Intervention
Does the age of the athlete matter, and would intervention
at an earlier age provide longer-lasting and perhaps better pro-
tection, or will “booster” training be necessary throughout the
49
 Anterior Crucite Ligament Injury
career of any athlete at risk? The young female athlete 15 to 25
years of age is known to be at particularly high risk for ACL
injury and may need different treatment than other popula-
tions. The Santa Monica Orthopedic Group is currently
collaborating with the University of Southern California to
delineate the appropriate age to introduce such programs and
to determine what elements of the program effectively change
faulty biomechanical patterns.
How Do These Programs Work?
More broadly, what is the optimal ACL injury-prevention
program? In order to answer this question, it becomes neces-
sary to determine the precise biomechanical adaptations that
develop in athletes as a result of participating in these
programs. The “pathokinetic chain” of increased hip adduction
moment, decreased hip abduction control, and increased hip
adduction angles is surmised to place the lower extremity in a
valgus position. With increased internal rotation moment and
motion at the knee joint, possibly in combination with ground
reaction force, the ACL may be overloaded to failure. How do
the injury-prevention programs make this less likely to occur?
Although further clinical studies may offer some insight into
the optimal prevention program, a definitive answer will
remain elusive until the biomechanical implications of clinically
successful intervention programs are studied and better
understood.
Individual Versus Population-Based
Programs
Once the specific responsive adaptations resulting from an
injury-prevention program are known, will screening become
possible? If an athlete already exhibits the biomechanical beha-
viors that are known to result from injury-prevention training,
is there any benefit to completing or continuing the program?
Can individuals be assessed and undergo tailored interventions
as opposed to a global program? As we continue our research
efforts to further delineate the mechanism(s) of ACL injury,
it may be possible to “red flag” specific individuals who demon-
strate biomechanical patterns that may directly correlate to an
increased risk of ACL injury. In addition, the age of exposure
to a neuromuscular training program may be a key piece of
the prevention puzzle. If the program is instituted prior to the
onset of puberty and, perhaps, prior to faulty biomechanical
patterns being neuromuscularly ingrained, can we avoid the
development of these patterns in the first place?
Effect on Performance
Another important issue is the effect of ACL injury-
prevention programs on athletic performance. This is
50
particularly important when the relatively poor compliance
with some of the injury-prevention programs reviewed
previously is compared with the much higher rates of com-
pliance, upwards of 80% to 90%, that have been reported
with training targeted toward improving performance.39–43
Recent studies have begun to assess this issue, and the
results are encouraging. In 1996, before the program had been
found to decrease ACL injury risk, Hewett et al44 reported that
the Sportsmetric program increased vertical jump, improved
control of dynamic loading of the knee, and increased
hamstring strength, power, and peak torque in female
volleyball players. Wilkerson et al45 looked at the impact of
the Cincinnati Sportsmetric program on performance in a
small cohort of female collegiate basketball players. They found
significantly increased hamstring strength in the intervention
group but no other changes in either group. Meyer et al43
looked at the effect of an enhanced training program based
on the Cincinnati Sportsmetric program on performance. In
this study, female athletes demonstrated increased strength
and power and improved knee biomechanics after training
compared with no change in the control group. Paterno
et al47 created their own program of exercises similar to those
described in the literature for injury prevention and found
improved single-limb total stability and anteroposterior
stability. There was no control group in this study. Holm
et al48 looked at the influence of the program used by
Myklebust35 on female team handball players and found an
improvement in dynamic balance but no other significant
changes. Again, there was no control group for this study.
Thus, although these studies suggest there may be some
improvement in performance from participation in ACL
injury-prevention programs, further study, particularly with
larger, well-designed studies, is needed to more precisely assess
the impact of such programs on performance.
CONCLUSION
There appears to be a quantifiable reduction in ACL risk for
athletes, particularly females, who complete well-designed
injury-prevention programs. Most of these programs attempt
to alter dynamic loading of the tibiofemoral joint through
neuromuscular and proprioceptive training. An emphasis on
proper landing technique, landing softly on the forefoot and
rolling back to the rearfoot, engaging knee and hip flexion
upon landing and with lateral (cutting) maneuvers; avoiding
excessive genu valgum at the knee upon landing and squat-
ting; increasing hamstring, gluteus medius, and hip abductor
strength; and addressing proper deceleration techniques
are activities that seem to be inherent in each of the aforemen-
tioned ACL prevention protocols. Further electromyography
and biomechanical analysis is warranted to better understand
 Analysis of Anterior Cruciate Ligament Injury-Prevention Programs for the Female Athlete 5
and identify the mechanism(s) of ACL injury and the 20. Malone TR, Hardaker WT, Garrett WE, et al. Relationship of gender
to ACL injuries in intercollegiate basketball players. J South Orthop
activities that offer a protective effect to the ACL.
Assoc 1992;2:36–39.
21. Strand T, Wisnes AR, Tvedte R, et al. ACL injuries in team handball.
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Med 1995;23:531–537.
and women: how common are they? In Griffin LY (ed): Prevention
26. Cahill BR, Griffith EH. Effect of preseason conditioning on the inci-
of noncontact ACL injuries. Rosemont, IL, 2001, American Academy
dence and severity of high school football injuries. Am J Sports Med
of Orthopaedic Surgeons, pp 1–9.
1978;6:180–184.
2. Bahr R, Holme I. Risk factors for sports injuries—a methodological
27. Caraffa A, Cerulli G, Projetti M, et al. Prevention of anterior
approach. Br J Sports Med 2003;37:384–392.
cruciate ligament injuries in soccer. A prospective controlled study of
3. Feagin JA, Jr, Lambert KL, Cunningham PR, et al. Consideration of
proprioceptive training. Knee Surg Sports Traumatol Arthrosc 1996;4:19–21.
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28. Soderman K, Werner S, Pietila T, et al. Balance board training: pre-
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vention of traumatic injuries of the lower extremities in female soccer
4. Frank CB, Jackson DW. The science of reconstruction of the anterior
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cruciate ligament. J Bone Joint Surg Am 1997;79:1556–1576.
Sports Traumatol Arthrosc 2000;8:356–363.
5. Griffin LY, Agel J, Albohn MJ, et al. Noncontact anterior cruciate
29. Henning CE, Griffis ND. Injury prevention of the anterior cruciate
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Orthop Surg 2000;8:141–150.
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6. Myklebust G, Holm I, Maehlum S. Clinical, functional and radiolog-
31. Wedderkopp N, Kaltoft M, Lundgaard B, et al. Prevention of injuries
ical outcome 6–11 years after ACL injuries in team handball players—
in young female players in European team handball. A prospective
a follow-up study. Am J Sports Med 2003;31:981–989.
intervention study. Scand J Med Sci Sports 1999;9:41–47.
7. Daniels DM, Stone MI, Dobson BL, et al. Fate of the ACL
32. Pfeiffer RP, Shea K, Grandstrand S, et al. Effects of a knee ligament
injured patient: a prospective outcome study. Am J Sports Med
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ACL injury: a two-year prospective study of exercise intervention in
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high school female athletes. Podium presentation at the American
after ACL reconstruction. Int Orthop 1991;15:367–371.
Orthopaedic Society for Sports Medicine (AOSSM), Specialty Day,
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33. Hewett TE, Lindenfeld TN, Riccobene JV, et al. The effect of
injured knee. Am J Sports Med 2005;33:23–28.
neuromuscular training on the incidence of knee injury in female
10. Lohmander LS, Osteber A, Englind M, et al. High prevalence of knee
athletes. A prospective study. Am J Sports Med 1999;27:669–706.
osteoarthritis, pain, and functional limitations in female soccer players
34. Heidt RS, Jr, Sweeterman LM, Carlonas RL, et al. Avoidance of
twelve years after anterior cruciate ligament injury. Ann Rheum Dis
soccer injuries with preseason conditioning. Am J Sports Med
2004;10:314–352.
2000;28:659–662.
11. Myklebust G, Maehlum S, Holm I, et al. A prospective cohort study
35. Myklebust G, Engebretsen L, Braekken IH, et al. Prevention of
of ACL injuries in elite Norwegian team handball. Scand J Med Sci
anterior cruciate ligament injuries in female team handball players: a
Sports 1998;8:149–153.
prospective intervention study over three seasons. Clin J Sport Med
12. Roos H, Adalberth T, Dahlberg L. Osteoarthritis of the knee after
2003;13:71–78.
injury to the anterior cruciate ligament or meniscus. The influence of
36. Olsen OE, Myklebust G, Engebretsen L, et al. Exercises to prevent
time and age. Osteoarthr Cart 1995;3:261–267.
lower limb injuries in youth sports: cluster randomised controlled trial.
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Med 1991;19:156–162.
neuromuscular and proprioceptive training program in preventing
14. Von Porat A, Roos EM, Roos H. High prevalence of osteoarthritis 14
anterior cruciate ligmaent injuries in female athletes. 2-year follow-
years after an anterior cruciate ligament tear in male soccer players: a
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study of radiographic and patient relevant outcomes. Ann Rheum Dis
38. Gilchrist J, Mandelbaum BR, Silvers HJ. AAOS Annual Meeting,
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AOSSM Specialty Day, San Francisco, CA, March 2004.
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39. Ben-Sira D, Ayalon A, Tavi M. The effect of different types of
in collegiate basketball and soccer. Am J Sports Med 1995;
strength training on concentric strength in women. J Strength Cond
23:694–701.
Res 1995;9:143–148.
16. Gillquist J, Messner K. Anterior cruciate ligament reconstruction
40. Hakkinen K, Alen M, Kraemer WJ, et al. Neuromuscular adaptations
and the long-term incidence of gonarthrosis. Sports Med
during concurrent strength and endurance training versus strength
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training. Eur J Appl Physiol 2003;89:42–52.
17. Chandy TA, Grana WA. Secondary school athletic injury in boys and
41. Kraemer WJ, Duncan ND, Volek JS. Resistance training and elite
girls: A three year comparison. Phys Sportsmed 1985;13:106–111.
athletes: adaptations and program considerations. J Orthop Sports Phys
18. Gray J, Taunton JE, McKenzie DC, et al. A survey of injuries to the
Ther 1998;28:110–119.
anterior cruciate ligament of the knee in female basketball players. Int
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J Sports Med 1985;6:314–316.
changes with periodized resistance training in women tennis players.
18a. Seitz H, Marlovits S, Wielke T, Vescei V. Meniscus lesions after
Med Sci Sports Exerc 2003;35:157–168.
isolated anterior cruciate ligament rupture. Wien Klin Wochenschr
43. Wroble RR, Moxley DR. The effect of winter sports participation on
1996;22:727–730.
high school football players: strength, power, agility and body compo-
19. Lindenfeld TN, Schmitt DJ, Hendy MP, et al. Incidence of injury in
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indoor soccer. Am J Sports Med 1994;22:364–371.

51
 Anterior Crucite Ligament Injury
44. Hewett TE, Stroupe AL, Nance TA, et al. Plyometric training in
female athletes: decreased impact forces and increased hamstring
torques. Am J Sports Med 1996;24:765–773.
45. Wilkerson GB, Colston MA, Short NI, et al. Neuromuscular changes
in female collegiate athletes resulting from a plyometric jump-training
program. J Athl Train 2004;39:17–23.
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47. Paterno MV, Myer GD, Ford KR, et al. Neuromuscular training
improves single-limb stability in young female athletes. J Orthop Sports
Phys Ther 2004;34:305–316.
48. Holm I, Fosdahl MA, Friis A, et al. Effect of neuromuscular training on
proprioception, balance, muscle strength, and lower limb function in
female team handball players. Clin J Sport Med 2004;14:88–94.
 PART B CLINICAL
Diagnosis of Anterior Cruciate
Ligament Tear
INTRODUCTION
The overwhelming majority of orthopaedists are
very skilled in the diagnosis of anterior cruciate
ligament (ACL) tears. However, acute ACL tear
is perhaps the most underdiagnosed orthopaedic
condition that usually requires surgery because
most tears present to emergency room or primary
care providers who cannot necessarily be expected
to make the diagnosis. The history and exam and
diagnostic tests are less reliable than commonly
thought, and the presentation is often not “clas-
sic.” Failure to refer to an orthopaedist in these
cases, or failure of the patient to actually see the
referred-to orthopaedist, results in underdiagno-
sis and delays in diagnosis that can extend over
months or years.
DIAGNOSIS IN THE ACUTE VERSUS
THE CHRONIC SETTING
Diagnosis of complete ACL tears differs in
some respects in the acute versus the chronic
state regarding the history, physical exam, and
diagnostic tests. This chapter will discuss the
acute versus chronic diagnostic dichotomy for
each of these diagnostic modalities. In the acute
setting the diagnosis is primarily of the ACL
tear itself, whereas in the chronic setting the
diagnosis more often includes the signs and
symptoms of secondary damage. Because the
most important aspect of ACL reconstruction
is the prevention or mitigation of subsequent
6
CHAPTER
meniscal and articular damage to the knee, it Chadwick C. Prodromos
is paramount that ACL tears are diagnosed
Brian J. Murphy
and treated acutely before such further damage
occurs.
PARTIAL TEARS
This chapter deals primarily with complete
ACL tears. Traditionally, partial tears have been
found to produce a smaller degree of antero-
posterior (AP) laxity than complete tears on
Lachman or instrumented Lachman testing, as
described later. Until the present time, the only
alternatives have been nonoperative treatment
or complete reconstruction, which would neces-
sitate ablation of the remaining ligament. Given
these alternatives, nonsurgical treatment has
been the usual alternative if less than 50% of
the ligament was torn.1 With more awareness
of ACL double-bundle anatomy, single-bundle
repairs that preserve the remaining ligament
have been developed.2 These repairs have been
used in some cases of single-bundle partial
ACL tear. Lachman testing and arthrometer
testing in these cases appear to show 2- to
3-mm asymmetry in anteromedial (AM) bundle
tears and 1- to 2-mm asymmetry in posterolat-
eral (PL) bundle tears.3 Arthroscopy is required
for definite anatomical diagnosis. The pivot
shift is of much greater value in the anesthetized
versus the awake patient. Diagnostic criteria as
well as surgical indications and techniques in
these cases continue to evolve.
53
 Anterior Cruciate Ligament Injury

HISTORY particularly in adolescents, as well as meniscal tear. Any

symptom of instability should cause the orthopaedist to rule
Acute in or rule out ACL tear.

The history and mechanism of ACL tear are familiar to all

orthopaedists.4–10 The history most commonly entails twist- PHYSICAL EXAM
ing, landing, or a valgus blow to the knee. However, almost
Pivot Shift
any history of knee trauma can be associated with ACL tear.
These atypical histories may represent unusual mechanisms
The pivot shift is a specific but very insensitive test for
or inaccurate remembrances by the patient. The important
ACL tear in the nonanesthetized patient.11,12 It is also
point is never to eliminate ACL tear from the differential
subject to great interobserver error. Because the pivot shift
diagnosis based on the history. Classically, swelling is marked
is often quite painful when positive, has low sensitivity,
within a few hours. However, some ACL tears never produce
and usually adds nothing beyond the Lachman test, I
more than minimal swelling, even acutely. Patients often hear
(C. Prodromos) use it only rarely for the diagnosis of
or feel a “pop,” but many do not. Similarly, patients may have
ACL tear in the office. I do use it routinely in the 1- and
felt the knee “go out of place,” or felt their “leg go one way
2-year follow-up exams, where its negativity confirms that
and the body another” but often they have not felt these
ACL reconstruction has been successful.
sensations. Pain may be severe and persisting or may be mild
and transient.
Nonorthopaedists are aware that ACL tear is a serious
Lachman Test
injury and are often misled into thinking that the injury “is only
The Lachman test,13 the anterior drawer test in approxi-
a sprain” because the history and exam are much less dramatic
mately 20 degrees of flexion, is the most reliable exam test
than they are expecting for such a serious injury. Team physi-
for ACL tear11 but is far more reliable in the chronic case,
cians should therefore perform a Lachman test on any knee
when secondary restraints have stretched and there is less
injury during a game because ACL tears in the heat of compe-
hamstring spasm, than in the acute case. After 21 years of
tition are often not obvious by the athlete's historical account
sports medicine practice, I still find the Lachman inconclusive
and sometimes produce little pain initially before swelling sets
with some frequency in the acute setting, particular in regards
in. This underdiagnosis by history is particularly true in emer-
to the differential between partial and complete tear, because
gency rooms (ERs), where the diagnosis of ACL tear may
of persisting hamstring spasm. The firmness of the endpoint
not be made by the emergency physician. Patients will often
may be particularly hard to evaluate. The examiner may or may
feel that the injury is not serious, especially if they do not have
not be successful in relaxing the hamstrings. Palpating them
a concomitant meniscal tear, which would have produced its
posteriorly and simultaneously while asking the patient to
own set of symptoms. This is particularly true if the injury is
relax them is often effective. It is important that the patient
called a “sprain,” such that the patient in many cases feels that
is in the supine, not sitting, position, and he or she should
there is no need for orthopaedic follow-up. Because magnetic
be instructed to relax the entire body to help relax the knee.
resonance imaging (MRI) will usually not be ordered at this
The Lachman test should be considered definitive only if it
time, the diagnosis is easily missed.
is clearly negative with a firm endpoint. It is important that
Patients with meniscal or articular cartilage damage will
the examiner be able to differentiate between a negative
usually have continued symptomatology from their cartilage
Lachman test and a false negative caused by this hamstring
damage and are more likely to follow-up. Patients with
spasm to avoid missing a torn ACL.
bucket-handle tears and locked knees will virtually always
seek further care and be diagnosed accurately by the exam or
MRI, or at arthroscopy. Anterior Cruciate Ligament Versus
Posterior Cruciate Ligament Tear

Chronic A posterior cruciate ligament (PCL) tear produces increased

Chronic ACL tears often present because of pain from a
meniscal tear or articular cartilage damage. Patients may or
may not give a history of instability. Classically instability
will occur during pivoting, but the symptoms can take
almost any form. It can be confused with patellar instability,
AP laxity and can mimic an ACL tear. Classically there will
be increased AP laxity, but with a firm anterior endpoint,
with a PCL tear. However, this can also be seen with a healed
partial ACL tear. If there is a question of ACL versus PCL
tear, then MRI or the quadriceps active test14 should be used
to differentiate the two. In addition, it is wise to always

54

arthroscopically inspect the knee before any graft harvesting
takes place to make certain that the ACL is in fact completely
torn.
Valgus Laxity
In patients with coexisting medial collateral ligament insuffi-
ciency, and hence valgus laxity, the Lachman test can be
false positive. Rotation of the lax proximal medial tibial
plateau can mimic translation of the entire proximal tibia if
rotation is not carefully controlled by the examiner during
the exam. Thus, when the examiner is aware that valgus laxity
exists, he or she should pay particular attention to controlling
tibial rotation during the test to minimize this possibility.
This can be challenging in patients with large-girth lower
extremities.
Locking
Diagnosis of Anterior Cruciate Ligament Tear 6
KT-1000 or Other Instrumented
Lachman Test
The KT-100024–29 (Figs. 6-1 and 6-2) maximum manual
examination is a highly accurate method for definitive diag-
nosis of ACL tear that is heavily relied on in our clinic.
When it indicates a complete ACL tear, we generally do
not order an MRI scan. A side-to-side difference of more
than 4 mm, particularly with an absolute value of 10 or
more, is nearly 100% specific for complete ACL tear30 if
the examiner is experienced in its use. The more difficult
differential may be between complete and partial ACL tear.
We have found partial ACL tears to usually have a laxity of
2 or 3 mm. When it is greater, a complete tear has almost
always existed. Others have found a slightly larger range.31
Larger differences, up to 4 and perhaps 5 mm, can be seen
after ACL reconstruction without graft discontinuity. It is

“Pseudolocking” may be seen classically with partial tears.15,16

However, a knee with a 20-degree or so persisting flexion
contracture (i.e., pseudolocking) can occasionally be seen with
isolated complete ACL tear from hamstring spasm alone.
True locking is seen with ACL tear in combination with
displaced bucket-handle meniscal tears. In these cases the
“locking” is actually reflex hamstring spasm in response to
extension in the presence of the displaced meniscal tear. Thus,
the Lachman test is always difficult to perform and frequently
false negative because of the hamstring spasm.17

Hemarthrosis

The presence of a large hemarthrosis is much more highly

associated with ACL tear in adults18–21 than in children.22 FIG. 6-1 Maximum manual examination is the most accurate KT-1000
Patellar dislocation and fracture are other leading causes of testing mode.
hemarthrosis. The former can usually be accurately diagnosed
by physical exam, the latter by radiography. Arthrocentesis is
usually not indicated. Its only diagnostic value is in determin-
ing whether a large effusion is a hemarthrosis. In most of these
cases, an MRI will be ordered, which will provide much more
information and spare the patient the pain of the arthrocent-
esis. If the effusion is sufficiently tense, hemarthrosis may be
indicated for pain relief. If MRI is unavailable and the exam
is equivocal, then arthrocentesis may be useful. A 16-gauge
needle is preferable, but an 18-gauge needle may be used.

Patellofemoral Injury

Although concomitant ACL tear and patellar dislocation or

injury is unusual, it does occur.23 The presence of physical
FIG. 6-2 Most complete tears will have a reading of 10 mm or more as
exam signs of acute patellar instability should not cause the well as a side-to-side difference of 4 mm or more on maximum manual
examiner to fail to test for ACL instability. testing.

55
 Anterior Cruciate Ligament Injury

important to point out that the maximum manual test is

more reliable than other methods. A 20-lb pull in particular
will understate the amount of laxity. The 30-lb pull will as
well, but to a lesser extent.32 Other arthrometers are in
use, particularly in Europe, with reportedly good results.33
We have no experience with them.
As described earlier, PCL tears can mimic ACL tears.
The “quadriceps active test”14 performed with the KT-1000
has been shown to reliably differentiate the two.

Examination Under Anesthesia

The examination under anesthesia (EUA) dramatically

increases the sensitivity of the pivot shift test.12 The accuracy
of the KT-1000 is also improved. We may perform both
just prior to arthroscopy when the diagnosis is in doubt. The
differential in question is usually between a partial and com-
plete ACL tear. EUA may appear to be unnecessary because
arthroscopic examination can seemingly determine whether a
complete tear exists. However, with partial tears the EUA is a
valuable supplement to the arthroscopic findings in deter-
mining whether reconstruction is needed. The difference
between a partially torn but substantially intact ACL that
would do well with conservative treatment versus a completely
torn ACL that has scarred in with fibrofatty tissue and is
essentially functionless is not always obvious arthroscopically.
In these circumstances the EUA is very helpful in helping to
determine proper treatment. FIG. 6-3 A rare tibial eminence avulsion (arrow) in an adult, producing
instability equivalent to interstitial anterior cruciate ligament (ACL) tear.

Radiographs

Radiographs are typically negative; however, certain radio-
graphic signs may be present. These include the lateral tibial
rim or “segond” fracture and posterior lateral tibial plateau
fracture or lateral femoral condyle impaction fracture.34
Tibial spine peaking is common in chronic tears but is a
nonspecific sign. Tibial eminence fracture is seen occasion-
ally in the skeletally immature and rarely in the skeletally
mature (Figs. 6-3 and 6-4). Radiographic signs of a hemar-
throsis are usually present.
Magnetic Resonance Imaging
Sensitivity rates of 80% to 81% for arthroscopically proven
complete ACL tears have been reported using MRI.30,35
Others have reported accuracy rates of more than 90%36,37
and sensitivity and specificity over 95%.38 However, Tsai et al
found only a 67% specificity rate for complete tear.39 The
MRI was very sensitive for detecting some ACL injury, but it
was much less specific for differentiating the complete from
the partial tear. This is an important distinction because the for-
mer is usually a surgical lesion, whereas the latter is usually not.
Although MRI is a useful test, a negative MRI should
not rule out an ACL tear that otherwise seems present clin-
ically. The best course of action in such circumstances is to
either obtain a KT-1000 exam by a reliable operator and/or
to proceed to examination under anesthesia using the pivot
shift and Lachman tests and to direct arthroscopic examina-
tion if necessary.
The normal ACL is both distinctly seen and appears
taut (Fig. 6-5). The torn ACL is indistinct and appears lax
(Fig. 6-6). Bone bruises (Fig. 6-7) in the lateral compartment
are seen in roughly half of acute ACL tears.40,41 Their absence
should thus not be relied on to rule out ACL tear. A fracture
of the posterior lip of the tibia is another characteristic
finding (Fig. 6-8). Transchondral fracture with intact
articular cartilage is sometimes also seen (Fig. 6-9).
High-field MRI machines generally produce better
accuracy for ACL tears than low-field MRI machines and
should be obtained where possible. If the only available
high-field MRI machine is closed-field and the patient is
claustrophobic, oral diazepam may be given. This will enable
many such claustrophobic patients to undergo a closed test,

56
 Diagnosis of Anterior Cruciate Ligament Tear 6

FIG. 6-5 The arrow points to a normal anterior cruciate ligament (ACL) on
an oblique sagittal T2 weighted image. Note that the ACL is taut and well
defined.

FIG. 6-4 A rare tibial eminence avulsion (arrow) in an adult, producing

instability equivalent to interstitial anterior cruciate ligament (ACL) tear.

especially if they understand that the improved quality of the

images is worth their trouble. Finally, the skill of the radiolo-
gist is extremely important. The same study can be inter-
preted as positive or negative depending on the radiologist's
experience. A skilled radiologist can be of great help to the
orthopaedist in interpreting difficult cases. False-positive
MRIs are less common but also occur. One study found
MRI to add no diagnostic accuracy beyond history, physical
exam, and radiographs (but not KT-1000) for all ACL tears.42
We believe this is greater clinical diagnostic accuracy than
most orthopaedists, including the author, would achieve.

CONCLUSIONS
1 Lachman testing is the most accurate physical exam test
for ACL tear diagnosis in the nonanesthetized patient.
2 KT-1000 or other instrumented Lachman test in the FIG. 6-6 The arrow points to a completely torn anterior cruciate ligament
hands of an experienced user is a highly accurate method (ACL), which appears ill defined and lax within the intercondylar notch on
of examination for ACL tear. sagittal T2 weighted image.

57
 Anterior Cruciate Ligament Injury
FIG. 6-7 The arrows point to some areas of hypointensity on a T1
weighted coronal image, which are consistent with lateral compartmental
bone contusions in this patient with complete anterior cruciate ligament
(ACL) tear.
FIG. 6-8 Sagittal proton density image. The arrow points to oblique
transchondral fracture of the posterior tibia without evidence of step-off of
the articular plate in this patient with complete anterior cruciate ligament
(ACL) tear.
58
FIG. 6-9 Inversion recovery coronal image. The arrow points to buckled
black subchondral cortex. Below is intact articular cartilage. The white
starburst area above is subchondral bone edema in this patient with
complete anterior cruciate ligament (ACL) tear.
3 MRI is a very good test but is less accurate than
commonly thought, particularly regarding the
differentiation of partial from complete tears. In
suspected complete tears with negative MRIs,
examination under anesthesia using both the Lachman
and pivot shift tests, instrumented Lachman testing,
and/or arthroscopic examination should be performed.
4 Very high diagnostic accuracy rates can be obtained by a
synthesis of the history, physical exam, and plain
radiographs in obvious cases and the addition of MRI,
examination under anesthesia, and/or instrumented
Lachman testing in questionable cases.
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the knee. Am J Sports Med 1997;25:231–237.
20. Lundberg M, Odensten M, Thuomas KA, et al. The diagnostic
validity of magnetic resonance imaging in acute knee injuries
with hemarthrosis. A single-blinded evaluation in 69 patients using
high-field MRI before arthroscopy. Int J Sports Med
1996;17:218–222.
21. Maffulli N, Binfield PM, King JB, et al. Acute hemarthrosis of the
knee in athletes. A prospective study of 106 cases. J Bone Joint Surg Br
1993;75:945–949.
22. Matelic TM, Aronsson DD, Boyd DW Jr, et al. Acute hemarthrosis
of the knee in children. Am J Sports Med 1995;23:668–671.
23. Chiang AS, Shin SS, Jazrawi LM, et al. Simultaneous ruptures of the
anterior cruciate ligament and patellar tendon: a case report. Bull Hosp
Joint Dis 2005;62:134–136.
24. Rangger C, Daniel DM, Stone ML, et al. Diagnosis of an ACL dis-
ruption with KT-1000 arthrometer measurements. Knee Surg Sports
Traumatol Arthrosc 1993;1:60–66.
Diagnosis of Anterior Cruciate Ligament Tear 6
25. Boyer P, Dijan P, Christel P, et al. Reliability of the KT-1000 arth-
rometer (Medmetric) for measuring anterior knee laxity: comparison
with Telos in 147 knees. Rev Chir Orthop Reparatrice Appar Mot
2004;90:757–764.
26. Bonnaire F, Berwarth H, Munst P, et al. Can the results of cruciate
ligament operations be arthrometrically evaluated? A comparison of
subjective assessment, Lysholm score, clinical stability classification
and measuring stability with the KT 1000 after complex knee injuries.
Unfallchirurgie 1995;21:83–91.
27. Anderson AF, Snyder RB, Federspiel CF, et al. Instrumented evalua-
tion of knee laxity: a comparison of five arthrometers. Am J Sports Med
1992;20:135–140.
28. Bach BR Jr, Warren RF, Flynn WM, et al. Arthrometric evaluation
of knees that have a torn anterior cruciate ligament. J Bone Joint Surg
Am 1990;72A:1299–1306.
29. Liu SH, Osti L, Henry M, et al. The diagnosis of acute complete tears
of the anterior cruciate ligament. Comparison of MRI, arthrometry
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30. Prodromos CC, Han YS, Keller BL, et al. Stability of hamstring ante-
rior cruciate ligament reconstruction at two- to eight-year follow-up.
Arthroscopy 2005;21:138–146.
31. Gonzalez-Couto E, Klages N, Strubin M. Synergistic and promoter-
selective activation of transcription by recruitment of transcription fac-
tors TFIID and TFIIB. Proc Natl Acad Sci U S A 1997;94:8036–8041.
32. Strand T, Solheim E. Clinical tests versus KT-1000 instrumented lax-
ity test in acute anterior cruciate ligament tears. Int J Sports Med
1995;16:51–53.
33. Anderson AF, Snyder RB, Federspiel CF, et al. Instrumented evalua-
tion of knee laxity: a comparison of five arthrometers. Am J Sports Med
1992;20:135–140.
34. Stallenberg B, Gevenois PA, Sintzoff SA Jr, et al. Fracture of the pos-
terior aspect of the lateral tibial plateau: radiographic sign of anterior
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35. Varanda P, Amado P, Monteiro A, et al. Diagnosis of complete
anterior cruciate ligament rupture: comparison of clinical examina-
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Arthroscopy, Innsbruck, Australia, May, 2006.
36. Vellet AD, Lee DH, Munk PL, et al. Anterior cruciate ligament tear:
prospective evaluation of diagnostic accuracy of middle-and high-field
strength MR imaging at 1.5 and 0.5 T. Radiology 1995;197:826–830.
37. Vaz CE, Camargo OP, Santana PJ, et al. Accuracy of magnetic reso-
nance in identifying traumatic intraarticular knee lesions. Clinics
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initial experience. Skeletal Radiol 2005;34:453–461.
39. Tsai KJ, Chiang H, Jiang CC. Magnetic resonance imaging of ante-
rior cruciate ligament rupture. BMC Musculoskelet Disord 2004;8:21.
40. Dimond PM, Fadale PD, Hulstyn MJ, et al. A comparison of MRI
findings in patients with acute and chronic ACL tears. Am J Knee Surg
1998;11:153–159.
41. Tung GA, Davis LM, Wiggins ME, et al. Tears of the anterior cru-
ciate ligament: primary and secondary signs at MR imaging. Radiology
1993;188:661–667.
42. Kocabey Y, Tetik O, Isbell WM, et al. The value of clinical exami-
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21:696–700.
59
 7
CHAPTER
Nonoperative Management of Anterior
Cruciate Ligament Deficient Patients
Elias Tsepis ANTERIOR CRUCIATE LIGAMENT
George Vagenas DEFICIENCY: THE NEED FOR MUSCLE
Giannis Giakas STRENGTHENING
Stavros Ristanis
Anastasios Georgoulis The knee joint's location in the middle of the
lower limb kinetic chain is imposed to high loads,
which reach multiple the body mass, particularly in
the single stance phase of sport activities.1,2
Rupture of the anterior cruciate ligament (ACL)
destabilizes the knee joint,3–5 thus making ACL
deficient knees prone to repeated subluxations,
which form a potential cause for secondary
damage to the joint.6–8 Subsequently, dynamic
stabilization through the quadriceps and ham-
strings becomes very crucial for the protection of
the injured knee.9,10 Apart from its mechanical
role, the ACL functions as a sensory organ due
to the mechanoreceptors within its substance.11
After its rupture, this function is lost, and therefore
optimization of the lower limb muscle properties
becomes increasingly important in order to com-
pensate for the resulting anterior and rotational
knee instability.
Exercise in ACL deficient patients aims
at the improvement of various aspects of muscle
properties including reflexes, strength, endur-
ance, and coordination with other muscles.
Functional exercise that reeducates the neuro-
muscular coordination holds the central role in
rehabilitation programs, as growing evidence
supports the development of preprogrammed
compensatory muscle activation strategies for
efficient shear force dissipation during injured
knee loading.12–16 However, the fundamental
60
issue of the need for strength testing and the
value of strengthening exercises still leaves room
for investigation.
Among the criteria for progression of
ACL rehabilitation is the level of quadriceps and
hamstring weakness.17,18 Strength testing and
exercise have been traditionally incorporated into
musculoskeletal rehabilitation regimens. Although
the connection between the level of quadriceps
strength and functional status has been dis-
puted,19–22 some studies support the interrelation
between functional performance of the knee and
thigh muscle strength. It is of clinical importance
for ACL rehabilitation that patients with greater
than normal strength in the injured limb seem to
reduce abnormalities during low- and high-stress
activities.23 Quadriceps strength appears to deter-
mine the functional ability of the ACL deficient or
operated limb to a great degree.24,25 Its weakness
coincides with low functional performance26 and
pathological gait pattern.27 In addition, functional
improvement in ACL deficient athletes after
training followed the same pattern as the strength
of both the quadriceps and hamstrings.23,28
Likewise, increase in hamstring strength
after functional exercise incorporating strengthen-
ing, stretching, and plyometric drills paralleled a
decrease in peak landing forces, and hence
safer landing.29 Hamstring strength has also been
associated with the level of knee function10,30
and performance,31 and increasing the ham-
string–quadriceps (H:Q) strength ratio has be
come a rule in order to promote dynamic control
of the ACL deficient knee.32,33 Even more,
this improvement has been connected with the

return to physical activity after ACL injury,34 and the strength
of both thigh muscle groups reflects the functional improve-
ment23,28 and the ability to return to physical activity.34
It appears that changes in muscle strength might be a
global reflection of muscle properties, including neural
changes.35 It seems that adequate strength ensures that a
solid basis is built for other refined neuromuscular proper-
ties. In other words, adequate strength secures the
proper background for the development of global muscle
properties. Therefore, it appears that objective evaluation
of strength has a valuable position in the functional assess-
ment after ACL injury, and in combination with our find-
ings, it could be suggested that therapeutic intervention
should minimize strength weakness, which persists over
time when not addressed.
IMPORTANCE OF THE HAMSTRINGS,
ESPECIALLY IN SOCCER PLAYERS: OUR
RESEARCH
Our group recently investigated the connection of thigh
muscle strength with the level of knee performance and
the chronic stage of the injury in ACL deficient athletes.
In order to reveal the net effect of ACL rupture on muscle
strength, we examined amateur soccer players who abstained
from structured rehabilitation in an attempt to exclude
interference of exercise with the results.
The first study focused on revealing a possible connec-
tion of quadriceps and hamstring strength deficits with the
level of knee function determined by Lysholm score.30 Three
groups of ACL deficient amateur soccer players were exam-
ined at different levels of knee function and were compared
with a group of controls matched for the preinjury level of
activity. The median Lysholm scores of the low, intermediate,
and high knee functioning groups were 64.5, 76, and 86
points, respectively. Weakness depicted by the contrast to
the healthy condition was significant in all cases and ranged
from 19% to 35% according to the muscle or the patient
group. Regarding the side-to-side deficit, these major muscle
groups did not follow the same pattern. The strength
asymmetry of the quadriceps was consistently significant even
in the high functioning knees, being greater than 14%, in
contrast to the hamstrings, which revealed acceptable symme-
try within the normal levels (about 2% to less than 6%) at the
high and intermediate knee function groups. Only the poorly
functioning athletes had a significant 19% deficit (Fig. 7-1),
which places hamstring strength asymmetry (H asymmetry)
as a discriminating factor for knee functionality.
The importance of assessing H asymmetry is high-
lighted in our recent study that examined different groups of
amateur athletes involved in cutting and twisting sports such
Nonoperative Management of Anterior Cruciate Ligament Deficient Patients 7
40
35
30
Asymmetry (percent)
25
20
15
10
5
0
Extension Flexion
L1: High Lysholm
L2: Intermediate
L3: Low Lysholm
Control
FIG. 7-1 The percentage of extensor and flexor deficit in each
experimental group formed according to the level of knee function (L1,
L2, and L3: high, intermediate, and low Lysholm score, respectively) and the
percentage of asymmetry in the control group (dominant versus
nondominant knee).
as soccer, basketball, and handball at different times since
ACL rupture.36 We tested the quadriceps and hamstring
strength of 36 patients with unilateral ACL deficiency who
were divided into three equal groups with mean times for
chronicity of about 4, 11, and 57 months for short term, inter-
mediate term, and long term, respectively. We investigated
how the strength weakness evolved with time, using the
strength of matched healthy controls as a baseline score.
Additionally, we questioned whether the quadriceps’ and
hamstrings' side-to-side asymmetry in strength would be
consistently significant in all stages of chronicity.
As in the previous study, significant weakness was
evident in both muscles in all patient groups, ranging from
21% to 32%. Considering the side-to-side asymmetry of
ACL deficient knees, the quadriceps deficit persisted through
time, whereas the hamstrings regained symmetry even after 1
year without organized rehabilitation. Regarding the side-to-
side strength differences, they tended to lower with time, but
in the case of quadriceps, they varied from 10% to 23%,
whereas the hamstrings were significantly asymmetric only
in the short-term group (14%) and acquired acceptable
symmetry within 1 year postinjury (Fig. 7-2).
Both studies show a trend for hamstring symmetry
much more emphatically than the quadriceps as function
improved or as the distance from the incidence of rupture
increased. The strength asymmetry evident only in the
worst-functioning group and the short-term group might
reveal a natural compensatory reaction for ACL deficiency
because no patients followed a structured rehabilitation
61
 Anterior Cruciate Ligament Injury

40 transform in order to quantify the smoothness of the isoki-

† Short term netic curve (Fig. 7-3). Each curve of biological signal that is
35 † Intermediate term
† not a perfect sine is actually the sum of other curves, and
Long term
30 therefore it can be analyzed into its fundamental compo-
Asymmetry (percent)

Control
nents. Our biological interpretation of this method is based
25
* on the notion that disturbed motion is generally connected
20 to poor level of joint functionality. Irregular torque output
15 has been connected to other pathologies such as anterior
knee pain.45,46 In contrast, smoothness of torque generation
10
is indicative of enhanced force control.47 The frequency
5 contained at three levels of the total power of the signal
0
(90%, 95%, and 99%) was calculated in order to exclude
Extension Flexion noise from the 100% power level but still include enough
*P < 0.05 compared with control
harmonics. Both extension and flexion isokinetic curves
†P < 0.01 compared with control demonstrated increased irregularities as expressed by the
P < 0.05 short term versus long term higher-frequency contents by 18.8%, 10.6%, and 40.0%
FIG. 7-2 The percentage of extensor and flexor deficit in each for knee extension and 49.5%, 24.5%, and 16.3% for
experimental group (injured versus intact knee: short term, intermediate, knee flexion, according to the power level of assessment
long term) and the percentage of asymmetry in the control group
(dominant versus nondominant knee). (Fig. 7-4). Although the results regarding quadriceps were
expected on the basis of previous reports using different

program. A supplementary finding of both studies was that

the strength of the healthy side was considerably affected 300
by the disuse, which was depicted on the mean reduction to Intact
250
the level of performance by a mean of 3 to 3.5 degrees Tegner. ACL
Torque (Nm)

This raises the issues of ensuring not to neglect the intact 200
side as well and counseling patients to maintain activity 150
with safe exercise after injury.
100
The quadriceps muscle is affected to a greater degree
after ACL injury possibly because of (1) postinjury neural 50
inhibition due to the loss of afferent feedback from ACL to
0
gamma motor neurons37,38 and (2) the adaptation toward a 0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8
“quadriceps avoidance gait” pattern39,40 to prevent anterior
A Time (s)
subluxation,41,42 which unloads the limb, promoting
quadriceps weakness in ACL deficient patients.12 The greater
atrophy of the quadriceps (10% versus 4%) reported even 1 year Time (s)
postinjury7 may also add to the explanation of their higher 0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8
deficit compared with the hamstrings. In contrast, evidence 0
exists that the hamstrings are recruited in weight-bearing –20
activities in a subconscious attempt to counteract anterior
–40
shear forces.5,43 This stimulus might have assisted with the
Torque (Nm)

improvements in our patients. Evidence in the literature also –60

supports the development of subtle electrophysiological modi- –80
fications in ACL deficient patients that retune the hamstrings
and preprogram their muscle activation strategies to optimize –100

shear force dissipation during injured knee loading.14–16 –120 ACL

In another study, we investigated the quality of muscle Intact
–140
contraction when ACL deficient patients performed maxi-
B
mal exercise via the smoothness of the torque curve
FIG. 7-3 A characteristic extensor (A) and flexor (B) isokinetic curve of the
throughout knee extension and flexion.44 Our methodology
intact knee (blue line) and the anterior cruciate ligament (ACL) deficient
comprised transformation of each torque-time curve pattern knee (red line), demonstrating the side-to-side difference to the torque-time
into the frequency domain (power spectrum) via fast Fourier curve smoothness.

62

250
200
Torque 150
100
50
0 – 40
0 0.2 0.4 0.6 0.8 1 1.2
Time
A B
FIG. 7-4 Example of transformation of the isokinetic data of knee extension from the time domain (A) to frequency
domain (B). The arrow shows the frequency content calculated for 99% of the signal power.
methodologies, the hamstrings' increased irregularity had
not been reported elsewhere. This finding might be of func-
tional importance and open a future area of investigation.
The higher oscillations characterizing the isokinetic
curve of the ACL deficient knee, which is expressed in
increased frequency contents, may be attributed to mechani-
cal and/or neuromuscular factors. Increased anterior gliding
of the tibia during knee extension might account for the
mechanical part. Quadriceps inhibition37,38 and poorly coor-
dinated activation within the hamstrings43,48 must explain the
neural aspects of abnormalities of mechanical output. This
loss of smoothness in extension-flexion might be clinically
important and should be investigated further. Quantification
of irregularity of the extension-flexion curve is an innovative
approach and could be a valuable tool in the assessment of
ACL deficient knees.
REVIEW OF THE LITERATURE ON THE ROLE OF THE
QUADRICEPS AND HAMSTRINGS IN ANTERIOR
CRUCIATE LIGAMENT DEFICIENT KNEES
The quadriceps is the muscle group suffering the most
dramatic effects after ACL tear.19,30,36,49 For this reason, in
addition to its functional importance for normal gait, it
attracts most of the attention from clinicians and researchers.
Quadriceps torque deficit is more than double hamstring def-
icit, which is attributed to its susceptibility for quick atrophy
due to disuse10,18 and neural inhibition.37,38 Marked weak-
ness of the quadriceps prevents the knee from functioning
normally, and given that this weakness is exaggerated in many
cases,30 it should be managed adequately. If the voluntary def-
icit measured via superimposed electrical burst to the maximal
voluntary contraction exceeds 5%, treatment with electrical
Nonoperative Management of Anterior Cruciate Ligament Deficient Patients 7
60
Power spectrum magnitude (dB)
50
40
30
20
10
0
–10
– 20
(4.12 Hz)
– 30
1.4 0 5 10 15 20 25 30 35 40 45 50
Frequency
stimulation effectively ameliorates loss of the quadriceps
strength and should be implemented from the early stages.50
Although in ACL deficient knees there is no graft to be
stressed due to the anterior instability of the tibia caused by
quadriceps contraction particularly near extension,9,42,51 this
might be harmful for other capsuloligamentous structures.
In contrast, the hamstrings are properly located to
counteract anterior tibial instability at flexion angles exceed-
ing 30 degrees.52–54 However, doubts exist regarding the
efficacy of the hamstrings to counterbalance shear loading
of the knee,53,55 based on two concerns: first, whether the
magnitude of the posteriorly directed muscle force is enough
to counteract shear forces in the functionally more impor-
tant knee angles near extension,41,54,56 and second, whether
reflex activation of the hamstrings during abrupt perturba-
tions of the knee is fast enough to develop tension in time
with the peak external destabilizing moment.57,58
Considering the development of the properly directed
stabilizing force, studies on cadavers,55,59 animals,54,60 and
mathematical models53,61,62 support that beyond 30 degrees
of knee flexion, the posteriorly directed vector of hamstring
force becomes adequate in stabilizing the ACL deficient knee
(Fig. 7-5). In addition, it should not be underestimated that
even when the line of pool of the hamstrings is inefficient,
co-contraction could increase joint stability due to joint
compression63 and widening of the pressure distribution
along the articular surfaces of the knee.64 Additionally, it
has been reported that the hamstrings cause greater stiffness
to the ACL deficient knee than they do to the intact knee.65
Regarding the question of the timely activation of the
hamstrings, an overfocus on their reflex latency of 40 to 50 ms,
which is a medium latency response,66–68 may be misleading
in regard to their efficacy to prevent instability. Growing
evidence in the literature supports the development of
63
 Anterior Cruciate Ligament Injury
A B
FIG. 7-5 As the knee flexes from A to B, the anti-shear vector of the
hamstring force (solid line) increases.
preprogrammed compensatory muscle activation strategies.12–16
These strategies suggest that subtle electrophysiological modifi-
cations of the subjects are implemented by deficient patients
after ACL injury to optimize shear force dissipation during
injured knee loading. Hence, feed-forward mechanisms can
be adopted that initiate hamstring co-contraction during
the expectation of knee loading, not only as a reflex
response.13,16,69,70 Therefore the hamstrings should be well
conditioned in order to have a greater potential to enhance
knee stability.
BRACING IN ANTERIOR CRUCIATE LIGAMENT
DEFICIENT PATIENTS: IS IT EFFECTIVE?
The use of functional knee braces is a common practice for
enhancing knee stability after rupture of the ACL or recon-
struction, with contradictory opinions about their importance
in knee unloading.71–73 A favorable change of firing pattern
for the hamstrings was observed more often when ACL defi-
cient patients performed single-leg landings wearing a brace69
and in skiers during periods of increased knee flexion.74 The
greater biceps femoris activity was exhibited by the more
unstable knees. Lam et al75 found that wearing a functional
brace improved hamstring reflex responses in ACL deficient
knees after fatigue induced by repeated extension and flexion
against spring resistance. Although their protocol did not
replicate a functional weight-bearing condition, it gives a
potentially useful message that bracing in ACL deficient
knees may enhance protection. Wojtys et al76 showed that
braces can decrease anterior tibial translation by a large
margin.
In contrast, other findings have shown a slowing of
hamstring muscle reaction times with bracing76 or decreased
activation.71,77
64
Research into the utility of functional knee bracing for
ACL protection is inconclusive due to a great heterogeneity
in the electromyography applied, experimental maneuvers,
and characteristics of the participants. Moreover, whether
the influence of braces on muscle function and propriocep-
tion is favorable for knee stability remains unclear.
However, patients with torn ACLs who do not cope
well with their injury and do not choose surgery might
benefit from bracing.78
REHABILITATION
Rehabilitation after ACL rupture is a multifactorial issue.
However, the general goals consist of gaining good functional
stability, optimizing the functional level, and minimizing the
risk for reinjury.79 Interventions follow a general scheme
depending on chronicity and are generally grouped into the
acute phase focusing on range of motion, pain management,
regaining ambulation, and retarding atrophy; the advanced
phase, which aims to increase strength and endurance; and
the return-to-play phase, with the final neuromuscular opti-
mization of knee function.80 Progression from one stage to
the other follows certain criteria, one being the achievement
of adequate strength for the demands of each stage.
Rehabilitation should aim at limiting thigh muscle
weakness after ACL rupture, reducing the quadriceps side-
to-side deficit to clinically acceptable levels, and assisting
the hamstrings to regain strength faster. These benefits could
enhance the natural reaction of the body against anterior knee
instability. The effect of organized rehabilitation protocols on
the time course of strength adaptations after ACL injury has
yet to be examined. A promising research area is the investiga-
tion of whether early and intensive postinjury strengthening
of the hamstrings will allow more ACL deficient patients to
cope with their injury. Nevertheless, only a small fraction of
ACL deficient athletes who choose not to have a recon-
struction return to their previous level of exercise, and those
who do so progress through rehabilitation through specific
training and by achieving certain criteria.81 The majority
follow a more conservative lifestyle attributed either to knee
problems79 or to social reasons and fear of reinjury.82
Excessive atrophy and weakness of the quadriceps are
evident in ACL deficient patients and, in cases of quadriceps
inhibition, might not be reversible without electrical stimula-
tion, which should commence from the early stages.38
Quadriceps activity potentially leads to knee instability, but
it can be exercised safely either through a closed kinetic chain
or in angles flexed more than 45 degrees. This deficit should
not be neglected because it persists through time.36
Hamstring strength has been connected with the
functional outcome of the ACL deficient30 and ACL

reconstructed knee10 or the possibility of engaging in
higher levels of sports participation.32 Strengthening of the
hamstrings holds a key position in the conservative treat-
ment of the ACL deficient knee,32,83 and it appears that
strength training of a specific muscle also increases its coac-
tivation level.84 A 3-month, high-resistance training pro-
gram with four sets of 8 RM (repetitions maximum: load
that permits the completion of only eight repetitions) per-
formed 3 times per week may increase the capacity of the
hamstrings to provide stability to the knee joint during fast
extension.85 This improvement was expressed through a sig-
nificantly elevated H eccentric:Q concentric ratio.
As a rule, ACL rupture leads to a decrease in the level of
physical activity, especially in those who were involved in cut-
ting and twisting sports.86,87 ACL deficient athletes appear to
reduce physical activity to 4 degrees Tegner from an initial 9
and 10 degrees.88 Characteristically, Lysholm et al3 reported
that although the activity of 62% of their sample was higher
than 7 degrees Tegner prior to ACL rupture, after the injury
only 10% remained above this limit. Reduction of physical
activity markedly affects the healthy side as well,30,36 compli-
cating the return to high-demand activities. To counteract
that, closed kinetic chain exercises with great hip flexion
angles are an evidence-based method to re-educate coordi-
nation and physiological properties with safety, along with
open chain single-joint exercise for more specific effects.
Hip control is crucial for the control of knee rotation
and proper lower limb alignment, but it is important to
remember that the knee is not only directly interrelated with
the hip joint but is also connected with the ankle joint.
Rudolph et al89 found that coping patients partly relieved
the ACL deficient knee by demonstrating a higher contribu-
tion of the ankle extensors to the total moment production of
the lower limb. Likewise, hamstring tasks to control knee
instability can be reinforced by synergists including the
anterior tibialis, soleus,90,91 and muscles of the deep posterior
compartment muscle group.90 Those synergists have the
potential to control the anterior translation and internal rota-
tion of the tibia. This occurs via their reverse action on the
ankle and the subtalar joints during closed kinetic chain activ-
ities, when the foot is planted on the ground and subsequently
the peripheral movement is restricted. Concerning the gas-
trocnemius, its origin above the knee joint complicates the
effect of its action. Fleming et al 92 implanted the more precise
and accurate differential variable reluctance transducer
(DVRT)93,94 on the anteromedial bundle of the ACL and
showed that isometric gastrocnemius muscle contraction
strained the ACL within the last 15 degrees of knee
extension. Additionally, gastrocnemius muscle contraction
combined with quadriceps or hamstring muscle contraction
increased the strain up to the last 30 degrees of flexion in com-
parison with isolated contractions of these muscles. This
Nonoperative Management of Anterior Cruciate Ligament Deficient Patients 7
study ensured muscle specificity in contraction by applying
transcutaneous electrical muscle stimulation in subjects under
spinal anesthesia. However, there are studies indirectly
showing that gastrocnemius contraction could stabilize the
tibia under certain circumstances. O'Connor,95 using a two-
dimensional mathematical model, found that simultaneous
contraction of the quadriceps, hamstrings, and gastrocnemius
totally unloaded the ACL at 22 degrees of flexion. Kvist
and Gullquist96 showed that when the gastrocnemius is
coactivated with the quadriceps in a closed chain exercise
(squatting) with the center of gravity over or posterior to the
foot, joint compression is increased but anterior tibial transla-
tion is not. They also suggest that ACL deficient patients
should enhance the spontaneous coactivation of quadriceps
with certain neuromuscular training. However, Fleming
et al97 questioned the safety of closed kinetic exercises, leaving
the area still open for investigation.
A safe compromise among those findings could be
that isolated contractions of the gastrocnemius should be
avoided after ACL rupture and their coactivation with other
muscles in open chain exercise can be avoided by performing
hamstring curls with the foot plantar flexed. Protective exer-
cise for the ACL should be global and include exercises for
the joints adjacent to the knee, and strengthening of those
muscles could create a background for improvement of the
overall muscle performance. Strengthening should combine
open chain exercises for all lower limb joints, executed in a safe
manner according to the current research, as well as closed
chain activities. Generally, neuromuscular training with
closed chain exercises appears beneficial when performed
with caution and progressively, as it provides more sophisti-
cated muscle interrelations that enhance safety but are still
difficult to define.
SUMMARY
ACL rupture deprives the knee of a major stabilizing struc-
ture, and therefore the role of the surrounding musculature
becomes crucial for dynamic protection of the joint. The
quadriceps suffer the greatest deficits in performance, which
affects the normal lower limb kinematics and should be trea-
ted, even with the use of electrical stimulation if necessary.
The hamstrings tend to recover earlier; this might be attribu-
ted to a natural reaction to promote stability. This trend
should be facilitated and reinforced because it appears that
neurophysiological adaptations include reprogramming of
muscle activation, during which hamstrings are activated ear-
lier in anticipation of perturbations. Even in knee angles in
which the magnitude of force is small and inefficient to coun-
terbalance anterior tibial subluxation, hamstrings contraction
still has a stabilizing potential for the knee through joint
65
 Anterior Cruciate Ligament Injury
compression. Adequate strength levels provide the basis for
further functional improvement during rehabilitation of
ACL deficient knees. Organized and specific exercises should
incorporate muscle strengthening, functional plyometric
drills, and joint perturbations advancing in steps under certain
criteria. The use of knee braces, although their degree of ACL
deficient knee protection is still unclear, might help in poorly
functioning patients.
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 Arthrosis Following Anterior Cruciate
Ligament Tear and Reconstruction
INTRODUCTION
The development of degenerative changes within
the knee following anterior cruciate ligament
(ACL) injury is well recognized. However, defin-
ing the exact incidence of arthrosis following an
ACL injury or after reconstruction of the ACL
is a challenge for several reasons. Long-term
clinical follow-up studies are difficult to perform
because most patients presenting with an ACL
injury are young and many will change geograph-
ical location in the years following surgery.
Outcome studies with long-term follow-up
periods tend to have a large number of patients
lost to follow-up for this reason.
Furthermore, the group of patients with
these injuries is heterogenous, with widely vary-
ing ages, preinjury levels of activity, and differ-
ent expectations following treatment. ACL
tears may occur in isolation, but a significant
proportion is associated with collateral ligament
injuries and concomitant or subsequent menis-
cal tears, which may also influence the develop-
ment of degenerative change. In addition to
these considerations, some patients may have a
previous history of knee injury or surgery and
may already have significant degenerative
changes within the knee at the time the ACL
injury is sustained.
Although most ACL reconstructions are
carried out using either hamstring or patellar
tendon autografts, there is wide variation in
the surgical techniques used to prepare and
anchor grafts, which may also influence
8
CHAPTER
development of osteoarthritis (OA). The timing Nicholas E. Ohly
of surgical reconstruction after injury may
John F. Keating
also be of considerable importance. Access to
expert orthopaedic opinion and treatment varies
considerably with geographical location, and in
some areas the duration from injury to
surgery may be prolonged. In this chapter we
consider the existing evidence linking ACL
injury and treatment to subsequent development
of OA.
PATHOPHYSIOLOGY OF
OSTEOARTHRITIS FOLLOWING
ANTERIOR CRUCIATE LIGAMENT
INJURY
Previous studies have shown that restoring knee
stability through ACL reconstruction does not
necessarily decrease the incidence of posttrau-
matic OA.1,2 It therefore follows that other
mechanisms, rather than the initial mechanical
disturbance of stability at the time of injury,
may be responsible for the development of OA,
both in the chronic ACL deficient knee and in
the reconstructed knee.
Several biochemical mechanisms have
been proposed. It has been shown that an early
increase in the proteoglycan content of articular
cartilage adjacent to the torn ligament occurs
following ACL rupture.3 Other studies4,5 have
shown an increase in collagenase activity leading
to increased denaturation and loss of type II
collagen in the articular cartilage of the knee
69
 Anterior Cruciate Ligament Injury
following injury. These changes are also seen in the knee
with idiopathic OA.
Intraarticular pro-inflammatory cytokines are also
increased immediately after ACL rupture.6,7 These include
interleukins (IL) -1, -6, and -8, tumor necrosis factor alpha
(TNF-a), and keratan sulfate. Of note, IL-1 (in both its alpha
and beta forms) and TNF-a have direct chondrodestructive
effects independent of their inflammatory properties.
These cytokines are present in higher concentrations with
more severe chondral damage, and levels fall gradually
beginning approximately 3 months postinjury. Granulocyte-
macrophage colony-stimulating factor (GM-CSF) concen-
trations are initially normal but become grossly elevated
beginning approximately 3 months postinjury. Conversely,
the chondroprotective cytokine IL-1Ra concentration
decreases with increasing severity of chondral damage and
with chronic ACL deficiency.
These findings suggest the existence of important
contributory biochemical factors in the development of
OA in the ACL deficient knee. Elevated intraarticular
concentrations of several cytokines are present during the
acute inflammation following ACL rupture, and this
inflammation subsides but does not completely resolve in
the subacute and chronic phases postinjury. Instead, a
potentially chondrodestructive cytokine imbalance persists
that can eventually lead to OA.
It has been shown that ligamentous knee injury is
strongly associated with bone bruising.8 Magnetic resonance
imaging (MRI) scans performed acutely following ACL
rupture have shown occult subchondral lesions in 85% of
patients, mainly involving the lateral femoral condyle and
lateral tibial plateau.9 Although the majority of these lesions
resolved with time, permanent chondral damage is known
to have occurred in some lesions. Histological analysis of
these bone bruises has shown associated areas of chondro-
cyte degeneration and necrotic osteocytes, which suggests
that significant damage to the articular cartilage is sustained
at the time of injury.10
Following ACL reconstruction, further factors may
play an additional role in the development of arthrosis. It
has been shown that pretensioning the graft can cause
changes in joint biomechanics that may lead to arthrosis in
the long term.11,12 Shortening of the patellar tendon may
occur after patellar tendon autograft, which has been shown
to lead to patellofemoral arthrosis and a worse functional
outcome, both of which are directly associated with the
degree of shortening of the patellar tendon.13
Any intraarticular damage that requires treatment
with meniscectomy will diminish the joint contact surface
area and increase the stress on the tibia.14 The resultant
increased stress on the knee joint has been shown to accel-
erate the development of OA.15
70
NATURAL HISTORY OF THE UNTREATED
ANTERIOR CRUCIATE LIGAMENT
DEFICIENT KNEE
The development of arthrosis following ACL rupture is
widely recognized,16,17 and in a review by Gillquist and
Messner18 it was concluded that in the long term (i.e., 10
to 20 years), as many as 70% of all ACL deficient knees
had radiological signs of arthrosis, although clinical symp-
toms of knee arthritis were infrequent. Segawa et al19 found
radiographic changes of OA in 63% of patients who were
followed for 12 years after a conservatively treated ACL
rupture. The main risk factor for arthrosis was shown to
be meniscectomy, in combination with the risk factors for
primary OA, such as increased age at time of injury,
increased level of sports activity, obesity, and OA of the
contralateral knee.
In a study of patients with symptomatic knee OA,
22.8% had complete ACL rupture identified at MRI,
compared with 2.7% of controls.20 Patients with OA in the
presence of an ACL rupture had more severe radiological OA.
A cohort of female soccer players in Sweden was
assessed 12 years after a known ACL injury, and although
radiographic evidence of OA was seen in 82%, there was no
difference in the incidence of OA between those ACL inju-
ries treated nonoperatively (38%) and those treated
with reconstruction, and the same proportion (75%) of those
without radiographic OA had knee symptoms.2 Comparable
results were seen in a similar study of male soccer players in
Sweden 14 years following a known ACL injury.21
In children and adolescents with ACL rupture, non-
operative treatment is often favored to avoid drilling surgical
tunnels across physeal growth plates. However, it has been
shown that ACL injuries treated nonoperatively in this age
group are likely to develop instability and poor function,
with development of radiological signs of degeneration in
almost half of children.22 Subsequent studies have shown
that ACL reconstruction can be safely undertaken in adoles-
cents nearing skeletal maturity.23 It has not yet been proven
that this can be safely performed in very young children
with opened physes.
Despite this evidence, some studies challenge the con-
cept that ACL tears are inextricably linked to development
of arthritis. It has been shown that in older patients (40 to
60 years old) with an ACL rupture treated nonoperatively,
87% had little or no radiographic changes at a mean of
7 years postinjury.24 In 46 young recreational athletes
followed up at an average of 5 years following conservative
treatment of an ACL tear diagnosed at arthroscopy, only
17.4% had mild radiographic osteoarthritic changes, and
only one patient (2.2%) was symptomatic.25

ARTHROSIS FOLLOWING ANTERIOR CRUCIATE
LIGAMENT RECONSTRUCTION
With the knowledge that ACL tears are associated with an
increased risk of OA, it would seem reasonable to assume that
ACL reconstruction would play a useful role in prevention of
arthrosis in the long term. The difficulties in implementing
large long-term follow-up studies following ACL reconstruc-
tion have already been mentioned. Table 8-1 summarizes the
recent literature that has evaluated the incidence of arthrosis
following ACL reconstruction. Analysis of these studies
clearly suggests that surgical reconstruction of the ligament
does not prevent the development of radiological OA. A
meta-analysis by Lohmander and Roos26 found no evidence
that ACL reconstruction slowed the progression of arthrosis
following ACL rupture, and it does not seem that ACL
reconstruction reduces the clinical symptoms of OA in the
long term.2 However, it is noteworthy that most authors have
found the majority of patients to be essentially asymptomatic
at follow-up, regardless of the radiological changes, which are
often mild. Clearly a spectrum of joint changes exists, with
many patients demonstrating minimal radiographic change
and few clinical symptoms, although unfortunately a minority
will go on to have symptomatic arthrosis (Fig. 8-1).
As with conservatively managed ACL tears, the major
risk factor associated with the development of OA is meniscal
damage27 and the need for meniscal resection at the time of
FIG. 8-1 Anteroposterior (AP) (A) and lateral (B) radiographs of the knee of a man who underwent an anterior
cruciate ligament (ACL) reconstruction associated with a medial meniscectomy 11 years previously. The initial femoral
tunnel was too anterior. The graft was revised, but the patient presented with symptomatic arthritis at age 34 years.
Arthrosis Following Anterior Cruciate Ligament Tear and Reconstruction 8
surgery.28–35 Some authors maintain that chondral damage
is of more importance than medial meniscal tears, which in
turn are more significant than lateral meniscal tears in the
development of OA.34 However, even in the absence of chon-
dral damage or meniscal injury, early mild degenerative
changes may occur after successful ACL reconstruction.36
Other risk factors appear to be female gender and age older
than 30 years,36,37 presence of persistent pivot shift following
reconstruction,32 bone–patellar tendon–bone autograft com-
pared with hamstring autograft,38,39 time to surgery,27,33,40
synthetic graft material,37,41 and maintenance of high levels
of sporting activity after surgery.42 Surgery within 12 months
of injury40,42 appears to reduce the incidence of arthrosis.
There does not appear to be any benefit to surgery earlier than
3 months postinjury.43 Anteroposterior (AP) instability post
reconstruction does not appear to be a risk.36,32
Looking at the most up-to-date studies that have
followed patients undergoing ACL reconstruction using
modern graft materials, it appears that the rate of radiographic
degenerative changes is between 4% and 47% between
5 and 10 years of follow-up. This figure has been shown to
rise as high as 100% following ACL reconstruction with
a total meniscectomy.35 It has even been reported that the
rate of degenerative change is higher in the reconstructed
knee compared with the chronic ACL deficient knee.1 This
is probably due to the fact that those patients who have
symptomatic instability and require ACL reconstruction
71
72

Anterior Cruciate Ligament Injury

TABLE 8-1 Summary of Studies Reporting Results Following Anterior Cruciate Ligament (ACL) Reconstruction
Author Year Study Type of ACL Follow-up Incidence of Radiographic OA Incidence of Symptomatic OA
Size Graft (Imaging
(Mean Modality)
Age)

Aglietti 1994 N ¼ 57 BPTB 4.6 years (XR) Those who had PM had more medial compartment degeneration compared More pain experienced by those following PM
28
et al (NA) with those who had meniscal repair or normal menisci

Asano 2004 N ¼ 105 NA 3 months 100% (significant deterioration on all articular surfaces except lateral femoral NA
et al36 (NA) (arthroscopy) condyle)

Deehan 2000 N ¼ 80 BPTB 5 years (XR) 3% abnormal XR, all patients had normal articular cartilage and menisci at time 90% rated knee as subjectively normal or nearly normal
et al42 (25 years) of surgery, 75% had surgery within 3 months of injury

Hart et al29 2005 N ¼ 31 BPTB 10 years (SPECT) 7% (menisci intact), 34% (PM) 7% (menisci intact), 13% (PM)
(27.8
years)

Hertel 2005 N ¼ 95 BPTB 10.7 years (XR) 19% PF joint space narrowing, 15% medial compartment narrowing, 25% 84% normal or nearly normal knees on subjective
et al30 (42.2 lateral compartment narrowing assessment
years)

Jager et al27 2003 N ¼ 74 BPTB 10 years (XR) 29.7% (radiographic OA), higher incidence with delay to reconstruction and 83.7% subjectively normal or nearly normal knees
(NA) with meniscal injury

Jarvela 2001 N ¼ 100 BPTB 7 years (XR) 53% had no PFOA, 34% had mild PFOA, 13% had moderate or severe PFOA; 54% with moderate or severe radiological PFOA scored
et al13 (31 years) tibiofemoral joint arthrosis was uncommon (no/mild changes in >95%) knee as subjectively abnormal or severely abnormal

Jomha 1999 N ¼ 53 BPTB 7 years (XR) Chronic ACL deficiency predisposed to early OA, even with intact menisci prior NA
et al31 (NA) to reconstruction; more severe changes in those undergoing PM

Jonsson 2004 N ¼ 63 QT/PT 2 and 5–9 years Positive pivot shift correlated with increased uptake on scintigraphy and Positive pivot shift correlated with inferior subjective
et al32 (NA) (XR bone higher incidence of OA functional outcome 2 years after surgery
scintigraphy)

Lynch 1983 N ¼ 227 ITB 3.8 years (XR) 88% XR changes following total/PM, 12% XR changes following meniscal Amount of pain poorly correlated with radiographic
et al33 (20.1) repair, 3% with normal menisci had XR changes changes

Maletius 1997 N ¼ 52 Dacron 9 years (XR) 83% of total had XR changes 86% unacceptable knee stability and function
37
et al (NA)
continued
 TABLE 8-1 Summary of Studies Reporting Results Following Anterior Cruciate Ligament (ACL) Reconstruction—Cont'd
Author Year Study Type of ACL Follow-up Incidence of Radiographic OA Incidence of Symptomatic OA
Size Graft (Imaging
(Mean Modality)
Age)

Murray and 2004 N ¼ 18 LK 13.3 years (XR) 100% Overall poor functional outcome for all patients
41
Macnicol (28.4
years)

Pinczewski 2002 N ¼ 180 BPTB (90) 5 years (XR) 4% with hamstring, 18% with BPTB Both groups had good clinical outcome at 5 years.
38
et al (NA) versus
hamstring
(90)

Roe et al39 2005 N ¼ 180 BPTB (90) 7 years (XR) 14% with hamstring, 45% with BPTB Both groups had good clinical outcome at 7 years.
(NA) versus
hamstring

Arthrosis Following Anterior Cruciate Ligament Tear and Reconstruction

(90)

Shelbourne 2000 N ¼ 482 NA 7.2 years (XR) 97% patients with no meniscectomy or articular cartilage damage had normal 87% of knees with normal cartilage, and 64.4% of knees
et al34 (22.4 or near normal XR; 23–25% with total/PM of medial or both menisci had following partial/total meniscectomy rated knee as
years) abnormal or severely abnormal XR subjectively normal or nearly normal

Wu et al 35
2002 N ¼ 63 BPTB 10.4 years (XR) 92% with normal/repaired menisci had normal XR; 100% following total Subjective functional outcome worse with increasing
(24 years) meniscectomy had radiographic OA amounts of meniscus resected

BPTB, Bone–patellar tendon–bone; ITB, iliotibial band; LK, Leeds-Keio polyester ligament; NA, not available; OA, osteoarthritis; PF, patellofemoral compartment; PM, partial meniscectomy; QT/PT, quadriceps tendon–patellar tendon strip
augmented with a polypropylene braid; SPECT, single-photon emission computerized tomography; XR, plain radiographs.
73

8
 Anterior Cruciate Ligament Injury
are more likely to have concomitant meniscal and/or
chondral damage predisposing to the development of OA.
By comparison, those patients with normal articular carti-
lage and menisci can often be satisfactorily managed
conservatively.
In our own study40 we investigated the relationship of
time from injury to surgery on the incidence of meniscal
tears and degenerative change. We evaluated 183 patients
who underwent ACL reconstruction for isolated ACL tears
using a quadruple hamstring graft. An arthroscopically
assisted single-incision technique was used. Patients were
divided into an early group (surgery within 12 months of
injury) and a late group (surgery more than 12 months from
injury). The late group was also subdivided into four groups
of 12-month periods ranging from 1 year to more than 4
years after injury. There was a significantly higher incidence
of meniscal tears in patients undergoing reconstruction
after 12 months compared with those in the early group
(71.2% versus 41.7%, P < 0.001) (Fig. 8-2). This was due
to a large increase in medial meniscal tears in the late group.
The incidence of lateral meniscal tears remained relatively
unchanged with time. This may indicate that lateral menis-
cal tears occur at the time of ACL injury or very early after
injury, whereas the majority of medial meniscal tears are
acquired after the initial ACL tear. The increase in
medial meniscal tears after 12 months probably correlates
with an attempted return to preinjury levels of sporting
activity. The data are consistent with development of knee
instability associated with a return to sport, with increased
torsional and shear forces resulting in acquired medial
meniscal injuries and acceleration of degenerative change
in the knee.
We also found an increased incidence of degenerative
change in the late group (31.3% versus 10.7%, P < 0.001)
(Fig. 8-3), even though the majority of patients in both
Meniscal Pathology
100%
90%
Type of
80% meniscal tear
70%
60%
50% Both
40%
Lateral
30%
Medial
20%
None
10%
0%
0–12 ⬎12
Time to surgery (months)
FIG. 8-2 Percentage of patients with meniscal pathology undergoing
surgery 0–12 months after injury or more than 12 months after injury.
74
Degenerative Change
100%
90%
Grade of
80% degenerative
70% change
60%
50% 4
40%
3
30%
2
20%
1
10%
0%
0
0–12 ⬎12
Time to surgery (months)
FIG. 8-3 Incidence of degenerative change found at surgery 0–12 months
and more than 12 months after injury.
groups had no degenerative change at all. The findings in
the study indicate that reconstruction carried out within
1 year of injury is associated with a very low incidence of
degenerative change. It remains to be seen whether an
ACL reconstruction carried out at this stage confers a lon-
ger-term benefit in prevention of late degenerative change.
In a recent study44 using modern reconstruction techniques
with a hamstring autograft, the reported incidence of signif-
icant radiographic degenerative change at 2- to 8-years
follow-up was only 4%, and these occurred in patients
who had undergone meniscectomy. It is possible, therefore,
that early reconstruction carried out in the presence of intact
menisci may carry a more favorable prognosis with a lower
incidence of arthrosis in the longer term.
CONCLUSION
The development of arthrosis is a well-recognized complica-
tion following ACL rupture. The ACL injury itself is unlikely
to be the sole causative mechanism, and initial chondral dam-
age at the time of injury combined with various biochemical
mediators may also be implicated. Meniscal damage, either
directly at the time of injury or subsequent to chronic ACL
deficiency, also plays a key role in the development of arthrosis.
It is well recognized that the untreated ACL deficient
knee has an increased risk of developing degenerative
change. However, there is evidence to show that a signifi-
cant number of patients also develop radiographic signs of
arthrosis following ACL reconstruction. Despite this, the
majority of ACL reconstructed patients have a very satisfac-
tory functional outcome. The radiographic appearances are
usually minimal, and patients are essentially asymptomatic
despite these early degenerative changes.
Several problems lie in meaningfully interpreting the
literature on outcomes following ACL reconstruction. Study

cohorts vary widely in terms of age, level of sports activity,
outcome measures, and duration of follow-up. All recent
studies have suboptimal follow-up rates, none of which
was longer than 10 years. Most studies in the literature have
looked at patients who have undergone ACL reconstruction
using bone–patellar tendon–bone autograft, although ham-
string autografts are now a popular choice. However, there
is no sound evidence linking graft choice to the rate of post
ACL reconstruction arthrosis.
Although there is no definite evidence that ACL recon-
struction prevents arthrosis in the long term, the literature
indicates that chronic ACL deficiency and meniscal tears
are the most important factors associated with the develop-
ment of degenerative change. Delays to reconstruction for
periods of longer than 12 months are associated with a greater
risk of meniscal tears and degeneration. The evidence also
suggests that early reconstruction of the ACL within 12
months of injury minimizes the rate of meniscal tears and
consequently should lead to lower rates of arthrosis. We
would advocate undertaking surgery within this timeframe.
Furthermore, we would also recommend that every effort be
made to repair meniscal injuries, as the loss of meniscal
tissue is a major risk factor in post-reconstruction arthrosis.
The most recent studies seem to indicate that early ACL
reconstruction in knees with a normal articular surface and
intact menisci will delay and may even prevent the develop-
ment of arthrosis. More evidence from clinical studies with
longer-term follow-up is required to support this view.
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31. Jomha NM, Borton DC, Clingeleffer AJ, et al. Long-term osteoar-
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32. Jonsson H, Riklund-Ahlstrom K, Lind J. Positive pivot shift after
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Long-term follow-up meniscus tear treatment in stable anterior cruciate
ligament reconstructions. Clin Orthop Relat Res 1983;172:148–153.
34. Shelbourne KD, Gray T. Results of anterior cruciate ligament recon-
struction based on meniscus and articular cartilage status at the time
of surgery. Five- to fifteen-year evaluations. Am J Sports Med
2000;28:446–452.
35. Wu WH, Hackett T, Richmond JC. Effects of meniscal and articular
surface status on knee stability, function, and symptoms after anterior
cruciate ligament reconstruction: a long-term prospective study. Am
J Sports Med 2002;30:845–850.
36. Asano H, Muneta T, Ikeda H, et al. Arthroscopic evaluation of the artic-
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prospective study of 105 patients. Arthroscopy 2004;20:474–481.
37. Maletius W, Gillquist J. Long-term results of anterior cruciate ligament
reconstruction with a Dacron prosthesis. The frequency of osteoarthritis
after seven to eleven years. Am J Sports Med 1997;25:288–293.
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38. Pinczewski LA, Deehan DJ, Salmon LJ, et al. A five-year comparison
of patellar tendon versus four-strand hamstring tendon autograft for
arthroscopic reconstruction of the anterior cruciate ligament. Am
J Sports Med 2002;30:523–536.
39. Roe J, Pinczewski LA, Russell VJ, et al. A 7-year follow-up of patellar
tendon and hamstring tendon grafts for arthroscopic anterior cruciate
ligament reconstruction: differences and similarities. Am J Sports Med
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40. Church S, Keating JF. Reconstruction of the anterior cruciate liga-
ment. Timing of surgery and the incidence of meniscal tears and
degenerative change. J Bone Joint Surg Br 2005;87:1639–1642.
41. Murray AW, Macnicol MF. 10–16 year results of Leeds-Keio anterior
cruciate ligament reconstruction. Knee 2004;11:9–14.
42. Deehan DJ, Salmon LJ, Webb VJ, et al. Endoscopic reconstruction of
the anterior cruciate ligament with an ipsilateral patellar tendon auto-
graft. A prospective longitudinal five-year study. J Bone Joint Surg Br
2000;82:984–991.
43. Meighan A, Keating JF, Will E. Early versus delayed reconstruction
for acute ACL tears: a prospective randomised trial. J Bone Joint Surg
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follow-up. Arthroscopy 2005;21:138–146.
 The Economics of Anterior Cruciate
Ligament Reconstruction
BACKGROUND
With more than 100,000 anterior cruciate liga-
ment reconstructions (ACLRs) now performed
yearly in the United States, total ACLR costs
exceed half a billion dollars annually. In this
chapter the major component costs of ACLR will
be analyzed along with institutional reimburse-
ment levels. Finally, the effect of current trends
and emerging technology as they affect ACLR cost
will be discussed.
PURPOSE
The purpose of this chapter is to help surgeons
understand the economic implications of their
choices for resource utilization in ACLR. All
of the relevant cost variables discussed in this
chapter are under surgeon control. These
choices are always made to maximize patient
outcomes. However, it is also useful to under-
stand the economic impact of these choices.
Limited resources coupled with increased
demand and increasingly expensive technology
may force the surgeon to make increasingly dif-
ficult decisions in the future in this regard.
WHOSE COSTS ARE BEING
CONSIDERED?
ACLR costs can be considered from both
macro- and microeconomic perspectives. The
macroeconomic perspective deals with how many
9
CHAPTER
societal dollars are being spent by patients and Chadwick C. Prodromos
third-party payers on ACLR. From this pers-
Julie Rogowski
pective the goal is to spend the minimal amount
consistent with high-quality care out of the finite Brian T. Joyce
healthcare dollars available. The microeconomic
perspective in this context deals with the insti-
tution (the hospital or surgicenter) where the sur-
gery is performed. The goal from this perspective
is to balance costs with payments so that losses are
avoided. Excessive macroeconomic costs can lead
to lower institutional reimbursements and dis-
allowal of charges (e.g., as have recently happened
with refusals to pay for mechanized cold units
after ACLR). It can also lead to reduced surgeon
reimbursements to both save money and attempt
to provide a disincentive to surgeons performing
the procedure. Excessive microeconomic institu-
tional costs relative to payments can also lead to
controls on choices by surgical facilities to reduce
those costs. The answer to both macro- and
microeconomic cost containment is for utiliza-
tion choices to be soundly grounded in patient
outcomes. Thus, by constraining excessive costs,
the procedure is less likely to become a target
for cost cuts. Furthermore, if cuts in necessary
services are proposed, the surgeon, as the patient
advocate, is better able to justify the necessity of
the provided service.
SOURCES OF COST INFORMATION
The information presented here was obtained
by personal communication between the authors
and various institutions and companies. The
79
 Anterior Cruciate Ligament Reconstruction
numbers are only approximations and are skewed toward
the Chicago area and the U.S. healthcare system. Some of
the information was provided only on condition of
confidentiality. Specific companies or devices have not been
listed partially for this reason and partially because the num-
bers are subject to great variation by region. Readers should
make inquiries specific to their practice environment and
area to acquire comparative data for their personal use.
THIRD-PARTY PAYER PAYMENTS
Some payers pay a percent of billed charges. Currently, how-
ever, third-party payers typically pay the hospital or
surgicenter a flat fee from which all their expenses must be
subtracted. Typically surgicenters are reimbursed at lower
rates than hospitals. For outpatient ACLR in the Chicago
area, these rates vary from a low of $1100 for Medicaid
to between $1800 and $3000 for private payers and
Medicare. Hospital admission for 1 night will typically
actually decrease the reimbursement rate by causing the
hospital to be paid its per-diem rate for 1 night instead of
the outpatient surgery cost. For institutions performing high
volumes of ACLR, “carve outs” become extremely important.
These remove the ACLR from the fixed surgery reimburse-
ment prepayment mode and substitute a percentage of
charges or a higher reimbursement payment level. This is a
matter of individual negotiation between the institution and
the payer. Most payers also reimburse implant invoices,
although some do not. These invoice reimbursements
often will occur only above a certain threshold: for example,
at the $1000 level. Risk contracts, in which institutions
are paid globally for all care for a given number of lives, are
still reasonably prevalent. They are of special concern to
the institution when typical surgical costs are exceeded
frequently.
INSTITUTIONAL FIXED COSTS
These costs are a combination of time charges, which reflect
fixed costs of operation such as rent, utilities, and staffing,
and additional costs associated with the given procedure.1,2
In 1996, Novak et al2 published rates of $12,040 for hospi-
tal ACLR with admission, $8815 for hospital ACLR with
same-day discharge, and $3853 for surgicenter ACLR. A
representative survey of Chicago-area hospitals and surgi-
centers indicates that current total charges typically vary
from $5000 to $12,000 for ACLR. In the following
discussion, we will break down the component costs that
are additive to the basic institutional time costs.
80
Anterior Cruciate Ligament
Reconstruction–Specific Additive Costs
Allografts
Allografts are increasing rapidly in popularity. A survey of the
largest U.S. tissue banks discloses a price range for various
ACL allografts of $1400 to more than $3000, with a mean of
about $2000 per case. A recently published study3 using patient
data from 1996 to 1998 showed allografts at that time to
substantially reduce costs by decreasing the likelihood of
admission and decreasing surgical time. However, today
virtually all ACLR procedures may be performed as outpatient
with the use of femoral blocks (see later), so there is little further
potential cost savings in this regard from the use of allografts.
Even without the use of femoral blocks, ACLR can usually
be performed easily on an outpatient basis.
Allograft use will produce slightly decreased costs
from reduced operating time due to the absence of a surgical
harvest. Experienced surgeons will generally accomplish the
harvest in about 10 minutes, but the time may be substan-
tially higher for surgeons who perform the procedure only
occasionally. In either case the reduced time will not signifi-
cantly offset the high cost of the allograft; in addition, there
is some diversion of assistant or surgeon time involved in
opening, thawing, and washing the allograft. The other
potential benefit of allograft use is avoidance of harvest mor-
bidity. This may be significant regarding kneeling pain after
bone–patellar tendon–bone (BPTB) harvest. The morbidity
for hamstring harvest has been shown to be negligible. Dis-
advantages with allograft versus autograft use may include
lower stability rates4 (see Chapter 69) as well as the small
but definite risk of disease transmission.
The cost implications of widespread allograft use are
staggering. Macroeconomically, $2000 per allograft multi-
plied by an estimated 110,000 predicted ACLRs yields a
cost differential of more than $200 million between no use
of allografts and complete use of allografts nationwide.
Microeconomically, if allografts are not separately reim-
bursed above the basic cost of the procedure, their use will
virtually always cause the procedure to be performed at a
net loss to the institution. Because most contracts do
reimburse for allografts, this is often not an issue, but it is
important to be aware of contract provisions at the given
institution for the specific payer involved.
Fixation Implants
We have surveyed the costs of the fixation implants
produced by the major manufacturers of such devices. The
cost range of these devices is summarized in Table 9-1.
However, discounting of up to 25% below the listed range
is common. Interference screws, which are still the most
 The Economics of Anterior Cruciate Ligament Reconstruction 9
TABLE 9-1 Economics of Anterior Cruciate Ligament Reconstruction Anterior Cruciate Ligament Instrumentation
Item Cost Range ($) Tray Rental
ACL tray rentals vary widely but will often cost the institu-
ACLR implants
tion about $500.
Interference screws 200–300
Disposables
Tibial fixation: other 80–500, typically 250
Disposable pins and the like typically cost about $300 or less
Femoral fixation: other 95–558, typically 250
per case.
Allograft cost 1400–3000, typically 2000
Total Cost
Total without allograft 500
As is seen from the previous remarks and Table 9-1, disposa-
Total with allograft 2500 bles, tray rental, and fixation devices will produce an aggregate
ACLR surgical costs cost of $1200 per case; the cost is lower for the institution that
owns its own ACL guide system. The addition of an allograft
Disposables 300
will increase the average cost to roughly $3200 per case. Thus,
ACLR tray rentals 500 it can be seen that ACLR without allograft falls below total
Total 800
payer payments in virtually all cases, allowing the institution
to retain some payment to cover its fixed costs. The addition
Future costs of an allograft will not be problematic, provided it is separately
Navigation 450 reimbursed. Thus, from a microeconomic perspective, payer
reimbursement of allografts becomes the key factor in preserv-
Double bundle 450 (extra fixation costs)
ing solvency.
Tissue engineering Unknown

Postoperative costs
Postoperative Costs
Continuous passive motion >23/day

Cold machine 300

Reimbursement is variable for some of the items in this sec-
tion, as described here. If the surgeon wishes to use them, it
Postoperative brace 300 is therefore important to check individual patient benefits to
Functional brace ensure that patients are not unexpectedly billed for items
that they thought would be paid by their insurance provider.
Custom 1500

Shelf 800 Femoral Blocks

Physical therapy 1000–3000
Femoral block 80
widely used devices, generally cost between $200 and $300
each. The cost differential between metal and bioabsorbable
screws has largely disappeared, and most sales today are of
the bioabsorbable devices. The former practice of using
metal devices as a cost-saving measure is thus generally no
longer productive. The tibial post screw stands alone as
the least expensive tibial or femoral device, with a cost of
less than $100. Some devices are priced as high as $500.
In general there is little relationship between the sophistica-
tion of the device and its cost, and pricing by the companies
would appear to be driven primarily by what the market
will bear. Overall, combined tibial and femoral fixation
device cost per case will generally be in the range of $400
to $500.
In the Chicago area, femoral blocks are reimbursed at
roughly $60 to $80 per block. They are reimbursed either
using a specific Current Procedural Terminology (CPT)
code or, more often, as an additional 15 minutes or so of
anesthesia time. They have been shown to be highly cost
effective by permitting reliable, same-day discharge.4–7
Although same-day discharge is routinely accomplished by
most orthopaedic surgeons without the block, the block
increases the percentage to nearly 100%, with greatly
increased patient comfort. Pain is eliminated as a discharge
obstacle, and nausea is also reduced as a discharge obstacle
because there is no postoperative narcotic nausea exacerba-
tion. Furthermore, femoral blocks clearly reduce short-term
narcotic use after discharge, thus decreasing the incidence of
nausea, constipation, and other opioid side effects at home,
which can be significant in some patients. The small cost of
the block is greatly outweighed by the overall reduced facil-
ity costs in allowing patients to leave the hospital expedi-
tiously. The morbidity of these blocks has been negligible.

81
 Anterior Cruciate Ligament Reconstruction
Cold Machines
Motorized ice-flow machines cost about $300. They are
beloved by patients for their pain-relieving properties. The
literature, including a meta-analysis, shows their efficacy
after ACLR8–10 and total knee arthroplasty.11 However,
despite this favorable literature, third-party payers have
increasingly refused to pay for motorized ice-flow machines
in recent years. In the absence of insurance reimbursement,
most patients are not willing to pay out of pocket for them.
Continuous Passive Motion
Continuous passive motion (CPM) is somewhat less com-
monly used and more difficult to obtain reimbursement for
than in prior years. Although early range of motion (ROM)
may be improved, studies have failed to show significant benefit
regarding ultimate ROM or postsurgical pain in ACLR.12–14
This parallels studies showing little or no long-term benefit
after total knee arthroplasty.15–17 This literature has somewhat
dampened third-party payer enthusiasm for these devices. The
daily cost ranges upward from the Medicare rate of $23.
Postoperative Knee Braces
Postoperative knee braces have a definite use in some reha-
bilitation protocols in regaining knee extension. They
also provide protection in the postoperative period. Some
surgeons do not use them. They are universally paid by
payers as a separate cost item.
Functional Knee Braces
So-called derotation braces were formerly routinely used
when patients returned to pivoting activities. However,
today they are used by far fewer surgeons than in past years.
In the presence of a stable knee, there is no evidence that
they are of significant benefit. In addition, the costs can be
substantial, especially for custom braces. Many payers will
reimburse the approximate $800 cost of “off the shelf”
braces but not the higher $1500 price tag of custom braces.
Physical Therapy
Adequate physical therapy is necessary to restore motion,
strength, and function. Although the costs vary by orders
of magnitude among various regimens, there is little evi-
dence regarding relative efficacies. Primarily home-based
regimens are clearly more economical, but it is not clear that
they are equally effective with clinic-based regimens. Also,
the quantity of therapy needed varies somewhat by the
demands of the patient, with high-performance competitive
athletes generally needing more than others. Individual visit
charges are also quite variable. The approximate cost range
can vary from about $1000 to $3000 and much more in
some cases. Most plans include physical therapy benefits,
82
but some do not. The number of available visits should be
known in advance so that the surgeon does not use them
all before the rehabilitation is completed. Many, but not
all, plans will allow expanded benefits in cases of special
need after appropriate appeal.
Future Added Costs
Navigation
Computerized navigation systems have been introduced18,19
but are not currently in widespread use. Their advantage is
said to be greater tunnel placement accuracy. It is not clear
whether their use will ever be widespread, but if so, they will
add both direct cost and increased operative time cost to
ACLR. The current cost of bringing in a system for a case is
about $450. There is insufficient literature to evaluate relative
outcomes with and without navigation. Some believe that the
less-expensive option of simple intraoperative radiographs
without computerized navigation can also be efficacious.
Double-Bundle Anterior Cruciate Ligament
Reconstruction
Double-bundle ACLR is more time consuming than single-
bundle cases and thus increases surgical times. It also gener-
ally doubles implant costs because two femoral and two tibial
implants are needed in most cases—an approximate average
increase of $450 per case for fixation implants alone. Early
clinical results have been good,20,21 but it is too soon to know
whether the benefits are sufficient to justify the increased
time, difficulty, and cost. Because many plans do not reim-
burse invoices at such a low level, the extra implant costs
may ultimately be subtracted from the often-thin profit mar-
gin of these cases.
Tissue Engineering
The use of growth factors and delivery vehicles for them is
imminent.22,23 This will inevitably add significant cost to
ACLR.
CONCLUSIONS
1 Allograft usage is currently the largest and most
important cost factor in ACLR. Macroeconomically,
allograft use can potentially add almost $200 million to
U.S. annual ACLR expenditures. Microeconomically, it
is imperative that contracting provides for separate
reimbursement above the basic cost of the procedure to
avoid net loss to the institution.
2 Femoral nerve blocks are a cost-effective means to avoid
the adverse economic effects of patient admission and
improve postoperative pain control.

3 CPM machines, cold machines, and functional knee
braces are no longer universally reimbursed. Physical
therapy is almost always covered but at variable levels.
Patient benefits should be determined prior to
prescription.
4 Tissue engineering, navigation, and double-bundle
techniques will increase ACLR cost if they come into
widespread use. Outcome studies will be necessary to
determine whether benefits justify costs.
5 Surgeon choice is the most important factor in
determining macroeconomic societal expense and
microeconomic institutional solvency for ACLR. It is
important to weigh patient outcomes against costs.
References
1. Curran AC, Park AE, Bach BR Jr, et al. Outpatient anterior cruciate
ligament reconstruction: an analysis of changes and perioperative com-
plications. Am J Knee Surg 2001;14:145–151.
2. Novak PJ, Bach BR Jr, Bush-Joseph CA, et al. Cost containment: a
change comparison of anterior cruciate ligament reconstruction.
Arthroscopy 1996;12:160–164.
3. Cole DW, Ginn TA, Chen GJ, et al. Cost comparison of anterior
cruciate ligament reconstruction: autograft versus allograft. Arthroscopy
2005;21:786–790.
4. Dauri M, Polzoni M, Fabbi E, et al. Comparison of epidural contin-
uous femoral block and intraarticular analgesia after anterior cruciate
ligament reconstruction. Acta Anaesthesiol Scand 2003;47:20–25.
5. Williams BA, Kentor ML, Vogt MT, et al. Economics of nerve block
pain management after anterior cruciate ligament reconstruction:
potential hospital cost savings via associated postanesthesia care unit
bypass and same-day discharge. Anesthesiology 2004;100:697–706.
6. Edkin BS, Spindler KP, Flanagan JF. Femoral nerve block as an alter-
native to parenteral narcotics for pain control after anterior cruciate
ligament reconstruction. Arthroscopy 1995;11:404–409.
7. Williams BA, DeRiso BM, Figallo CM, et al. Benchmarking the peri-
operative process: III. Effects of regional anesthesia clinical pathway
techniques on process efficiency and recovery profiles in ambulatory
orthopedic surgery. J Clin Anesth 1998;10:570–578.
8. Raynor MC, Pietrobon R, Guiller U, et al. Cryotherapy after ACL
reconstruction: a meta analysis. J Knee Surg 2005;18:123–129.
The Economics of Anterior Cruciate Ligament Reconstruction 9
9. Barber FA. A comparison of crushed ice and continuous flow cold
therapy. Am J Knee Surg 2000;13:97–101.
10. Barber FA, McGuire DA, Click S. Continuous-flow cold therapy for
outpatient anterior cruciate ligament reconstruction. Arthroscopy
1998;14:130–135.
11. Morsi E. Continuous-flow cold therapy after total knee arthroplasty.
J Arthroscopy 2002;17:718–722.
12. Gaspar L, Farkas C, Szepesi K, et al. Therapeutic value of continuous
passive motion after anterior cruciate replacement. Acta Chir Hung
1997;36:104–105.
13. McCarthy MR, Yates CK, Anderson MA, et al. The effects of
immediate continuous passive motion on pain during the inflamma-
tory phase of soft tissue healing following anterior cruciate ligament
reconstruction. J Orthop Sports Phys Ther 1993;17:96–101.
14. Richmond JC, Gladstone J, MacGillivray J. Continuous passive
motion after arthroscopy assisted anterior cruciate ligament recon-
struction: comparison of short- versus long-term use. Arthroscopy
1991;7:39–44.
15. Leach W, Reid J, Murphy F. Continuous passive motion following total
knee replacement: a prospective randomized trial with follow-up to 1
year. Knee Surg Sports Traumatol Arthrosc 2006;14:922–926.
16. Denis M, Moffet H, Caron F, et al. Effectiveness of continuous
passive motion and conventional phsycial therapy after total knee
arthroplasty: a randomized clinical trial. Phys Ther 2006;86:174–185.
17. Lau SK, Chin KY. Use of continuous passive motion after total knee
arthroplasty. J Arthroplasty 2001;16:336–339.
18. Plaweski S, Cazal J, Rosell P, et al. Anterior cruciate ligament recon-
struction using navigation: a comparative study on 60 patients.
Am J Sports Med 2006;34:542–552.
19. Hiraoka H, Kuribayashi S, Fukuda A, et al. Endoscopic anterior cru-
ciate ligament reconstruction using a computer-assisted fluoroscopic
navigation system. J Orthop Sci 2006;11:159–166.
20. Muneta T, Koga H, Morito T. A retrospective study of the midterm
outcome of two-bundle anterior cruciate ligament reconstruction using
quadrupled semitendinosus tendon in comparison with one-bundle
reconstruction. Arthroscopy 2006;22:252–258.
21. Yasuda K, Kondo E, Ichiyama H, et al. Clinical evaluation of ana-
tomic double-bundle anterior cruciate ligament reconstruction proce-
dure using hamstring tendon grafts: comparisons among three
different procedures. Arthroscopy 2006;22:240–251.
22. Ju YJ, Tohyama H, Kondo E, et al. Effects of local administration of vas-
cular endothelial growth factor on properties of the in situ frozen-thawed
anterior cruciate ligament in rabbits. Am J Sports Med 2006;34:84–91.
23. Yamazaki S, Yasuda K, Tomita F, et al. The effect of transforming
growth factor-beta1 on intraosseous healing of flexor tendon autograft
replacement of the anterior cruciate ligament in dogs. Arthroscopy
2005;21:1034–1041.
83
 PART A GRAFT MECHANICAL PROPERTIES
10
CHAPTER
The Relative Strengths of Anterior Cruciate
Ligament Autografts and Allografts
Chadwick C. Prodromos INTRODUCTION
Brian T. Joyce
Graft strength is only one of the factors influencing
anterior cruciate ligament (ACL) graft choice.
However, it has a direct bearing on ultimate stabil-
ity, which is the goal of ACL. The relative strengths
of potential ACL grafts are often not clearly appre-
ciated. It is the purpose of this chapter to present
the available data on the relative strengths of ten-
dons that can be used as ACL reconstructive grafts.
METHODS
Table 10–1 summarizes the data that we were
able to find in the literature on graft strengths.
Load to failure (LTF) is the parameter com-
pared in each case. This data was found from
computerized literature searches targeting ACL
reconstruction and each of the specific grafts in
clinical use. Although some tissue banks have
performed their own studies on graft strengths,
we have purposely excluded such proprietary
data and relied only on data published in the
peer-reviewed literature to avoid bias.
COMPARISON OF GRAFT STRENGTHS
There is significant variability in LTF results
among different studies for the same graft (see
Table 10–1). This is likely related to differences
in testing methodologies. Thus, it is necessary
to look at the totality of the data to get an overall
idea of relative graft strengths. Some of the
84
authors have what appears to be outlier LTFs,
but the relative strengths between grafts within
their study generally reflect the bulk of the litera-
ture. The two main examples here are the data of
Brahmabhatt21 and Harris, with low LTFs for all
grafts tested relative to other studies. When com-
paring grafts it is important also to notice the
configuration of the tested grafts; in other words,
whether it is a single, double, or quadruple graft,
and in the case of bone–patellar tendon–bone
(BPTB), whether it is a 10-mm or 15-mm graft.
The data in Table 10–1 also show that braiding of
grafts has been shown to weaken rather than
strengthen grafts and is not clinically indicated.
EFFECT OF LIGAMENTIZATION
Chapter 55 describes the effects of ligamentization
on graft strength. Although there is some dis-
agreement, it appears that grafts retain only about
half their initial strength at long-term follow-up.
Thus, grafts that are significantly stronger than
the native ACL at time zero may indeed be neces-
sary to produce ultimate strengths that are as
strong as the ACL initially was. Indeed, some
studies report a lower re-rupture rate for recon-
structed ACLs than for the contralateral normal
ACL,1 perhaps due to greater graft strength.
ALLOGRAFT STRENGTHS
Autograft strengths are relatively straightfor-
ward to measure. However, allograft strengths
 The Relative Strengths of Anterior Cruciate Ligament Autografts and Allografts 10
TABLE 10–1 Load to Failure Data for Anterior Cruciate Ligament Grafts
Author Year Graft Average SD Author Year Graft Average SD
Load to Load to
Failure (N) Failure (N)

Allografts Hamner22 1999 2ST/2Gr 3880.0 NR

Haut22 2002 Double anterior tibialis 4122.0 893.0 Noyes19 1984 2ST/2Gr 4108.0 NR

Pearsall27 2003 Double anterior tibialis 3412.0 NR Hamner22 1999 2ST/2Gr 4090.0 295.0
27 24
Pearsall 2003 Double peroneus 2483.0 NR Kim 2003 2ST/2Gr 3000.0 563.0

Haut22 2002 Double post tibialis 3594.0 1330.0 Millett23 2003 2ST/2Gr 3404.2 922.0
27 22
Pearsall 2003 Double post tibialis 3391.0 NR Haut 2002 2ST/2Gr 2913.0 645.0

King30 2004 Achilles 1470.0 511.9 Kim24 2003 2ST/2Gr—braided 1673.0 504.0
30 25
King 2004 Tibialis 1806.7 496.2 Millett 2003 2ST/2Gr—braided 2223.5 1056.0

Semitendinosus (ST) Bone–patellar tendon–bone (BPTB)

Brahmabhatt21 1999 Double ST 1029.0 158.4 Noyes19 1984 15-mm BPTB 2734.0 298.0

Hamner22 1999 Double ST 2330.0 452.0 Noyes19 1984 15-mm BPTB 2900.0 260.0

King30 2004 Double ST 1640.7 236.5 Harris31 1997 10-mm BPTB 876.0 NR

Noyes19 1984 Single ST 1216.0 50.0 Brahmabhatt21 1999 10-mm BPTB 850.0 159.2

Hamner22 1999 Single ST 1060.0 227.0 King30 2004 10-mm BPTB 863.9 417.4

Gracilis (Gr) Noyes 19

1984 10-mm BPTB 1822.7 NR

Brahmabhatt21 1999 Double Gr 648.7 112.4 Noyes19 1984 10-mm BPTB 1933.3 NR
22 20
Hamner 1999 Double Gr 1550.0 428.0 Cooper 1993 10-mm BPTB 2664.0 395.0

Noyes19 1984 Single Gr 838.0 30.0 Cooper20 1993 10-mm BPTB 3057.0 351.0

Hamner 22
1999 Single Gr 837.0 138.0 Quadriceps

Double ST/double Gr (2ST/2Gr) Brahmabhatt21 1999 Quadriceps/bone 991.0 282.0

31
Brahmabhatt 21
1999 2ST/2Gr 1677.0 NR Harris 1997 Quadriceps/bone 1075.0 NR

NR, Not reported.

are more complicated because of the varying effects of graft
preparation and sterilization techniques on the graft. Thus,
any study that measures allograft strength can only be
considered accurate for an allograft prepared in a similar
manner. The relevant parameters may include radiated
versus not radiated, the amount of radiation, and whether
or not a radioprotectant was used. Other processes shown
to significantly affect tissue properties include the use of
cryoprotectant2 and even simple freezing.3 This is further
complicated by the fact that these parameters may affect
allograft strength at longer-term follow-up by influencing
revascularization and cellular repopulation in addition to
their effects at time zero. Thus, time zero data may not be
sufficient for comparison between autografts and allografts,
particularly in light of evidence that late failure rates may
be higher for allografts than for autografts.4–7 The literature
has also shown overall lower stability rates for allograft
BPTB versus autograft BPTB,8–17 suggesting that ligamen-
tization may weaken allografts more than autografts.18
QUADRICEPS TENDON GRAFT STRENGTH
The only published data we could find was from Brahmab-
hatt and Harris. Their LTF for the quadriceps tendon (QT)
graft is quite low. However, we believe the proper way to
interpret these data is by comparing them with their BPTB
data, which are also much lower than other studies, probably
due to testing methodology. The important point is that the
QT LTF values in both of these studies are each about 20%

85
 Anterior Cruciate Ligament Reconstruction
stronger than the LTF for 10-mm BPTB tested the same
way. Therefore, it would appear that a QT graft is likely a
little stronger than a 10-mm BPTB graft.
RELATIVE STRENGTH OF HAMSTRING AND
BONE–PATELLAR TENDON–BONE GRAFTS
The classic paper of Noyes et al19 first compared various tis-
sues with the ACL from the same cadaveric specimen.
Other works have followed a similar methodology. These
studies are summarized in Table 10–1. It should be noted
that the study by Noyes et al used a 15-mm BPTB graft,
whereas in practice a roughly 10-mm graft is used. Extrapo-
lating from their numbers, a 10-mm BPTB graft would be
110% as strong as the native ACL. A two-strand semitendi-
nosus (ST) and two-strand gracilis (Gr) (2ST/2Gr) graft
would be 238% as strong as the native ACL. A four-strand
ST (4ST) would be 280% as strong as the ACL. The real
values for these multistrand grafts are probably a little less
than these extrapolations because it is unlikely that the
entire tendon is as strong as these index values. Some more
recent studies have produced very different absolute num-
bers, perhaps related to testing methodological differ-
ences.20–29 However, within studies the relative strengths
of various grafts show general agreement.
OVERALL RELATIVE GRAFT STRENGTHS
Overall, 4ST and 2ST/2Gr grafts would appear to be the
strongest available grafts in common use. Two-strand tibia-
lis grafts are nearly as strong, followed by 10-mm BPTB
and peroneus grafts, which are roughly two-thirds as strong
as four-strand hamstring grafts. It should be pointed out
that 15-mm BPTB can be used as an allograft and will more
closely approximate the strength of a four-strand hamstring
graft. The only data of which we are aware on tendo Achil-
les grafts show a low LTF. From the high girth of the graft
it is likely, however, that a full-thickness tendo Achilles
graft has much greater strength. This supposition will
require more testing for validation.
CONCLUSIONS
1 Four-strand hamstring autografts are the strongest
available grafts, followed by tibialis, QT, and BPTB
grafts, with insufficient data to evaluate tendo Achilles
grafts. All have greater strength than the native ACL.
2 Graft strength is only one of many factors contributing to
knee stability after ACL reconstruction.
86
3 Because grafts appear to retain only about half of their
time zero strength at ultimate follow-up, grafts
significantly stronger than the native ACL would seem to
be desirable.
4 Allograft ligamentization has not been well studied. LTF
studies between autografts and allografts may not be
comparable if the ligamentization of allografts differs
significantly from that of autografts.
References
1. Prodromos CC, Han YS, Keller BL, et al. Stability of hamstring ante-
rior cruciate ligament reconstruction at two- to eight-year follow-up.
Arthroscopy 2005;21:138–146.
2. Caborn D, Nyland J, Chang HC, et al. Tendon allograft cryoprotectant
incubation and rehydration time alters mechanical stiffness properties.
Presented at the 2006 meeting of the European Society of Sports Trauma-
tology, Knee Surgery, and Arthroscopy, Innsbruck, Australia, May 2006.
3. Clavert P, Kempf JF, Bonnomet F, et al. Effects of freezing/thawing
on the biomechanical properties of human tendons. Surg Radiol Anat
2001;23:259–262.
4. Prodromos CC, Fu F, Howell S, et al. Controversies in soft tissue
anterior cruciate ligament reconstruction. Presented at the 2006
Symposium of the American Academy of Orthopaedic Surgeons.
AAOS Symposium; Controversies in Soft Tissue ACL Reconstruction,
Chicago, May, 2006.
5. Scheffler S, Unterhauser F, Keil J, et al. Comparison of tendon-to-bone
healing after soft tissue autograft and allograft ACL reconstruction in a
sheep model. Presented at the 2006 meeting of the European Society
of Sports Traumatology, Knee Surgery, and Arthroscopy, Innsbruck,
Australia, May, 2006.
6. Siegel MG. Personal communication. Meeting of the Arthroscopy
Association of North America, Hollywood, Florida, May, 2006.
7. Risinger RJ, Bach BR, Jr. Late anterior cruciate ligament reconstruction
failure by femoral bone plug dislodgement. J Knee Surg 2006;19:202–205.
8. Barrett G, Stokes D, White M. Anterior cruciate ligament reconstruc-
tion in patients older than 40 years: allograft versus autograft patellar
tendon. Am J Sports Med 2005;33:1505–1512.
9. Gorschewsky O, Klakow A, Riechert K, et al. Clinical comparison of
the Tutoplast allograft and autologous patellar tendon (bone–patellar
tendon–bone) for the reconstruction of the anterior cruciate ligament:
2- and 6-year results. Am J Sports Med 2005;33:1202–1209.
10. Harner CD, Olson E, Irrgang JJ, et al. Allograft versus autograft ante-
rior cruciate ligament reconstruction: 3- to 5-year outcome. Clin
Orthop Rel Rsch 1996;324:134–144.
11. Kleipool AEB, Zijl JAC, Willems WJ. Arthroscopic anterior cruciate
ligament reconstruction with bone-patellar tendon-bone allograft or
autograft: a prospective study with an average follow up of 4 years.
Knee Surg Sports Traumatol Arthrosc 1998;6:224–230.
12. Peterson RK, Shelton WR, Bomboy AL. Allograft versus autograft
patellar tendon anterior cruciate ligament reconstruction: a 5-year
follow-up. Arthroscopy 2001;17:9–13.
13. Shelton WR, Papendick L, Dukes AD. Autograft versus allograft ante-
rior cruciate ligament reconstruction. Arthroscopy 1997;13:446–449.
14. Stringham DR, Pelmas CJ, Burks RT, et al. Comparison of anterior
cruciate ligament reconstruction using patellar tendon autograft or
allograft. Arthroscopy 1996;12:414–421.
15. Victor J, Bellemans J, Witvrouw E, et al. Graft selection in anterior cru-
ciate ligament reconstruction—prospective analysis of patellar tendon
autografts compared with allografts. Int Orthop 1997;21:93–97.
16. Zijl JAC, Kleipool AEB, Willems WJ. Comparison of tibial tunnel
enlargement after anterior cruciate ligament reconstruction using patel-
lar tendon autograft or allograft. Am J Sports Med 2000;28:547–551.
 The Relative Strengths of Anterior Cruciate Ligament Autografts and Allografts
17. Chang SKY, Egami DK, Shaib MD, et al. Anterior cruciate
ligament reconstruction: allograft versus autograft. Arthroscopy
2003;19:453–462.
18. Prodromos CC, Joyce BT, Shi KS. A meta-analysis of stability of
autografts compared to allografts after anterior cruciate ligament
reconstruction. Knee Surg Sports Traumatol Arthrosc (In press).
19. Noyes FR, Butler DL, Grood ES, et al. Biomechanical analysis of
human ligament grafts used in knee-ligament repairs and reconstruc-
tions. J Bone Joint Surg Am 1984;66A:344–352.
20. Brahmabhatt V, Smolinski R, McGlowan J, et al. Double-stranded
hamstring tendons for anterior cruciate ligament reconstruction. Am
J Knee Surg 1999;12:141–145.
21. Cooper DE, Deng XH, Burstein AL, et al. The strength of the central
third patellar tendon graft. Am J Sports Med 1993;21:818–824.
22. Haut Donahue TL, Howell SM, Hull ML, et al. A biomechanical eval-
uation of anterior and posterior tibialis tendons as suitable single-loop
anterior cruciate ligament grafts. Arthroscopy 2002;18:589–597.
23. Hamner DL, Brown CH Jr, Steiner ME, et al. Hamstring tendon
grafts for reconstruction of the anterior cruciate ligament: biomechan-
ical evaluation of the use of multiple strands and tensioning techni-
ques. J Bone Joint Surg Am 1999;81A:549–557.
24. Kim DH, Wilson DR, Hecker AT, et al. Twisting and braiding
reduces the tensile strength and stiffness of human hamstring tendon
10
grafts used for anterior cruciate ligament reconstruction. Am J Sports
Med 2003;31:861–867.
25. Millett PJ, Miller BS, Close M, et al. Effects of braiding on tensile
properties of four-strand human hamstring tendon grafts. Am J Sports
Med 2003;31:714–717.
26. Nicklin S, Waller C, Walker P, et al. In vitro structural properties of
braided tendon grafts. Am J Sports Med 2000;28:790–793.
27. Pearsall AW, Hollis JM, Russel GV, et al. A biomechanical compari-
son of three lower extremity tendons for ligamentous reconstruction
about the knee. Arthroscopy 2003;19:1091–1096.
28. Stapleton TR, Curd DT, Baker CL Jr. Initial biomechanical proper-
ties of anterior cruciate ligament reconstruction autografts. J South
Orthop Assoc 1999;8:173–180.
29. Tis JE, Klemme WR, Kirk KL, et al. Braided hamstring tendons for
reconstruction of the anterior cruciate ligament. Am J Sports Med
2002;30:684–688.
30. King W, Mangan D, Endean T, et al. Microbial sterilization and viral
inactivation in soft tissue allografts using novel applications of
high-dose gamma irradiation. Presented at the American Academy
of Orthopaedic Surgeons, March 2004, San Francisco,CA.
31. Harris NL, Smith DA, Lamoreaux L, Purnell M. Central quadriceps
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metric and biomechanical evaluation. Am J Sports Med 1997;5:725–727.
87
11
CHAPTER Why Synthetic Grafts Failed
Don Johnson HISTORY OF SYNTHETIC GRAFTS FOR
ANTERIOR CRUCIATE LIGAMENT
RECONSTRUCTION
Synthetic grafts for anterior cruciate ligament
(ACL) reconstruction had a brief period of pop-
ularity in the mid-1980s. At this time the routine
operation was an open patellar tendon graft with
6 weeks of postoperative immobilization. The
concept of implanting a sterile, off-the-shelf
synthetic ligament with no postoperative immo-
bilization was very appealing. There was no
harvest site morbidity, and the rehabilitation
was very quick. In a very short period, it was
recognized that there was a higher rate of failure
compared with autogenous grafts, an increased
rate of late infection, considerable bone tunnel
enlargement, and significant sterile effusions; in
addition, the grafts were expensive. In a 2005
article reviewing the choices of graft for ACL
reconstruction, West and Harner1 stated that
there is no indication for synthetic ligaments.
TYPES OF SYNTHETIC GRAFTS
During the 1980s, numerous synthetic grafts
were developed. They were used either as aug-
mentation or as a complete prosthetic replace-
ment. One of the original grafts that was
designed as an augmentation device was the
Kennedy ligament augmentation device (LAD).
When this graft was sutured to the autogenous
graft and fixed to the bone at both ends, it
88
stressed shielded the autogenous graft and led to
failure. Gore-Tex was a prosthetic graft, but it
was placed in a nonanatomical position over the
top of the femur. The theory was to avoid the
bending forces at the entrance to a femoral tunnel.
However, because this was a nonanatomical
position, it eventually led to graft failure at the
proximal tunnel (a second tunnel was drilled in
the femur several inches above the joint capsule).
The Styker Dacron graft was a complete replace-
ment graft placed through anatomical tunnels in
the femur and tibia. The ABC graft was a combi-
nation of polyester and carbon fiber, and it was
also placed through bony tunnels. The Ligastic
graft was another polyester graft that evolved to
the LARS graft. This was placed through bony
tunnels and could be used as augmentation or as
a complete prosthetic replacement. The graft
was anchored in the tunnels with metal interfer-
ence screws. The Leeds-Keio was a coventure
between Leeds University in England and Keio
University in Japan. This was a polyester mesh
graft designed to augment the autogenous graft.
It was placed through bony tunnels and anchored
outside the tunnel with staples. The Trevira
ligament was polyester and resembled the LAD
in design, but it was placed in a nonanatomical
position.
CAUSES OF FAILURE OF SYNTHETIC
GRAFTS
The most common cause of failure of synthetic
grafts was the fiber abrasion due to bending forces
 Why Synthetic Grafts Failed 11
over the edge of the bony tunnels (Fig. 11-1). In order to
OTHER PROBLEMS WITH SYNTHETIC GRAFTS
avoid this problem, the Gore-Tex graft was placed over the
top of the femur. This nonanatomical position eventually led The problem of synthetic grafts is not only that they failed,
to graft failure. Carson et al2 have stated that approximately but that there were other significant issues such as biocom-
50% of the failures of ACL reconstruction are due to technical patibility. The carbon fiber grafts produced a black synovitis
error, and the anterior femoral tunnel placement is one of the in the joint. The regional lymph nodes also became enlarged
most common errors. It is likely that many of the failures of with the carbon fiber debris. The Gore-Tex ligament often
synthetic grafts were due to the same causes. The literature produced a very severe sterile synovitis that resembled a
has numerous articles reporting the unacceptable failure rate septic arthritis (Fig. 11-2). This prompted many patients
after synthetic ACL reconstruction. Kumar and Maffuli3 to undergo a repeat arthroscopy to irrigate the joint.
reported on the stress shielding caused by the use of the Biopsy of the synovium showed a foreign body reaction.
LAD. Riel4 reported numerous complications following the The Gore-Tex ligament would occasionally produce a
use of the LAD and concluded that there was no indication ganglion-type reaction at the tibial tunnel that required
for its use. Muren et al5 published results that showed no excision (Fig. 11-3). The bony tunnels would often become
advantage to augmenting the patellar tendon graft with the extremely large, requiring removal of the graft and bony
LAD device. Guidoin et al6 reviewed 69 failed synthetic fiber grafting of the tunnels (Fig. 11-4). The revision ACL
ligament grafts and found that they all failed by fiber abrasion reconstruction would be staged some months later, when
of the textile fiber around the bony tunnel edge. Kock et al7 the bony tunnels had healed.
stated that the Trevira ligament failed due to fiber abrasion
and the nonanatomical position of the graft. Wredmark and
Engstrom8 reviewed the results of the Stryker Dacron graft
and found an 80% failure rate. Engstrom et al9 also compared THE FUTURE
the Leeds-Keio with an autogenous patellar tendon graft and
There is still considerable interest and investigation into
found the failure rate of the synthetic to be unacceptable.
some form of synthetic bioabsorbable scaffold to implant
Andersen et al10 reported unsatisfactory results with the
into the stump of the ACL after injury to the ligament.16
Dacron synthetic graft. Bowyer and Matthews11 reported an
In fact, a type of scaffold that is augmented with growth
unacceptable failure rate with the Gore-Tex ligament graft.
factors holds the most promise for the future. This
Indelicato et al12 reported on the sterile effusions that were
minimally invasive approach to ACL repair would be an
foreign body reactions to the synthetic graft. Woods et al13
improvement over the relatively barbaric procedure of
published the deteriorating results of the Gore-Tex graft with
harvesting of the hamstring tendons to reconstruct the
longer follow-up from 2 to 3 years. Barrett et al14 also reported
ACL.
on the high failure rate (47%) with the Dacron synthetic liga-
ment. This ligament had been placed in a nonanatomical,
over-the-top position. Paulos et al15 reported 13% fair and
42% poor results with the Gore-Tex graft. Looseness
and failure of the graft occurred in 30% of the cases with this
graft placed in the over-the-top position. The 2.7% infection
rate was higher than that reported with autogenous grafts.

FIG. 11-1 The Gore-Tex ligament failure at the tunnel entrance. FIG. 11-2 The severe foreign body reaction to the Gore-Tex ligament.

89
 Anterior Cruciate Ligament Reconstruction
FIG. 11-3 A large ganglion type of foreign body reaction at the tibial
tunnel entrance.
References
1. West RV, Harner CD. Graft selection in anterior cruciate ligament
reconstruction. J Am Acad Orthop Surg 2005;13:197–207.
2. Carson EW, Anisko EM, Restrepo C, et al. Revision anterior cruciate
ligament reconstruction: etiology of failures and clinical results. J Knee
Surg 2004;17:127–132.
3. Kumar K, Maffullli N. The ligament augmentation device: an histori-
cal perspective. Arthroscopy 1999;15:422–432.
4. Riel KA. [Augmented anterior cruciate ligament replacement with the
Kennedy-LAD (ligament augmentation device)—long term outcome].
Zentralbl Chir 1998;123:1014–1018.
5. Muren O, Dahlstedt L, Dalen N. Reconstruction of acute anterior
cruciate ligament injuries: a prospective, randomised study of 40
patients with 7-year follow-up. No advantage of synthetic augmenta-
tion compared to a traditional patellar tendon graft. Arch Orthop
Trauma Surg 2003;123:144–147.
6. Guidoin MF, Marois Y, Bejui J, et al. Analysis of retrieved polymer fiber
based replacements for the ACL. Biomaterials 2000;21:2461–2474.
7. Kock HJ, Sturmer KM, Letsch R, et al. Interface and biocompatibility
of polyethylene terephthalate knee ligament prostheses. A histological
and ultrastructural device retrieval analysis in failed synthetic implants
used for surgical repair of anterior cruciate ligaments. Arch Orthop
Trauma Surg 1994;114:1–7.
8. Wredmark T, Engstrom B. Five-year results of anterior cruciate liga-
ment reconstruction with the Stryker Dacron high-strength ligament.
Knee Surg Sports Traumatol Arthrosc 1993;1:71–75.
9. Engstrom B, Wredmark T, Westblad P. Patellar tendon or
Leeds-Keio graft in the surgical treatment of anterior cruciate
ligament ruptures. Intermediate results. Clin Orthop Relat Res
1993;6:190–197.
90
FIG. 11-4 The tunnel enlargement (arrows) after a Gore-Tex ligament
implantation.
10. Andersen HN, Bruun C, Sondergard-Petersen PE. Reconstruction of
chronic insufficient anterior cruciate ligament in the knee using a syn-
thetic Dacron prosthesis. A prospective study of 57 cases. Am J Sports
Med 1992;20:20–23.
11. Bowyer GW, Matthews SJ. Anterior cruciate ligament reconstruction
using the Gore-Tex ligament. J R Army Med Corps 1991;137:69–75.
12. Indelicato PA, Pascale MS, Huegel MO. Early experience with the
GORE-TEX polytetrafluoroethylene anterior cruciate ligament
prosthesis. Am J Sports Med 1989;17:55–62.
13. Woods GA, Indelicato PA, Prevot TJ. The Gore-Tex anterior cruci-
ate ligament prosthesis. Two versus three year results. Am J Sports Med
1991;19:48–55.
14. Barrett GR, Line LL Jr, Shelton WR, et al. The Dacron ligament
prosthesis in anterior cruciate ligament reconstruction. A four-year
review. Am J Sports Med 1993;21:367–373.
15. Paulos LE, Rosenberg TD, Grewe SR, et al. The GORE-TEX ante-
rior cruciate ligament prosthesis. A long-term followup. Am J Sports
Med 1992;20:246–252.
16. Bourke SL, Kohn J, Dunn MG. Preliminary development of a novel
resorbable synthetic polymer fiber scaffold for anterior cruciate
ligament reconstruction. Tissue Eng 2004;10:43–52.
 PART B AUTOGRAFT HARVEST TECHNIQUES
Hamstring Harvest Technique for Anterior
Cruciate Ligament Reconstruction
ABSTRACT
The use of the hamstring tendons for anterior
cruciate ligament (ACL) reconstruction has
gained in popularity over the past several years.
For those unfamiliar with the harvest technique
of the hamstring tendons, this is often the most
difficult part of the procedure. Several important
steps in the procedure are described to avoid
the common complication of cutting the grafts
short.
TECHNIQUE OF HAMSTRING GRAFT
HARVEST
The graft harvest can be the most difficult aspect
of this operation. Videotapes of this technique by
Fowler, Prodromos, and Fox are available from
the AAOS library.1
The anatomy of the hamstrings has been
described in the literature by Ferrari and Ferrari.2
The strength of the hamstrings after harvest of
the tendons was initially reported by Lipscomb
et al3 to be the same as the opposite side. Since
then, weakness of knee flexion above 90 degrees
of knee flexion has been reported.4 Based on
these reports, one should be cautious in recom­
mending hamstring grafts for sprinters, who
require full, active knee flexion strength. Yasuda
et al5 have described the harvest site morbidity
as minimal. Gobbi et al6 recommend preser­
vation of the gracilis to prevent postoperative
knee flexion weakness. The regeneration of the
12
CHAPTER
hamstring tendons after the harvest was Don Johnson
described by Cross et al.7
SKIN INCISION
The skin incision for hamstring harvest should
be made with the knee flexed in the figure-four
position (Fig. 12-1). An oblique, 3-cm skin
incision is made 5 cm below the joint line over
the proximal edge of the pes anserine. The inci­
sion should start 1 cm medial to the tibial tuber­
cle and then continue posteromedially. The
oblique incision is preferable to the vertical inci­
sion for two reasons: It gives a greater exposure
to the top of the pes anserine, and it also has
less potential to injure the infrapatellar branch
of the saphenous nerve. Plan to harvest the graft
and drill the tibial tunnel through this incision.
Incise the subcutaneous fat, and strip the fat off
the pes anserine with a sponge.
EXPOSURE OF THE TENDON
Identify the superior border of the pes by pal­
pating the superior edge with your finger. Lift
up this superior border, and incise the fascia.
Identify the bursa between the pes and the
medial collateral ligament by placing the tip of
the scissors in the space. With the scissors,
continue the incision medially down the tibia,
in an L-shaped fashion, removing the tendons
distally. Use a Kocher to apply traction to this
91
 Anterior Cruciate Ligament Reconstruction

TENDON RELEASE
Free the distal end of the tendon with the scissors. Make sure
you get the full length distally. Grasp it with a Kocher, and
pull it firmly into the incision. Many of the bands can be
released with the traction and by blunt finger dissection.
The main band that goes to the medial head of the gastrocne­
mius will usually have to be cut with the scissors (Fig. 12-3).
Pull firmly on the tendon, and cut away from the tendon (to
avoid cutting the tendon with the scissors) (Fig. 12-4). The
tendon should not retract proximally if all the bands are cut.
When the tendon is pulled distally, there is no dimpling
posteriorly over the gastrocnemius.

STRIPPING OF THE TENDON

FIG.12-1 The oblique anteromedial incision for hamstring harvest.
Advance the tendon stripper up over the tendon to free it from
the muscle proximally (Fig. 12-5). The key to a successful

top corner. Turn the pes down to look on the underside for
the most inferior tendon, the semitendinosus (Fig. 12-2).
Lift the tendon up with the tip of the scissors, and grasp it
with a Kocher. Lift up the gracilis, and grasp it in a similar
fashion with a Kocher. Divide the conjoined tendon
between the semitendinosus and the gracilis.

FIG. 12-3 The bands from the tendon to the gastrocnemius are identified
and cut.

FIG. 12-2 The pes is turned down to visualize the tendons on the
underside. FIG. 12-4 The scissors are used to cut the bands to the gastrocnemius.

92

FIG. 12-5 The tendon stripper is pushed up the tendon to remove it
proximally from the muscle.
harvest is to keep tension on the distal end. This will
prevent the tendon from folding over and being cut off
short (Fig. 12-6). Make sure that the tendon stripper is
heading up the thigh in the same direction as the tendon.
There is often resistance at the muscle tendon junction, and
the stripper should be rotated to slip it up along the surface
of the muscle. This gives extra length. The total length is
usually 28 to 30 cm. Strip the gracilis tendon in a similar
fashion.
PREPARATION OF THE GRAFT
Preparation of the Four-Bundle
Semitendinosus and Gracilis Graft
Take the graft to the graft master on the back table. Lay out,
measure, and cut the graft to 22 cm. Remove the muscle
with the periosteal elevator. Loop the two tendons over a
FIG. 12-6 One small band may kink the tendon, and the stripper will cut
the tendon off short.
Hamstring Harvest Technique for Anterior Cruciate Ligament Reconstruction 12
FIG. 12-7 The two tendons are looped over a suture.
#5 braided nonabsorbable suture to produce an 11-cm graft
(Fig. 12-7). With this length, 2.5 cm is in the femur, 2.5 cm
is intraarticular, and 5 cm is in the tibial tunnel. This
ensures a small portion of the graft is at the cortex of the
tibia for fixation with the screw. Whipstitch the individual
ends of the tendons with a #2 nonabsorbable suture for
a distance of 4 cm (Fig. 12-8). Make sure that each
tendon has a suture in it. This allows you to tension each
bundle of the composite graft. The completed four-bundle
graft should be 11 cm in length. This four-bundle graft will
be three times the strength of a single strand of semitendi­
nosus, assuming all bundles are equally tensioned.8 Incor­
porate the graft into the bone tunnel by Sharpey fibers.9
This will take about 10 to 12 weeks to heal. This graft will
have at least 2.5 cm of graft in each tunnel. The depth of
graft in the tunnel can be determined by the suture marks
at each end.
Graft Sizing
Measure the size of the composite graft to the nearest half
centimeter (7.5 mm and 8 mm are the most common sizes)
(Fig. 12-9). Drill the tunnels according to the size of the
tendon.
FIG. 12-8 The tendon ends are whipstitched individually.
93
 Anterior Cruciate Ligament Reconstruction
FIG. 12-9 Sizing of the graft.
TIPS FOR HARVESTING THE HAMSTRING GRAFTS
TO AVOID COMPLICATIONS
� Make sure that the incision is in the correct position to
easily access the tendons. The landmarks are found with
the knee in the figure-four position. The incision should
be oblique, running from 2 cm medial to the tibial
tubercle and 5 cm below the joint line (3 fingerbreadths)
and directly along the course of the tendons.
� After making the skin incision and stripping the fat off
the fascia, palpate the tendons and incise the fascia on the
superior surface.
� Use the tip of the Metz to fall into the pes bursa. This
ensures that you are in the correct plane and will not
dissect under the medial collateral ligament.
� Use the scissors or knife to remove the tendon attachment
to the tibia. Turn this flap over to visualize the two
tendons. Split the conjoined tendon distally.
� Now pull the tendon into the wound to show the bands
that attach to the gastrocnemius. It is preferable to pull
94
the tendons into the wound to avoid pushing the scissors
proximally and injuring the saphenous nerve.
� After the bands have been divided and there is no
dimpling of the skin when the tendon is tugged, you can
proceed to use the stripper to remove 22 to 25 cm of
tendon.
References
1. www.aaos.org.
2. Ferrari JD, Ferrari DA. The semitendinosus: anatomic considerations
in tendon harvesting. Orthop Rev 1991;20:1085–1088.
3. Lipscomb AB, Johnston RK, Snyder RB, et al. Evaluation of
hamstring strength following use of semitendinosus and gracilis
tendons to reconstruct the anterior cruciate ligament. Am J Sports Med
1982;10:340–342.
4. Tashiro T, Kurosawa H, Kawakami A, et al. Influence of medial
hamstring tendon harvest on knee flexor strength after anterior cruciate
ligament reconstruction. A detailed evaluation with comparison of
single- and double-tendon harvest. Am J Sports Med 2003;31:522–529.
5. Yasuda K, Tsujino J, Ohkoshi Y, et al. Graft site morbidity with
autogenous semitendinosus and gracilis tendons. Am J Sports Med
1995;23:706–714.
6. Gobbi A, Domzalski M, Pascual J, et al. Hamstring anterior cruciate
ligament reconstruction: is it necessary to sacrifice the gracilis? Arthros­
copy 2005;21:275–280.
7. Cross MJ, Roger G, Kujawa P, et al. Regeneration of the semitendino­
sus and gracilis tendons following their transection for repair of the
anterior cruciate ligament. Am J Sports Med 1992;20:221–223.
8. Hamner DLB, Steiner CH Jr, Hecker ME, et al. Hamstring tendon
grafts for reconstruction of the anterior cruciate ligament: biomechani­
cal evaluation of the use of multiple strands and tensioning techniques.
J Bone Joint Surg Am 1999;81:549–557.
9. Weiler A, Hoffmann RF, Bail HJ, et al. Tendon healing in a bone tun­
nel. Part II: histologic analysis after biodegradable interference fit fixa­
tion in a model of anterior cruciate ligament reconstruction in sheep.
Arthroscopy 2002;18:124–135.
 Posterior Mini-Incision Hamstring Harvest
Approach for Anterior Cruciate Ligament
Reconstruction*
OVERVIEW
Hamstring (HS) use for anterior cruciate liga-
ment reconstruction (ACLR) has increased
greatly in the past 5 years as improved fixation
techniques have allowed stability rates to meet
or exceed those of bone–patellar tendon–bone
(BPTB) grafts.1 It has been said that the harvest
is the most difficult part of HS ACLR2 and
may require a learning curve of roughly 50
procedures.3
The primary difficulty is that the interten-
dinous cross-connections of the semitendinosus
(ST) and gracilis (Gr) must be sectioned
before the tendon stripper is used to harvest
the tendons. If they are not, the tendons can be
cut too short to use, necessitating an unplan-
ned switch to a different graft. These cross-
connections, however, are significantly posterior
to the traditional anterior harvest incision,
requiring often-difficult retraction and dissection
to reach. The primary benefit of the posterior
approach is that it puts the incision in the area
of the cross-connections, thus facilitating their
visualization and sectioning.
The second benefit of the technique is that
it allows easier location and identification of the
ST and Gr in the posterior incision, where they
are separate from each other and easy to find. In
the area of the traditional anterior approach, the
tendons exist as a single insertional structure,
which requires posterior dissection for positive
*
The principles and technique described in this chapter are
presented in greater detail in the DVD that accompanies this
textbook.
13
CHAPTER
identification of individual tendons. This is Chadwick C. Prodromos
made more difficult by the close apposition of
the superficial fascial sheath anteriorly, whereas
posteriorly the fascia is separated from the
tendons by fat. The anterior incision, when used
in conjunction with the posterior mini-incision,
is then used only for tibial tunnel drilling and
tibial fixation. It can thus be made much smaller
than in the traditional anterior technique, only
about 1 inch in length.
The author has used this technique con-
tinuously without problem for 15 years since
devising it after 6 years of experience with the
traditional anterior approach.
ANATOMY
The accessory ST tendon is the primary structure
leading to premature amputation of the ST
tendon after tendon harvesting. This structure is
not described in any standard anatomy texts.
However, several papers have described it.4–6 It is
present in about 70% of patients. Other cross-
connections exist variably from the ST and Gr
tendons. In some patients they are thin and will
be easily cut with a tendon stripper. However,
the accessory ST in particular can be almost as
thick as the main trunk of the ST. Especially in
these cases, the tendon stripper can easily sever
the main trunk of the ST, rendering it too short
to use. The variability of the anatomy is such that
it is difficult to devise a consistent plan for freeing
the tendon using the traditional approach, except
to run a scissors along both sides of both tendons.
95
 Anterior Cruciate Ligament Reconstruction
Branches of the saphenous nerve, and indeed its main trunk,
are very close by, and saphenous neurapraxia is very common
after these dissections. The takeoff of the accessory ST was
shown in our studies to be an average of 5 to 6 cm posterior
to the tibial crest. Although orthopaedic surgeons rarely oper-
ate posteriorly and may be apprehensive about a posterior
approach, the posterior approach does not subject neurovascu-
lar structures to significant risk. Our cadaver studies showed
that the closest neurovascular structure was the popliteal
artery, but in eight specimens it was always at least 2.9 cm
away from the ST tendon. It was also shielded from the ST
tendon by the semimembranosus muscle.
SURGICAL TECHNIQUE
Patient Positioning
The patient is positioned supine. We use a lateral post
rather than a circumferential leg holder, but the latter can
be used if the surgeon desires.
Making the Posterior Skin Incision
The ST is the most prominent tendinous structure in the
popliteal fossa and runs just medially to the midline. The
affected lower extremity is externally rotated, and the knee
is flexed about 30 degrees. The surgeon bends over the leg
Sartorius
Semitendinosus
Semimembranosus
Gracilis
Mini-incision
96
to see posteromedially. The incision should be made directly
over it in the popliteal fossa, shading slightly anteromedially
(Fig. 13-1). If the ST cannot be felt, the incision can be put
into the soft spot in the skin just medial to the midline. The
location of this incision is not critical because the tendon
can always be found by moving the highly mobile skin in
this area. The incision should be made 3 cm in length
initially but need only be 2 cm in length once experience is
gained. It should be put within or parallel to a skin crease.
After the dermis is incised with a #15 blade, the subcutane-
ous tissue is opened by spreading with Metzenbaum
scissors.
Finding the Semitendinosus
An index finger should probe the incision, fishing the tendon
out bluntly. If it is not easily found in this manner, two Senne
retractors can be used to open the incision, and the tendon can
be found under direct visualization. Once the tendon is identi-
fied, a right-angle clamp is passed around it. A ¼-inch Penrose
drain then captures it and is loosely clamped (Fig. 13-2).
Finding the Semitendinosus Insertion
Once the tendon is identified, the surgeon runs his or her
index finger under it to its tibial insertion. This may necessi-
tate opening the fascia posteriorly slightly with Metzenbaum
scissors. At the insertion the surgeon can verify that he or
Tibial nerve
Popliteal vein
Popliteal artery
FIG. 13-1 The semitendinosus (ST)
and gracilis (Gr) tendons are shown
posteriorly, where they are separate
from each other and easy to identify.
 Posterior Mini-Incision Hamstring Harvest Approach for Anterior Cruciate Ligament Reconstruction
FIG. 13-2 The semitendinosus (ST) tendon is isolated in the posterior
mini-incision.
she indeed has the ST and not the Gr, which is sometimes
found first. The ST is the most distal tendinous insertion in
the pes. If the Gr is found first, the surgeon can find the inser-
tion of the ST adjacent to the insertion of the Gr. The surgeon
can then pull his or her finger back to the posterior incision to
find the ST there.
Making the Anterior Incision
The skin is tented just anterior to the posteromedial tibial
border by the index finger inserted in the posterior incision
under the ST. The surgeon makes a 2-cm longitudinal inci-
sion here with a #15 blade. This area is then opened with
Metz scissors, and the superficial fascia is incised carefully
to avoid scoring the tendons.
Identifying the Semitendinosus in the
Anterior Incision
A right-angle clamp is inserted in the anterior incision and
passed around the ST tendon to grasp a ¼-inch Penrose
drain (Fig. 13-3). The surgeon's other index finger is still
under the tendon and guides the clamp. The surgeon
may insert the short end of an Army-Navy retractor and
identify the tendon by direct visualization. A ¼-inch
Penrose is then passed around the tendon and clamped
with a right angle.
Identifying the Gracilis
Using the ST as a guide, the Gr can be found either in the
posterior or anterior incision (Fig. 13-4) either before or
after the ST is stripped proximally. If the ST is 30 cm or
longer, we do not harvest the Gr but rather use a
four-strand ST graft.
13
FIG. 13-3 The semitendinosus (ST) is isolated in the anterior mini-incision.
FIG. 13-4 The gracilis (arrow) is isolated in the anterior mini-incision.
Harvesting the Semitendinosus and
Sectioning the Accessory Semitendinosus
A small, closed corkscrew tendon stripper is passed around the
ST near its common insertion with the Gr without disrupting
it. It is gently but firmly passed proximally with a firm rotary,
back-and-forth motion. Resistance will be felt when the strip-
per encounters the accessory ST (Fig. 13-5). At this point the
stripper should be carefully advanced another 1 or 2 cm, tak-
ing care not to apply excessive force. Two Senne rakes are then
placed in the posterior incision, and the mobile skin is moved
anteriorly over the head and neck of the tendon stripper to
expose them while maintaining firm pressure on the stripper.
The surgeon uses a forceps and Metz scissors to dissect the
filmy tissue off the stripper neck. Sitting directly on the neck
of the tendon stripper will be the accessory ST, with the main
trunk of the tendon extending outward from the corkscrew
(Fig. 13-6). This accessory ST should be cut with either a
Metz scissors or a #15 blade. The stripper will now slide freely
97
 Anterior Cruciate Ligament Reconstruction
Sartorius
Gracilis
Semimembranosus
sling
Main
semitendinosus
Incision
FIG. 13-6 The accessory semitendinosus (ST) sits on the neck of the
tendon stripper outside of the posterior incision, where it can be easily
sectioned under clear visualization.
toward the proximal. It should be pushed until the tendon is
freed proximally while countertension is maintained with a
¼-inch Penrose or index finger near its insertion. Once
freed, the ST is delivered out the anterior incision.
What if the Tendon Stripper Gets Caught in
the Thigh?
This can happen at the semimembranosus sling or at the
fanning-out of the ST. If firm resistance is met, the surgeon
98
Incision
Accessory
semitendinosus
FIG. 13-5 The tendon stripper is
shown as it is about to deliver the
accessory semitendinosus cross-
connection out of the posterior mini-
incision.
need only slide his or her index finger along the tendon with
the tendon stripper via the posterior incision. The surgeon
can guide it so that it does not get caught up on fascia but rather
glides along the tendon. The surgeon can also effectively dilate
the path the tendon stripper takes proximally, allowing it to
pass further until the full length of the tendon is harvested.
Freeing the Tendon Distally
With the two (or one) tendons delivered out the anterior
incision, the periosteum is scored parallel and to the deep
side of the tendon(s) (Fig. 13-7). An additional 2 cm of
periosteum can then be harvested in line with the insertion,
essentially prolonging it with tough tissue that also has the
benefit of the growth factors found on its cambium layer
for intratunnel fixation and ingrowth.
Graft Preparation
The tendon(s) is given to the assistant at the back table for
cleaning and measuring.
Time of Harvest
The harvest can usually be accomplished in less than 10
minutes. However, occasionally the harvest will be a little
 Posterior Mini-Incision Hamstring Harvest Approach for Anterior Cruciate Ligament Reconstruction
FIG. 13-7 The harvested semitendinosus/gracilis (ST/Gr) tendon is seen
with periosteum extending the common insertion onto the tibia.
more difficult. In these cases the surgeon should take time
to find and free the tendons safely. The greatest virtue of
this technique is that the bi-incisional access allows the sur-
geon to accomplish even the most difficult harvests safely.
However, patience and more time are required for some
harvests, and the surgeon should not be in a rush if the har-
vest is problematic. It is still possible to cut the tendon short
if the surgeon attempts to force rather than finesse a difficult
harvest.
HARVEST PROBLEMS WITH THE TRADITIONAL
APPROACH AND SOLUTIONS USING THE
COMBINED POSTERIOR/ANTERIOR
MINI-INCISION APPROACH
Problem 1: Premature Tendon Amputation
The chief danger in the harvest is that the intertendinous
cross-connections, which variably occur, will not be ade-
quately sectioned prior to harvesting with the tendon strip-
per as described earlier, resulting in premature tendon
amputation. These cross-connections can be difficult to
visualize from the anterior approach.
Solution
The posterior mini-incision facilitates identification of the
intertendinous cross-connections by putting the incision
where these structures exist—posteromedially. The tendon
stripper delivers the cross-connections out of this incision,
where they can be sectioned under direct vision, instead of
in the depths of the anterior incision, where both they and
neurovascular structures are difficult to see.
13
Problem 2: Tendon Identification
When only an anterior incision is used, its location must be
estimated from the tibial tubercle. When the fascia is lifted,
it can be difficult to clearly identify which pes tendon is
which or even where the tendon starts and the fascia
ends—particularly in large patients—because the ST and
Gr insert as a common tendon. As they course distally, they
cease being separate structures at roughly the posteromedial
tibial border. Definite verification involves posterior dissec-
tion to this point or beyond where the anatomy is clearer.
This can be time consuming and also increases the risk of
saphenous neurapraxia.
Solution
The pes tendons exist as separate structures roughly 1.5 cm
apart posteriorly. The ST can usually be easily palpated pos-
teriorly, which is not the case anteriorly. A small posterior
incision placed directly over the ST and slightly anterome-
dial to it allows ready identification of the ST. Running
an index finger under this tendon precisely allows placement
of the anterior incision over the tendon insertion by tenting
the skin at this point.
Problem 3: Hang-Up of the Tendon Stripper
in the Distal Thigh at the Fanning-Out of
the Semitendinosus or Semimembranosus
Sling
Even if the cross-connections are cut, the tendon stripper
can still cut the tendon short at this point. This point is
too high up in the thigh to be reached from a traditional
anterior approach.
Solution
If marked resistance to the tendon stripper is met in the
thigh, an index finger can be inserted up the thigh through
the posterior incision to free it, after which the stripper will
easily pass.
Problem 4: Saphenous Nerve Trauma and
Numbness
Numbness has been shown to occur in more than half of
patients after ACL surgery.7,8 Most of the time it is not sig-
nificantly bothersome to the patient. However, it is bother-
some to occasional patients. In addition, there is evidence
that stiffness and complex regional pain syndrome (formerly
reflex sympathetic dystrophy) are more common with
significant nerve trauma after knee surgery.
99
 Anterior Cruciate Ligament Reconstruction
Solution
The posterior mini-incision diminishes saphenous nerve
trauma in three ways. First, the posterior mini-incision is pos-
terior to the saphenous nerve, where there is no danger of
trauma to it or its branches. Second, the anterior incision is
made much smaller because the posterior incision allows it
to be precisely placed. This decreases the chances that a
saphenous branch such as the infrapatellar branch will
be cut. Third, because the tendon stripper delivers the cross-
connections externally out of the posterior incision, there is
no need to dissect and retract anteriorly. This diminishes
trauma to the saphenous nerve and its branches from retrac-
tion and dissection. We have found that if only the short
end of an Army-Navy is used for retraction, and if very little
retraction is done, the incidence of numbness is much less
than if longer retractors are used or vigorous retraction is
performed.
Problem 5: Cosmesis
Cosmesis is not generally a significant problem, but our
studies have shown4 that cosmesis does matter to many
patients, especially to females.
Solution
The posterior incision is hidden and becomes essentially
invisible. The anterior incision is much smaller, usually only
1 inch or smaller, and it is the only incision the patient sees.
It also becomes very hard to detect by 1 year after surgery.
Problem 6: Harvest in Large Patients
It has been suggested that allografts are a better choice than
HS in large or obese patients because of the difficulty of the
harvest.
Solution
The presence of a posterior incision removes the difficulty in
finding, identifying, and freeing the tendon. It is more diffi-
cult than in a slender person but can always be accomplished.
The usually 1-inch incisions should be made a little larger, but
no other technical modifications are necessary.
CLINICAL EXPERIENCE
We have used this technique continuously and exclusively
since 1991. Harvested ST tendons tend to vary between
24 and 34 cm in length. Depending on ST length, we will
either perform a 4ST or 2ST/2Gr graft. Roughly 85% of
our grafts are 2ST/2Gr. We have never had tendons cut
100
too short to produce a four-strand graft. We have had no
complications referable to this approach, neurovascular or
otherwise. In addition to essentially eliminating the risk of
cutting tendons short, use of this approach has also reduced
harvest time. Numbness was reduced initially with the short
incision and has now been almost completely eliminated by
the minimal retraction technique. Cosmesis and patient
satisfaction have been excellent.
WHO SHOULD USE THIS TECHNIQUE?
This technique is particularly desirable for the new or occa-
sional HS harvester and has proven valuable to those in
training programs. However, it will also facilitate the harvest
and improve cosmesis for most experienced HS surgeons
who now use the traditional approach—as it did for the
author, who began to use it after fellowship training in ham-
string ACLR and 6 years of practice performing the stan-
dard technique. Initially the incisions can be made larger.
Cosmesis will still be better than with the traditional
approach. The incisions can be reduced with experience if
the surgeon wishes. 4HS grafts have now been shown to
have excellent stability rates1 (see Chapter 69), and the har-
vest has been shown to be the chief obstacle to use of
the technique. With this approach the surgeon can accom-
plish the harvest safely and reliably so that harvesting is no
longer a significant factor in graft choice.
References
1. Prodromos CC, Joyce BT, Shi KS, et al. A meta-analysis of stability
after anterior cruciate ligament reconstruction as a function of ham-
string versus patellar tendon graft and fixation type. Arthroscopy
2005;21:1202–1208.
2. Williams RJ, III, Hyman J, Petrigliano F, et al. Anterior cruciate liga-
ment reconstruction with a four-strand hamstring tendon autograft.
J Bone Joint Surg Am 2004;86A:225–232.
3. Howell SM. Principles of hamstring fixation. In: ACL reconstruction:
from graft choices and fixation to single and dual tunnel techniques.
Instruction course presented at the meeting of the Arthroscopy Associ-
ation of North America, Vancouver, BC, Canada, May 2005.
4. Prodromos CC, Han YS, Keller BL, et al. Posterior mini-incision
technique for hamstring anterior cruciate ligament reconstruction graft
harvest. Arthroscopy 2005;21:130–137.
5. Ferrari JD, Ferrari DA. The semitendinosus: anatomic considerations
in tendon harvesting. Orthop Rev 1991;20:1085–1088.
6. Pagnani MJ, Warner JJ, O'Brien SJ, et al. Anatomic considerations in
harvesting the semitendinosus and gracilis tendons and a technique of
harvest. Am J Sports Med 1993;21:565–571.
7. Portland GH, Martin D, Keene G, et al. Injury to the infrapatellar
branch of the saphenous nerve in anterior cruciate ligament reconstruc-
tion: comparison of horizontal versus vertical harvest site incisions.
Arthroscopy 2005;21:281–285.
8. Spicer DDM, Blagg SE, Unwin AJ, et al. Anterior knee symptoms
after four-strand hamstring tendon anterior cruciate ligament recon-
struction. Knee Surg Sports Traumatol Arthrosc 2000;8:286–289.
 Technique for Harvesting a Mid-Third
Patella Tendon Graft for Anterior Cruciate
Ligament Reconstruction
INTRODUCTION
The middle third of the patella tendon (bone–
tendon–bone) is frequently used as a graft to
replace a torn anterior cruciate ligament (ACL).
A segment of bone is taken from the tibial tuber­
cle. It is left attached to the distal end of the
patella tendon. A segment of bone is taken from
the inferior pole of the patella. It is left attached
to the proximal end of the tendon. The graft is
reversed and is pulled upward through the tibial
tunnel, across the joint, and into the femoral tun­
nel. The leading end of the graft (the bone plug
that was taken from the tibia) is fixed to the femur
using an interference screw. The trailing end of
the graft (the patella portion) is fixed in the tibial
tunnel using an interference screw. Extra pieces
of bone that were trimmed from the bone plugs
are placed in the patella defect. The edges of the
patella tendon are closed.
SKIN INCISION
A vertical skin incision is made medial to the tib­
ial tubercle approximately 0.5 cm medial to the
medial edge of the patella tendon (Fig. 14-1).
The upper end of the incision begins near the
level of the joint line. The incision is extended
distally to the level of the lower end of the tibial
tubercle, approximately 6 to 8 cm below the joint
line. Do not place this vertical incision in the
midline of the knee: this leaves an unsightly scar,
and it is difficult to reach the tibial tunnel
from this midline position. This anteromedial
14
CHAPTER
incision is placed distally, which is necessary to Bertram Zarins
allow positioning of the tibial guide and drilling
of the tibial tunnel (Fig. 14-2). It is not necessary
to extend the incision very far proximally beyond
the level of the joint; when the knee is extended
and a single spike retractor is placed at the
superior pole of the patella, the patella is pushed
distally. The patella can thus be reached through
this short, distally placed incision.
Bupivacaine 0.5% with epinephrine
1:200,000 is infiltrated subcutaneously along
the edges of the incision. Dissection is carried
out through the superficial fascial layer to reach
the deep fascial layer.
EXPOSURE
Incise the deep fascial layer lengthwise over the
center of the underlying patella tendon. This
deep fascial layer is thin but becomes even thinner
over the tibial tubercle. Divide the deep fascial
layer proximally to the level of the upper portion
of the patella (Fig. 14-3). This exposes the under­
lying patella, patella tendon, and tibial tuberosity.
Enlarge the prepatella bursa to gain access to the
patella.
TAKING THE GRAFT
The average width of the patella tendon is about
30 mm. An approximately 10-cm width of ten­
don, or one-third, is taken as a graft. A ⅜-inch
osteotome (which is about 9 mm wide) can be
101
 Anterior Cruciate Ligament Reconstruction
FIG. 14-1 The skin incision is made on the medial aspect of the right knee.
The incision begins at the joint line and extends distally about 6 to 8 cm.
Do not place the incision over the center of the tibial tubercle.
FIG. 14-2 The skin incision has been placed distally and medially to
allow proper placement of the tibial drill guide.
used as a template for judging the width of the graft and
bone plugs.
An osteotome 3 cm in length is used to make two par­
allel vertical cuts in the tibial tubercle to fashion a 9-cm-wide
bone plug (Fig. 14-4). The ⅜-inch osteotome is used to
make a transverse cut in the bone at the level of the distal
end of the graft. The resulting bone plug is about 30 mm in
length. Use the wide osteotome to extend the cuts in the tibial
tubercle proximal to the tibial tubercle almost to the level of
the joint; otherwise, the plug might crack proximally near
the tendon-bone junction. Drill a single small hole in the
distal end of the tibial bone plug, slightly less than 1 cm from
102
FIG. 14-3 The deep fascia is incised over the center of the tibial
tubercle, patella tendon, and patella.
FIG. 14-4 A 3-cm-wide osteotome is used to make two parallel cuts in
the tibial tubercle to fashion a 9-mm-wide bone plug.
the end of the tibial bone plug (Fig. 14-5). Pass a single
suture of #5 Fiberwire through the tibial bone plug.
Apply traction to the tibial bone plug, and slightly
incise the superficial surface of the patellar tendon in line
with the tibial tubercle bone plug. Use your finger to sepa­
rate the edges of the patella tendon graft from the adjacent
patella tendon (Fig. 14-6). This blunt dissection avoids
cutting fibers of the patella tendon graft.
 Technique for Harvesting a Mid-Third Patella Tendon Graft for Anterior Cruciate Ligament Reconstruction 14

FIG. 14-7 The single spike retractor has been placed at the superior pole
of the patella and is used to lever the patella distally. The cutting current of
the electrocoagulation devices is used to mark the proposed bone cut.

FIG. 14-5 A hole is drilled in the bone plug that was taken from the
tibial tubercle.
proposed cuts in the patella using electrocautery, which will
achieve an 11-mm-wide plug that will be about 30 mm long
(Fig. 14-8). Drill the corners of the graft to create round
stress risers. Drill two small holes in the patella bone plug
for later passage of sutures. Make the remaining cuts in
the patella using the fine reciprocating saw to a depth of
1 cm (Fig. 14-9).
To loosen the bone plug from the patella, use a ¼­
inch-wide curved osteotome inserted into the kerf at the
superior end of the plug (Fig. 14-10). Never insert the
osteotome into the medial or lateral kerfs along the edges
of the patella bone plug, which will likely fracture the
patella. Apply tension to the distal end of the graft, and

FIG. 14-6 The patella tendon is split in line with its fibers using a finger.

Insert a single spike retractor under the proximal edge

of the skin incision. The prepatella bursa provides space to
reach the superior pole of the patella. The spike of the
retractor is set into the quadriceps tendon at the superior
pole of the patella and is used to lever the patella distally
(Fig. 14-7).
Using the cutting current of the cautery device, mark
the line of the proposed first cut in the patella (see
Fig. 14-7). Use a fine reciprocating saw to cut a slot in the
patella for a length of about 25 mm and to a depth of
1 cm. Insert a metal ruler into this kerf (the cut made by a
FIG. 14-8 A ruler has been placed in the kerf. A ⅜-inch-wide osteotome
saw) and use it as a guide from which to measure. Using is used as a template, and electrocautery is used to mark out a bone
the ⅜-inch-wide osteotome as a template, mark the plug 11 mm wide and 25 mm long.

103
 Anterior Cruciate Ligament Reconstruction
FIG. 14-9 After the corners of the graft have been drilled, a fine
reciprocating saw is used to make superior and then lateral cuts in the
bone plug.
FIG. 14-10 A ¼-inch curved osteotome loosens the upper end of the
bone plug. Never put the osteotome into the medial or lateral kerfs to
prevent fracturing the patella.
use the ¼-inch-wide curved osteotome from below (starting
at the inferior pole of the patella) to lift the patella bone
plug from its bed (Fig. 14-11).
FASHIONING THE GRAFT
Use a bone cutter or rongeur to remove excess bone from
both bone plugs to fashion a 9-mm-diameter bone plug
from the tibial tubercle and an 11-mm-diameter bone
plug from the patella (Fig. 14-12). Use a bone sizer to com­
press any excess cancellous bone. Do not use the bone
sizer to compress cortical bone; doing so may fracture the
patella. Place the extra pieces of bone into the defect in
104
FIG. 14-11 A ¼-inch curved osteotome is used from below to create a 1­
cm-thick bone plug from the patella.
FIG. 14-12 A sizer is used to fashion an 11-mm-diameter bone plug
that was taken from the patella (the trailing end of the graft).
the patella. Close the deep fascial layer over the patella to
prevent the bone pieces from falling out. Leave the edges
of the patella tendon defect open for the time being.
At a side table, fashion the graft. To prevent dropping
the graft, keep the suture that is attached to the graft
wrapped around your little finger. Pass #5 Fiberwire sutures
through each of the two holes and clamp the ends of
the sutures. Use a 2–0 Vicryl running suture to tubularize the
tendon at the end attached to the tibial bone plug (which
will become the leading end of the graft) (Fig. 14-13). This
will make it easier to place the interference screw into the
femoral tunnel. Measure the total length of the graft and
the lengths of the bone plugs. Use a colored marker pen
to mark the bone-tendon junctions of the graft. Also mark
the tendon side of the trailing end of the patella bone plug;
this will aid in positioning the tibial interference screw on
the opposite (cancellous) side of the plug (Fig. 14-14).
 Technique for Harvesting a Mid-Third Patella Tendon Graft for Anterior Cruciate Ligament Reconstruction 14

FIG. 14-14 The mid-third patella tendon graft is about 10 cm long. The
graft incorporates (in continuity) segments of bone from the inferior pole of
the patella (9 � 30 mm) and from the tibial tubercle (11 � 25 mm). The
bone-tendon junctions have been marked. The trailing end of the graft
(tendon side) is marked.

FIG. 14-13 The tendon of the leading edge of the graft is tubularized to
allow easy placement of the interference screw in the femoral tunnel.
The final length of the graft is about 10 cm long. The
leading end of the graft (taken from the tibial tubercle) is
9 mm in diameter and about 30 mm long. The trailing
end of the graft (formerly patella) is 11 mm in diameter
and about 25 mm long.
CLOSURE
After the graft has been fixed, flex the knee to 90 degrees to
achieve equal tension on the medial and lateral thirds of the
patella tendon. Close the defect in the patella tendon using
interrupted #0 Vicryl figure-eight sutures. Close the deep
fascial layer.

105
15
CHAPTER
The Central Quadriceps Free Tendon for
Anterior Cruciate Ligament Reconstruction
John P. Fulkerson INTRODUCTION
The central quadriceps has been used for ante-
rior cruciate ligament reconstruction (ACLR)
for more than 25 years.1,2 Stability results are
similar to those with other autograft alterna-
tives, but patients experience less pain and reach
rehabilitation landmarks sooner.3 Staubli et al4,5
have studied the anatomy and biomechanical
properties of the quadriceps tendon. We
became interested in this ACL graft in the early
1990s, first using it with bone6 but later discov-
ering that it is a desirable free tendon graft
option7 for ACLR. We wanted to avoid the risk
of postoperative problems noted with bone–ten-
don–bone–patella tendon graft harvest,8,9
were concerned about subtle weakness after
taking out the medial hamstring tendons for
ACLR in young athletes,10 and continue to
worry about the possibility of prions in allograft
tissue. We wanted to avoid these risks by using
the central quadriceps free tendon (CQFT) for
our ACLR. We confirmed and later reported
the strength of the quadriceps tendon after har-
vesting the graft.11 Our experience has
remained very positive as we begin our 10th year
with the CQFT graft. Also, patients frequently
come into our office impressed with how
little postoperative pain and difficulty they
have compared with bone–tendon–bone and
hamstring ACLR patients they encounter in
physical therapy, as noted by Joseph et al3
in their short-term recovery study of ACLR
patients.
106
TECHNIQUE
We use the CQFT graft in all patients except
those who specifically request another graft
type, usually an allograft.
To harvest the CQFT, make a short 1.5- to
2-inch incision from the mid proximal patella
upward (Fig. 15-1), and retract to view the quad-
riceps tendon. Retract slightly medially and note
the vastus medialis obliquus (VMO). The graft
should be taken preferentially from the thicker
medial part of the quadriceps tendon but started
proximally by retracting upward to the proximal
VMO where the first incision is placed. Use a
#10 scalpel blade and draw it distally at a 6- to
7-mm depth (just slightly less than the breadth
of a #10 blade). The medial border of the graft
then will usually be about 5 to 8 mm from the
VMO at the level of the proximal patella.
Place the second incision 9 to 11 mm lat-
eral to the first at the level of the proximal
patella and extend it proximally, keeping the
blade at 90 degrees to the quadriceps tendon
and at a 6- to 7-mm depth (the quadriceps ten-
don is about 9 mm thick).
After placing these incisions, place the tip
of a hemostat at the desired depth beneath the
CQFT, and spread the hemostat to separate
the CQFT posterior fibers within the substance
of the quadriceps tendon. This leaves a thin 1 mm
of posterior quadriceps tendon attached to the
synovium of the suprapatellar pouch. If the joint
has been entered, the defect is then easily closed
with this remaining tissue and synovium.
 The Central Quadriceps Free Tendon for Anterior Cruciate Ligament Reconstruction
FIG. 15-1 Exposure for quadriceps tendon graft harvest.
Properly done, you now have a piece of tendon that is
about 6 to 7 mm thick and includes portions of the rectus
and intermedius tendons. Note that there is a cleavage plane
between these two components of the quadriceps tendon.
Keep spreading at the desired depth, and then dissect
the tip of the graft at its insertion into the patella and
release it without cutting any of the surrounding quadriceps
tendon.
Grasp the released end of the quadriceps tendon with
a uterine T clamp, and further dissect it proximally using a
combination of blunt stripping and careful sharp dissection.
We usually place two whipstitches12 with at least one Fiber-
wire (Arthrex, Naples, FL) in the released end and use this
for traction during the dissection.
Release the CQFT graft proximally at 7 to 8 cm from the
distal end. May scissors work best in our hands (Fig. 15-2).
TROUBLESHOOTING CENTRAL QUADRICEPS
FREE TENDON HARVEST
At first, harvesting the CQFT graft can seem a bit daunting
until the surgeon becomes familiar with the anatomy, depth,
and extent of the tendon. It is a very large, thick, and
forgiving graft source. The quadriceps tendon is thickest
near the VMO, so the harvest should be as close to the
VMO as possible while avoiding all but the proximal muscle
fibers of the VMO. Thus, think of the harvest as midline,
starting at the proximal central aspect of the quadriceps ten-
don but 1 or 2 mm medially.
When first harvesting the graft, be sure to make an
adequate incision. The incision gets smaller with experience.
Define the graft borders carefully and try to avoid entering
15
FIG. 15-2 Release of the proximal end of the quadriceps tendon graft.
the pouch—you have a good 7 mm of tendon thickness to
work with in almost every patient, but do not cut any
deeper. If you do, cut all water flow, finish the harvest
leaving the posterior fibers of quadriceps tendon, and run
a continuous Vicryl suture along the synovium to close the
defect before resuming arthroscopy.
Releasing the graft distally is easiest with a #15 scalpel
blade. While retracting with the hemostat, you can define
the insertion point of the graft on the patella nicely and
release only the graft portion of the quadriceps tendon from
the top of the patella.
A hemostat works well for defining the posterior
border of the graft spread generously. If you do not
obtain a thick-enough graft depth initially, place the
hemostat a little deeper and define a larger, thicker graft
as needed. The author prefers to use almost entirely blunt
dissection after defining the borders, but a few careful
clips with Metzenbaum scissors to aid the graft removal is
usually helpful. Visualize all sides of the graft while
stripping it out.
Keep the knee flexed to 90 degrees, with tension on
the quadriceps tendon, during the entire harvest.
Use a uterine T clamp to grasp the end of the graft
and then put #5 whipstitches in the free end, before strip-
ping the graft proximally, to apply tension for the
stripping. Use Mayo scissors to release the graft proximally
under direct vision while retracting skin proximally and
pulling the graft distally. As you release it, be careful
not to flip the graft back into your face mask with the
tension.
Take the graft to the back table and keep it under ten-
sion for whipstitching the other end, sizing it, and preparing
it for placement in the knee.
107
 Anterior Cruciate Ligament Reconstruction
FIG. 15-3 Sizing of the quadriceps tendon graft.
FIXATION OF THE CENTRAL QUADRICEPS
FREE TENDON GRAFT
We take the CQFT graft to the back table and place two
sets of #5 whipstitches in each end using a combination of
Ethibond or Ticron and Fiberwire. McKeon et al have
shown that it is not necessary to place more than two whip-
stitch throws in each side of the tendon.12 Use sizing cannu-
las (Fig. 15-3) to determine the size of the graft and the
tunnels you will drill in the tibia and femur. In most cases,
the graft will fit snugly into 8- or 9-mm tunnels.
Next, place a circumferential mark on the graft at the
point where it will exit the femoral socket (we like 2 cm of
CQFT in the femoral socket). We prefer an Endobutton
on the femoral end (Fig. 15-4), tying the #5 sutures (four
strands off the end of the graft) after measuring the depth
⭓7 cm
Tibial tunnel/socket
screw/washer
FIG. 15-4 Quadriceps tendon with Endobutton.
108
FIG. 15-5 Bottom view of the central quadriceps free tendon (CQFT) graft
in the tibial tunnel.
of the femoral tunnel such that the distance from the Endo-
button to the marked femoral socket exit point on the graft
is the same as the tunnel length, measured with the Endo-
button depth gauge. Tie the sutures together (we use a
Graftmaster to hold the graft and Endobutton during this
process) with the knot just adjacent to the tendon graft (tying
it elsewhere may cause problems in full deployment of the
Endobutton).
We pull the graft into the tunnels and deploy the
Endobutton in the usual fashion, using a #5 suture and then
a #2 in the other end to flip the Endobutton after it is
through the lateral femur.
Femoral
socket
#5 leading
suture
#2 trailing
suture
Knot close to the graft to
avoid problem with Endobutton
 The Central Quadriceps Free Tendon for Anterior Cruciate Ligament Reconstruction 15
We use a biointerference screw that is one size larger
than the tunnel size for tibial side fixation. After thoroughly
cycling the graft in the knee and while maintaining tension
on the graft, flex the knee 20 degrees and insert the biointer-
ference screw over a guidewire that is held in place just ante-
rior to the graft in the tibial tunnel. Be sure not to push the
screw and graft, but rather advance it by turning only after
seating the screw. We prefer to have the tip of the screw
5 to 8 mm back from the intercondylar notch and recommend
viewing the screw/graft construct from below to confirm
proper placement (Fig. 15-5). A button may be tied over the
tibial tunnel for added fixation if desired.13 We have been
pleased with these fixation methods (Figs. 15-6 and 15-7).

FIG. 15-7 Quadriceps tendon with bone or biointerference disk and screw.

References
1. Marshall JL, Warren RF, Wickiewicz TL, et al: The anterior cruciate
ligament: a technique of repair and reconstruction. Clin Orthop Relat
Res 1979;Sep:97–106.
2. Blauth W: Die zweizugelige Ersatzplastik des Vorderen Kreuzband
der Quadricepssehne. Unfallheilkunde 1984;87:45–51.
3. Joseph M, Fulkerson J, Nissen C, et al: Short-term recovery after
anterior cruciate ligament reconstruction: a prospective comparison
after three autografts. Orthopedics 2006;29:243–248.
4. Staubli HU, Schatzmann L, Brunner P, et al: Quadriceps tendon and
patellar ligament: cryosectional anatomy and structural properties in
young adults. Knee Surg Sports Traumatol Arthrosc 1996;4:100–110.
5. Staubli HU, Schatzmann L, Brunner P, et al: Mechanical tensile
properties of the quadriceps tendon and patellar ligament in young
adults. Am J Sports Med 1999;27:27–34.
6. Fulkerson JP, Langeland R: An alternative cruciate reconstruction
graft: the central quadriceps tendon. Arthroscopy 1995;11:252–254.
7. Fulkerson J: Central quadriceps free tendon for anterior cruciate liga-
ment reconstruction. Oper Tech Sports Med 1999;7:195–200.
8. Viola R, Vianello R: Three cases of patella fracture in 1320 anterior
cruciate ligament reconstructions with bone-patellar tendon-bone
autograft. Arthroscopy 1999;15:93–97.
9. Sachs RA, Daniel DM, Stone ML, et al: Patellofemoral problems after ante-
rior cruciate ligament reconstruction. Am J Sports Med 1989;17:760–765.
10. Marder RA, Raskind JR, Carroll M: Prospective evaluation of arthros-
copically assisted anterior cruciate ligament reconstruction. Patellar
tendon versus semitendinosus and gracilis tendons. Am J Sports Med
1991;19:478–484.
11. Adams D, Mazzocca A, Fulkerson J: Residual strength of the quadri-
ceps versus patellar tendon after harvesting a central free tendon graft.
Arthroscopy 2006;22:76–79.
12. McKeon B, Heming J, Fulkerson J, et al: The Krackow whipstitch: a
biomechanical evaluation of changing the number of loops versus the
number of sutures. Arthroscopy 2006;22:33–37.
13. Nagarkatti DG, McKeon BP, Donahue BS, et al: Mechanical evalua-
tion of a soft tissue interference screw in free tendon anterior cruciate
FIG. 15-6 Central quadriceps free tendon ACL reconstrution. ligament graft fixation. Am J Sports Med 2001;29:67–71.

109
 PART C HAMSTRING GRAFT CONFIGURATIONS
16
CHAPTER
Hamstring Anterior Cruciate Ligament
Reconstruction with a Quadrupled
or Tripled Semitendinosus Tendon Graft
Alberto Gobbi INTRODUCTION
Ramces Francisco
A wide variety of techniques and graft types are
now available for the reconstruction of the ante-
rior cruciate ligament (ACL). Years of clinical
and surgical experiences gained by surgeons
together with the development and modifica-
tion of the various instrumentations have greatly
contributed to the better results currently
reported in literature. However, disagreement
persists among experts with regard to the ideal
technique and graft type most suitable for
reconstruction.
Currently, most surgeons use either the
hamstring graft or the bone–patellar tendon–
bone (BPTB) graft for ACL reconstruction.
Previous studies have demonstrated the advan-
tages and disadvantages of using one type of
graft over the other. However, recent investiga-
tions have confirmed that comparable outcomes
can be achieved with either of these two graft
types.1–3
Inherent advantages cited with the use of
hamstring grafts include its strength, decreased
incidence of donor site morbidity, easier reha-
bilitation, smaller incisions, and better cos-
mesis.1,2,4 With BPTB graft, the strong
bone-to-bone fixation and the faster healing
achieved with the bone plugs at the graft’s
end1,5 remain important advantages.
In this chapter, we describe the technique
of using a quadrupled semitendinosus tendon
graft harvested with a bone block for the
reconstruction of a torn ACL.
110
Studies have demonstrated that this type
of graft configuration is capable of producing a
clinically stable construct that allows recovery
of normal limb strength and early return to
active sports and results in low donor site
morbidity.
SCIENTIFIC RATIONALE FOR
A QUADRUPLED CONSTRUCT
Hamstring grafts have gained popularity among
surgeons due to the well-documented higher
donor site morbidity when patellar tendon graft
is used.6–8 Although prospective randomized
studies comparing patellar tendon and hamstring
grafts demonstrated no significant difference in
final outcome, the apparent advantages offered
by hamstring grafts remain appealing to surgeons.
Previous concerns related to the hamstring
tendon’s viability have long been dismissed, and
studies comparing different graft types and con-
figurations have demonstrated that failure load
and stiffness values for four-stranded hamstring
tendon grafts are higher than values reported
for the natural ACL (2160N, 242 N/mm),
10-mm-wide patellar tendon grafts (2977N,
455 N/mm), and 10-mm-wide quadriceps tendon
grafts (2353N, 326 N/mm).9,10
On the other hand, concerns related to
hamstring graft incorporation within the tunnel
was addressed with Morgan’s11 introduction of
an “all inside” technique using bone–hamstring–
bone composite graft. Therefore to address the
 Hamstring Anterior Cruciate Ligament Reconstruction with a Quadrupled or Tripled Semitendinosus Tendon Graft
concerns related to morbidity and delayed graft incorporation,
we developed a technique that combines the advantages of a
decreased donor site morbidity by using only one hamstring ten-
don (semitendinosus) with the possibility of achieving faster
graft–tunnel incorporation by including a bone block with the
distal limb of the semitendinosus tendon during harvest.1,12,13
SURGICAL TECHNIQUE
The surgery can be performed under spinal anesthesia or
general anesthesia. The patient is positioned supine on the
operating table, and the tourniquet is placed as high as
possible on the thigh to allow sufficient distance from the exit
point of the Beath needles in the lateral thigh. The tourniquet
is inflated only during graft harvest. A thigh support is placed
at the level of the tourniquet cuff while a foot bar is positioned
at the end of the table to enable the knee to be fixed at 90
degrees of flexion during surgery while at the same time still
allowing free range of motion.
A 3-cm vertical incision centered approximately 5 cm
below the medial joint line, midway between the tibial tuber-
cle and the posteromedial aspect of the tibia, is performed.
The sartorial fascia is incised, and the semitendinosus tendon
is dissected and detached proximally with a tendon stripper.
The distal limb of the tendon is detached along with a tibial
bone plug and periosteum with the use of an osteotome.
To achieve the desired 7-cm quadrupled graft construct
(2 cm inserted in the femoral tunnel, 3 cm intraarticular,
and 2 cm inserted in the tibial tunnel), the required minimum
tendon length would be 28 cm (range 28–30 cm) (Fig. 16-1).
Alternatively, semitendinosus tendons that are shorter than
28 cm can be prepared in a tripled configuration.
Graft Preparation
Quadrupled Semitendinosus Graft
At the back table, all the muscle tissues attached to the tendon
are removed with the use of a curette. Once devoid of excess
tissues, the tendon is folded in a quadrupled fashion with
the bone plug tied outside. Prior to suture placement on the
tendon construct, the depth of the femoral tunnel is measured
to determine the appropriate size of the Endobutton-CL
FIG. 16-1 The semitendinosus tendon harvested with a bone block
attached on one end. The ideal length for the graft should be at least
28 cm to allow the preparation of a quadrupled construct.
16
(Smith & Nephew, Endoscopy, Andover, MA) to be used.
Once the proper size is chosen, the Endobutton is then posi-
tioned in the quadrupled construct’s end where the bone block
is located. Both ends of the graft are then whipstitched using
#5 nonabsorbable sutures. A polyester tape is then knotted at
the other end of the graft (Fig. 16-2, A, B). Measurement of
the graft diameter follows, using 0.5-mm increment sizers
to match this with the diameter of the femoral and tibial
tunnels. Once in place, the grafts are pretensioned and
preconditioned prior to fixation with cyclical flexion and
extension of the knee under maximum manual tension.1,6
Tripled Semitendinosus Graft (Alternative Option
for Short Semitendinosus Grafts)
Harvested semitendinosus tendons with a total length of
less than 28 cm can be prepared in a tripled configuration.
Once the excess tissues are removed, both ends of the semi-
tendinosus tendon are whipstitched using #5 nonabsorbable
sutures (Fig. 16-3, A). The tendon is then folded in three
parts (three limbs) to determine the graft’s length and to
approximate the size of the Endobutton-CL to be used. In
general, we usually use either a 20- or 25-mm Endobutton-
CL, considering that we have a tunnel length of about
40 to 45 mm. On the end of the graft where the bone
plug is located, the free ends of the suture are used to
tie a knot around the Endobutton-CL so that it becomes
attached to the graft (Fig. 16-3, B). The other end of the
graft is then passed through the loop of the Endobutton-
CL as the tendon is folded in three parts. After passing
through the Endobutton-CL, the suture at the free end
of the graft is separated and positioned in such a way that
it would catch the looped tendon at the opposite end
(Fig. 16-3, C). With this configuration the diameter of
this tripled semitendinosus is measured to make sure that
it corresponds with the femoral and tibial tunnels. Prior
to the final fixation, routine pretensioning and precondi-
tioning of the graft are performed.
Arthroscopic Anterior Cruciate Ligament
Reconstruction
A standard anterolateral portal is created through which the
arthroscope is inserted followed by an anteromedial portal
where instruments can be introduced. While the graft is
being prepared at the back table, tunnel preparations are
completed. The tibial tunnel is prepared with the Acufex
aimer set at 45 degrees with 70 degrees of inclination from
the sagittal plane. During tibial tunnel reaming, a bone plug
is obtained through the coring system used. On the
other hand, the femoral tunnel is drilled in the 10:30
position for the right knee. Femoral fixation is achieved
with the Endobutton connected to the graft while tibial
fixation is obtained with an 8-mm titanium Fastlok device
111
 Anterior Cruciate Ligament Reconstruction

Endobutton Bone plug

9–10
BONE
mm

Quadrupled semitendinosus autograft

A

FIG. 16-2 Diagram (A) and actual

quadrupled semitendinosus
construct with Endobutton on one
end and polyester tape in the other
end (B). The bone block is positioned
and stitched outside the graft.

Bone plug

Semitendinosus autograft
A

Endobutton Bone plug

Semitendinosus autograft

Endobutton Bone plug

Tripled semitendinosus autograft

C
FIG. 16-3 A, Diagram of the semitendinosus tendon with both ends sutured. B, Endobutton-CL is knotted on the
end where the bone plug is located; the free end of the graft is then passed through the Endobutton-CL to
form the three limbs. C, The free ends of the suture are separated and hooked around the opposite loop to
complete the configuration.

(Neoligaments, Leeds, United Kingdom), which is also Clinical Results

connected to the graft with a quadrupled polyester tape.
Finally, the bone block previously obtained from reaming
the tibia is press-fitted in the tibial tunnel (Fig. 16-4). Post-
operatively, rehabilitation is commenced according to the
protocol described by Rosenberg and Pazik.14
In a previous study10 of 100 patients who underwent ACL
reconstruction using this technique, it was demonstrated
that the average postoperative VAS pain score was 5 (range
2–7), with 90% of the patients discharged within 24 hours

112
 Hamstring Anterior Cruciate Ligament Reconstruction with a Quadrupled or Tripled Semitendinosus Tendon Graft
Endobutton-CL
Bone block attached to ST
Quadrupled
semitendinosus
Bone block
Polyester tape
Fastlok tibial fixation
FIG. 16-4 Diagram of quadrupled semitendinosus with bone (QSTB)
anterior cruciate ligament reconstruction. Femoral fixation was achieved
with a continuous loop Endobutton while tibial fixation was carried out with
a Fastlok device augmented by a bone block impacted in the tibial tunnel.
following the procedure. This finding was consistent with
the subjective IKDC scores in which an average rating of
80% was obtained. Six months following the procedure,
10% of patients had noted pain over the tibial hardware
with associated hypoesthesia over the surgical incision. Clin-
ical examination at final evaluation demonstrated 90
patients with less than 1 cm difference in thigh circumfer-
ence, two patients with extension lag of 6 degrees, and
another two patients with flexion loss of 10 degrees. Kneel-
ing test was positive only in 7% of these patients, while the
postoperative Lachman test was negative in 90% (þ1 in
nine cases and þ2 in one case). Sensory changes were evi-
dent in 30% of patients at 3 months with only 10% having
localized hypoesthesia at the proximal third of the tibia at
final evaluation.
Subsequent radiographs and magnetic resonance ima-
ging (MRI) revealed that only three tibial tunnels and four
femoral tunnels were widened more than 25% from the original
diameter. However, all these cases retained an anterior laxity
that was less than 3 mm and subjectively rated their knees
above 80%. MRI studies using T1- and T2-weighted transax-
ial sequences in 30 patients at 3 and 6 months demonstrated
graft incorporation in the tunnels with evidence of viability.
Computerized analysis of knee laxity at final follow-
up showed 90 cases to have a side-to-side difference of less
than 3 mm, nine cases with 3 to 5 mm of difference, and one
case with more than 5 mm of difference. The mean side-to-
side difference was 1.9 mm (1.7 mm in males and 2.3 mm
in females).
16
Isokinetic tests were not significantly different between
6 and 12 months (P ¼ 0.6526). The hamstring/quadriceps
ratio was slightly lower in the operated limbs compared with
the normal limbs at all test intervals and speed settings but
was not statistically significant (P ¼ 0.9576). Neither exter-
nal (P ¼ 0.6181) nor internal rotation strength (P ¼ 0.3681)
demonstrated significant deficits at 6 and 12 months post-
reconstruction when compared with the normal limb.
Knee evaluation scores demonstrated the following:
IKDC (A, 66%; B, 24%; C, 9%; D, 1%); Noyes, 87.9 (range
65–100); Lysholm, 93 (range 70–100); and preinjury and
postoperative Tegner, 6.1 and 6.0, respectively.
Complications
A few patients noted pain on incidental contact at the tibial
side, which eventually required removal of the Fastlok
device. In five cases, on second-look arthroscopy the grafts
remained viable and functional. In addition, two cases had
transient superficial wound infection that resolved with anti-
biotic treatment. In one case, a deep streptococcal infection
was documented, which required arthroscopic lavage and
débridement. Further evaluation demonstrated chondral
damage with loss of motion.
CONCLUSION
The technique of using a quadrupled bone-semitendinosus
graft construct for ACL reconstruction has results compara-
ble to other techniques in terms of restoration of knee
stability, recovery of normal limb strength, and patient satis-
faction. This technique effectively combines the biological
principles of healing with bone-to-bone contact and high
cross-sectional graft area. It provides a viable alternative to
other graft types, particularly in patients with preexisting
patellar or extensor apparatus problems.
References
1. Gobbi A, Zanazzo M, Tuy B, et al. Patellar tendon versus quadrupled
bone semitendinosus ACL reconstruction: a prospective investigation
in athletes. Arthroscopy 2003;19:592–601.
2. Aune AK, Holm I, Risberg MA, et al. Four-strand hamstring tendon
autograft compared with patellar tendon autograft for anterior cruciate
ligament reconstruction: a randomized study with two year follow-up.
Am J Sports Med 2001;29:722–728.
3. Prodromos CC, Han YS, Keller BL, et al. Stability results of
hamstring anterior cruciate ligament reconstruction at 2- to 8-year
follow-up. Arthroscopy 2005;21:138–146.
4. Shelbourne KD. Donor site problems after anterior cruciate ligament
reconstruction using the patellar tendon graft. J Sports Traumatol Rel
Res 1995;17:120–128.
5. Pinczewski LA, Clingeleffer AJ, Otto BD, et al. Case report:
integration of hamstring tendon graft with bone in reconstruction of
the anterior cruciate ligament. Arthroscopy 1997;13:641–643.
113
 Anterior Cruciate Ligament Reconstruction
6. Cooley VJ, Deffner KT, Rosenberg TD. Quadrupled semitendinosus
anterior cruciate ligament reconstruction: 5 year results in patients
without meniscus loss. Arthroscopy 2001;17:795–800.
7. Corry IS, Webb JM, Clingeleffer AJ, et al. Arthroscopic reconstruc-
tion of the anterior cruciate ligament. A comparison of patellar tendon
autograft and four-strand hamstring tendon autograft. Am J Sports
Med 1999;27:444–454.
8. Maeda A, Shino K, Horibe S. Anterior cruciate ligament reconstruc-
tion with multi stranded autogenous semitendonosus tendon. Am
J Sports Med 1996;24:504–509.
9. Brown CH Jr, Sklar JH. Endoscopic anterior cruciate ligament
reconstruction using quadrupled hamstring tendons and Endobutton
femoral fixation. Tech Orthop 1998;13:281–298.
10. Weiler A, Scheffler S, Gockenjau A, et al. Different hamstring tendon
graft fixation techniques under incremental loading conditions
(abstract). Arthroscopy 1998;14:425–426.
114
11. Morgan C. The bone-hamstring-bone composite autograft for ACL
reconstruction. Presented at the AAOS, New Orleans, Month, 1994.
12. Gobbi A, Panuncialman I. Quadrupled bone-semitendinosus ACL
reconstruction: a prospective clinical investigation in 100 patients.
J Orthopaed Traumatol 2003;3:120–125.
13. Gobbi A, Domzalski M, Pascual J, et al. Hamstring anterior cruciate
ligament reconstruction: is it necessary to sacrifice the gracilis?
Arthroscopy 2005;21:275–280.
14. Rosenberg TD, Pazik JT. Anterior cruciate ligament reconstruction
with quadrupled semitendinosus autograft. In Parisen JS (ed). Current
techniques in arthroscopy. Current medicine. Philadelphia, 1996,
Churchill Livingstone, pp 77–78.
 2ST/2Gr, 4ST, and 3ST/2Gr Techniques:
Deciding Which Hamstring Configuration
to Use
INTRODUCTION
Use of the four-strand hamstring (4HS) graft
using the semitendinosus (ST) with or without
the gracilis (Gr) has increased dramatically in
the past 5 years. This graft has long been consid-
ered to have lower morbidity than bone–patellar
tendon–bone (BPTB) grafts. After reports
showed its clinical stability results to meet or
exceed those of the BPTB,1–7 its use began to
significantly increase. 2ST/2Gr is the most
commonly used hamstring graft, followed by
4ST. However, a total of six different multi-
strand hamstring graft configurations have been
reported and are in current use. This chapter will
describe the advantages of each configuration
according to the five parameters involved in
decision making. Graft preparation techniques
will also be described.
THE PARAMETERS FOR CHOOSING A
HAMSTRING GRAFT CONFIGURATION
Five parameters (Table 17-1 and see later dis-
cussion) will drive decision making regarding
which HS graft, or soft tissue graft in general,
will be used. The first three parameters are
available graft length in the tunnel, the type of
fixation that can be used, and whether the
gracilis must be sacrificed. These are generally
themost important considerations to most
orthopaedic surgeons. The last two parameters,
relative graft strengths and whether it is dou-
ble-bundle compatible, are important to some.
17
CHAPTER
1. Is the Graft Long Enough to Chadwick C. Prodromos
Allow Adequate Tunnel Healing?
In our experience, ST harvests range in length
from 24 to 34 cm, with most being between
26 and 30 cm in usable length. Intraarticular
anterior cruciate ligament (ACL) length is 3 to
3.5 cm.8 Roughly 1 cm of shortening occurs as
a result of whipstitch implantation. Thus, for
example, a 27-cm graft will be 26 cm after
suturing. When quadrupled, this length is
6.5 cm. Subtracting 3 cm for the intraarticular
portion leaves 3.5 cm of graft for both tunnels,
or about 1.75 cm or 17.5 mm for each tunnel.
If the ST is only doubled and not quadrupled,
the resultant 12 cm or longer graft can provide
4 cm or more of graft length in each tunnel.
Some surgeons9 will use 4ST if the ST is
30 cm or longer and 2ST/2Gr if the ST harvest
is less than 30 cm.
The Argument for Greater Length Being
Necessary
Many surgeons are not comfortable with graft
lengths of less than 2 cm in each tunnel. The
principal argument in favor of this is the study
by Greis et al10 that shows greater pull-out
strength as graft length increases.
The Argument for Less Length Being
Sufficient
However, there is a significant body of data
indicating that 15 mm or even less graft in a
tunnel is acceptable. A recent study by Zantop
et al in goats using Endobutton fixation showed
115
 Anterior Cruciate Ligament Reconstruction

TABLE 17-1 Advantages and Disadvantages of Various Graft Configurations

Strength Sacrifice Gracilis Interference Screw Compatible Graft Length in Tunnel Two-Bundle Compatible

2ST/2Gr High Yes Yes Long No

3ST Moderate No No Medium No

3ST/2Gr High Yes No Medium Yes

3ST/3Gr High Yes No Medium Yes

4ST High No No Short Yes (?)

4ST/4Gr High Yes No Short Yes

Gr, Gracilis; ST, semitendinosus.

no difference in load to failure between 15 mm and 25 mm
of graft in the tunnel.11 A study by Yamazaki et al in dogs
using whipstitch cortical screw post fixation showed no dif-
ference between 5 mm and 15 mm.12 Equally persuasive in
favor of shorter lengths being acceptable is the clinical expe-
rience of a number of experienced surgeons such as Rosen-
berg and Cooley2 and Paulos13 who have had excellent
results using 15-mm grafts. We have also used 15 mm as
a minimum without a graft failure.
2. Is the Graft Long Enough to Allow Direct
Tibial Fixation or Only Indirect?
Direct fixation includes all interference screw and interfer-
ence screw–based techniques such as Intrafix and techniques
that rely on direct friction with the graft, such as the
WasherLoc. Indirect fixation uses a fabric interface with
the graft such as the whipstitch post technique or Fastlok.
As seen in Table 17-1, use of the Gr as well as the ST is
necessary to be certain of a long-enough graft to ensure
the use of direct fixation techniques.
3. Is the Gracilis Sacrificed?
The Gracilis Is not Really a Hamstring
One argument against the 2ST/2Gr graft is that it disables
not one but two hamstring muscles because the Gr is also
harvested in addition to the ST. However, the Gr is not
really a hamstring. Gray’s Anatomy14 lists only three
hamstring muscles: the biceps femoris, semimembranosus,
and ST. All are innervated by the sciatic nerve; all flex the
knee. The Gr is not listed as a hamstring. Rather, the Gr
is listed with the adductors longus, brevis, and magnus as
“medial femoral muscles.” All of these muscles, including
the Gr, are innervated by the obturator nerve. The gracilis’
action is listed as “adducts the thigh.” Thus, the loss of
the Gr is not the loss of a second hamstring. Rather, it is
the loss of an accessory adductor, much as the loss of the
ST is the loss of an accessory hamstring.
What Is Lost by Harvesting the Gracilis in Addition
to the Semitendinosus?
Chapter 67 reviews strength after hamstring harvest. Ham-
string strength can be restored in virtually 100% of patients
in our experience. Specific testing has noted a small decrease
in peak flexion torque at high flexion angles and decreased
tibial internal rotation strength in flexion; however, no clin-
ical deficit has ever been reported in function as a result of
the addition of Gr harvest relative to ST alone. On theoret-
ical grounds, some have avoided Gr harvest in sprinters and
soccer players.15 However, performance deficits or subjective
complaints have not been reported in this group. Anec-
dotally, we have performed bilateral 2ST/2Gr in a profes-
sional soccer player with excellent subsequent performance.
4. How Strong Is the Graft?
Using the data from the classic study of Noyes et al16 in
which the ST was 70% of the strength of the native
ACL and the Gr was 49% of the strength, extrapolated
hamstring graft strengths can be estimated. The 4ST would
be 280%, the 2ST/2Gr would be 238%, the 3ST would be
210%, and the 2ST would be 140%. The 4ST and 2ST/
2Gr have produced very high stability rates in clinical
series.2–7 The 2ST has been associated with low rates,
although this may well be largely due to the outmoded fixa-
tion that was used when those studies were done.17–19
Regardless of whether this is true, few surgeons today are
comfortable with only a 2ST graft. The 3ST graft has pro-
duced high stability in some20 but not all21 series. This
mixed clinical performance and the lower strength of the
graft coupled with the increased complexity of using an
odd-stranded graft in the femur has resulted in this graft
being seldom used.

116
 2ST/2Gr, 4ST, and 3ST/2Gr Techniques: Deciding Which Hamstring Configuration to Use
5. Is the Graft Double-Bundle Compatible?
Yasuda et al22 have reported a six-strand, double-bundle
technique with 3ST/3Gr, as described in Chapter 22.
Christel uses a 2ST anteromedial (AM) bundle and either
a 2Gr or 3Gr (if the Gr is small) posterolateral (PL) bundle,
as described in Chapter 23. Zhao et al have reported a 4ST
AM and 4Gr PL bundle eight-strand technique.23 Gener-
ally, excellent stability has been reported with these techni-
ques. As with the later-described 5HS single-bundle
technique, 6HS and 8HS techniques have not seemed to
have the problems associated with the large size of these
grafts, which are significantly larger than the native ACL.
2ST/2Gr has generally not been used in a double-bundle
configuration. Single-bundle techniques use primarily AM
bundle positioning. This has produced high success rates.
The argument for double-bundle techniques supposes that
the addition of a PL bundle can only help stability. How-
ever, PL bundle techniques are new and questionable to
many. If the AM bundle is significantly weakened to pro-
vide a graft for the PL bundle, then the entire graft may
be too weak if the PL technique is indeed not providing sig-
nificant additional strength. Taking the Gr away from the
AM bundle would leave only a 2ST graft, which alone has
performed poorly in the literature in the past. It would seem
safer to leave a stronger AM bundle, at least a 3ST graft,
which would then be augmented by the PL bundle. Gobbi
has reported excellent success with a 2ST AM bundle, but
he has used the stronger 2ST graft rather than 2Gr for a
PL bundle (see Chapter 24).
GRAFT PREPARATION TECHNIQUES
2ST/2Gr Graft Preparation Technique Using
Endobutton Femoral and Whipstitch
Posttibial Fixation
Cleaning and First Whipstitch Implantation
After harvest the tendons should be cleaned of muscle tissue.
We place whipstitches (see Chapter 42) in the combined tib-
ial attachment of #5 braided nonabsorbable or #2 braided
high-strength nonabsorbable suture such as Fiberwire
(Arthrex, Naples, FL) or ultra-braid (Smith & Nephew,
Andover, MA). We do not cut the graft at this point and
do not whipstitch the other end. It is better to determine
length once tunnel lengths have been determined.
Sizing the Graft
The graft is then sized. Usually the femoral end where the graft
is looped will be about 1 mm thinner than the tibial end.
17
A sizer is slipped down the over the loop of the quadrupled
graft for a distance of about 3 cm to ascertain the size of
this femoral end separately from the tibial. We then add 0.5
to 1 mm of size to the tibial measurement to account for
the greater bulk that will result from the second whipstitch
when it is put into the paired proximal ends of the tendons
after their length is determined. The tibial and femoral
tunnels are then drilled using these tendon girth
measurements.
Calculating the Optimal Length for the Graft
If sufficient length exists, we will try to obtain 2.5 to 3 cm
of graft in the femoral socket but will accept as little as
15 mm as described. Approximately 3.5 cm of intraarticu-
lar length and 3 cm of tibial length are then added to
the calculation so that the usual graft will be about
9.5 cm in length. The graft is then cut to the necessary
length. In this example the graft would be cut at 20 cm
in length because 0.5 cm of shortening usually occurs
between the insertion of the second whipstitch and the
folding of the graft in the Endobutton. Thus, this 20-cm
graft when doubled will be 10 cm in theory but closer to
9.5 cm in practice. However, if the femoral tunnel is
shorter we will make the graft correspondingly shorter as
well. In this example, if the femoral socket were 1.5 cm
we would add 3.5 cm intraarticular and 3 cm tibial for a
length of 8 cm. In theory this would require a 16-mm
graft, but again we would add 1 cm to make it 17 mm
in length. We restrict the graft length so that the graft will
not have excessive length and abut the cortical screw post
we use, resulting in an inability to create tension in the
graft. In making these calculations, one can always assume
the tibial tunnel to be at least 3 cm in length, and usually
it is 4 to 5 cm in length. If any question exists in the sur-
geon’s mind, the intraarticular length and tibial tunnel
length can be easily directly measured using the long-
depth gauge in the Endobutton system or by other means.
Second Whipstitch Implantation and Trimming
Once the appropriate length has been determined, the two
free proximal ends of the graft are doubled and a hemostat
is clamped just beyond the desired length. The extra graft
is cut off with a 15 blade scalpel, with the hemostat left in
place on the doubled ends of the graft. The other whipstitch
is then woven into the graft. The hemostat is removed after
the second suture pass. Excess graft is carefully then
trimmed from both ends. Removing “dog ears” will facilitate
smooth graft passage. A snug fit is desirable, but do not
try for too tight a fit or the graft will be traumatized
during passage or may not pass at all. The graft is now ready
for passage and fixation.
117
 Anterior Cruciate Ligament Reconstruction

TROUBLESHOOTING
What if Either the ST or Gr Is Cut Too Short
to Double?

We have not had this occur using the posterior mini-incision

harvest technique (see Chapter 13). However, if graft length
is questionable, the first step should be to precisely measure
the intraarticular length. The minimum graft we have used
is this length plus 15 mm for each of the tibial and femoral
tunnels. Thus, a 30-mm intraarticular length would allow a
30 þ 15 þ 15 ¼ 60 mm total graft. Six centimeters doubled
is 12 cm. Adding 1 cm for shortening yields a 13-cm graft.
Thus, all that should be necessary for most knees for a FIG. 17-1 The fifth limb of the graft is shown as elevated above the
4ST/Gr graft is a total length of 13 cm or 14 cm, allowing remaining 2ST/2Gr graft. Whipstitches are tied around the Endobutton
loop.
for measurement error. If the surgeon has this length, then
he or she should be fine to proceed. If either the ST or Gr is
shorter than this length, then the surgeon should plan to triple
Results
the other tendon to add to the single short limb of the short
We recently presented an 8- to 9-year follow-up of a five-
tendon. The two possibilities would thus be either 3ST/1Gr
strand technique using whipstitch post fixation on both
(stronger than 2ST/2Gr) or 1 ST/3Gr (not as strong as
the tibia and femur24 in 20 consecutive patients. This was
2ST/2Gr but more than sufficiently strong). We would then
the first report of a greater than four-strand HS graft using
implant whipstitches in the free ends. Whipstitch post fixa-
a single-bundle technique. No graft failures were found, and
tion or Endobutton could then be used for femoral fixation.
89% of the grafts were within 1 mm of the opposite knee.
Cross-pin fixation would generally be difficult without the
The mean side-to-side KT-1000 difference of 0.44 mm is
ability to loop each graft.
the lowest reported for an ST/Gr graft. We compared this
group with a previously reported high-stability 2ST/2Gr
What if the Graft Is Too Big to Pass? cohort and found significantly higher stability with the
five-strand graft.
The easiest first step is to trim the graft at the edges or else-
where and try again. If it still will not pass, then the tunnel
or tunnels must be enlarged slightly.
Morbidity

All patients regained full motion. There were no symptoms

FIVE STRAND USING 3ST/2Gr attributable to the greater size of the graft. Thus, we believe
that this larger graft can safely be used without concerns for
Surgical Technique impingement if tunnels are properly placed.

The ST and Gr are harvested in the usual fashion. The ST is Uses

measured and, provided that it is at least 22.5 cm in length,
the proximal one-third is sectioned from the distal two-thirds.
For example, a 24-cm ST would be cut to leave 16 cm intact
with its insertion, and the proximal 8 cm would be cut off to
use as a single limb. This tissue would otherwise be discarded.
In our experience the ST is always at least 24 cm in length, and
no more than 15 cm is ever required for 2ST/2Gr. Thus, there
is almost always a third (if not a fourth) limb of ST that would
otherwise be discarded. Number 2 whipstitches are placed in
each end of this extra graft limb. The whipstitches from one
end are tied one to one around the fabric loop of the Endo-
button loop (Fig. 17-1). The sutures from the other end are
tied one to one around the tibial cortical screw.
This technique is useful in patients with ligamentous laxity,
small tendons, or other stability risk factors for which the
strongest possible graft is required. It is also of use in dou-
ble-bundle techniques. The 3ST part of the graft allows
the AM bundle to approximate the strength of a 2ST/2Gr
single bundle (210% versus 238% of the approximate
strength of the native ACL by extrapolation from the data
of Noyes25). Thus, the use of the Gr for the PL bundle does
not need to significantly weaken the AM bundle, which
closely corresponds to what most surgeons were using for
a single bundle. This provides a measure of insurance in case
the more difficult PL bundle is misplaced or inadequately

118
 2ST/2Gr, 4ST, and 3ST/2Gr Techniques: Deciding Which Hamstring Configuration to Use
tightened. Because double-bundle techniques are new
to most surgeons, this should essentially eliminate any
“learning curve” laxity as facility with the double-technique
is gained and as further research shows the best ways to
perform the double-bundle procedure.
FOUR-STRAND ST GRAFT PREPARATION
TECHNIQUE
4ST with Bone Block
See Chapter 16 for a description of this technique.
4ST Free Graft Without Bone Block
This technique is similar to the 2ST/2Gr described previ-
ously. The two free ends of the graft are overlapped, and a
whipstitch of #5 braided nonabsorbable suture is placed.
Another whipstitch is then put into the apex of the graft as
it is held taut with a #5 or #2 suture placed within the fold
of the tendon while strong tension is exerted on the opposite
free ends. The net result is a double-thickness graft, which can
be fixated in an identical manner as the 2ST/2Gr graft.
CONCLUSIONS
1 There are five parameters for choosing a hamstring graft
configuration: length for tunnel healing, length for
fixation compatibility, whether or not the Gr is sacrificed,
strength, and double-bundle compatibility.
2 2ST/2Gr is preferred to 4ST by most surgeons due to the
greater available graft length. Some surgeons will use 4ST
with 30 cm or longer ST harvests and 2ST/2Gr with
shorter harvests.
3 4ST offers the advantage of not harvesting the Gr.
4 The 3ST/2Gr five-strand graft offers very high strength
and more length than the 4ST. It is useful in patients
with ligamentous laxity, small tendons, or other stability
risk factors.
5 Regarding minimum graft tunnel length: 15 mm of graft
would appear to be all that is necessary in the tunnels for
adequate healing. Overly aggressive rehabilitation in the
first 8 weeks should be avoided.
6 Gracilis harvest does not disable two hamstrings because
the Gr is not a hamstring but rather is an adductor, both
anatomically and functionally. It deactivates one accessory
hamstring and one accessory adductor. In both cases,
17
function is well taken up by the prime movers in each
group.
References
1. Prodromos CC, Joyce BT, Shi K, et al. A meta-analysis of stability
after anterior cruciate ligament reconstruction as a function of ham-
string versus patellar-tendon graft and fixation type. Arthroscopy
2005;21:1202–1208.
2. Cooley VJ, Deffner KT, Rosenberg TD. Quadrupled semitendinosus
anterior cruciate ligament reconstruction: 5-year results in patients
without meniscus loss. Arthroscopy 2001;17:795–800.
3. Gobbi A, Tuy B, Mahajan S, et al. Quadrupled bone-semitendinosus
anterior cruciate ligament reconstruction: a clinical investigation in a
group of athletes. Arthroscopy 2003;19:691–699.
4. Prodromos CC, Han YS, Keller BL, et al. Stability results of ham-
string anterior cruciate ligament reconstruction at two- to eight-year
follow-up. Arthroscopy 2005;21:138–146.
5. Feller JA, Webster KE. A randomized comparison of patellar tendon
and hamstring tendon anterior cruciate ligament reconstruction. Am J
Sports Med 2003;31:564–573.
6. Yasuda K, Kondo E, Ichiyama H, et al. Anatomic reconstruction of
the anteromedial and posterolateral bundles of the anterior cruciate
ligament using hamstring tendon grafts. Arthroscopy 2004;20:
1015–1025.
7. Gobbi A, Mahajan S, Zanazzo M, et al. Patellar tendon versus qua-
drupled bone-semitendinosus anterior cruciate ligament reconstruc-
tion: a prospective clinical investigation in athletes. Arthroscopy
2003;19:592–601.
8. Duthon VB, Barea C, Abrassart S, et al. Anatomy of the anterior
cruciate ligament. Knee Surg Sports Traumatol Arthrosc 2006;14:
204–213.
9. Prodromos CC, Fu F, Howell S, et al. Controversies in soft tissue
anterior cruciate ligament reconstruction. Presented at the 2006 Sym-
posium of the American Academy of Orthopaedic Surgeons, AAOS
Symposium—Controversies in Soft Tissue Reconstruction, Chicago,
March, 2006.
10. Greis PE, Burks RT, Bachus K, et al. The influence of tendon length
and fit on the strength of a tendon-bone tunnel complex: a bio-
mechanical and histologic study in the dog. Am J Sports Med
2001;29:493–497.
11. Zantop T, Brucker P, Bell K, et al. The effect of tunnel-graft length
on the primary and secondary stability in ACL reconstruction: a study
in a goat model. Presented at the 2006 meeting of the European Soci-
ety of Sports Traumatology, Knee Surgery, and Arthroscopy,
Innsbruck, Australia, May, 2006.
12. Yamazaki S, Yasuda K, Tomita F, et al. The effect of intraosseous
graft length on tendon-bone healing in anterior cruciate ligament
reconstruction using flexor tendon. Knee Surg Sports Traumatol
Arthrosc 2006;14:1086–1093.
13. Paulos L. Personal communication, May 2006.
14. Goss CM. Muscles and Fasciae. In Gray's anatomy, ed 29. Philadel-
phia, Lea and Febiger, Courage Books, 1973, pp 495–503.
15. Gobbi A, Domzalski M, Pascual J, et al. Hamstring anterior cruciate
ligament reconstruction: is it necessary to sacrifice the gracilis? Arthros-
copy 2005;21:275–280.
16. Noyes FR, Butler DL, Grood ES, et al. Biomechanical analysis of
human ligament grafts used in knee-ligament repairs and reconstruc-
tions. J Bone Joint Surg Am 1984;66A:344–352.
17. Meyestre J, Vallotton J, Benvenuti J. Double semitendinosus anterior
cruciate ligament reconstruction: 10-year results. Knee Surg Sports
Traumatol Arthrosc 1998;6:76–81.
18. Aglietti P, Buzzi R, Menchetti P, et al. Arthroscopically assisted
semitendinosus and gracilis tendon graft in reconstruction for acute
119
 Anterior Cruciate Ligament Reconstruction
anterior cruciate ligament injuries in athletes. Am J Sports Med
1996;24:726–731.
19. Anderson A, Snyder R, Lipscomb B. Anterior cruciate ligament
reconstruction: a prospective randomized study of three surgical meth-
ods. Am J Sports Med 2001;29:272–279.
20. Goradia VK, Grana WA. A comparison of outcomes at 2 to 6 years
after acute and chronic anterior cruciate ligament reconstructions using
hamstring tendon grafts. Arthroscopy 2001;17:383–392.
21. Harilainen A, Sandelin J, Jansson KA. Cross-pin femoral fixation versus
metal interference screw fixation in anterior cruciate ligament recon-
struction with hamstring tendons: results of a controlled prospective
randomized study with 2-year follow-up. Arthroscopy 2005;21:25–33.
22. Yasuda K, Kondo E, Ichiyama H, et al. Clinical evaluation of
anatomic double-bundle anterior cruciate ligament reconstruction
120
procedure using hamstring tendon grafts: comparisons among three
different procedures. Arthroscopy 2006;22:240–251.
23. Zhao J, Peng X, He Y, et al. Two-bundle anterior cruciate ligament
reconstruction with eight-stranded hamstring tendons: four-tunnel
technique. Knee 2006;13:36–41.
24. Prodromos CC, Joyce BT. Five-strand hamstring ACL reconstruc-
tion: a new technique with better long-term stability than four-strand.
Presented at the 2006 meeting of the Arthroscopy Association of
North America Hollywood, FL, May, 2006.
25. Noyes FR, Butler DL, Grood ES, Zernicke RF, Hefzy
MS. Biomechanical analysis of human ligament grafts used in knee-
ligament repairs and reconstructions. J Bone Joint Surg Am
1984;66-A:344–352.
 PART D PRINCIPLES OF TUNNEL FORMATION
SUB PART I SINGLE FEMORAL-TUNNEL FORMATION
Use of the Transtibial Technique to Avoid
Posterior Cruciate Ligament and Roof
Impingement of an Anterior Cruciate
Ligament Graft
INTRODUCTION
This chapter discusses the definition, complica-
tions, diagnosis, and prevention of posterior
cruciate ligament (PCL) and roof impingement,
which must be avoided to restore motion and
stability in an anterior cruciate ligament
(ACL) reconstructed knee. Evidence will be
presented that the key tunnel in the transtibial
technique is the tibial tunnel. Correct placement
of the tibial tunnel in the coronal and sagittal
planes, and subsequent drilling of the femoral
tunnel through the tibial tunnel, avoids PCL
and roof impingement, replicates the tension
pattern of the intact ACL, and determines the
motion and stability of the knee.
The rationale for preventing PCL and
roof impingement requires an understanding of
the anatomy of the intercondylar notch, espe-
cially the wide variations in the cross-sectional
relationship between the ACL graft, intact
ACL, and PCL. A time-tested and scientifi-
cally evaluated surgical technique for placing
the tibial and femoral tunnels that consistently
prevents PCL and roof impingement is pre-
sented. This simple and accurate technique
relies on widening the notch by performing a
wallplasty and using a tibial guide that controls
the angle of the tibial tunnel in the coronal
plane and registers the intercondylar roof with
the knee in extension in the sagittal plane. In
the coronal plane, the tibial guide prevents
PCL impingement by customizing the place-
ment of the guidewire at 60 to 65 degrees with
18
CHAPTER
respect to the medial joint line of the tibia and Stephen M. Howell
placing the lateral edge of the tibial tunnel
through the tip of the lateral tibial spine.
In the sagittal plane, the tibial guide prevents
roof impingement by placing the guidewire 5 to
6 mm posterior and parallel to the intercondylar
roof with the knee in maximal hyperextension.
DEFINITION, COMPLICATIONS, AND
DIAGNOSIS OF POSTERIOR CRUCIATE
LIGAMENT IMPINGEMENT
PCL impingement occurs when the ACL graft
wraps around the PCL as the knee is flexed.
Impingement of the ACL graft around the
PCL causes a tension rise in flexion that either
limits flexion or stretches the ACL graft, result-
ing in anterior instability. Not widening the
notch and malplacement of the ACL graft in
the coronal plane cause PCL impingement in
the transtibial technique.1–3
PCL impingement can be suspected if
bone was not removed from the lateral femoral
condyle (i.e., a wallplasty) until the space between
the PCL and lateral femoral condyle exceeded
the width of the ACL graft by 1 mm. An antero-
posterior (AP) radiograph is diagnostic of PCL
impingement when the tibial tunnel is at an angle
greater than 70 degrees with respect to the medial
joint line or when the lateral edge of the tibial
tunnel is medial to the apex of the lateral
tibial spine2 (Fig. 18-1). Magnetic resonance
imaging (MRI) with three-dimensional (3D)
121
 Anterior Cruciate Ligament Reconstruction

FIG. 18-1 The anterior cruciate ligament (ACL) grafts in both of these knees suffered from posterior cruciate
ligament (PCL) impingement. The surgical error in the left radiograph was that the tibial tunnel was placed too
vertical at 85 degrees, which placed the femoral tunnel at the apex of the notch. The tibial tunnel should have
been placed at 65 degrees with respect to the medial joint line of the tibia. However, placing the tibial tunnel at 65
degrees does not guarantee that the ACL graft is placed without PCL impingement. The surgical error in the right
radiograph is that the notch was not widened with a wallplasty, and the tibial tunnel and femoral tunnel were
placed too medial, such that the femoral tunnel was at the apex of the notch. The lateral edge of the tibial tunnel
should pass through the tip of the lateral spine, not through the tip of the medial spine.

reconstruction is diagnostic of PCL impingement when there
is no space between the ACL graft and PCL or when the
ACL graft does not run straight and is deformed by
the PCL.1 Arthroscopy is diagnostic of PCL impingement
when there is no space between the ACL graft and PCL at
the apex of the notch and when the ACL graft is slack and
bows laterally with the knee in 30 degrees of flexion.3
Surgeons who avoid PCL impingement will find that their
patients have better knee flexion and better anterior and
rotatory stability.1,2
DEFINITION, COMPLICATIONS, AND DIAGNOSIS
OF ROOF IMPINGEMENT
Roof impingement occurs when the intercondylar roof con-
tacts the ACL graft before the knee reaches full extension.
Impingement of the ACL graft against the intercondylar
roof causes either a loss of extension or a stretching out of
the graft from abrasion, resulting in anterior instability.
The cause of roof impingement is malplacement of the
ACL graft in the sagittal plane. Placing the tibial tunnel
anterior to the intercondylar roof with the knee in maximal
extension causes roof impingement.4–7
A lateral radiograph of the knee in maximal extension is
diagnostic of roof impingement when the tibial tunnel is
anterior to the intercondylar roof (Fig. 18-2). The lateral
radiograph is less helpful in evaluating a bone–patellar
tendon–bone graft than a soft tissue graft because the bone
plug may obscure the wall and orientation of the tibial tunnel
and because the tendon does not fill the bone tunnel.7 An MRI
is diagnostic of roof impingement when the pathognomonic
regionalized signal increase occurs in the graft, which is con-
fined to the distal two-thirds of the ligament within the inter-
condylar notch. The portion of the ACL graft in the tibial and
femoral tunnel and the portion of the graft that exits the fem-
oral tunnel retain a low signal, which is identical to the PCL
and patellar tendon.8–10 Arthroscopy is diagnostic of roof
impingement when the ACL graft is frayed or a fibrous nod-
ule is formed at the entrance of the tibial tunnel into the
notch.11 Surgeons who avoid roof impingement will find that
their patients have better knee extension and stability.7,12
THE TIBIAL TUNNEL: THE KEY TUNNEL IN
THE TRANSTIBIAL TECHNIQUE
The advantage of the transtibial technique is that when the
notch is widened and the tibial tunnel is placed correctly in

122
 Use of the Transtibial Technique to Avoid Posterior Cruciate Ligament and Roof Impingement of an Anterior Cruciate Ligament Graft 18

FIG. 18-2 The bone–patella–bone graft failed from roof impingement (left radiograph). The surgical error was that
the tibial tunnel was placed anterior to the intercondylar roof with the knee in full extension. The graft failed due to
abrasion and stretch-out. The tibial tunnel was moved more posterior in the revision with a hamstring anterior
cruciate ligament (ACL) graft (right radiograph). The hamstring graft was pushed more posterior by a bone graft
placed along the anterior edge of the tunnel (asterisk). The tibial tunnel should be placed posterior to the
intercondylar roof with the knee in maximal extension.

the coronal and sagittal plane, the correct placement of the

femoral tunnel is automatic. The reason for this is that the
position of the over-the-top femoral aimer and the position
of the reamer are both controlled by the tibial tunnel.3 If the
notch is not widened and the tibial tunnel is placed incor-
rectly in either the coronal or sagittal plane, then the femoral
tunnel will be placed incorrectly and the patient will suffer
from motion loss or instability.1,2,7
The feasibility of the transtibial technique to replicate
the tension pattern of the intact ACL was determined by a
cadaveric study that analyzed the effect of varying the angle
of the tibial tunnel (and femoral tunnel) in the coronal plane
on the tension pattern of the ACL graft (Fig. 18-3). Dril-
ling the tibial tunnel at an angle of 60 degrees in the coronal
plane placed the ACL graft far down the side wall of the
notch away from the PCL, and the tension in the graft
matched the intact ACL. Drilling the tibial tunnel at 70
and 80 degrees placed the ACL graft near the apex of the
notch and the PCL, and the tension increase in the ACL
graft with knee flexion was subsequently abolished by incre-
mental excision of 2 to 6 mm of the lateral edge of the PCL.
Therefore, the cause of the abnormal tension rise in flexion
is the premature mechanical impingement of the ACL graft
on the PCL during flexion and is avoided by placing the
tibial tunnel at an angle less than 70 degrees.3
RATIONALE FOR WIDENING THE NOTCH TO
PREVENT POSTERIOR CRUCIATE LIGAMENT
IMPINGEMENT
The surgeon must recognize that a soft tissue ACL graft is
bigger than the intact ACL. Women of the same height
and weight as men have significantly narrower notches,
which means that women require more of a wallplasty than
males for the same-diameter graft.13 An MRI study of the
cross-section of the intercondylar notch has shown that
the intact ACL is thin and elongated and fits snugly
between the lateral edge of the PCL and the medial edge
of the lateral femoral condyle.1 The use of a soft tissue
ACL graft that is rounder and larger in a cross-sectional
area than the intact ACL requires widening the notch until
the space between the lateral femoral condyle and PCL
exceeds the width of the graft by 1 mm. Arthroscopy has
shown that the portion of the notch occupied by the PCL
and intact ACL varies widely. Most notches are “PCL
dominant,” in which the PCL occupies a larger cross-
sectional area than the ACL (Fig. 18-4). Because surgeons
prefer an ACL graft with a diameter of 8 to 10 mm, a wall-
plasty is required to make room for the larger ACL graft in
almost every ACL reconstruction, especially in females.

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 Anterior Cruciate Ligament Reconstruction

FIG. 18-3 The key tunnel in the transtibial technique is the tibial tunnel because the position of the over-the-top
femoral aimer and the position of the reamer are both controlled by the tibial tunnel. When the tibial tunnel is
drilled at 60 degrees with respect to the medial joint line, the femoral tunnel is placed farther down the side wall
away from the posterior cruciate ligament (PCL), and the tension pattern in the graft is the same as the intact
anterior cruciate ligament (ACL). When the tibial tunnel is drilled at 80 degrees, the femoral tunnel is placed near
the apex of the notch adjacent to the PCL, and the tension pattern in the graft is abnormally increased at 60
degrees of knee flexion. The tension increase in flexion is caused by the graft impinging against the PCL, which
either limits knee flexion or causes the graft to stretch, resulting in increased anterior laxity.

PRINCIPLE FOR AVOIDING POSTERIOR CRUCIATE
LIGAMENT AND ROOF IMPINGEMENT
The principle for avoiding PCL and roof impingement is to
widen the notch and correctly place the tibial tunnel in the
coronal and sagittal planes (Fig. 18-5). In the coronal plane,
the angle of the tibial tunnel should be 60 to 65 degrees with
respect to the medial joint line of the tibia, and the lateral
edge of the tibial tunnel should pass through the tip of the
lateral spine.3 In the sagittal plane, the position of the tibial
tunnel should be posterior and parallel to the intercondylar
roof with the knee in extension, and the position should be
customized based on variability in knee extension and roof
angle so that a roofplasty is not required.6,14,15
Customized placement of the tibial tunnel in the sagit-
tal plane is necessary because the sagittal depth of the inser-
tion of the ACL is variable, the roof angle varies from 23 to
60 degrees, and knee extension varies from 5 to 15 degrees

FIG. 18-4 Notches come in many sizes and shapes; however, most notches are too narrow to hold an 8- to
10-mm round soft tissue anterior cruciate ligament (ACL) graft. The normal ACL is thin, spindle shaped, and much
narrower than the cross-section of an 8- to 10-mm graft. Furthermore, the notch in females is narrower than in
males, and many notches in both genders are posterior cruciate ligament (PCL) dominant, with more than half of
the cross-section of the notch occupied by the PCL (left). Performing a wallplasty until the width between the
lateral edge of the PCL and the lateral femoral condyle exceeds the width of the graft by 1 mm helps prevent PCL
impingement. Widening the notch allows the tibial tunnel to be placed more lateral so that the lateral edge of the
tibial tunnel passes through the tip of the lateral spine.

124
 Use of the Transtibial Technique to Avoid Posterior Cruciate Ligament and Roof Impingement of an Anterior Cruciate Ligament Graft 18

FIG. 18-5 The optimal placement for the tibial tunnel in the coronal and sagittal planes is shown. The lateral edge
of the tibial tunnel passes through the tip of the lateral tibial spine (asterisk), and the tibial tunnel forms an angle
between 60 and 65 degrees with respect to the medial joint line in the coronal view (left). The tibial tunnel is
posterior to the intercondylar roof with the knee in extension (right). This patient regained full flexion and
extension and remained stable because the anterior cruciate ligament (ACL) graft was placed without posterior
cruciate ligament (PCL) and roof impingement.

of hyperextension.14 The variability in the sagittal depth of
the ACL insertion from 11 to 30 mm makes it a poor land-
mark for a point-and-shoot guide to select the position for
an ACL graft with a diameter of 8, 9, or 10 mm.6 Customiz-
ing the placement of the tibial tunnel in the sagittal plane
requires a tibial guide that registers the intercondylar roof
with the knee in maximal hyperextension.16,17 The advantage
of customizing the tibial tunnel is that roof impingement is
avoided without a roofplasty, which has been shown to
increase the graft tension at midrange of flexion and increase
anterior laxity as the knee is flexed.15
SURGICAL TECHNIQUE FOR AVOIDING POSTERIOR
CRUCIATE LIGAMENT AND ROOF IMPINGEMENT
AND REPLICATING THE TENSION PATTERN OF
THE INTACT ANTERIOR CRUCIATE LIGAMENT
This surgical technique requires the use of a tibial guide
that registers the intercondylar roof and a coronal alignment
rod placed in the handle of the guide that allows the angle of
the tibial tunnel in the coronal plane to be visually adjusted
by the surgeon at the time of reconstruction (Howell 65 ,
Howell Tibial Guide, Arthrotek, Warsaw, IN)18 (Fig. 18-6).
The use of a coronal alignment guide reduces the need for
inoperative radiography to check the positioning of the tibial
tunnel.
The initial arthroscopic examination of the notch should
focus on removing the remnant of the torn ACL and clearly
visualizing the lateral edge of the PCL. The tip of the guide,
which is 9.5 mm wide, is passed between the PCL and the lat-
eral femoral condyle. The knee is then gradually extended to
examine whether enough space exists between the lateral fem-
oral condyle and the PCL. The notch is then widened from its
base to the apex until the 9.5-mm-wide tip of the guide easily
passes between the lateral femoral condyle and the PCL
(Fig. 18-7). A roofplasty is not performed.
The tibial guide is then reinserted, and the knee is
placed in full hyperextension (see Fig. 18-6). The heel of
the patient’s leg is placed on the Mayo stand to maintain
the knee in maximal hyperextension. The coronal alignment
guide is inserted into the guide, the knee is brought into full
hyperextension so that it is parallel to the roof, and the cor-
onal alignment rod is adjusted so that it is parallel to the
joint line and perpendicular to the tibia. The guidewire is
drilled through the lateral hole in the bullet, which moves
the guidewire laterally away from the PCL. The position
of the guidewire is then checked arthroscopically. In the
AP view the guidewire should enter midway between the
lateral edge of the PCL and lateral femoral condyle. In full
extension a probe can be placed between the anterior surface
of the guidewire and the roof, and there should be 2 to
3 mm of clearance, which indicates that the guidewire is
not placed too far posterior.

125
 Anterior Cruciate Ligament Reconstruction

FIG. 18-6 The 65-degree Howell Tibial Guide simultaneously orients the tibial tunnel in both the sagittal and
coronal planes. The guide is inserted into the notch, the knee is maximally extended, and the surgeon lifts the
handle of the guide, which aligns the guidewire 6 mm posterior and parallel to the intercondylar roof.
An alignment rod (a) is inserted into the handle of the guide, and the guide is rotated until the rod is parallel to the
joint line and perpendicular to the long axis of the tibia, which sets the angle of the tibial tunnel in the coronal
plane at 65 degrees. The guidewire is drilled through the lateral rather than the central hole in the bullet, which
moves the tibial tunnel away from the lateral edge of the posterior cruciate ligament (PCL).

After drilling the tibial tunnel, an impingement rod is

passed into the knee through the tibial tunnel with the knee
in maximal hyperextension. Free passage of the impinge-
ment rod into the notch indicates no impingement of the
ACL graft against the PCL, lateral femoral condyle, and
intercondylar roof. A size-specific femoral aimer with an
offset that produces a femoral tunnel with a 1-mm back wall
is then inserted through the tibial tunnel. The tip of the
femoral aimer is hooked proximal to the lateral wall of the
notch and rotated slightly lateral away from the PCL.
Once the graft is passed, a triangular space should be
seen between the PCL and the ACL graft at the apex of the
notch (Fig. 18-8).
VALIDATION OF TIBIAL GUIDE
One advantage of drilling the tibial tunnel with the knee in
full hyperextension using the 65-degree tibial guide is that
no manipulation of the knee is required to reduce the knee
and drill the guidewire anatomically. Simply extending the
knee and placing the heel on the Mayo stand suspends the
knee and allows gravity to reduce the tibia on the femur.17
The 65-degree tibial guide was shown to place the
tibial tunnel on the posterior half of the ACL footprint
and avoid roof impingement without a roofplasty in a cadav-
eric study of 21 knees.13 Mapping demonstrated a wide-
variety in width, depth, and shape of the footprint of the

FIG. 18-7 Most notches are too narrow to accommodate an 8- to 10-mm round soft tissue anterior cruciate
ligament (ACL) graft. In this case, the notch is posterior cruciate ligament (PCL) dominant, with more than half of
the cross-section of the notch being occupied by the PCL (left). A wallplasty is performed until the space between
the PCL and lateral femoral condyle exceeds the width of the graft by 1 mm (center). The adequacy of the
wallplasty is confirmed by free passage of the 9.5-mm-wide tip of the tibial guide between the PCL and lateral
femoral condyle (right).

126
 Use of the Transtibial Technique to Avoid Posterior Cruciate Ligament and Roof Impingement of an Anterior Cruciate Ligament Graft 18

FIG. 18-8 These arthroscopic views show what not to do and what to do to correctly place the tibial and femoral
tunnel using the transtibial technique. The tibial guidewire should pass midway between the posterior cruciate
ligament (PCL) and the lateral femoral condyle and not cross the PCL at the floor of the notch (left). The femoral
tunnel ends up too vertical when the guidewire crosses the PCL at the floor of the notch, and there is no triangular
space between the anterior cruciate ligament (ACL) graft and PCL at the apex of the notch, which is diagnostic of
PCL impingement (center). The correctly placed tibial and femoral tunnel is more lateral to the PCL, and a relatively
large triangular space exists at the apex of the notch between the ACL graft and PCL (right).

intact ACL insertion, which emphasizes the difficulty in
selecting the location of the tibial tunnel with use of a
point-and-shoot guide and using the ACL insertion as a
target. The consistency of the relationship of the ACL to
the intercondylar roof and the inconsistency of the footprint
substantiate the principle of using a tibial guide that regis-
ters the intercondylar roof with the knee in full hyperexten-
sion to select the position of the tibial guidewire.19
The use of the coronal alignment guide is preferred over
the use of a “clock” as a way of judging whether the femoral
tunnel is placed correctly in the coronal plane. A simple exper-
iment can be done to show how imprecise the use of the clock
is in determining the location of the femoral tunnel in the cor-
onal plane. With the femoral guidewire drilled through the
tibial tunnel and into the notch, place the scope through the
anterolateral or transpatellar porta, and rotate the 30-degree
arthroscope and camera independently. The “time” formed
by the guidewire and the margin of the intercondylar notch
will vary by 2 hours. Repeat the experiment in the anterome-
dial portal, and observe how the maximal and minimal time
differs from the view in the previous portal. Therefore, one
surgeon’s two-o’clock position may be another surgeon’s
one-o’clock position, depending on the choice of portal,
rotation of the scope, and rotation of the camera.
SUMMARY
Proper tunnel placement is essential for a successful ACL
reconstruction. The complications that are caused by a
poorly placed tibial tunnel in the coronal or sagittal plane
cannot be overcome by the best graft material, fixation
methods, or rehabilitation program. Correct tibial tunnel
placement in the AP plane requires that the notch be
widened so that the space between the PCL and lateral fem-
oral condyle exceeds the diameter of the graft by 1 mm, the
tibial tunnel is placed such that the lateral edge passes
through the tip of the lateral spine, and the angle formed
by the tibial tunnel and the medial joint line and tibia is
between 60 and 65 degrees. In the sagittal plane, the center
of the tibial tunnel must be aligned 4 to 5 mm posterior to
the intercondylar roof in the extended knee so that roof
impingement is avoided without performing a roofplasty.
References
1. Fujimoto E, Sumen Y, Deie M, et al: Anterior cruciate ligament graft
impingement against the posterior cruciate ligament: diagnosis using
MRI plus three-dimensional reconstruction software. Magn Reson
Imaging 2004;22:1125–1129.
2. Howell SM, Gittins ME, Gottlieb JE, et al: The relationship between
the angle of the tibial tunnel in the coronal plane and loss of flexion
and anterior laxity after anterior cruciate ligament reconstruction. Am
J Sports Med 2001;29:567–574.
3. Simmons R, Howell SM, Hull ML: Effect of the angle of the femoral
and tibial tunnels in the coronal plane and incremental excision of the
posterior cruciate ligament on tension of an anterior cruciate ligament
graft: an in vitro study. J Bone Joint Surg Am 2003;85A:1018–1029.
4. Goss BC, Howell SM, Hull ML: Quadriceps load aggravates and
roofplasty mitigates active impingement of anterior cruciate ligament
grafts against the intercondylar roof. J Orthop Res 1998;16:611–617.
5. Goss BC, Hull ML, Howell SM: Contact pressure and tension in
anterior cruciate ligament grafts subjected to roof impingement during
passive extension. J Orthop Res 1997;15:263–268.
6. Howell SM, Clark JA, Farley TE: A rationale for predicting anterior
cruciate graft impingement by the intercondylar roof. A magnetic res-
onance imaging study. Am J Sports Med 1991;19:276–282.
7. Howell SM, Taylor MA: Failure of reconstruction of the anterior cru-
ciate ligament due to impingement by the intercondylar roof. J Bone
Joint Surg Am 1993;75:1044–1055.
8. Howell SM, Berns GS, Farley TE: Unimpinged and impinged ante-
rior cruciate ligament grafts: MR signal intensity measurements. Radi-
ology 1991;179:639–643.
9. Howell SM, Clark JA, Blasier RD: Serial magnetic resonance
imaging of hamstring anterior cruciate ligament autografts during

127
 Anterior Cruciate Ligament Reconstruction
the first year of implantation. A preliminary study. Am J Sports Med
1991;19:42–47.
10. Howell SM, Clark JA, Farley TE: Serial magnetic resonance study
assessing the effects of impingement on the MR image of the patellar
tendon graft. Arthroscopy 1992;8:350–358.
11. Watanabe BM, Howell SM: Arthroscopic findings associated with
roof impingement of an anterior cruciate ligament graft. Am J Sports
Med 1995;23:616–625.
12. Howell SM, Taylor MA: Brace-free rehabilitation, with early return to
activity, for knees reconstructed with a double-looped semitendinosus
and gracilis graft. J Bone Joint Surg Am 1996;78:814–825.
13. Shelbourne KD, Kerr B: The relationship of femoral intercondylar
notch width to height, weight, and sex in patients with intact anterior
cruciate ligaments. Am J Knee Surg 2001;14:92–96.
14. Howell SM, Barad SJ: Knee extension and its relationship to the slope
of the intercondylar roof. Implications for positioning the tibial tunnel
128
in anterior cruciate ligament reconstructions. Am J Sports Med
1995;23:288–294.
15. Markolf KL, Hame SL, Hunter DM, et al: Biomechanical effects of
femoral notchplasty in anterior cruciate ligament reconstruction. Am
J Sports Med 2002;30:83–89.
16. Howell SM: Principles for placing the tibial tunnel and avoiding
roof impingement during reconstruction of a torn anterior
cruciate ligament. Knee Surg Sports Traumatol Arthrosc 1998;6:
S49–S55.
17. Howell SM, Lawhorn KW: Gravity reduces the tibia when using a
tibial guide that targets the intercondylar roof. Am J Sports Med
2004;32:1702–1710.
18. www.drstevehowell.com/ezloc_video.cfm.
19. Cuomo P, Edwards A, Giron F, et al: Validation of the 65 degrees
Howell guide for anterior cruciate ligament reconstruction. Arthroscopy
2006;22:70–75.
 The Anteromedial Portal for Anterior
Cruciate Ligament Reconstruction
INTRODUCTION
The correct placement of the femoral tunnel is
very essential for the success of the anterior
cruciate ligament (ACL) reconstruction. The
transtibial drilling of the femoral tunnel has been
very much popularized because of its simplicity
and good visualization. However, there is evi­
dence that drilling the femoral tunnel through
the tibial tunnel can result in a nonanatomical
placement of the graft in the femur.1
In the past, drilling the femoral tunnel
more laterally at the medial surface of the lateral
femoral condyle (LFC) (2 or 10 o’clock) has been
proposed for better functional results, especially
to avoid not only the anterior drawer but also
the pathological rotation of the tibia.2–4 Recently
it was shown the tension curve of grafts in the
9-o’clock position is similar to the characteristic
pattern of the normal ACL’s tension curve.5 To
reach this position (centered at 2 or 10 o’clock
with the lowest point near 9 or 3 o’clock), the
anteromedial portal is essential.
Thus, the anteromedial portal has become
more and more attractive lately, and a large num­
ber of orthopaedic surgeons prefer this portal.6–12
ADVANTAGES
The advantages of this technique are as follows:
1 Easy manipulation of the instruments to drill
the tunnel in any position at the medial side
of the LFC without considering the
placement of the tibial tunnel.
19
CHAPTER
2 The femoral and tibial tunnels are drilled Manfred Bernard
separately. Thus, one can choose the desired
Stavros Ristanis
placement of the femoral tunnel without
considering the placement of the tibial Vassilis Chouliaras
tunnel. Hans Paessler
3 There is no risk of enlarging the tibial tunnel Anastasios Georgoulis
posteriorly, which can lead to poor fitting and
stabilization of the graft in the tunnel.
4 By using bone–patellar tendon–bone (BPTB)
graft, there is not any divergence when
placing the interference screw.
5 In two-bundle ACL reconstruction, it is
easier to choose the two entry points.
6 The drilling can be performed with the knee
flexed to 120 degrees. In this position the
10-o’lock and also the 9-o’clock position can
easily be reached without the risk of a blow­
out fracture of the dorsal corticalis of the
femoral condyle.
7 The correct rotation of the graft insertion
toward the long femur axis (important to
restore the anteromedial and posterolateral
bundle using BPTB graft) is easily found
because it is parallel to the tibia plateau in the
120-degree flexion position.
TECHNIQUE
The technique is as follows:
1 Place the anterolateral portal for the
arthroscope 2 to 3 cm higher than the tibial
plateau between the lateral distal border of
129
 Anterior Cruciate Ligament Reconstruction
the patella and the LFC. Place the anteromedial portal
1 cm higher than the tibial plateau and very close to the
medial border of the patellar tendon.
2 Resect the ligamentum mucosum and, if needed, pieces
of infrapatellar fat for better visualization. In 90 degrees
of flexion, débride the posterior surface of the medial
side of the LFC from soft tissues. The posterior margin
of the notch must be clearly identified to ensure an
over-the-top position. This identification is very
important to place the femoral tunnel as far posteriorly
as desired. Introduce a femoral guide (6 mm offset for
an 8-mm hamstring graft or 7 mm offset for a 10-mm
BPTB graft) through the medial portal.
3 Slowly flex the knee to 120 degrees, and check for good
visualization. Sometimes, higher fluid pressure is
demanded, or parts of the fat pad have to be removed to
have good visualization of the femoral footprint of the
ACL. The center of the femoral tunnel is the center of
the ACL footprint at 10 o’clock in the left knee and
2 o’clock in the right knee. Drill a 2.5-mm guidewire
through the LFC with the knee in 120 degrees of
flexion; the drill exits from the skin at the lateral side of
the femur. In this position (120 degrees of flexion), the
drill should be aligned parallel to the tibial plateau.
Thus, a dorsal blow-out fracture is surely avoided.
4 If you are certain that the guidewire is in the correct
position, overdrill the guidewire with a reamer in the
chosen depth (8-mm diameter and 35-mm depth for a
hamstring graft stabilized by Endobutton or 10-mm
diameter and 25-mm depth for a BPTB graft).
5 If you are not sure about the correct position, the
placement of the guidewire should be controlled
fluoroscopically (recommended for all arthroscopic
procedures) as follows:
FIG. 19-1 Withdraw the K wire (A) until its end is flush with the wall of the lateral condyle (B).
130
Change the drilling machine and fix it at that end of
the wire that exits through the skin. Withdraw the
Kirschner wire (K wire) until its inner end is flushed
with the bone level of the LFC. Now the ending of
the K wire marks the estimated center of ACL
insertion (Fig. 19-1).
Under fluoroscopic control in strictly lateral
projection, superimpose both femoral condyles on
the monitor. Measure the position of the end of the
K wire using the quadrant method (Figs. 19-2
and 19-3).13
It is not necessary to perform an additional
fluoroscopic tunnel view because the quadrant method
determines the position of the end of the K wire in
the anteroposterior direction as well (Fig. 19-4).
Overdrill the K wire if its position is correct; if not,
replace the K wire, and repeat the fluoroscopy.
6 Remove a small piece of the entry of the femoral tunnel,
where the screw has to be inserted by BPTB graft.
7 Drill the tibial tunnel in 90 degrees of flexion. The entry
point is selected close to the anterior border of the medial
collateral ligament (MCL). The center of the tibial
tunnel in the intraarticular space is slightly medial to the
center of the intercondylar region on a line joining the
inner edge of the anterior horn of the lateral meniscus
and the medial tibial spine. With the knee joint in
hyperextension and dorsal drawer position, we check that
this point is at least 5 mm dorsal from the roof of the
intercondylar notch to avoid an impingement of the graft.
8 Introduce the tibial guide, and insert a guidewire at an
angle of 60 degrees to the tibial plateau. Overdrill the
guide with the desired reamer, and check for possible
impingement.

FIG. 19-2 Fluoroscopic control in lateral projection (A). The end of the K
wire (red circle) marks the estimated center of the insertion (B).
9 With eyelet K wire, pull a suture to the lateral side of
the femur. Pull the suture from the tibial tunnel until
the medial side of the tibia is reached.
10 Pull the graft to the desired position, using this suture.
Sometimes it is necessary to extend or flex the knee joint
to facilitate passing the graft through the tibial and
femoral tunnels.
11 Using the BPTB graft, rotate the femoral bone
block in the tunnel such that the anatomical angle
between the long axis of the insertion area and the
long axis of the femur is restored. This is reached
by adjusting the corticalis of the bone block
parallel to the tibial plateau in 120 degrees of
The Anteromedial Portal for Anterior Cruciate Ligament Reconstruction 19
FIG. 19-3 Quadrant method: taking a strictly lateral radiograph,
superimposing both condyles, quartering the sagittal diameter, and
quartering the notch height. The center of the anterior cruciate ligament
(ACL) insertion is located in the distal corner of the most superoposterior
quadrant (arrow).
knee flexion. In this position the anatomy of
the anteromedial and posterolateral bundle is
reconstructed.
12 Performing the double-bundle technique; the line
between both femoral drill holes should be parallel to
the tibial plateau in 120 degrees of knee flexion to
restore the correct course of the bundles. This
orientation is only achieved using the anteromedial
portal (Fig. 19-5).
13 Using the BPTB graft, insert a screw guide parallel to
the bone plug through the small widening of the
femoral tunnel. Flex the knee joint to 120 degrees, and
insert the screw under visualization.
14 Fix the graft at the tibia in about 25 to 30 degrees of
flexion.
POSSIBLE COMPLICATIONS
Possible complications include the following:
1 Risk of breaking the posterior femoral cortex if the knee
is not in 120 degrees of flexion.
2 Poor visualization by inserting an interference screw
in 120 degrees of flexion. In this case, insert the screw
in 90 degrees of flexion until the tip is at the
femoral tunnel, and then bend the knee joint in
120 degrees of flexion, and insert the screw in this
position.
131
 Anterior Cruciate Ligament Reconstruction

FIG. 19-4 Example of K wire positioning in true lateral projection (A) and in Frick’s projection (B). The yellow
arrows demonstrate the correlation of the endings of the K wires (black points) in both projections if they are even
with the bony surface of the condyle. The position in craniocaudal direction in the lateral view corresponds to the
clockwise position in the tunnel view. For instance, a positioning at 25% of B (height of the notch) in the lateral
view leads to the 1:30 clock position in the anteroposterior view (left knee). A drill hole that is positioned at 0% of B
in the lateral projection would be in the high-noon position in Frick’s projection.

120˚

Axis femur

25˚

90˚
26˚

Axis tibia

5˚

A B
FIG. 19-5 In 120 degrees of knee flexion, the corticalis of bone block should be adjusted toward and parallel to the tibial plateau. Because of the tibial slope,
an angle of 25 degrees results between the long axis of the insertion area and the axis of the femur (A). This corresponds to the anatomical inclination angle
of 26 degrees between both axes (B). Restoring this correct inclination angle is important to reconstruct the course of the anteromedial and posterolateral
bundle. Similar conditions are valid when performing the double-bundle technique. In this case the line between both femoral drill holes should be parallel
to the tibial plateau in 120 degrees of knee flexion. This orientation is only achieved using the anteromedial portal.

132

References
1. Arnold MP, Kooloos J, van Kampen A. Single-incision technique
misses the anatomical femoral anterior cruciate ligament insertion: a
cadaver study. Knee Surg Sports Traumatol Arthrosc 2001;9:194–199.
2. Georgoulis A, Papadonikolakis A, Papageorgiou CD, et al. Three-
dimensional tibiofemoral kinematics of the anterior cruciate ligament-
deficient and reconstructed knee during walking. Am J Sports Med
2003;31:76–79.
3. Ristanis S, Giakas G, Papageorgiou CD, et al. The effects of anterior
cruciate ligament reconstruction on tibial rotation during pivoting
after descending stairs. Knee Surg Sports Traumatol Arthrosc 2003;
11:360–365.
4. Yagi M, Wong E, Kanamori A, et al. Biomechanical analysis of an
anatomic anterior cruciate ligament reconstruction. Am J Sports Med
2002;30:660–666.
5. Arnold MP, Verdonschot N, van Kampen A. ACL graft can replicate
the normal ligament’s tension curve. Knee Surg Sports Traumatol
Arthrosc 2005;13:625–631.
6. Paessler HH. New techniques in knee surgery. Darmstadt, 2003.
7. Scranton PE, Pinczewski L, Auld MK, et al. Outpatient endoscopic
quadruple hamstring anterior cruciate ligament reconstruction. Oper
Tech Orthop 1996;6:177–180.
8. Giron F, Buzzi R, Aglietti P. Femoral tunnel position in anterior cru­
ciate ligament reconstruction using three techniques. A cadaver study.
Arthroscopy 1999;15:750–756.
9. Hertel P, Behrend H, Cierpinski T, et al. ACL reconstruction using
bone-patellar tendon-bone press-fit fixation: 10-year clinical results.
Knee Surg Sports Traumatol Arthrosc 2005;13:248–255.
10. Chhabra A, Kline AJ, Nilles KM, Harner CD. Tunnel expansion after
anterior cruciate ligament reconstruction with autogenous hamstrings:
a comparison of the medial portal and transtibial techniques. Arthro­
scopy 2006;22:1107–1112.
The Anteromedial Portal for Anterior Cruciate Ligament Reconstruction 19
11. Bellier G, Christel P, Colombet P, et al. Double-stranded hamstring
graft for anterior cruciate ligament reconstruction. Arthroscopy 2004;
20:890–894.
12. Morgan CD, Stein DA, Leitman EH, Kalman VR. Anatomic tibial
graft fixation using a retrograde bio-interference screw for endoscopic
anterior cruciate ligament reconstruction. Arthroscopy 2002;18(7):E38.
13. Bernard M, Hertel P, Hornung H, et al. Femoral insertion of the ACL.
Radiographic quadrant method. Am J Knee Surg 1997;10:14–22.
Suggested Readings
Galla M, Uffmann J, Lobenhoffer P. Femoral fixation of hamstring
tendon autografts using the TransFix device with additional bone grafting
in an anteromedial portal technique. Arch Orthop Trauma Surg
2004;124:281–284.
Georgoulis AD, Papageorgiou CD, Makris CA, et al. Anterior cruciate lig­
ament reconstruction with the press-fit technique: 2–5 years follow-up of
42 patients. Acta Orthop Scand Suppl 1997;275:42–45.
Georgoulis AD, Tokis A, Bernard M, et al. The anteromedial portal for
drilling of the femoral tunnel for ACL reconstruction. Tech Orthop
2005;20:228–229.
Gobbi A, Mahajan S, Tuy B, et al. Hamstring graft tibial fixation: bio­
mechanical properties of different linkage systems. Knee Surg Sports
Traumatol Arthrosc 2002;10:330–334.
Hantes ME, Dailiana Z, Zachos VC, et al. Anterior cruciate ligament
reconstruction using the Bio-TransFix femoral fixation device and ante­
romedial portal technique. Knee Surg Sports Traumatol Arthrosc
2006;14:497–501.
Lobenhoffer P, Bernard M, Agneskirchner J. Qualitätssicherung in der
Kreuzbandchirurgie. Arthroskopie 2003;16:202–208.
Pässler HH, Höher J. Intraoperative Qualitätskontrolle bei der Bohrkanalplat­
zierung zum vorderen Kreuzbandersatz Unfallchirurg 2004;107:263–272.
133
20
CHAPTER
The Retrodrill Technique for Anterior
Cruciate Ligament Reconstruction
Giancarlo Puddu INTRODUCTION
Guglielmo Cerullo
Arthroscopic controlled retrograde drilling of
Massimo Cipolla femoral and tibial sockets and tunnels using a spe-
Vittorio Franco cially designed cannulated drill pin and retrocutter
Enrico Giannì (Fig. 20-1) provides greater flexibility for anatomi-
cal graft placement and avoids previous tunnels
and intraosseous hardware in revision cases.
Inside-out drilling of femoral and tibial sockets
minimizes incisions and eliminates intraarticular
cortical bone fragmentation of tunnel rims com-
mon to conventional antegrade methods. This
technique is also ideal for skeletally immature
patients because drilling and graft fixation through
growth plates may be avoided. Initial tunnel posi-
tioning (and not referencing) for cannulated drill
guide pin placement is carried out from outside-
in. This technique (outside-in/inside-out) com-
bines the advantages of the two-incision and
one-incision techniques. In fact, it permits sur-
geons, as with the two-incision technique, to drill
a pin guide from outside to inside in order to
obtain the correct anatomical insertion of the ante-
rior cruciate ligament (ACL) (Fig. 20-2), which is
otherwise not reproducible from inside-out.
This technique permits the surgeon to
prepare a femoral and a tibial socket or tunnel
by initiating the socket drilling from the intra-
articular surfaces in an inside-out method
(Fig. 20-3). Since November 2004, our preferred
technique for hamstring (autogenous quadrupled
semitendinosus/gracilis) ACL reconstruction in-
corporates the just-mentioned femoral socket
creation. In recent years, arthroscopically assisted
134
ACL reconstruction has become the procedure of
choice. Initially, arthroscopic techniques required
two incisions for outside-in drilling of bone tun-
nels, but there has been a trend toward using a
single incision with inside-out drilling of the
femoral tunnel. Those who advocate the two-
incision technique state that they do so primarily
because they believe that the two-incision proce-
dure facilitates accurate femoral tunnel place-
ment.1,2 Harner et al3 found no difference in
tunnel placement using the two-incision tech-
nique, whereas Schiavone et al4 found that the
femoral tunnels were significantly more vertical
in the one-incision procedure. We have per-
formed two-incision ACL reconstruction rou-
tinely since 1977 with very favorable results.
The recent variation in our technique affords a
reduction in morbidity associated with improved
cosmesis and quicker postoperative recovery.
A factor related to our success appears to be the
result of a more anatomically positioned femoral
tunnel, which in our hands is difficult to accom-
plish with single-incision transtibial femoral
socket creation. Arnold et al,1 who examined
the arthroscopic appearance of the ACL attach-
ment in fresh frozen cadaver knees, found that
the ligament consistently inserted on the lateral
wall of the notch. No fibers were found to attach
high in the roof. Furthermore, they found that
the single-incision technique always missed the
anatomical femoral ACL insertion. Another
advantage of the retrodrill is that the traditional
(outside-in) drilling methods disrupt the proxi-
mal tibial cortex with the drill penetration and
 The Retrodrill Technique for Anterior Cruciate Ligament Reconstruction 20

FIG. 20-1 The 3-mm threaded cannulated drill pin with the retrodrill
assembled.

FIG. 20-3 The retrodrill is assembled into the guide pin and begins to
create the femoral socket.

FIG. 20-2 The pin is in the correct anatomical position in the notch.

may lead to tunnel widening. Retrodrilling produces a

consistently smooth tibial and femoral intraarticular socket
or tunnel entrance, maintaining the desired cortical
integrity (Fig. 20-4).
The retrodrill technique allows preparation of the
correct anatomical femoral and tibial socket or tunnel with a
very small lateral skin incision or without any skin incisions
if the surgeon is using an allograft, and it appears to represent
a promising futuristic technique in ACL reconstruction.

FEMORAL TUNNEL PLACEMENT

Over the past several decades, bioengineers and orthopaedic
surgeons have applied the principles of biomechanics to gain
valuable information about the tunnel placement in ACL
FIG. 20-4 The traditional drilling method disrupts the proximal tibial
reconstruction and its relationship to knee stability. Still, cortex (A); the retrodrill technique produces consistently a smooth tibial
both short- and long-term clinical outcomes studies have entrance, maintaining the desired cortical integrity (B).

135
 Anterior Cruciate Ligament Reconstruction
revealed that 11% to 32% of the patients experience unsatis-
factory results after ACL reconstruction.5 The position of
an ACL graft is the most critical surgical variable because
it has a direct effect on knee biomechanics and, ultimately,
on clinical outcome. Currently, limited data are available
from prospective studies that identify the optimal intraarti-
cular position of an ACL graft on the femur and tibia.
A recent review of the literature by Beynnon et al6 shows
that the center of the femoral attachment of an ACL graft
should be located along a line parallel to the Blumensaat
line, just posterior to the center of the normal ACL’s inser-
tion to bone at either the 10-o’clock position (right knee) or
the 2-o’clock position (left knee) when observed through the
femoral notch. Graft placement, especially the tunnel on the
femoral side, has long been a subject of debate. To date,
most surgeons choose to place it in the footprint of the ante-
romedial bundle of the ACL (i.e., near the 11-o’clock posi-
tion on the frontal view of the right knee). However, results
of biomechanical and clinical research have suggested that it
is necessary to place the tunnel more laterally for rotatory
knee stability. Yamamoto et al5 compared a lateral and an
anatomical tunnel placement using a robotic universal force
sensor and concluded that a lateral tunnel placement can
restore rotatory and anterior knee stability similarly to an
anatomical reconstruction when the knee is near extension.
Loh et al7 published a paper studying how well an ACL
graft fixed at the 10- and 11-o’clock positions could restore
knee function in response to both externally applied anterior
tibial and combined rotatory loads by comparing the bio-
mechanical results with each other and with the intact knee.
They concluded that the 10-o’clock position more effec-
tively resists rotatory loads when compared with the
11-o’clock position, as evidenced by smaller anterior tibial
translation and higher in situ force in the graft. More
recently Scopp et al8 performed a biomechanical study on
10 matched pairs of fresh frozen cadaver knees alternately
assigned to a standard or an oblique tunnel position (at
10-o’clock) reconstruction. The investigators concluded
that an ACL reconstruction using oblique femoral tun-
nels restored normal knee kinematics. In conclusion, it
appears that actually there is a trend toward placing the
femoral tunnel more laterally between the anteromedial
and posterolateral anterior cruciate footprints (i.e., the
10-o’clock position). Biomechanics helped to clarify that
although fixation at 11 o’clock is effective to resist an
anterior tibial load, the more lateral 10-o’clock position
could achieve better knee stability under rotatory loads
(i.e., pivot shift). More recently, Arnold et al9 found that
it is possible to replicate the characteristics of the tension
curve of the normal ACL with a graft in a tunnel located
at the 9-o’clock position.
136
SURGICAL TECHNIQUE
With the knee flexed at 90 degrees, after removing the
remnants of the torn ACL, soft tissue and periosteum are
débrided from the lateral wall of the notch. Additional bony
notchplasty is performed as needed. The posterior margin of
the notch is clearly identified.
To locate the desired center of the femoral tunnel, we
use a femoral guide recently made by Arthrex (Naples, FL)
that keys off the over-the-top position. The guide enters the
knee from the anteromedial portal and with its curved hook
is fastened to the lateral femoral condyle in the over-the-top
position at the 10:30 position for the right knee and the
1:30 position for the left knee. Our guide, with its variable
hook, permits us to drill a specially designed cannulated guide
pin from outside to inside that emerges in the lateral wall of
the notch just 4 to 6 mm anterior to the posterior margin of
the notch. When drilled, this creates a tunnel 7 to 10 mm in
diameter, which leaves a 0.5- to 1-mm rim of posterior cortex.
Reproducing this tunnel with the exact location in the frontal,
sagittal, and coronal planes with a guidewire drilled from
inside-out is quite impossible, especially if done through a
predrilled tibial tunnel. With the guide positioned in the
notch, a mini (2-cm) lateral skin and fascia incision is carried
out corresponding with the tip of the guide, and the drill
sleeve is advanced to the femoral cortex along the lateral
aspect of the knee (Fig. 20-5). A cannulated threaded pin
(3 mm in diameter) is drilled through the drill sleeve and
the femoral condyle until it enters intraarticularly, as observed
with the arthroscope (see Fig. 20-2). The correct location is
confirmed. Then a mini retrograde cutting drill (retrocutter)
(Arthrex) 7 to 10 mm in diameter (depending on the width
of the graft that has been previously harvested and measured)
FIG. 20-5 Via the placement of a special femoral guide, a cannulated pin is
inserted from outside into the femoral notch.

is introduced in the knee from the anteromedial portal
already preloaded on a reverse-threaded instrument. As
threads of the guide pin engage the retrocutter, the reverse
threads of the drill holder facilitate simultaneous disengage-
ment of the retrocutter from the instrument (Fig. 20-6, A ).
A handle is set up on the outer end of the pin to permit
the manual advancement of the inner end of the pin onto
the retrocutter.
The cannulated pin is also calibrated in order to easily
know the lateral condyle width. Then a socket of 2.5 to
3.5 cm is retrodrilled, pulling the drill from outside
(Fig. 20-6, B), leaving 1 cm of intact bone. The retrodrill
is then gently pushed back in the joint. Once the retrocutter
engages its holder, the drill is reversed; reverse drilling
securely engages the retrocutter on the holder and simul-
taneously disengages the retrocutter from the threaded
guide pin. A shaver is used to remove any debris in the
joint and to chamfer the tunnels edges, and a suture (#2
FiberStik, Arthrex) is introduced in the joint through the
cannulated pin for graft passing.
A tibial tunnel of the same diameter is prepared in a
routine manner, or a tibial socket can be made in the same
way as the femoral (Fig. 20-7) if so planned by the surgeon.
The suture is pulled out from the tibial tunnel. The graft
(quadruple gracilis and semitendinosus) is marked to locate
the exact portion that has to fill the femoral tunnel and is
prepared with two #5 Fiberwire (Arthrex) sutures at the
femoral end and passed in the knee from the tibial to the
FIG. 20-6 The femoral cannulated guide pin engages the retrodrill and simultaneously disengages it from the
holding instrument (A); the femoral socket is created by pulling distally, and retrograde drilling is completed to the
socket depth planned by the surgeon (B). (Reprinted with permission from Arthrex, Inc., Naples, FL.)
The Retrodrill Technique for Anterior Cruciate Ligament Reconstruction 20
femoral tunnel. The fixation sutures exiting the lateral cor-
tex of the femur are passed through a four-hole metal but-
ton and tied securely to fix the graft on the femur
(Fig. 20-8). Either square or sliding knots can be used for
this kind of suspension fixation.
The tibial fixation is carried out in a routine way using
an interference metal screw coupled with a staple or, more
recently, with Fiberwire whipstitches interwoven in the graft
and tied around a screw.
PRELIMINARY RESULTS AND CONCLUSIONS
Our 70 cases performed from November 2004 to November
2005 (2 to 14 months of follow-up) do not permit a long-
term evaluation. No intraoperative complications occurred
when performing the retrodrill technique. In three cases
the drill was not perfectly engaged in the pin, so we had
to retrieve the drill from the joint with a grasper and reposi-
tion it onto the cannulated pin. There were no postoperative
complications, and the early results evaluated with the Inter-
national Knee Documentation Committee (IKDC) scoring
system are very good.
The retrodrill technique seems to be safe and effective
for femoral socket preparation, as it is very likely to be for
the tibial socket, representing the initial step for a
completely “all inside” arthroscopic ACL reconstruction.
137
 Anterior Cruciate Ligament Reconstruction

FIG. 20-7 The 3-mm cannulated drill guide pin is drilled through the tibia and the retrodrill is assembled (A); the
tibial socket or tunnel is created, pulling the retrodrill to the depth planned by the surgeon (B). (Reprinted with
permission from Arthrex, Inc., Naples, FL.)

References
1. Arnold MP, Kooloos J, van Kampen A. Single incision technique
misses the anatomical femoral anterior cruciate ligament insertion: a
cadaver study. Knee Surg Sports Traumatol Arthrosc 2001;9:194–199.
2. Khon D, Busche T, Carls J. Drill hole position in endoscopic anterior
cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthroscop
1998;6:S13–S15.
3. Harner C, Marks P, Fu F, et al. Anterior cruciate ligament reconstruc-
tion: endoscopic versus two incision technique. Arthroscopy 1994;
10:502–512.
4. Panni AS, Milano G, Tartarone M, et al. Clinical and radiographic
results of ACL reconstruction: a 5- to 7-year follow-up study of
outside-in versus inside-out reconstruction technique. Knee Surg Sports
Traumatol Arthrosc 2001;22:77–85.
5. Yamamoto Y, Hsu WH, Woo SL-Y, et al. Knee stability and graft
function after anterior cruciate ligament reconstruction: a comparison
of a lateral and an anatomical femoral tunnel placement. Am J Sports
Med 2004;32:1825–1832.
6. Beynnon BD, Johnson RJ, Abate J, et al. Treatment of anterior cruciate
ligament injuries, part II. Am J Sports Med 2005;33:1751–1767.
7. Loh JC, Fukuda Y, Tsuda E, et al. Knee stability and graft function fol-
FIG. 20-8 The button is inserted through the lateral femoral incision, and lowing anterior cruciate ligament reconstruction: comparison between
with two limbs of #5 reinforced suture (Fiberwire, Arthrex), the graft is fixed 11 o’clock and 10 o’clock femoral tunnel placement. Arthroscopy
to the femur. 2003;19:297–304.

138

8. Scopp JM, Jasper LE, Belkoff SM, et al. The effect of oblique femoral
tunnel placement on rotational constraint of the knee reconstructed
using patellar tendon autografts. Arthroscopy 2004;20:294–299.
9. Arnold MP, Verdonschot N, Van Kampen A. ACL graft can replicate
the normal ligament’s tension curve. Knee Surg Sports Traumatol
Arthrosc 2005;13:625–631.
Suggested Readings
Andersen H, Dyhre-Poulsen P. The anterior cruciate ligament does play a
role in controlling axial rotation in the knee. Knee Sur Sports Traumatol
Arthrosc 1997;5:145–149.
The Retrodrill Technique for Anterior Cruciate Ligament Reconstruction 20
Beynnon BD, Johnson RJ, Abate JA, et al. Treatment of anterior cruciate
ligament injuries, part I. Am J Sports Med 2005;33:1579–1602.
Markolf KL, Hame S, Hunter DM, et al. Effects of femoral tunnel place-
ment on knee laxity and forces in an anterior cruciate ligament graft.
J Orthop Res 2000;20:1016–1024.
Puddu G, Cerullo G. My technique in femoral tunnel preparation: the ret-
rodrill technique. Tech Orthop 2005;20:224–227.
Ristanis S, Stergiou N, Patras K, et al. Excessive tibial rotation during
high-demand activities is not restored by anterior cruciate ligament
reconstruction. Arthroscopy 2005;1:1323–1329.
Sommer C, Friederich NF, Muller W. Improperly placed anterior cruciate
ligament grafts: correlation between radiological parameters and clinical
results. Knee Surg Sports Traumatol Arthrosc 2000;8:207–213.
139
21
CHAPTER
Femoral Tunnel Placement to Restore
Normal Knee Laxity After Anterior Cruciate
Ligament Reconstruction
Andrew A. Amis* INTRODUCTION
In order to perform a successful anterior cruciate
ligament (ACL) reconstruction, the surgeon
must make a number of steps that require correct
judgment and execution, but there is evidence
that the most frequent cause of failure is malposi-
tioning of the graft tunnel in the femur.1 This is
not surprising because of the anatomy of the inte-
rior of the knee joint and the difficulty of seeing
the femoral attachment of the ACL. Because
the surgeon views the interior of the intercondy-
lar notch when the knee is flexed, the ACL
attachment is carried back into the furthest recess
of the knee. This means that there is plenty of
scope to err with the tunnel placement if the
ACL attachment is not visualized clearly. In par-
ticular, the undulating surface of the femoral
intercondylar notch includes a transverse ridge
or bulge that should come between the observer
and the proximal part of the ACL attachment;
the inexperienced surgeon may believe that this
ridge is the posterior outlet of the notch and then
place the graft tunnel shallow to that ridge in a
nonanatomical position. The frequency of this
error has led to common usage of the term “resi-
dent’s ridge” to describe this anatomical feature.
The aim of this chapter is to describe the
evolution of knowledge regarding ACL graft
placement on the femur, which relates closely to
our understanding of the function of the ACL
*The author thanks all the surgeons engaged in ACL surgical
research who have generously shared their expertise with him
recently in his travels around the world, which were undertaken with
the generous support of the BREG-ACL Study Group International
Research Professorship.
140
itself. There has been a recent move toward
“anatomical” reconstructions, with two grafts in
parallel, attempting to reproduce two functional
fiber bundles of the ACL. This has prompted a
better appreciation of the natural ACL attach-
ment anatomy when performing a conventional
single-bundle reconstruction. The tibial attach-
ment is not considered here because changes of
the femoral attachment have a much larger effect
on ACL graft tension and length changes.2
In this chapter, two distinct sets of termi-
nology will be used to describe femoral graft
tunnel positions: (1) anatomical nomenclature for
describing positions when the knee is in extension
(anterior-posterior, proximal-distal) and (2) surgi-
cal nomenclature for describing what the surgeon
views when the knee is flexed approximately 90
degrees (high-low, deep-shallow, respectively).3
FUNCTIONAL ANATOMY OF THE
ANTERIOR CRUCIATE LIGAMENT
RELATED TO GRAFT TUNNELS
The ACL has a complex fiber structure com-
posed of many fascicles bound together within a
synovial covering layer. The fibers are not
arranged simply in parallel, and this gives rise to
the cross-sectional area being less at the mid-
length than at the bony attachments: the fibers
must splay out toward the bones.4 The functional
significance of this architecture is not under-
stood. However, at a gross level, the fibers of the
ACL are arranged as a flat band, and all are
 Femoral Tunnel Placement to Restore Normal Knee Laxity After Anterior Cruciate Ligament Reconstruction
tensed when the knee is extended (Fig. 21-1, A ). This fiber
band is oriented in a sagittal plane so that the ACL fits into
and fills the narrow slot between the posterior cruciate
ligament (PCL), which occupies most of the width of the
intercondylar notch, and the lateral femoral condyle. The
sagittal plane of the ACL orientation means that it attaches
to the tibia over an area that is oriented anteroposterior
(AP). The ACL attaches to the femur over an area that
is oriented from anteroproximal to posterodistal.5 This
femoral attachment is close to and bounded posteriorly by
the condylar articular cartilage and has an overall alignment
approximately 35 degrees posterior-distal to the axial.6
When the knee flexes, the axis of rotation moves within
the distal femur and the kinematics are affected by the loads
AMB tight
PLB tight
A a graft isometrically is that this implies the graft will not be
AMB tight
PLB slack
in flexion
B ner of the natural ACL attachment area.2,9 This means that
FIG. 21-1 A, The anterior cruciate ligament (ACL) is arranged to form a
parallel-fibered, ribbon-like structure when the knee is extended; the fibers
are tensed in both the anteromedial bundle (AMB) and posterolateral
bundle (PLB). B, When the knee flexes, the PLB slackens and its femoral
attachment passes between the tight AMB and the wall of the notch; this
causes the ACL to twist with knee flexion.
21
imposed on the knee, but the overall effect in the intact knee
is that the most anterior fibers of the ACL remain close to a
constant length and thus are often described as being “isomet-
ric.” Meanwhile, the more posterior the fibers, the more they
slacken as the knee flexes, up to 90 degrees flexion2,7–10
(Fig. 21-1, B). These length change patterns have been
measured in a number of studies,2,7,11 and it is generally
accepted that an “isometry map” can be derived from such
measurements.2,9,10 A modern surgical navigation system
can produce such maps in response to the surgeon moving
the knee during ACL reconstruction procedures, giving a
patient-specific feedback on the likely length changes
associated with choices of graft tunnel positions around the
intercondylar notch12 (Fig. 21-2).
ANTERIOR CRUCIATE LIGAMENT ISOMETRY
AND RECONSTRUCTION
The observation that the anterior fibers of the ACL remained
tight across the range of knee flexion, whereas the more pos-
terior parts slackened, led to the belief that the anterior fibers
were the most important. This was reinforced by the finding
that the more anterior fibers had a greater material failure
strength,13 which suggests that they have adapted to a more
mechanically demanding role. A similar finding has been
made for the PCL.14 These findings have been correlated
with a higher collagen density in the anterior fiber bundles
of both the ACL and PCL.15 A more practical reason to place
subjected to cyclical length changes when the knee is moving,
thus helping to protect it from fatigue or loosening effects.
For example, O’Meara et al16 reported that isometric grafts
survived cyclical motion in a continuous passive motion
machine, whereas nonisometric grafts did not.
The problem with this line of reasoning is that isom-
etry measurements depend on the ACL being intact; other-
wise the kinematics may be abnormal. Even when the ACL
is intact, the isometric area on the femoral condyle is influ-
enced sensitively by the loads imposed on the knee while it
is being moved. This was shown by Zavras et al,17 who pub-
lished a map showing a range of different recommended
isometric graft locations from the previous literature
(Fig. 21-3). Their reproduction of the published works con-
firmed that isometric behavior could be found reliably for
attachment points only at the extreme anteroproximal cor-
“isometric” ACL reconstructions are nonanatomical, with
the femoral graft tunnel centered higher and deeper in the
notch (with the knee flexed) than the natural attachment
area. Despite this, the mainstream of opinion through the
1990s favored femoral graft tunnels placed isometrically.
141
 Anterior Cruciate Ligament Reconstruction
M L
Although many clinical papers were published to report a
high percentage of good and excellent results, there
remained a high level of interest in ACL research and devel-
opment, reflecting an underlying dissatisfaction with clinical
outcome and a desire to find ways of improvement.
One of the underlying principles that emerged from
the isometry research studies was that there is a transition
line between attachments that causes graft tightening or
slackening with knee flexion.2 The transition line passes
through the isometric point at the anteroproximal edge of
the ACL attachment and from there runs distal and slightly
posterior.2,8,9 Attachments anterior to the transition line
lead to graft tightening with knee flexion, whereas grafts
posterior to the transition line slacken (Fig. 21-4).
At present, the principal method for objective assess-
ment of the restoration of normal mechanics to the knee
after ACL reconstruction is the measurement of tibiofe-
moral anterior translation laxity; that is, how far anteriorly
the tibia moves in response to a known displacing force at
142
FIG. 21-2 A map of fiber attachment
length changes produced during
anterior cruciate ligament (ACL)
reconstruction surgery by a
navigation system. The “contour
lines” represent areas with a given
length change measured over a
range of knee flexion. They converge
toward a central zone of minimal
length change. (With thanks for
permission to Dr. Philippe Colombet,
Merignac, France.)
a given angle of knee flexion. Very little work has been done
to examine how well different ACL graft positions can
restore anterior laxity to normal across the range of knee
flexion. Even an incorrect graft placement might restore
anterior drawer to normal at one angle of knee flexion (by
adjusting the tension appropriately), but then it might
behave abnormally and either overconstrain or allow exces-
sive laxity as the knee moves away from the posture where
the graft had been tensed.
A study of alternative graft attachments investigated
the effect of moving to different attachment points either
at or around the isometric area on the femur.18 The
in vitro study used artificial grafts secured into a barrel that
was centered at the femoral isometric point (which had been
ascertained by isometry measurements while the ACL was
intact). Five attachment points were investigated: isometric,
then anteroproximal, anterodistal, posteroproximal, or pos-
terodistal to the isometric point, as shown in Fig. 21-5. It
was found to be possible to restore tibiofemoral anterior
 Femoral Tunnel Placement to Restore Normal Knee Laxity After Anterior Cruciate Ligament Reconstruction 21
S1 F H
Isometric
drill hole

L Original ACL B An
Proposed insertions 26

P AA
AM P
PP

18

15
F Superior
Central
T Inferior 11
5 mm

24
FIG. 21-3 Published isometric graft attachment sites: S1, Sidles et al10; F, Friederich and O’Brien9; H, Hefzy et al2;
L, Cazenave and Laboureau31; B, Blankevoort et al32; An (anatomic), Odensten and Gillquist.33 (Reproduced from
Zavras TD, Race A, Bull AMJ, et al. A comparative study of isometric points for ACL reconstruction. Knee Surg Sports
Traumatol Arthrosc 2001;9:28–33, with kind permission of Springer Science and Business Media.)

pp
ap

pd
ad

FIG. 21-4 The transition line between graft attachments, which leads to
graft tightening or slackening, passes posterodistally from the isometric
area. Anterior attachments cause tightening, and posterior attachments
cause slackening as the knee flexes.
FIG. 21-5 The five anterior cruciate ligament (ACL) graft attachment points
investigated by Zavras et al.17 The central isometric point and the more
posterior points lead to restoration of normal anterior laxity across the
range of knee flexion; the posterodistal point is close to the center of the
anatomical ACL attachment area. ad, Anterodistal; ap, anteroproximal;
pd, posterodistal; pp, posteroproximal. (Reproduced from Zavras TD, Race A,
Bull AMJ, et al. A comparative study of isometric points for ACL
reconstruction. Knee Surg Sports Traumatol Arthrosc 2001;9:28-33, with kind
permission of Springer Science and Business Media.)

143
 Anterior Cruciate Ligament Reconstruction
laxity close to normal across the range of knee flexion
investigated, with attachments that were either on that tran-
sition line or just posterior to it.18 The tendency of anterior
femoral attachments to move away from the matching tibial
attachment, and therefore cause the graft to tighten with
knee flexion, led to overconstraint of the flexed knee; this
was accompanied by elevated graft tension as the knee
flexed. Grafts placed distal and posterior to the isometric
point, which meant that they were in the anatomical ACL
attachment, restored anterior laxity to that of the intact knee
across the range of knee flexion investigated.
ANATOMICAL SINGLE-BUNDLE ANTERIOR
CRUCIATE LIGAMENT RECONSTRUCTION
The trend from isometric toward anatomical graft placement
was encouraged by growing evidence of limitations with
isometric grafts. In particular, their placement high in the
notch meant that they were close to the center of the knee,
which is not efficient if they are supposed to limit tibial
rotational laxity. There has been a growing awareness that res-
toration of physiological anterior laxity, as measured routinely
by a KT-1000 or similar device, is not sufficient to define a
return to the knee working normally and that tibial rotational
laxity is also important. The drawback of grafts placed high in
the notch has been demonstrated in vivo after ACL recon-
struction: one study found that the majority of knees with a
patellar tendon ACL reconstruction had traces of residual
rotational laxities during pivot-shift testing (a mini-pivot
remained).19,20 Other studies have found that the limb with
a reconstructed ACL had a persistence of abnormal tibial
rotation during gait analysis.21,22 In addition, Amis and
Dawkins7 cut the fiber bundles sequentially and measured
the reduction in force needed to induce a given tibial anterior
translation. The reduction in force needed to displace the tibia
indicated the contribution that the cut fiber bundle had made
to resisting tibial anterior drawer. It was found that the ante-
romedial fiber bundle was dominant in the flexed knee, as
expected, knowing that the rest of the ACL was then slack-
ened (see Fig. 21-1, B). Conversely, the posterolateral fiber
bundle was dominant when the knee was near extension.
This, of course, is the posture in which knee stability is most
important, when standing.
Such observations have led to a trend toward more
anatomical graft placement. In single-bundle ACL recon-
struction, that means that the tunnel should be placed at the
center of the ACL attachment, which is distal and posterior
to the isometric point. During surgery, with the knee flexed,
this translates into a tunnel that is lower on the lateral side wall
of the notch and also more shallow toward the surgeon
compared with the isometric point. In practice, this translates
144
into continuing to use a fixed offset from the posterior outlet
but bringing the guide around from approximately the
11-o’clock or 11:30 position to approximately the 10-o’clock
position in a right knee. If there is any doubt about the
accuracy of finding this point, in a chronic case in which
the ACL remnants have disappeared, a guidewire may be
placed and checked radiographically using the quadrant
method of Bernard et al,23 who documented the center of
the femoral ACL attachment. A method to navigate to
this point3 is shown in Fig. 21-6. Studies on cadaveric
knees24,25 have found that the anatomical tunnel placement
(at the 10 o’clock position) led to better control of tibial rota-
tion than did a tunnel placed higher in the notch (at the
11 o’clock position).
ANATOMICAL DOUBLE-BUNDLE ANTERIOR
CRUCIATE LIGAMENT RECONSTRUCTION
Recently there has been increasing interest in attempting to
more closely achieve an anatomical reconstruction using a
double-bundle graft. Although some studies have used dou-
ble grafts passing to or from single tunnels in either the tibia
or femur, it is usually accepted that an anatomical recon-
struction has two grafts in parallel when the knee is ex-
tended, with two tunnels in each of the tibia and femur.
The femoral ACL attachment has been split into the two
bundle areas in Fig. 21-7.
High
0%
Shallow Deep
28%
100%
100% 25% Low
FIG. 21-6 The center of the femoral attachment of the anterior cruciate
ligament (ACL) can be found by navigation in percentage terms from the
over-the-top position in deep–shallow and high–low directions in the
flexed knee.3 Bernard et al23 found the center of the ACL attachment to be
25% more shallow and 28% lower from the over-the-top position.
 Femoral Tunnel Placement to Restore Normal Knee Laxity After Anterior Cruciate Ligament Reconstruction 21

AM

AMB
PL
PLB AC

PCL

FIG. 21-7 The femoral anterior cruciate ligament (ACL) attachment with
the areas of the anteromedial (AMB) and posterolateral (PLB) fiber bundles.

FIG. 21-8 The typical positions of double tunnels in a right knee flexed 90
If the knee is viewed arthroscopically, the anatomical degrees, viewed from an anteromedial portal. Note how the anteromedial
bundle tunnel (AM) is close to the over-the-back position (asterisk) and that
ACL attachment area may be visualized via an anteromedial the posterolateral bundle tunnel (PL) is shallow (distal) and low (posterior)
portal; the viewpoint across the notch gives a better appreci- compared with the AM tunnel. Interrupted line, Approximate boundary of
ation of depth than can be gained when looking along the ACL attachment; AC, articular cartilage; PCL, posterior cruciate ligament.
(Illustration provided kindly by Dr. F. Giron, Prima Clinica Ortopedica,
lateral side wall from an anterolateral portal.26 The differ-
Florence, Italy.)
ences in the double-bundle attachment sites, compared with
the conventional tunnel high and deep in the notch, then
become apparent. The tunnel for the anteromedial graft will
still be close to the posterior outlet of the notch but will now DISCUSSION
be brought down to approximately the 10:30 position.
This chapter has outlined some of the thinking and research
Because of the sloping orientation of the posterior outlet
behind the recent evolution of femoral ACL graft tunnel
of the notch, moving to the lateral wall also takes the graft
placement. At one period the predominant doctrine was
tunnel toward the surgeon, which is more shallow (more
that the tunnel placement should produce isometric graft
distal). The tunnel for the posterolateral graft is farther dis-
behavior, but that resulted in the tunnel being placed high
tal and posterior anatomically, which means that it is lower
in the notch, which was not anatomical. The mainstream
on the side wall of the notch and much more shallow than
of opinion has more recently moved toward an acceptance
the first tunnel (Fig. 21-8). Typical positions will be at the
of anatomical graft placement, a philosophy to which some
9-o’clock orientation, with an offset sufficient to maintain
surgeons have always adhered. However, until recently there
a bone bridge between the tunnel mouths. With autogenous
has been little interest in making a comparison between
hamstring tendon grafts, the tunnels are typically 6 mm in
these approaches. Biomechanical researchers have produced
diameter, and an offset of 8 mm between the tunnel centers
evidence in vitro to support a move toward placing the ACL
maintains a bone bridge and matches the spacing of the
graft more anatomically, which is onto the lateral side wall
natural fiber bundle attachments. This position will be
of the intercondylar notch, at approximately 10 o’clock,
much closer to the surgeon than with a conventional recon-
and more shallow compared with the conventional isometric
struction and should also be low enough that the posterior
placements. A more recent development is the anatomical
edge of the tunnel is close to the articular cartilage margin
double-bundle reconstruction,28,29 but at present there is
at the place where it is closest to the tibia6 (see Fig. 21-8).
no reliable clinical evidence to support a change from a sin-
Various instruments are being developed to allow the second
gle-bundle ACL reconstruction.30
(posterolateral) tunnel to be located relatively easily at a
fixed offset distance from the first (anteromedial) tunnel,27
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 Anterior Cruciate Ligament Reconstruction
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ligament and a rationale for its reconstruction. J Bone Joint Surg
1985;67A:257–262.
 SUB PART II DOUBLE ANTEROMEDIAL AND POSTEROLATERAL FEMORAL-
TUNNEL FORMATION
Anatomical Double-Bundle Anterior
Cruciate Ligament Reconstruction
Procedure Using the Semitendinosus
and Gracilis Tendons
INTRODUCTION
The anterior cruciate ligament (ACL) is com-
posed of the anteromedial bundle (AMB) and
the posterolateral bundle (PLB), each with a
different function.1–3 Since 2000, the author
has reported the surgical principle4 and the
latest procedure5 for an anatomical double-
bundle ACL reconstruction that is intended
to anatomically reconstruct the AMB and the
PLB. In addition, the author’s team reported
a prospective cohort study to evaluate this ana-
tomical double-bundle procedure in compari-
son with single-bundle and nonanatomical
double-bundle ACL reconstruction procedures
using hamstring tendon grafts.6 Our procedure
has several noteworthy characteristics. First, all
four ends of two tendon grafts are grafted at
the center of the anatomical attachment of
the AMB or the PLB, not only on the femur
but also on the tibia. Second, we use the trans-
tibial tunnel technique to create femoral
tunnels. Third, we use the hamstring tendon-
hybrid graft,7,8 in which the femoral end is
connected with an Endobutton CL and the
tibial end is connected with a polyester tape.
Fourth, we fix the polyester tape portion
of the graft onto the tibia with two staples at
10 degrees of knee flexion, simultaneously
applying a 30N load to each graft. In this
chapter, the surgical principle and the proce-
dure of our anatomical double-bundle ACL
reconstruction are explained.
22
CHAPTER
PROCEDURE Kazunori Yasuda
Preparation for Arthroscopic
Surgery
Surgery is performed with an air tourniquet in
the standard supine position. An approximately
3-cm-long oblique incision is made in the ante-
romedial portion of the proximal tibia. The semi-
tendinosus and gracilis tendons are harvested
using a tendon stripper in the figure-four knee
position. When the semitendinosus tendon is
thick and long enough, the gracilis tendon is
not harvested. At the beginning of arthroscopic
surgery, a surgeon sits beside the knee joint of
the patient. An edge of a drape is attached to
a lumbar portion of the surgeon so that the
patient’s leg hanging beside the table can be
put on the surgeon’s knee in a sterile condition.
This setup allows the surgeon to control the
patient’s knee position using the surgeon’s own
knee. An arthroscope is inserted through the lat-
eral infrapatellar portal. After a routine arthro-
scopic examination, a remnant of the torn ACL
is resected, leaving 1-mm-long ligament tissue
at the femoral and tibial insertions, which can
be used as landmarks for inserting guidewires.
Creation of Tibial Tunnels
In ACL reconstruction procedures with the
transtibial tunnel technique, the greatest key
to success is to create a tibial tunnel with an
147
 Anterior Cruciate Ligament Reconstruction
D
TP
*
A
C FIG. 22-1 The wire navigator (A)
B Subsequently, the direction and the
B automatically determined.
appropriate three-dimensional (3D) direction. In other
words, a tibial tunnel should be created so that a guidewire
for femoral tunnel creation can be easily inserted at a tar-
geted point on the lateral condyle through the tibial tunnel.
To create such a tibial tunnel, we use a specially designed
wire guide, called a wire navigator (Fig. 22-1, A), which
was developed in our previous study.7,8 This device is com-
posed of a navi-tip and a wire sleeve. The navi-tip consists
of sharp tibial and femoral indicators. The axis of the wire
sleeve passes through the tip of the tibial indicator
(Fig. 22-1, B). First, a tibial tunnel for the PLB is created.
The navi-tip is introduced into the joint cavity through
148
and the concept of wire navigation
for the tibia (B). The wire navigator is
composed of a navi-tip (A) and a wire
sleeve (B). The navi-tip consists of the
tibial indicator (C) and femoral
indicator (D). The axis of the wire
sleeve is passed through the tip of
the tibial indicator. Keeping the tibial
indicator at the targeted point on the
tibia, we aim the femoral indicator at
the targeted point (TP) on the femur.
insertion point of the wire are
the medial infrapatellar portal. The surgeon holds the tibia
at 90 degrees of knee flexion, keeping the femur horizontal.
The tibial indicator of the navi-tip is placed at the center
of the PLB footprint on the tibia, which is located at the
most posterior aspect of the area between the tibial emi-
nences and 5 mm anterior to the posterior cruciate ligament
(Fig. 22-2). Keeping the tibial indicator on this point,
we aim the femoral indicator at the center of the PLB
footprint on the femur (Fig. 22-3, A), which is precisely
explained in the next section, and the proximal end of the
extraarticularly located wire sleeve is fixed on the antero-
medial aspect of the tibia through the skin incision made
 Anatomical Double-Bundle Anterior Cruciate Ligament Reconstruction Procedure Using the Semitendinosus and Gracilis Tendons
FIG. 22-2 Two tibial tunnel outlets are shown. They are created at the
center of the normal attachment of the anteromedial bundle (AMB) and
posterolateral bundle (PLB).
22
Next, a Kirschner wire for the AMB reconstruction
is drilled using the same wire navigator. The tibial indicator
is placed at the center of the tibial footprint of the AMB,
which is located at a point approximately 7 mm anterior
to the center of the first tunnel (see Fig. 22-2). Keeping
the tibial indicator on this point, we then aim the femoral
indicator at the center of the femoral footprint of the
AMB (Fig. 22-3, B). The wire sleeve is fixed on the antero-
medial cortex of the tibia. A Kirschner wire is then drilled
through the sleeve in the tibia. The knee should be extended
to ensure that the tip of the second wire is located at a
point 5 mm posterior to the anterior edge of the roof in
the intercondylar notch. The second tunnel is drilled with
an approximately 7-mm cannulated drill corresponding to
the measured diameter of the prepared substitute. Subse-
quently, two intraarticular outlets are aligned in the sagittal
plane (see Fig. 22-2).

for the graft harvest. The proximal end and the direction of
the wire sleeve are automatically determined depending on
the direction of the intraarticular navi-tip (see Fig. 22-1,
B). A Kirschner wire of 2 mm in diameter is drilled through
the sleeve in the tibia. According to our basic studies, this
tunnel does not injure this ligament because the insertion
point of the wire on the anteromedial aspect of the tibia is
located several millimeters anterior to the medial collateral
ligament.4 The first tunnel is made with an approximately
6-mm cannulated drill corresponding to the measured
diameter of the prepared substitute.
Creation of Femoral Tunnels
In the anatomical double-bundle procedure, it is essential
to precisely understand the attachment of the main ACL
fibers that should be reconstructed in ACL reconstruction.
Although the normal ACL has a wide footprint on the
lateral condyle,9–11 the author has found that the main
ACL fiber attachment that should be reconstructed in
ACL reconstruction is in the form of an egg, with its long
axis inclined toward the posterior direction by 30 degrees

FIG. 22-3 The navi-tip of the wire navigator in an arthroscopic visual field. First (A), keeping the tibial indicator at the
center of the posterolateral bundle (PLB) footprint on the tibia, a surgeon aims the femoral indicator at the center of
the PLB footprint on the femur. Then (B), keeping the tibial indicator at the center of the anteromedial bundle (AMB)
footprint on the tibia, a surgeon aims the femoral indicator at the center of the AMB footprint on the femur.

149
 Anterior Cruciate Ligament Reconstruction
to the long axis of the femur on the medial surface of the
lateral femoral condyle4 (Fig. 22-4).
First, a Kirschner wire is drilled at the center of the
femoral footprint of the AMB through the second tibial
tunnel, using the offset guide system (Transtibial Femoral
ACL Drill Guide, Arthrex, Naples, FL). This point is
located at the point 5 to 6 mm distal from the back of the
femur (see Fig. 22-4). This point is consistent with the
1:30 (or 10:30) orientation for the left (or right) knee. Using
this wire as a guide, a tunnel is made with a 4.5-mm cannu-
lated drill. The length of the tunnel is measured with a
scaled probe. Then, to precisely observe the lateral condyle
in the arthroscopic visual field, the portal for the arthroscope
is changed to the medial infrapatellar one. We have devel-
oped a reproducible method to identify the targeted point
in the arthroscopic visual field.4 When the surgeon holds
the tibia at 90 degrees of knee flexion, keeping the femur
horizontal, we can draw an imaginary vertical line through
the contact point between the femoral condyle and the tibial
plateau in the arthroscopic visual field (see Fig. 22-4). The
center of the attachment of the PLB is located approxi-
mately at the crossing point between the vertical line and
the long axis of the ACL attachment. Therefore, when the
remnant of the ACL is observed on the lateral condyle, this
point can be easily determined. If the remnant of the ACL
is not identified on the lateral condyle, the center of the
attachment of the PLB can be determined as the point
5 to 8 mm anterior to the edge of the joint cartilage on
FIG. 22-4 Attachment of the anterior cruciate ligament (ACL) on the
femur. The dotted lines show the attachment of the main fibers of the ACL.
When we drew a vertical line (VL) through the contact point (C) between
the femoral condyle and the tibial plateau on a picture taken at 90 degrees
of flexion, this line and the long axis of the ACL attachment (AX) was
crossed at the point (PL) on the vertical line 5 to 8 mm anterior to the edge
of the joint cartilage. The center (AM) of the attachment of the
anteromedial bundle was located at the point 5 to 6 mm distal from the
back of the femur as measured using the offset guide. AFS, A parallel line
with an axis of the femoral shaft.
150
the imaginary vertical line (see Fig. 22-4). The femoral tun-
nel that has been created already for the AMB reconstruc-
tion can be used as a good landmark to determine the
center of the attachment of the PLB. To insert a guidewire
at this point, the surgeon manually holds a Kirschner wire
and aims it at the center of the attachment of the PLB on
the femur through the tibial tunnel, keeping the femur hor-
izontal at 90 degrees of knee flexion. Then the surgeon
lightly hammers the wire into this point and drills it
(Fig. 22-5, A). A 4.5-mm diameter tunnel is drilled using this
wire as a guide. Our cadaveric study showed that this tech-
nique provides some benefits for Endobutton fixation,
including easy passage of the graft and easy flip of an Endo-
button.4 The tunnel length is measured in the same manner.
Finally, two sockets are created for the AMB and
PLB reconstruction with cannulated drills in the Endobut-
ton fixation system (Acufex Microsurgical, Mansfield,
MA), the diameter of which is matched to the two grafts
prepared with the technique described in the following sec-
tion. Thus, two tunnels are created inside the ACL remnant
on the lateral condyle (Fig. 22-5, B). The different direc-
tions of the two pairs of tunnels are demonstrated by insert-
ing two wires through the tibial tunnel to the femoral tunnel
at 90 degrees of knee flexion (Fig. 22-5, C).
Graft Fashioning
The harvested semitendinosus is cut in half. Regarding the
gracilis tendon, both ends are resected so that the thickest
portion is used for the graft, and the length is matched to
half the length of the semitendinosus tendon. One-half of
the semitendinosus tendon and the resected gracilis tendon
are doubled and used for AMB reconstruction. The remain-
ing half of the semitendinosus tendon is also doubled and
used for the PLB reconstruction. Using these tendon mate-
rials, the hybrid grafts are fashioned (Fig. 22-6). At the
looped end of each doubled tendon graft, an Endobutton-
CL (Acufex Microsurgical, Mansfield, MA) is attached.
The length of the Endobutton-CL is determined such that
a 15- to 20-mm long tendon portion can be placed within
the bone tunnel. A commercially available polyester tape
(Leeds-Keio Artificial Ligament, Neoligament, Leeds,
United Kingdom) is mechanically connected in series with
the other end of the doubled tendons, using the original
technique5 (see Fig. 22-6). This tape is strong, soft,
meshed, 10 mm wide, and 15 cm long. In our experience,
the diameter of the tendon portion ranges from 6 to 8 mm
for the AMB graft and from 5 to 6 mm for the PLB graft.
The first advantage of the hybrid graft is that it is stronger
and stiffer than the tendon-suture composite.12,13 The
second advantage is that the tape portions of the two grafts
can be simultaneously fixed to the tibia with an initial tension.
 Anatomical Double-Bundle Anterior Cruciate Ligament Reconstruction Procedure Using the Semitendinosus and Gracilis Tendons 22

FIG. 22-5 Insertion of a guidewire for the posterolateral bundle (PLB) into the femur using the transtibial tunnel
technique (observed through the medial portal). A, First, a surgeon drills a Kirschner wire into the center of the PLB
attachment on the femur. B, Two tunnels are independently created within the anterior cruciate ligament (ACL)
remnant on the lateral condyle. C, Each wire is inserted through a tibial tunnel to a femoral tunnel at 90 degrees of
knee flexion demonstrates the position and direction of a pair of tunnels. Note that the directions of the
anteromedial bundle (A) and PLB (P) wires are different.

The latter feature is specifically important for anatomical
double-bundle reconstruction.
Graft Placement
The graft for the PLB reconstruction is introduced through
the tibial tunnel to the femoral tunnel using a passing pin
and is fixed on the femur by an Endobutton. Then the graft
for the AMB is placed in the same manner. Thus, the two
bundles having different directions are intraarticularly
grafted (Fig. 22-7). The grafts rarely impinge to the femur.
Notchplasty is performed only in knees with an extremely
narrow notch due to osteochondral spar formation or a similar
problem.

151
 Anterior Cruciate Ligament Reconstruction
FIG. 22-6 The hybrid grafts. At the looped end of each doubled tendon
graft, an Endobutton-CL is attached. A polyester tape is mechanically
connected in series with the other end of the doubled tendons, using the
original technique. An absorbable suture marker is attached to each graft to
show the point of flip of the Endobutton. The diameter of this tendon
portion shows 7 to 8 mm for the anteromedial bundle (AMB) graft and
5 to 6 mm for the posterolateral bundle (PLB) graft.
FIG. 22-7 The reconstructed two bundles as observed through the lateral
portal. The posterolateral bundle (P) is observed behind the anteromedial
bundle (A).
Graft Tensioning and Fixation
For graft fixation, the knee is flexed to 10 degrees with
a sterilized thin pillow placed beneath the thigh, keeping
the heel in contact with the operating table (Fig. 22-8).
A spring tensiometer (Meira, Nagoya, Japan) is attached at
each end of the polyester tape portion of the graft. An assis-
tant surgeon simultaneously applies tension of 30N to each
graft for 2 minutes at 10 degrees of knee flexion, and a sur-
geon simultaneously secures the two tape portions onto the
anteromedial aspect of the tibia using two spiked staples in
the turn-buckle fashion.5
152
FIG. 22-8 A surgeon simultaneously secures the two tape portions onto
the anteromedial aspect of the tibia using two spiked staples, applying a
30N tension to each graft for 2 minutes using tensiometers (TM) at
10 degrees of knee flexion.
The mechanism of our tensioning technique is explained
as follows14: According to our in vivo measurement studies,
when we applied the same initial tension on each bundle at 10
degrees of knee flexion, each tension pattern was similar to that
of the normal bundle. This fact suggested that the slight flexion
position (10 degrees of knee flexion) is recommended as the
most appropriate knee flexion angle for easy graft tensioning.
On the other hand, the full extension position may be clinically
recommended to avoid flexion contracture of the knee after
surgery. However, our previous studies13,15 showed that the
initial graft tension in the hamstring tendon graft was dramati-
cally reduced in the early phase after surgery. Therefore, the
slight flexion position is again recommended as the most appro-
priate knee flexion angle for graft tensioning, when we take into
account the postoperative graft relaxation. Another important
question about graft tensioning is whether we should separately
fix the two grafts at different flexion angles. According to our
in vivo measurement studies, if we apply a tension to the
AMB after fixing the PLB at the extension position, the initial
tension applied to the PLB is reduced to an unknown degree.
A surgeon cannot sufficiently control the graft tension in this
technique. Therefore, in anatomical double-bundle ACL
reconstruction, it is important to simultaneously fix the two
bundles, applying appropriate initial tensions to the two grafts.
Postoperative 3D computed tomography shows that
each tunnel outlet was created at the center of the anatomi-
cal attachment of the AMB or the PLB (Fig. 22-9).
CLINICAL RESULTS
A prospective comparative cohort study was carried out
with 72 consecutive patients with chronic ACL deficiency
to compare three ACL reconstruction procedures using
 Anatomical Double-Bundle Anterior Cruciate Ligament Reconstruction Procedure Using the Semitendinosus and Gracilis Tendons
FIG. 22-9 Postoperative three-dimensional computed tomography showing that each tunnel outlet was created
at the center of the anatomical attachment of the anteromedial bundle (A) or the posterolateral bundle (P).
hamstring tendon grafts.6 The first 24 patients underwent a
single-bundle procedure using a six-strand hamstring ten-
don graft. The next 24 patients underwent a nonanatomical
double-bundle procedure using four-strand and two-strand
hamstring tendon grafts. The final 24 patients underwent
the anatomical double-bundle procedure using the same
four-strand and two-strand hamstring tendon grafts. All
72 patients underwent postoperative management with the
same rehabilitation protocol.6 There were no significant dif-
ferences among the background factors. The postoperative
anterior laxity measured with the KT-2000 was significantly
less after the anatomical double-bundle reconstruction than
after the single-bundle reconstruction. Concerning the
results of the pivot-shift test, the anatomical double-bundle
reconstruction was significantly better than the single-
bundle reconstruction, although this test was not an objec-
tive evaluation (Table 22-1). In the International Knee
Documentation Committee (IKDC) evaluation, the anato-
mical double-bundle reconstruction clinically tended to be
superior to the single-bundle reconstruction, although no
statistical significance could be calculated. There were
no significant differences in the range of knee motion and
the muscle torque. Thus, this study demonstrated that the
anatomical double-bundle ACL reconstruction with the
hamstring tendons was clinically useful in the treatment
for the ACL deficient knee. In addition, this study also
showed that in ACL reconstruction with the hamstring
tendons, the anatomical double-bundle procedure was supe-
rior to the single-bundle procedure, at least in terms of
restoration of the anterior and rotational knee stability as
measured with the KT-2000 and pivot-shift examinations.
We should consider reasons why the results con-
cerning knee stability are superior in the anatomical
double-bundle reconstruction in our clinical study compared
22
with the single-bundle reconstruction. Yagi et al16 reported
that anatomical double-bundle reconstruction restores knee
kinematics closer to normal than does single-bundle recon-
struction. Namely, under a 134N anterior tibial load, ante-
rior tibial translation for the anatomical reconstruction was
significantly similar to that of the intact knee than was the
single-bundle reconstruction. The in situ force in the ACL
reconstructed with the anatomical double-bundle procedure
averaged 97% of that in the normal ACL, whereas the force
in the ACL reconstructed with the single-bundle procedure
averaged only 89%. Therefore we can make the following
speculations: First, the reconstructed PLB as well as the recon-
structed AMB may be effective to reduce the anterior transla-
tion of the tibia in the range of less than 30 degrees. Second,
excessively overloading to one bundle can be avoided during
the remodeling phase, resulting in good maturation of not
only the PLB graft but also the AMB graft. The good matura-
tion of the AMB graft might result in the reduction of the
anterior tibial translation at 90 degrees as well as 30 degrees.
Third, the graft surface area of the two thin tendon grafts used
in the anatomical procedure was greater than the area of the one
thick graft used in the single-bundle procedure. Therefore,
concerning graft anchoring and revascularization, the two thin
bundles in the double-bundle reconstruction may be superior
to the one thick bundle in the single-bundle reconstruction,
resulting in the reduction of the anterior tibial translation at
30 and 90 degrees of knee flexion.
Thus, there is a high possibility that the anatomical
double-bundle ACL reconstruction with the hamstring
tendons is clinically useful in the treatment for the ACL
deficient knee. However, there are some limitations in our
clinical study.6 To establish the clinical utility of the anato-
mical double-bundle ACL reconstruction for the ACL defi-
cient knee, further clinical studies are needed concerning the
153
 Anterior Cruciate Ligament Reconstruction

2. Amis AA, Dawkins GPC. Functional anatomy of the anterior cruciate

TABLE 22-1 Clinical Results in the Postoperative Evaluation
ligament. Fiber bundle actions related to ligament replacement and
Single Bundle Nonanatomical Anatomical injuries. J Bone Joint Surg 1991;73B:260–267.
Double Bundle Double 3. Back JM, Hull ML, Patterson HA. Direct measurement of strain in
the posterolateral bundle of the anterior cruciate ligament. J Biome-
Bundle chanics 1997;30:281–283.
4. Yasuda K, Kondo E, Ichiyama H, et al. Anatomic reconstruction of
Loss of knee 1 patient 2 patients 1 patient the anteromedial and posterolateral bundles of the anterior cruciate
flexion (<10 ligament using hamstring tendon grafts. Anatomic and clinical studies.
degrees) Arthroscopy 2004;20:1015–1025.
5. Yasuda K, Kondo E, Ichiyama H, et al. Surgical and biomechanical
Loss of knee 0 0 1 concept of anatomic anterior cruciate ligament reconstruction. Oper
Tech Orthop 2005;25:96–102.
extension
6. Yasuda K, Kondo E, Ichiyama H, et al. Anatomic double-bundle
Pivot-shift test reconstruction of the anterior cruciate ligament. Comparisons with
non-anatomic single- and double-bundle reconstructions. Arthroscopy
(
) 12 patients 16 patients 21 patients 2006;22:240–251.
7. Yasuda K, Tsujino J, Ohkoshi Y, et al. Graft site morbidity with
(þ) 9 patients 5 patients 3 patients autogenous semitendinosus and gracilis tendons. Am J Sports Med
1995;23:706–714.
(þþ) 3 patients 3 patients 0 patients 8. Yasuda K, Tsujino J, Tanabe Y, et al. Effects of initial graft tension on
clinical outcome after anterior cruciate ligament reconstruction.
Side-to-side 2.8  1.9 2.2  1.5 1.1  0.9
Autogenous doubled hamstring tendons connected in series with poly-
anterior laxity ester tapes. Am J Sports Med 1997;25:99–106.
9. Girgis FG, Marshall JL, Monajem ARS. The cruciate ligaments of
<2 mm 13 patients 17 patients 22 patients
the knee joint. Anatomical, functional and experimental analysis. Clin
3–5 mm 9 patients 4 patients 2 patients Orthop 1975;106:216–231.
10. Dodds JA, Arnoczky SP. Anatomy of the anterior cruciate ligament:
>5 mm 2 patients 3 patients 0 patients a blueprint for repair and reconstruction. Arthroscopy 1994;10:
132–139.
IKDC evaluation (points) 11. Harner CD, Baek GH, Vogrin TM, et al. Quantitative analysis of
human cruciate ligament insertions. Arthroscopy 1999;15:741–749.
A 10 patients 11 patients 16 patients 12. Miyata K, Yasuda K, Kondo E, et al. Biomechanical comparisons of
anterior cruciate ligament reconstruction procedures with flexor ten-
B 12 patients 11 patients 8 patients
don graft. J Orthop Sci 2000;5:585–592.
C 2 patients 2 patients 0 patients 13. Yamanaka M, Yasuda K, Nakano H, et al. The effect of cyclic dis-
placement upon the biomechanical characteristics of anterior cruciate
D 0 patients 0 patients 0 patients ligament reconstructions. Am J Sports Med 1999;27:772–777.
14. Yasuda K. Author reply to “Letter to editor” on “Anatomical recon-
struction of the anteromedial and posterolateral bundles of the anterior
effects on rotatory stability, long-term survival of the graft cruciate ligament using hamstring tendon grafts. Anatomical and
functions, and comparisons with other procedures involving clinical studies.” Arthroscopy 2005;21:639–640.
reconstruction with the bone–tendon–bone graft. 15. Numazaki H, Tohyama H, Yasuda K, et al. The effect of initial graft
tension on mechanical behaviors of the femur-graft-tibia complex
References with anterior cruciate ligament reconstruction during cyclic loading.
Am J Sports Med 2002;30:800–805.
16. Yagi M, Wong EK, Kanamori A, et al. Biomechanical analysis of an
1. Kurosawa H, Yamakoshi K, Yasuda K, et al. Simultaneous measure-
anatomic anterior cruciate ligament reconstruction. Am J Sports Med
ment of changes in length of the cruciate ligaments during knee
2002;30:660–666.
motion. Clin Orthop 1991;265:233–240.

154

Anatomical Anterior Cruciate Ligament
Reconstruction with Double-Bundle,
Double-Stranded Hamstring Autografts:
A Four-Tunnel Technique
INTRODUCTION
Anterior cruciate ligament (ACL) reconstruc-
tion is now commonly performed, and the pro-
cedure has become progressively more reliable as
our understanding of the ligament’s anatomy
and biomechanics has improved. Correct tunnel
placement, sturdy grafts, and rigid fixation tech-
niques all contribute to a good postoperative
outcome, but the contemporary literature reveals
that success rates following single-bundle ACL
reconstruction vary between 69% and 95%.1–3
Moreover, the persistence of a pivot “glide”
(International Knee Documentation Committee
Grade B) in 15% of cases4 has raised doubts as
to whether subsequent arthrosis can be pre-
vented. Single-bundle ACL reconstruction tech-
niques do not completely reproduce the native
anatomy and function. Grafts behave similarly
to the anteromedial (AM) bundle of the ACL,
resulting in anterior tibial translation not being
fully controlled toward extension,5 where the
posterolateral (PL) bundle has been shown to
have a more important action. Several studies
using different measurement techniques have
also shown that single-bundle grafts are even
less efficacious in providing rotatory stability.6–8
A number of authors have proposed recon-
structing both AM and PL bundles to address
these issues. Zaricznyj9 first published early clinical
results of this type of procedure in 1987, but
Japanese researchers were instrumental in subse-
quently developing “double-bundle reconstruc-
tion.” Combined with a strong European interest
23
CHAPTER
in the technique, several papers have since been Pascal Christel
published.10–27 These have described numerous
Philippe Colombet
technical variations using either one or two tibial
or femoral tunnels, either autograft or allograft, James Robinson
and using different graft tensioning methods. Jean Pierre Franceschi
This chapter describes a double-bundle Patrick Djian
ACL reconstruction technique that uses two Abdou Sbihi
independent tibial and two independent femoral
tunnels. This was first described by Franceschi
Guy Bellier
et al16 in 2002 and subsequently refined.17,20
SURGICAL PROCEDURE
Surgical Setup
The patient is placed supine on the operating
table. A pneumatic tourniquet is placed around
the proximal thigh to allow the safe percutane-
ous passage of Beath needles distally. A lateral
post, resting against the tourniquet, controls
external rotation of the hip. The foot rests
against a distal support that maintains the knee
at 90 degrees of flexion. This setup allows the
knee to be moved freely throughout its comp-
lete range of flexion and is essential for drilling
the femoral tunnels through the AM portal.
Graft Harvesting
The gracilis and semitendinosus tendons are
harvested using a tendon stripper as per a rou-
tine single-bundle hamstring reconstruction.
The maximal length of tendon is harvested
155
 Anterior Cruciate Ligament Reconstruction
n 100
90
80
70
60
50
40
30
20
10
0
5 6 6 6.5
PL bundle
and the residual muscle removed. The gracilis graft (future
PL bundle) is passed through a 15-mm continuous loop
Endobutton-CL (Smith & Nephew, Mansfield, MA).
A 20- to 30-mm Endobutton-CL is used for the semitendi-
nosus graft (future AM bundle) due to the longer femoral
AM tunnel. Each graft is then placed on a tensioning board
and whipstitched with an absorbable #1 suture over 40 mm
of its length. The two bundles are then calibrated. Grafts and
the corresponding tunnel diameters are sized in 0.5-mm
increments. The diameters of the double-stranded grafts
are on average 6 mm for the PL bundle and 7 mm for the
AM bundle (Fig. 23-1). If the diameter of the PL bundle
graft measures less than 5 mm, we recommend attempting
to triple the graft to increase its diameter. This is usually pos-
sible because the required length of the PL graft is shorter
than the AM. If, however, the length is insufficient, then
we recommend converting to a single-bundle technique.
Arthroscopic Reconstruction
The position of the arthroscopy portals is critical to allow
the correct positioning of the bone tunnels. We recommend
that the AM and anterolateral portals are made just adjacent
to the corresponding borders of the patella tendon. Both
should be placed as high as possible, just beneath the infe-
rior border of the patella. The high anterolateral portal
allows the tibial attachment of the ACL to be well visua-
lized in the flexed knee. We do not find it necessary to
use an accessory medial portal as proposed by Yagi et al.22
Following the arthroscopic evaluation and treatment of
meniscal and articular lesions, the intercondylar notch is
prepared. Scar tissue and ligament remnants are cleared from
the 9 to 12 o’clock positions (the 12 to 3 o’clock positions in
left knees), allowing the limits of the femoral ACL footprint
to be well visualized.
156
7 8 mm FIG. 23-1 Distribution of graft
diameters for 140 reconstructions.
AM bundle AM, Anteromedial; PL, posterolateral.
Preparation of the Femoral Tunnels
Both femoral tunnels are drilled via the AM portal.
In order to do this successfully, two critical steps must
be observed. First (as described earlier), it is important
that the AM tunnel is placed as midline as possible (i.e.,
just adjacent to the patella tendon) so that the drill
does not damage the articular surface of the medial
femoral condyle. Second, when placing the guidewires and
during cannulated drilling, the knee should be flexed
beyond 120 degrees. This is particularly important for the
correct positioning of the AM femoral tunnel guidewire
into the correct anatomical position “high” and “deep”
(using notch navigation terminology) in the intercondylar
notch.
The choice to drill the femoral tunnels via the AM
portal and not via a transtibial approach is based on anato-
mical considerations. Several authors have shown that it is
difficult to place a femoral tunnel in the anatomical attach-
ment of the ACL via the transtibial approach.28–30 The
advantages of using the AM portal have been outlined by
Cha et al30 and Aglietti et al,21 who found that not only
can the femoral tunnel be placed more anatomically, but
that the femoral and tibial tunnels can be made indepen-
dent of each other and that tunnel placement is also
independent of graft type.
Although it is possible to drill the femoral AM tun-
nel via the tibial tunnel,24 it is not possible to reach the
anatomical attachment of the PL bundle on the femur
via this approach. In order to achieve anatomical place-
ment of both tunnels on the femur, the alternative would
be to use an “outside-in” approach.21,23 This necessitates
the use of a second incision, made laterally, in order to
position the drill guide. This approach is more invasive
(incising both the lateral intermuscular septum and the
 Anatomical Anterior Cruciate Ligament Reconstruction with Double-Bundle, Double-Stranded Hamstring Autografts: A Four-Tunnel Technique
FIG. 23-2 Posterolateral femoral drill guide. The round tip of the guide
is introduced into the anteromedial tunnel and then rotated so that the
posterolateral bundle tunnel is positioned. A 4.5-mm drill is used to
pierce the posterolateral tunnel, which will be later adjusted to its final
diameter.
capsule, which may be associated with some morbidity),
and for this reason using the AM portal seems more
appropriate.
The AM femoral tunnel is made first. With the
knee flexed to at least 120 degrees, a 4-mm offset femoral
guide (Acufex, Smith & Nephew) is introduced through
the AM portal. The 2.4-mm guidewire is placed at the
1-o’clock position in the left knee (the 11 o’clock position
in the right knee). The 4.5-mm Endobutton-CL reamer is
then run over the guidewire in order to pierce the lateral
cortex. The tunnel is then reamed up to the corresponding
graft size using the cannulated dilators.
After drilling the AM tunnel, a femoral PL bundle
drill guide (Fig. 23-2) is used. The appropriate size guide
is introduced into the AM tunnel and then rotated so that
the PL bundle tunnel is positioned lower, more shallow,
and more laterally (using notch navigation terminology) in
the intercondylar notch at the 2:30 position (the 9:30 posi-
tion in right knees). The drill guide allows the PL tunnel to
be pierced with a 4.5-mm drill (again piercing the lateral
cortex) so that the two femoral tunnels diverge at 15
degrees. With the knee flexed, the AM tunnel is more ver-
tical, measuring 45 to 50 mm in length compared with the
more oblique PL tunnel, which varies between 30 and
35 mm long. The PL tunnel should breach the cortex prox-
imal to the tibial insertion of the lateral collateral ligament
such that the cortical bone is sufficient to support the Endo-
button. As with the AM bundle, the PL bundle is then
dilated to the appropriate diameter. The drill guide is
designed so that an approximate 2-mm bony bridge is left
between the tunnels as they emerge into the intercondylar
notch. This corresponds to the anatomical positions of the
two tunnels in the femoral ACL attachment.
23
Preparation of the Tibial Tunnels
The method for drilling the two tibial tunnels is based on
the use of individual AM and PL bundle drill guides. The
AM guide has an arm that can be hooked over the back
of the retroeminence ridge (RER), which lies just anterior
to the tibial attachment of the posterior cruciate ligament
(PCL) (Fig. 23-3). Our anatomical studies have shown
that the distance of the center of the AM bundle from the
RER varies very little individually, and the guide allows
a 2.4-mm wire to be reliably positioned into the center of
the AM tibial bundle attachment. The wire entry point is
on the proximal tibia, just medial to the tuberosity (slightly
more anterior than for a routine single bundle), and is
passed at 55 degrees to the horizontal. Although the posi-
tion of this tunnel as it emerges into the joint is a little
more anterior than for a single-bundle reconstruction, there
is no risk of impingement with the roof of the notch in
extension because the graft diameter is smaller and the
AM bundle lies more horizontally in the notch due to the
position of the femoral tunnel.
After preparing the AM tunnel, the correspondingly
sized PL bundle drill guide is used to prepare the second
tibial tunnel. This drill guide is designed with two conver-
gent barrels, one of which is introduced into the AM tunnel
(Fig. 23-4) until it is just arthroscopically visible in the
joint. The barrel has a line marked on its end that indicates
the direction of the PL bundle guidewire. After rotating
the handle guide so that the line points toward the native
PL bundle attachment, a 2.4-mm guidewire is placed.
The barrels of the guide converge so that the PL bundle
wire is placed 9 mm posteriorly and laterally to the center
of the AM bundle tunnel. This tunnel can then be drilled
and dilated to the corresponding graft size. The PL bundle
tibial tunnel lies less vertically, and the entry point is close to
the anterior edge of the superficial medial collateral liga-
ment. The two tunnels converge to leave an approximate
2-mm bony bridge between them as they emerge into the
joint.
Graft Positioning, Tensioning,
and Fixation
A loop of strong suture material (5–0 Ticron) is then pas-
sed through the PL femoral tunnel using a Beath needle
via the AM portal. A similar-strength loop (preferably of a
different color) is passed through the AM femoral tunnel.
The intraarticular portions of these loops are then retrieved
via their corresponding tibial tunnel and are used to pull
the grafts through their corresponding tunnels. The PL
bundle graft (gracilis) is drawn first through its tibial and
then femoral tunnels, and the Endobutton is “flipped.”
157
 Anterior Cruciate Ligament Reconstruction

40
45
50
55
60
65

FIG. 23-3 The tip of the anteromedial tibial drill guide hooks the retroeminence ridge just anterior to the posterior
cruciate ligament. With the bullet oriented at 60 degrees, the anteromedial guidewire is inserted.

The AM bundle graft (semitendinosus) is then pulled in its

FIG. 23-4 The posterolateral tibial drill guide has two convergent barrels.
One is introduced in the anteromedial tunnel and, after appropriate
rotation, a 2.4-mm guidewire is placed.
tunnels, and the Endobutton is similarly deployed. The
distal ends of both grafts, as they emerge from the tibial
tunnels, are then marked with a pen. Each graft is grasped
manually and the knee is cycled throughout its full range
of flexion 30 times to ensure they are adequately precondi-
tioned with respect to their viscoelastic properties and to
ensure that the Endobuttons sit flush against the femoral
cortex. The AM bundle is relatively isometric, and usually
there is no appreciable length change. The PL bundle, how-
ever, is anisometric, and 5 to 6 mm of length change is
common.
Tibial fixation is performed while 50N tension is
applied to the graft via a spring dynamometer. The AM
bundle is fixed at between 45 and 60 degrees using an over-
size bioabsorbable interference screw. The PL bundle is
then similarly fixed with an oversized bioabsorbable inter-
ference screw. The flexion angle for PL bundle fixation
depends on the length change throughout knee flexion. If
this is less than 3 mm, we recommend that the bundle be
fixed in 20 degrees of flexion. If, however, there is greater
than 4 mm variation in length, the PL bundle should be
fixed close to extension. After this, the intraarticular graft
positions are assessed arthroscopically to ensure that there
is no notch or PCL impingement.

158
 Anatomical Anterior Cruciate Ligament Reconstruction with Double-Bundle, Double-Stranded Hamstring Autografts: A Four-Tunnel Technique
Postoperative Care
We recommend the use of an intraarticular closed suction
drain to reduce the postoperative hemarthrosis. The patients
may perform weight-bearing as tolerated immediately post-
operatively in a hinged knee brace, allowing a protected
range of motion from 0 to 60 degrees for the first 3 weeks
and then 0 to 90 degrees until the brace is discarded at 6
weeks. Patients begin passive range-of-motion exercises
immediately postoperatively, progressing to bicycling exer-
cises during the first 2 postoperative months and jogging
at 3 months; multidirectional activities are progressively
introduced into a supervised rehabilitation program at 3 to
6 months. Return to cutting sports is allowed at 6 months.
DISCUSSION
Our group began to use two-bundle reconstruction in 2001.
Since then we have performed approximately 1000 pro-
cedures. In the light of this experience we have noted
that two-bundle reconstruction using four tunnels appears
to improve the control of rotational stability. Other
authors who previously performed three-tunnel, two-bundle
reconstructions (using either a single tibial tunnel with two
femoral tunnels, or the inverse) have also switched to using
a four-tunnel technique, having found no difference
between the three-tunnel techniques compared with routine
single-bundle ACL reconstruction.31–33
There is now a consensus as to the positioning of the
two femoral tunnels, although the question of whether to
prepare them via the AM portal18,20,22,25 or with an out-
side-in technique13,21,23 is still the subject of debate. These
alternative methods both allow anatomical tunnel place-
ment within the native femoral ACL attachment, using
slightly differing tunnel orientations. It is also increasingly
clear that a transtibial approach does not allow correct ana-
tomical positioning of the PL bundle. However, several
questions persist: What is the importance of tensioning
the bundles during fixation? Should the AM bundle be
tensioned to the same level as the PL bundle? In which
order should the bundles be fixed? There also needs to be
some consensus about the correct angle of knee flexion
for the fixation of each bundle,20,34 and no results are cur-
rently available to indicate the correct tibial rotation.
Authors vary with regard to their preferred graft fixation
methods, with some recommending femoral interference
screws. However, there are no results that would indicate
superior fixation characteristics using interference screws,
and the majority of authors use Endobuttons. We can state
from our experience that their use does not appear to be
linked to significant tunnel enlargement. Yasuda et al32
23
found similar results, with only 9% of tunnels widening
following two-bundle, four-tunnel reconstruction com-
pared with 46% using a three-tunnel, two-bundle technique
and 35% for single-bundle reconstructions. We hypothesize
that the lack of tunnel widening may be explained by the two
separate drill holes in both the tibia and femur, which provide
a larger “footprint” and improve graft healing due to
an increased bone-tendon interface. Also, when individual
tunnels are used for each bundle, the grafts are more likely
to restrain knee kinematics in a more physiological manner
compared with a two-tunnel, single-bundle graft.35
Single-bundle grafts behave as a compromise: by
moving the femoral tunnel around the clock face to create
a more oblique graft, there is a risk that, although rotation
and translation will be better controlled toward knee
extension, reduced control of translation in the flexed knee
will occur. Similarly there is a tendency to position the tibial
tunnel more posteriorly to avoid notch impingement, thus
creating a vertical graft.
Although the size of the doubled tendon grafts may
be a problem, tripling or quadrupling the tendons is likely
to yield a sufficiently strong graft. Zhoa et al27 published
their 1-year results of a four-tunnel technique using two
quadrupled hamstring grafts and found that 95.3% of
patients had a normal Lachman (KT-1000 at 30 lb), 95%
had a normal pivot shift, and 97.7% had a normal or nearly
normal (A or B) IKDC score. The use of tibialis anterior
and posterior allografts25 is another alternative that allows
graft sizes of 8 to 9 mm for the AM bundle and 7 to
8 mm for the PL bundle.
Although some clinical results in the literature show
little improvement in the control of AP stability with two-
bundle, four-tunnel reconstruction,19 others have shown a
tendency toward improved anterior laxity.11,26 However, it
is the control of rotational kinematics that is critical; the
primary disability experienced by patients with ACL rupture
tends to be instability during cutting sports or turning
about a weight-bearing leg, not straight anterior laxity.
Unfortunately, objective assessment is still laboratory based,
and an easy office method for the routine measurement of
tibial rotation kinematics remains elusive.
CONCLUSION
Considering the complex anatomy of the ACL and the
failure of single-bundle procedures to restore rotational kine-
matics of the knee, we propose a more physiological recon-
struction. This replaces both the AM bundle, which better
restrains anterior tibial translation at greater than 45 degrees
of knee flexion, and the PL bundle, which is less isometric
and a more important restraint toward full extension.
159
 Anterior Cruciate Ligament Reconstruction

The key features of this technique are utilization of 16. Franceschi JP, Sbihi A, Champsaur P. Arthroscopic reconstruction of
the anterior cruciate ligament using double anteromedial and postero-
doubled or tripled hamstring tendon autografts, four inde-
lateral bundles. Rev Chir Orthop 2002;88:691–697.
pendent bone tunnels (two femoral and two tibial), drilling 17. Bellier G, Christel P, Colombet P, et al. Double stranded hamstring
of the femoral tunnels via the AM portal, use of original graft for anterior cruciate ligament reconstruction. Arthroscopy
instrumentation to assist tunnel placement, and indepen- 2004;20:890–894.
18. Yasuda K, Kondo E, Ichiyama H, et al. Anatomic reconstruction of
dent fixation of the two bundles at differing angles of knee the anteromedial and posterolateral bundles of the anterior cruciate
flexion under controlled tension. ligament using hamstring tendon grafts. Arthroscopy 2004;20:
We believe that reconstructing both bundles should 1015–1025.
19. Adachi N, Ochi M, Uchio Y. Reconstruction of the anterior cruciate
provide a reconstruction that is more effective at restraining ligament: single versus double-bundle multistranded hamstring ten-
both anterior tibial translation and rotation of the tibia than dons. J Bone Joint Surg 2004;86B:515–520.
is a traditional single-bundle graft. 20. Christel P, Franceschi JP, Sbihi A, et al. Anatomic ACL reconstruc-
tion: the French experience. Op Tech Orthop 2005;15:103–110.
21. Aglietti P, Cuomo P, Giron F, et al. Double-bundle anterior cruciate
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23. Shino K, Nakata K, Nakamura N, et al. Anatomic anterior cruciate
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cruciate ligament reconstruction: a meta-analysis comparing patellar ten-
15:130–134.
don and hamstring tendon autografts. Am J Sports Med 2003;31:2–11.
24. Brucker PU, Lorenz S, Imhoff AB. Anatomic fixation in double-bun-
3. Yunes M, Richmond JC, Engels EA, et al. Patellar versus hamstring
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2005;15:135–139.
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25. Vidal AF, Brucker PU, Fu FH. Anatomic double-bundle anterior cru-
4. Nedeff DD, Bach BR Jr. Arthroscopic anterior cruciate ligament
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26. Colombet P, Robinson J, Jambou S, et al. Two-bundle, four-tunnel
5. Yagi M, Wong EK, Kanamori A, et al. Biomechanical analysis of
anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol
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27. Zhao J, Peng X, He Y, et al. Two-bundle anterior cruciate ligament
6. Bull AM, Earnshaw PH, Smith A, et al. Intraoperative measurement
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28. Giron F, Buzzi R, Aglietti P. Femoral tunnel position in anterior cru-
7. Georgoulis AD, Papadonikolakis A, Papageorgiou CD, et al. Three-
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Arthroscopy 1999;15:750–756.
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9. Zaricznyj B. Reconstruction of the anterior cruciate ligament of the
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1987;220:162–175.
31. Giron F, Aglietti P, Mondanelli N, et al. Single versus double bundle
10. Rosenberg T, Brown G. Anterior cruciate ligament reconstruction
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11. Muneta T, Sekiya I, Yagishita K, et al. Two-bundle reconstruction of
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34. Miura K, Woo S L-Y, Brinkley R, et al. Determination of suitable
14. Hamada M, Shino K, Horibe S, et al. Single- versus bi-socket anterior
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160
 Anatomical Double-Bundle Anterior
Cruciate Ligament Reconstruction with
a Semitendinosus Hamstring Tendon Graft
INTRODUCTION
Anterior cruciate ligament (ACL) reconstruction
is one of the most frequently performed knee
surgical procedures today. Through the years,
the various technical modifications together
with the introduction of better instrumentations
have led to the improved outcome currently
reported in the various orthopaedic literature.
Conventional techniques of reconstruct-
ing the torn ACL employ the use of either
a bone–patellar tendon or hamstring graft. The
majority of these reconstruction techniques,
however, basically reconstructs the anteromedial
(AM) bundle of the cruciates as the femoral
tunnel is placed between the 10- and 11-o’clock
position for the right knee (or 1- and 2-o’clock
position for the left knee). Although good
results have been generally demonstrated con-
current with its ability to restore the knee’s
anteroposterior (AP) stability, questions remain
regarding its efficiency in restoring rotational
stability.1 Recently, the performance of an
anatomical double-bundle reconstruction tech-
nique has generated renewed interests as several
in vitro analyses demonstrated better results in
terms of restoring knee rotational stability.2–8
Performing an anatomical double-bundle
reconstruction usually entails the use of both
the semitendinosus (ST) and gracilis (Gr) auto-
grafts, requiring the use of independent
femoral and tibial fixations.5,9,10 With this tech-
nique, therefore, the surgery becomes more costly
with the additional fixation required. Moreover,
24
CHAPTER
with the use of both the ST/Gr, hamstring Alberto Gobbi
strength deficits can become apparent, as has
Ramces Francisco
been demonstrated by previous studies.3,4,11
This section illustrates a modification of
the anatomical double-bundle technique using
a single ST autograft with independent femoral
but single tibial fixation system. This double-
bundle, single-tendon (DBST) technique ena-
bles the surgeon to achieve an anatomical
reconstruction without compromising the ham-
string function while at the same time avoiding
the use of additional fixations limiting the cost
of the surgery.
ANATOMY OF THE ANTERIOR
CRUCIATE LIGAMENT
Anatomical studies have shown that the ACL
consists of two functional bundles, the AM and
the posterolateral (PL) bundle, whose nomen-
clature is related to their insertion in the tibial
plateau.1,12 These two bundles are already iden-
tifiable between the 16th to 22nd weeks of fetal
development. Analyzing the insertions of these
two bundles reveals that they do not lie on the
same coronal plane; the AM bundle originates
more proximally than the PL bundle. Biomecha-
nically, the AM bundle tightens in flexion while
the PL bundle slackens. On the other hand, the
PL bundle tightens in extension while the AM
bundle loosens.1,13 The ACL attaches to the
femur and tibia as a collection of fascicles that
fan out as they approach their insertions sites.
161
 Anterior Cruciate Ligament Reconstruction
SCIENTIFIC RATIONALE
Early cadaveric investigations performed by Radford and
Amis1 demonstrated the superior AP knee stability achieved
through various ranges of flexion with a double-bundle
reconstruction compared with single-bundle ACL recon-
struction. Their investigation, however, did not include tests
for rotational stability. Yamamoto et al,14 on the other hand,
reported no significant differences between double-bundle
and single-bundle ACL reconstruction of the PL bundle in
terms of response to rotatory loads. However, single PL
bundle reconstruction was found to be associated with
increased anterior tibial translation with application of
anterior loads. A more recent cadaveric study emphasized
that single-bundle ACL reconstruction is mostly successful
in restoring AP knee stability but is inadequate in
controlling the combined rotatory loads of internal tibial
torque and valgus torque.
In a biomechanical study by Yagi et al6 restoration of
the knee kinematics, particularly in terms of rotational
control, was also demonstrated to be better with a double-
bundle versus single-bundle reconstruction technique. Fur-
ther in vivo studies by Tashman et al5 also revealed that
single-bundle reconstruction sufficiently restores AP tibial
translation but failed to provide rotational stability during
dynamic loading.
In general, the available studies thus far have demon-
strated that single-bundle ACL reconstruction can only
partially restore the normal knee kinematics because it
limits anterior translation but is unable to control pivot
shift. In addition, biomechanical analysis of an anatomically
reconstructed knee also demonstrated that anterior tibial
translation for double-bundle reconstruction is significantly
closer to that of an intact knee and produces better
rotatory stability.7,8
FIG. 24-1 A, The femoral posterolateral (PL) tunnel guide with a customized arm capable of reaching either the
9-o’clock or 3-o’clock position for anatomical placement of the PL tunnel. B, Outside-in technique for preparing the
PL tunnel. C, Arthroscopic view of the guide pin as it emerges on the medial wall of the lateral condyle where
the PL tunnel would be positioned.
162
SURGICAL TECHNIQUE
Following the administration of either a spinal or general
anesthesia, the patient is positioned supine on the operating
table. A tourniquet is placed at the proximal aspect of the
thigh with sufficient distance from the expected exit point
of the Beath needle in the thigh’s lateral aspect. A lateral
post for thigh support and a foot bar are then placed to
enable the knee to be positioned at 90 degrees of flexion on
the table during surgery. This set-up also allows sufficient
provision for full range of motion (Fig. 24-1).
Once standard prepping and draping are completed,
the tourniquet is inflated to 300 mmHg. A 3-cm vertical
incision is then made, centered approximately 5 cm below
the medial joint line, midway between the tibial tubercle
(Gerdy’s tubercle) and the posteromedial (PM) aspect of
the tibia. The sartorial fascia is incised, and the ST tendon
is dissected. The tendon is completely detached from its
proximal attachment with an open tendon stripper. On its
tibial end, the tendon’s length is maximized, preserving as
much length as possible by detaching the ST close to the
bone. Ideally, a length of more than 28 cm is desired.
Preparation of the Double-Bundle
Semitendinosus Graft
At the back table, while the surgeon prepares the tunnels, the
surgical assistant proceeds with the preparation of the double-
bundle graft. Once the graft is cleaned and devoid of excess
tissues, measurement of the tendon follows. The minimum
length needed is 28 cm to allow the possibility of cutting the
graft in half, with sufficient length to fold each half of the graft
to a length of 7 cm. In such a way, we can have 2 cm of graft
length for the femoral and tibial tunnels and 3 cm intra-
articularly. The ends of the grafts are then whipstitched using
 Anatomical Double-Bundle Anterior Cruciate Ligament Reconstruction with a Semitendinosus Hamstring Tendon Graft
Ticron #5 sutures. The appropriate sizes of the Endobutton-
CL (Smith & Nephew Endoscopy, Andover, MA), as deter-
mined by the AM and PL tunnel lengths, are then attached at
the end of each graft. The diameter of each bundle is
then measured using 0.5-mm increment sizers to match the
size of the femoral and tibial tunnels. Pretensioning and
preconditioning of the grafts with cyclical flexion and exten-
sion of the knee under maximal manual tension follow.15,16
Arthroscopic Anterior Cruciate Ligament
Reconstruction
Using standard anterolateral (AL) and AM portals, the knee
joint is visualized and prepared for tunnel placements
(Fig. 24-2). The anatomical footprints of the native ACL on
both the femoral and tibial sides are identified. The PL femoral
tunnel is initially prepared using an “outside-in” technique. To
properly achieve this step, a customized PL tunnel guide is
used. This customized guide has a component arm designed
to reach either the 9- or 3-o’clock position. The arm of the
PL guide is inserted in the AL portal and positioned at either
9 o’clock or 3 o’clock on the medial wall of the lateral condyle
while the handle is maneuvered at the area of the junction of
the distal femur and lateral condyle to fix the entry point for
the tunnel. A guidewire is inserted from the outside, which is
followed by a 4.5-mm cannulated drill to prepare the pilot hole.
Once the length of this hole is measured, a 6-mm PL tunnel
with its appropriate depth is drilled.
Once the PL tunnel is completed, preparation of the
AM tunnel follows. The standard technique is used to pre-
pare the 7-mm tunnel positioned at either the 11- or
1-o’clock position. At the end of these steps, two anatomi-
cally positioned divergent tunnels are achieved.
Attention is then placed at the tibial tunnels. We pre-
pare our tibial tunnels at an angle of 60 degrees with the
FIG. 24-2 A, Once the tibial tunnels are done, the femoral anteromedial (AM) tunnel is prepared using the AM
portal. B, A 6-mm reamer is used to complete the AM tunnel.
24
entry points separated by a distance of 1 to 1.5 cm. These
tunnels converge on the ligament’s footprint intraarticularly.
Once the guide pins are properly positioned, the 6-mm tib-
ial PL tunnel and the 7-mm AM tunnel are drilled
accordingly.
Once the femoral and tibial tunnels are completed,
the 6-mm graft is placed inside the PL tunnel and locked
in position with an Endobutton. This is then followed by
the placement of the 7-mm graft in the AM tunnel
(Fig. 24-3). The fixation of both grafts are double-checked
to determine whether they are securely anchored against
the femoral cortex. At this time, it is also possible to
arthroscopically check the grafts for impingement.
With the femoral end of the grafts securely posi-
tioned, fixation on the tibial end is achieved using a single
screw-post construct. This simple construct allows fixation
of the two bundles at the prescribed angles. The AM bundle
is fixed at 40 to 60 degrees of flexion while the PL bundle is
fixed at full extension (Fig. 24-4).
Prior to wound closure, the knee is examined for
range of motion and stability (Fig. 24-5). Postoperatively,
radiographs are taken to check the position of the grafts,
and the patient is started on a standard ACL rehabilitation
regimen17 (Fig. 24-6).
PRELIMINARY RESULTS
Preliminary investigations comparing the results between
the first 25 cases we treated with an anatomical double-
bundle ACL reconstruction demonstrated that the results
are comparable with those obtained with a single-bundle
quadrupled ST graft, as no significant differences were
noted in terms of the standard knee scales (subjective,
Lysholm, Noyes, and IKDC) used at a short-term follow-
163
 Anterior Cruciate Ligament Reconstruction

FIG. 24-3 A, The posterolateral (PL) bundle demonstrated here with the attached Endobutton-CL is initially
inserted. B, The anteromedial (AM) bundle is then inserted. Both bundles are checked to ensure that they are
properly anchored against the cortical surface of the femur.

FIG. 24-4 A, B, Tibial fixation is achieved using a post-screw construct. The anteromedial (AM) bundle is fixed at
60 degrees of flexion while the posterolateral (PL) bundle is fixed at full extension.

FIG. 24-5 A, The grafts are then checked for impingement and stability. B, The knee is also checked for full range
of motion.

164
 Anatomical Double-Bundle Anterior Cruciate Ligament Reconstruction with a Semitendinosus Hamstring Tendon Graft
FIG. 24-6 Anteroposterior (AP) and lateral postoperative radiographs are taken to check the position of the grafts.
Femoral fixation (yellow circle) is achieved with end buttons while tibial fixation (green circle) is secured with a screw.
up of 2 years. Computerized analysis of anterior knee trans-
lation, however, demonstrated slightly better results with the
double-bundle reconstruction. In some instances in which
second-look arthroscopy was performed within the first 3
months following reconstruction, sufficient stability with
Lachman’s and rotational (internal and external) tests were
documented. The graft was also observed to have complete
vascularization at this stage.
OTHER APPLICATIONS
Other possible applications for this technique would be the
reconstruction of isolated tears of either the AM or PL
bundle of the ACL. In these instances, the possibility
of restoring the ligament to its original form is achieved.
Furthermore, even cases previously reconstructed but with
persistent instability can be revised by augmenting the in
sufficient ligament with isolated reconstruction of either
the AM or PL bundle. Functional recovery from such a
procedure is usually fast and uneventful.
SPECIAL CONSIDERATIONS
The primary concern with this DBST technique is the
length of the available ST autograft. Ideally, it is preferable
24
to have a minimum of 70 mm of graft length to have at least
20 mm of graft in the femoral and tibial tunnels and 30 mm
intraarticularly. Some surgeons, however, would prefer to
have a graft length of 25 mm within the femoral tunnel,
whereas others have reported successful outcomes with
15 mm of the graft in contact with the tunnels.17 In our
experience using DBST reconstruction, a 20-mm length of
graft within the AM and PL femoral tunnels is usually suf-
ficient. With this length, the surgeon then has the option
of using a 20- or 25-mm Endobutton-CL for the AM
bundle and a 15- or 20-mm Endobutton-CL for the PL
bundle, considering that the average AM tunnel length
ranges between 40 and 45 mm, whereas PL tunnel length
usually ranges from 35 to 40 mm.
Of the two femoral tunnels needed, proper place-
ment of the PL tunnel is the more technically demanding
because it can be quite a challenge to reach the 3-o’clock
(or the 9-o’clock) position with an “inside-out” technique.
To avoid this problem, careful attention to anatomical
landmarks must be observed in both the flexed and
extended position of the knee. To facilitate drilling, an
“outside-in” technique is used with the aid of a PL tunnel
guide. The tip of the guide’s arm is pointed at either the
9- or 3-o’clock position on the medial wall of the lateral
condyle, depending on which knee is being recon-
structed. The other end of the guide is directed midway
through the AP plane of the junction of the distal
165
 Anterior Cruciate Ligament Reconstruction
femur and the lateral condyle to create the entry point for
the pilot hole of the PL tunnel, which is angulated 20 to
30 degrees from the horizontal plane. In this position, an
average PL tunnel length of 35 to 40 mm can be expected.
By strictly observing these measures, problems associated
with tunnel positioning can be avoided.
In instances where the semitendinosus tendon graft
obtained is less than 28 cm, it is advisable to abandon
the double-bundle reconstruction in favor of a triple ST
reconstruction technique.
Recently, the possibility of predicting the length of
the hamstring graft prior to ACL reconstruction has been
achieved by using simple anthropometric measurements.
Inclusion of this computation to the preoperative evaluation
of the patients would facilitate the identification of the
appropriate reconstruction technique to be used.
TROUBLESHOOTING
Concerns related to the performance of an anatomical
double-bundle reconstruction involve the proper placement
of the AM and PL tunnels. Ideally, the PL tunnel is posi-
tioned at the 3- or 9-o’clock position. To accurately do this,
an “outside-in” technique should be used with a PL tunnel
guide. However, other surgeons performing a double-bundle
reconstruction prefer to drill the PL tunnel through an acces-
sory AM portal. Currently, no prospective comparative stud-
ies have been made to determine which of these two
techniques is better in terms of accuracy and reproducibility
in preparing the PL tunnel.
Another concern associated with this technique is the
risk of encountering tunnel blow-out between the adjacent
walls of the closely positioned tibial or femoral tunnels.
Conventional ACL techniques also carry this risk when
femoral tunnels are placed too posteriorly. Therefore, with
the double-bundle procedure, this risk becomes more appar-
ent as adequate distance between the two femoral and two
tibial tunnels must be maintained. In our experience,
a distance of at least 1 cm between the guidewires would
be sufficient to maintain the integrity of the tunnels’ adja-
cent wall. In addition, correct orientation of the tunnels
(diverging for femoral tunnels, converging for tibial tunnels)
should always be observed to minimize the chances of
encountering this problem. Furthermore, even if the tibial
tunnels appear to be intact immediately after drilling, there
is greater risk of breaking the common wall separating the
AM and PL tunnels during fixation, especially when using
interference screws. Therefore, to avoid this complication
we prefer to use indirect fixation for the tibial end with a
screw-post construct where we can anchor the two bundles
at the recommended angle of fixation.
166
Other useful measures to observe when preparing the
PL tunnel include maintaining the guidewire after drilling
the pilot hole and tunnel. Doing otherwise would make it
difficult to relocate the entry point for this tunnel from the
outside when passing the nitinol loop to pull the PL bundle
into the tunnel.
Finally, in terms of patient positioning we prefer to
have the knee positioned at 90 degrees of flexion on top of
the table with the use of a lateral thigh post and a foot bar,
instead of having the leg hang from the side of the table.
This position offers the surgeons more room to make tunnel
preparations more comfortable. At the same time, the com-
bined position of the knee flexed at 90 degrees makes orien-
tation easier when drilling the femoral and tibial tunnels.
At present, it is obvious that several issues remain
regarding the use of an anatomical double-bundle recon-
struction. Some of these include the determination of the
ideal means by which to measure rotational stability (com-
puter navigation, motion analysis, or high-speed radio-
graphy) and the identification of the specific group of
patients who would benefit most from a double-bundle
reconstruction procedure.
In the future, with the numerous clinical trials under
way, we expect to see the long-term functional outcome
of the double-bundle ACL reconstruction and to compare
these results with the long-term outcome of conventional
techniques currently used.
References
1. Radford WJ, Amis AA. Biomechanics of a double prosthetic ligament
in the anterior cruciate ligament. J Bone Joint Surg Br 1990;72:
1038–1043.
2. Adachi N, Ochi M, Uchio Y, et al. Reconstruction of the anterior cru-
ciate ligament: single versus double multistranded hamstring tendons.
J Bone Joint Surg Br 2004;86:515–520.
3. Gobbi A, Francisco R. Anatomic double bundle ACL reconstruction
with the semitendinosus tendon. Presented at the Multi Media
Education Center of the 73rd American Academy of Orthopaedic
Surgeons Annual Meeting, March 22–26, 2006, Chicago.
4. Makihara Y, Nishino A, Fukubayashi T, et al. Decrease of knee flex-
ion torque in patients with ACL reconstruction: combined analysis of
the architecture and function of the knee flexor muscles. Knee Surg
Sports Traumatol Arthrosc 2006;14:310–317.
5. Tashman S, Colon D, Anderson K, et al. Abnormal rotational knee
motion during running after anterior cruciate ligament reconstruction.
Am J Sports Med 2004;32:975–983.
6. Yagi M, Wong E, Kanamori A, et al. Biomechanical analysis of an
anatomic anterior cruciate ligament reconstruction. Am J Sports Med
2000;28:660–666.
7. Yasuda K, Koga H, Morito T, et al. A retrospective study of the mid-
term outcome of two-bundle anterior cruciate ligament reconstruction
using quadrupled semitendinosus tendon in comparison with one-
bundle reconstruction. Arthroscopy 2006;22:252–258.
8. Yasuda K, Kondo E, Ichiyama H, et al. Clinical evaluation of ana-
tomic double-bundle anterior cruciate ligament reconstruction proce-
dure using hamstring tendon grafts: comparison among different
procedures. Arthroscopy 2006;22:240–251.
 Anatomical Double-Bundle Anterior Cruciate Ligament Reconstruction with a Semitendinosus Hamstring Tendon Graft
9. Hamada M, Shino K, Horibe S, et al. Single versus bi-socket anterior
cruciate ligament reconstruction using autogenous multiple-stranded
hamstring tendons with Endobutton femoral fixation: a prospective
study. Arthroscopy 2001;17:801–807.
10. Muneta T, Sekiya I, Yagishita K, et al. Two-bundle reconstruction of
the anterior cruciate ligament using semitendinosus tendon with
Endobutton: operative technique and preliminary results. Arthroscopy
1999;15:618–624.
11. Gobbi A, Domzalski K, Pascual J, et al. Hamstring anterior cruciate
ligament reconstruction: is it necessary to sacrifice the gracilis? Arthros-
copy 2005;21:275–280.
12. Woo S. News in biomechanics research on ACL. Presented at the 8th
International Conference on Orthopaedics, Biomechanics, and Sports
Rehabilitation, Nov 19–21, 2004, Assisi, Italy.
24
13. Mae T, Shino K, Matsumoto N, et al. Force sharing between two
grafts in the anatomical two-bundle anterior cruciate ligament recon-
struction. Knee Surg Sports Traumatol Arthrosc 2006;6:1–5.
14. Yamamoto Y, Hsu W-H, Woo SL-Y, et al. Knee stability and graft
function after anterior cruciate ligament reconstruction. Am J Sports
Med 2004;32:1825–1832.
15. Chen L, Cooley V, Rosenberg T. ACL reconstruction with hamstring
tendon. Orthop Clin North Am 2003;34:9–18.
16. Gobbi A, Mahajan S, Tuy B, et al. Hamstring graft tibial fixation:
biomechanical properties of different linkage systems. Knee Surg Sports
Traumatol Arthrosc 2002;10:330–334.
17. Rosenberg TD, Graft B. Techniques for ACL reconstruction with multi-
trac drill guide, Mansfield, MA, 1994, Acufex Microsurgical.
167
 25
CHAPTER
Anatomical Double-Bundle Reconstruction
of the Anterior Cruciate Ligament
Anthony Buoncristiani INTRODUCTION
Fotios Paul Tjoumakaris
Anterior cruciate ligament (ACL) reconstruc-
James S. Starman tion remains one of the most common proce-
Freddie H. Fu dures performed by orthopaedic surgeons in
the United States, with approximately 100,000
performed per year.1 ACL surgery has evolved
tremendously from the original open techniques
to modern procedures focusing on endoscopic
reconstruction of the anteromedial (AM) bun-
dle using a variety of graft choices and fixation
techniques. However, the success of single-
bundle ACL reconstruction ranges from 69% to
90%.2,3 In addition, according to Fithian et al,4
95% of patients who underwent single-bundle
ACL reconstruction developed medial compart-
ment degenerative radiographic changes after
7 years, and only 47% were able to return to their
previous activity level. Because arthrosis was
observed medially, it could not be attributed
to the initial subluxation event, which usually
results in a bone contusion or a concomitant
meniscal tear involving the lateral compartment.4
Single-bundle ACL reconstruction is the
“gold standard,” but some authors have noted
persistent instability with functional testing
of single-bundle ACL reconstruction.5,6 Thus,
there is a growing trend toward a more anato-
mical ACL reconstruction that recreates both
the AM and the posterolateral (PL) bundles.
The double-bundle anatomy of the ACL was
first described in 1938 by Palmer et al.7 The
terminology of the AM and PL bundles are
chosen according to their tibial insertions. The
168
tibial and femoral insertion sites of both the
AM and PL bundles have been well des-
cribed.8,9 The femoral origin has an oval shape,
with the center of the AM bundle close to the
over-the-top position and the center of the PL
bundle close to the anterior and inferior carti-
lage margin. The femoral origin site changes
as the knee is taken through an arc of motion.
The two bundles are parallel with a vertical ori-
entation when the knee in extension (i.e., the
AM footprint is situated directly superior to
the PL footprint). This changes to a more hori-
zontal orientation, with the PL footprint be-
coming actually anterior to the AM footprint
when the knee is flexed beyond 90 degrees.
The changing orientation of the two bundles’
footprints as the knee is taken through an arc
of motion leads to the observed crossing pattern
of the independent components of the ACL.
Although the two bundles are intertwined, their
functional tensioning pattern is independent
throughout the knee’s range of motion.10 Close
to extension, the AM is moderately loose and
the PL is tight. As the knee is flexed, the fem-
oral attachment of the ACL takes a more hori-
zontal orientation, causing the AM bundle to
tighten and the PM bundle to loosen. The
ACL has been described as a restraint to ante-
rior tibial displacement and internal tibial ro-
tation. The rotational stabilizing component
might be better attributed to the PL bundle.
The idea of reconstructing both bundles of
the ACL was described by Mott and Zaricznyj
in the 1980s.11,12 They independently described

a double-bundle technique. Mott drilled two separate tun-
nels, whereas Zaricznyj used a single femoral and two tibial
tunnels. Despite publishing their results, the technique did
not become mainstream. Recent biomechanical evidence
supports the anatomical double-bundle ACL reconstruction
as more accurately recreating the natural anatomy.13,14 Both
translational and coupled rotational translation were signi-
ficantly less in the specimens with double-bundle ACL
reconstruction. We present the senior author’s (F.H.F) tech-
nique of anatomical double-bundle ACL reconstruction
with two femoral and tibial tunnels using two tibialis anterior
allografts.
PREOPERATIVE CONSIDERATIONS
History: Signs and Symptoms
ACL injuries occur frequently in sports that involve running,
jumping, and cutting movements. They can occur without
contact when the foot is anchored to the playing surface—
usually by way of cleats or a rubber sole—and the body rotates
beyond the tolerance of the ligament as the knee buckles.
Thus, it is important to ask the patient how the injury
occurred and the position of the knee during the injury, which
may also allude to the ACL bundle injury pattern.15 This
may be associated with an audible “pop.” Asking whether
the athlete was able to continue to play will give you an idea
of the severity of the injury. Knee pain and a hemarthrosis
are usually present acutely. A complaint of instability is also
common, especially with walking downhill or down stairs.
Physical Examination
Inspect and palpate for an effusion. If a large effusion is
present, consider aspiration for pain relief, and inspect the
aspirate for any fat globules, which would be suggestive of
a fracture. Check the range of motion; if it is limited, mag-
netic resonance imaging (MRI) should be ordered to ensure
that no displaced meniscal tear is present. The physical
examination of an isolated ACL tear is usually significant
for a side-to-side difference with regard to Lachman and
pivot-shift maneuvers. If a discrepancy between the Lach-
man and pivot-shift maneuvers exists, this may signify a
partial tear involving either the AM or PL bundles. The
PL bundle is mainly responsible for rotational stability,
and a large pivot shift will be evident if it is torn. Similarly,
the AM bundle is mainly responsible for translational sta-
bility when the knee is flexed, and a large Lachman maneu-
ver will be present if the AM bundle is torn. A KT-1000
test can also be used to confirm a side-to-side difference
in anterior translation. A more prominent anterior drawer
Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament 25
compared with a Lachman test should alert the examiner
to consider a concomitant posteromedial or posterior horn
medial meniscal injury. Varus/valgus instability testing
should be performed to ensure no collateral injury is present.
Dial testing and posterolateral drawer testing at 30 degrees
should be performed to assess for a posterolateral knee
injury. Gait analysis should be performed to inspect for
any underlying varus laxity. Tests for possible meniscal
pathology should also be performed (i.e., joint line tender-
ness, McMurray maneuver), but it may be difficult to distin-
guish between a lateral meniscal tear and a bone contusion
acutely. Thus, appropriate imaging is important.
Imaging
A complete knee series consisting of weight-bearing antero-
posterior and notch, lateral, and patellofemoral sunrise views
should be obtained. The soft tissues can be inspected for an
effusion. The bony anatomy should be inspected for any
fractures or subtle signs of a rotational injury, such as segond
or reverse segond capsular lesion. In addition, the status of
the physes and any arthritic changes should be noted. Long
cassette films should be obtained for any patient with varus
alignment on examination or if any arthritic changes are
noted on the knee series obtained. This will help determine
whether an osteotomy should be performed. An MRI is
essential not only to confirm an ACL injury but, more
importantly, to assess for any concomitant ligamentous
or cartilage injuries that will affect the operative plan. The
PL bundle is more easily visualized on coronal sectioning.
Specifically, it may be seen at the level of the first cut, which
includes the PCL.
Indications
The absolute indications for double-bundle ACL recon-
struction are evolving. Even though single-bundle ACL
reconstruction is considered the “gold standard,” the tech-
nique can be improved. Gait analysis after single-bundle
reconstruction has demonstrated that rotatory instability
persists.5 Furthermore, biomechanical cadaveric studies have
shown that even lowering the femoral insertion site to the
3- or 9-o’clock position does not fully prevent rotatory
instability.16 Clinically, as many as one-fifth of the patients
do not resume preinjury activities and usually complain of
vague instability symptoms that objectively correspond to a
mild persistent pivot shift.17 In comparison, double-bundle
ACL reconstruction does restore the rotational component
in a cadaveric model.14 It has been suggested that a positive
pivot shift after ACL reconstruction is correlated with the
development of later osteoarthrosis.18 Perhaps with recon-
struction of both the AM and PL bundles, the decreased
169
 Anterior Cruciate Ligament Reconstruction
rotational instability will provide improved overall knee
kinematics and may prevent or slow the degenerative
changes seen after single-bundle ACL reconstruction.4 A
contraindication to performing the double-bundle technique
is in the young athlete with open physes. Two tunnels
would risk physeal arrest with subsequent malalignment
and possible leg length discrepancy.
SURGICAL TECHNIQUE
Anesthesia and Positioning
The operative extremity is identified by the patient and ini-
tialed by a member of the surgical team. All patients under-
go a preoperative femoral nerve block in the holding area
by our anesthesia colleagues. The patient is then placed in
a supine position and given intravenous conscious sedation.
A careful exam under anesthesia is performed and recorded
to document the Lachman and pivot-shift maneuvers. Again,
the senior author is interested in correlating the exam with
the tear pattern of the individual bundles of the ACL.
A tourniquet is applied to the proximal thigh. The extremity
is then secured within a circumferential leg holder placed
at the level of the tourniquet. The foot of the operating table
is completely retracted to permit hyperflexion of the knee,
which is crucial for later placement of the PL femoral tunnel.
The contralateral extremity is placed within a well-leg holder
with the hip flexed approximately 90 degrees and abducted
and externally rotated away from the surgical field to allow
unobstructed access to the operative knee (Fig. 25-1). The
leg is elevated for 5 minutes, and the tourniquet is then
inflated. The knee is prepped and sterilely draped.
Anterior Cruciate Ligament Graft
Preparation
Two tibialis anterior allografts are individually fashioned
as a double loop. The folded length of each graft should
FIG. 25-1 Leg positioned to allow for range of motion between full extension and 120 degrees of flexion.
170
be approximately 12 cm for sufficient graft tissue. The grafts
are trimmed to a folded diameter of 7 mm for the PL
bundle and 8 mm for the AM bundle. A #2 braided suture
is whipstitched up and down both ends of the graft for
3 cm. The stitch depth is alternated, and care is taken to
avoid penetrating the suture and risking weakening or
breaking. The graft is then passed through the closed-
looped Endobutton (Smith & Nephew, Andover, MA).
Two Fiberwire sutures (Arthrex, Naples, FL) (one stripped
and one nonstripped for later identification) are placed
within the button holes. A 2–0 absorbable suture is tied
through both strands of the folded graft to secure them once
the graft is passed within the closed-looped Endobutton.
Each graft is marked to alert the surgeon when to engage
or “flip” the Endobutton (Fig. 25-2).
Surgical Landmarks
With the knee flexed approximately 45 degrees, the inferior
pole of the patella is marked. The inferior extent of the
lateral parapatellar portal begins at the level of the inferior
pole of the patella and extends proximally for approximately
2 cm. The medial parapatellar portal begins at the level of
the inferior pole of the patella and extends distally along
the medial aspect of the patellar tendon for approximately
2 cm. The high placement of the portals allows the arthro-
scopic instruments to enter the knee above the level of the
fat pad. The 11 scalpel blade is angled approximately
45 degrees to the skin and distally toward the notch to safely
FIG. 25-2 Doubled-over tibialis anterior allograft with whipstitch.
Anteromedial diameter, 8 mm; posterolateral diameter, 7 mm.
Endobutton-CL pictured at right.
 Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament 25
The posterior third of the lateral meniscus is more easily
viewed with the knee flexed to 90 degrees; the middle third
with the knee flexed to 60 degrees; and the anterior third
with the knee flexed to 30 degrees. Any meniscal pathology
is addressed with either repair or débridement. The lateral
femoral condylar articular surface is inspected for any defects
as the knee is brought through an entire range of motion.

Specific Steps

Attention is then redirected to the notch. Any obstructing

fat pad or ligamentum mucosum is removed with the shaver
or ArthroCare Coblation device. The bundles of the ACL
are carefully dissected with a small ArthroCare Coblation
device to fully appreciate the injury tear pattern. Because
the two bundles are differentially tensioned depending on
the position of the knee at the time of injury, the tear
FIG. 25-3 Arthroscopic portal placement and skin incisions. AMP, pattern can be quite different for each bundle.18 We are cur-
Accessory medial portal; MP, medial portal; LP, lateral portal. rently performing a prospective study to correlate the pre-
operative examination (i.e. KT-1000, examination under
enter the knee without harming the articular cartilage. A low anesthesia [pivot-shift and Lachman maneuvers]) with the
AM accessory portal will be placed with the assistance of individual tear pattern of each bundle (Fig. 25-4). The rem-
a spinal needle to ensure proper trajectory for the PL femoral nant of the ACL bundles is then débrided from both their
tunnel (Fig. 25-3). The knee is flexed 90 degrees, and the femoral and tibial insertions. The ArthroCare Coblation
11 scalpel blade is angled upward as it enters the skin at the device is used to mark the AM and PL femoral and tibial
level of the spinal needle marking. The portal is extended footprints (Fig. 25-5). No notchplasty is performed.
proximally approximately 1 cm, avoiding injury to both the An 18-gauge spinal needle is directly visualized as
underlying meniscus and the articular cartilage. it passes from the location of the low AM portal onto the
medial face of the lateral femoral condylar notch in the
Diagnostic Examination region of the previously marked PL bundle (Fig. 25-6).
Once satisfactory trajectory for the PL bundle with the
The knee is flexed approximately 25 degrees, and the
arthroscopic trochar is placed in the lateral parapatellar
portal angled toward the notch and then redirected beneath
the patella. The patellofemoral joint is visualized. Any car-
tilage defects are addressed as needed. The arthroscope is
then dropped down over the trochlea and into the notch
to grossly view the ACL. The knee is then extended, and
a valgus stress is applied to open the medial compartment.
The entire meniscus is visualized and probed for stability.
Medial meniscal tears are usually seen with chronic ACL
tears. Any meniscal pathology is addressed with either repair
or débridement depending on the location and character
of the tear. The knee is brought through a range of motion
to inspect the femoral condylar articular surface for any
defects. The tibial plateau articular cartilage is also inspected
for any defects. The knee is then placed in a figure-four
position to view the lateral compartment. The PL bundle
is best visualized in this position. The entire meniscus is
FIG. 25-4 Anterior cruciate ligament (ACL) tear of anteromedial (AM) and
once again observed and probed for stability. Lateral menis-
posterolateral (PL) bundles, each from femoral insertion. Preoperative exam
cal longitudinal tears are commonly seen with acute ACL under anesthesia demonstrated a 3þ Lachman and a 3þ pivot shift. LFC,
tears at the junction of the middle and posterior thirds. Lateral femoral condyle.

171
 Anterior Cruciate Ligament Reconstruction
FIG. 25-5 Anteromedial (AM) and posterolateral (PL) tibial (A) and femoral (B and C) footprints marked. LFC,
Lateral femoral condyle.
FIG. 25-6 A, B, Accessory medial portal visualization with an 18-gauge needle.
spinal needle has been determined, remove the spinal needle
and make the low AM portal with an 11 scalpel blade
angled upward to avoid cutting the anterior horn of the
medial meniscus. Pass a 3/32-mm Steinman pin via the low
AM portal onto the medial face of the lateral femoral con-
dylar notch. Place the pin approximately 8 mm posterior
to the anterior articular margin and approximately 5 mm
superior to the inferior articular margin of the lateral femoral
condyle. Once correct placement of the pin has been
obtained, bring the knee into approximately 120 degrees
of hyperflexion and tap it into place with a mallet
(Fig. 25-7). Ensure that the pin did not penetrate the
medial meniscus, and then slide the 7-mm acorn reamer
over the Steinman pin and have it rest against the medial
face of the lateral femoral condylar notch. Ream to a depth
of 25 mm. Then place the Endobutton drill within the
previously reamed canal, and drop your hand before starting
172
the drill, which will maximize the PL tunnel length. With
the knee still flexed at 120 degrees, have your assistant place
his or her hand on the lateral aspect of the knee and push the
biceps tendon inferiorly, which will deflect the common
peroneal nerve away from the drill trajectory. Barely perfor-
ate the lateral femoral cortex with the Endobutton drill, and
quickly retract it backward to minimize the risk of injury to
the common peroneal nerve. Measure the transcondylar
length, and choose the appropriately sized continuously
looped Endobutton. If the length is greater than 35 mm,
replace the 7-mm acorn reamer within the PL tunnel and
dilate the tunnel depth to 30 mm by hand. There should be
at least 15 mm of graft tissue within the tunnel (Fig. 25-8).
Make a 3- to 4-cm incision over the AM surface of
the tibia for creation of the tibial tunnels and passage of
the grafts. This is in a location midway between the tibial
tubercle and the posteromedial border of the tibia. Dissect

FIG. 25-7 A, Guide pin placement for posterolateral femoral tunnel. B, 7-mm acorn reamer as inserted from
accessory medial portal. LFC, Lateral femoral condyle.
FIG. 25-8 Posterolateral (PL) femoral tunnel. LFC, Lateral femoral condyle.
the soft tissues both medially and laterally for easy access to
the future tibial AM and PL tunnels. Identify the tibial PL
footprint, which is located just medial to the posterior horn
of the lateral meniscus and anterior to the PCL. The foot-
print should have been previously marked with the Arthro-
Care Coblation device. Place the ACL director guide
(Smith & Nephew, Andover, MA) at 55 degrees with the
tip centered within the PL tibial footprint (Fig. 25-9). Drill
a 3/32 Steinman pin through the guide and within the joint
so that a few millimeters are visible. Identify the AM tibial
footprint with the ArthroCare Coblation device, which is a
couple of millimeters anterior to the ideal single-bundle
reconstruction location: the posterior aspect of the anterior
Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament 25
horn of the lateral meniscus, downward sloping side of the
medial tibial eminence, and approximately 7 mm anterior
to the PCL. Reset the ACL director guide to 45 degrees
and place it within the previously marked AM tibial
footprint (Fig. 25-10). Drill a second 3/32 Steinman
pin through the guide and within the joint so that a few
millimeters are visible. Note that the PL tibial guide pin is
quite vertical in comparison with the AM tibial guide pin,
which is quite horizontal. This pin attitude also prevents
impingement within the notch because the PL tunnel is
centered within the knee and the AM tunnel is horizontal.
Once again, no notchplasty is necessary. The PL tibial guide
pin also enters the AM surface of the tibia more postero-
medially than the AM tibial guide pin, which is more lateral
and centered (Fig. 25-11). Retract the skin on the tibia to
allow placement of a 7-mm reamer over the PL tibial guide
pin, and place a curette within the joint overlying the PL
pin to protect the articular surfaces. Ream the PL tunnel,
and remove debris with a shaver. Then place the 8-mm
reamer over the AM tibial guide pin, and once again place
a curette overlying the pin to protect the articular surfaces.
Ream the AM tunnel, and remove debris with a shaver.
There should be an approximately 1-cm bony bridge
between the two tibial tunnels.
Then direct your attention to the AM femoral foot-
print. Guide the AM femoral tunnel off the previously
made femoral PL tunnel and not off the back wall of the
notch, which is traditionally done with over-the-top femoral
tunnel drill guides. Place the 3/32 Steinman pin 3 mm
posterior and slightly superior to the previously drilled
femoral PL tunnel. The Steinman pin can be placed trans-
tibially via the previously drilled AM tunnel or via the low
AM portal, whichever will allow the proper trajectory to
173
 Anterior Cruciate Ligament Reconstruction

FIG. 25-9 A, Posterolateral (PL) tibial insertion landmarks. Anterior cruciate ligament (ACL) director guide set at 55
degrees. B, Guide pin drilling. AM, Anteromedial; Lat men, lateral meniscus; PCL, posterior cruciate ligament.

FIG. 25-10 A, Anteromedial (AM) tibial insertion landmarks, guide pin drilling. B, Anterior cruciate ligament (ACL)
director guide set at 45 degrees. PL, Posterolateral.

FIG. 25-11 A, Guide pins for posterolateral (PL) and anteromedial (AM) tibial tunnels. B, External view of guide pins.

174

be low enough within the notch (Fig. 25-12). Hyperflex the
knee as the Steinman pin is then tapped into place. Then
place an 8-mm acorn reamer over the pin and pass it within
the joint to rest against the notch wall. Ream the AM fem-
oral tunnel to a depth of 40 mm. Place the Endobutton drill
within the AM tunnel. Your hand should be dropped as the
knee is maintained in the hyperflexed position to maximize
tunnel length and ensure that the anterolateral femoral cor-
tex will be perforated to allow passage of the Beath pin distal
to the tourniquet. Measure the transfemoral diameter, and
choose the appropriately sized closed-looped Endobutton.
Ideally, there should be at least 15 to 20 mm of graft tissue
within the canal.
With the knee hyperflexed, place a Beath pin via the
low AM portal, through the PL femoral tunnel, and out
of the skin on the lateral aspect of the knee. Once again,
you want to drop your hand and push the biceps tendon
inferiorly as you pass the pin to protect the common pero-
neal nerve from injury. Tie a long looped suture through
the eyelet of the Beath pin, which is pulled intraarticularly
and grasped out the tibial PL tunnel with arthroscopic
suture retrievers. Place the 7-mm prepared PL allograft
within the long looped suture attached to the Beath pin,
and pull it through the respective tibial and femoral tunnels.
Flip the Endobutton, and pull the graft to ensure proper
engagement. Pass the Beath pin through the tibial and
femoral AM tunnels with the knee hyperflexed to ensure
the pin exits the thigh distal to the tourniquet and remains
sterile. Depending on the trajectory of the tunnels, the
Beath pin may first need to be passed via the low AM portal
FIG. 25-12 Anteromedial femoral guide pin landmarks. TT, Transtibial; MP,
medial portal; PL, posterolateral.
Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament 25
through the AM femoral tunnel and the long looped suture
pulled out through the AM tibial tunnel with arthroscopic
suture retrievers. Place the 8-mm prepared AM allograft
within the long looped suture attached to the Beath pin,
and pull it through the respective tibial and femoral tunnels.
Flip the Endobutton, and pull the graft to ensure proper
engagement (Fig. 25-13).
Cycle the knee through a full range of motion from
approximately 0 to 120 degrees, approximately 20 to 30
times, while maintaining tension on both graft ends to
remove any slack, and check the isometry. Tension the PL
bundle first between 0 and 10 degrees of flexion. Then
tension the AM bundle with the knee in approximately
60 degrees of flexion (Fig. 25-14). Tibial fixation is achieved
with bioabsorbable interference screws, which are the same
diameter as the corresponding tunnel. One staple is used
as adjunctive fixation for each graft on the tibial side. Note
that the reconstructed state recreates the crossing pattern
of the PL and AM bundles (Fig. 25-15).
POSTOPERATIVE CONSIDERATIONS
Rehabilitation
Postoperatively, the patient is placed in a hinged knee brace.
Full weight-bearing is allowed with the knee locked in
extension. Continuous passive motion (CPM) is started
immediately from 0 to 45 degrees of flexion and is increased
by 10 degrees per day until the maximal obtainable flexion
FIG. 25-13 Posterolateral (PL) graft in place; anteromedial (AM) graft
position represented by Fiberwire sutures in tunnel. Note that the position
of the two bundles is parallel with the knee in full extension.
175
 Anterior Cruciate Ligament Reconstruction
FIG. 25-14 Anteromedial (AM) and posterolateral (PL) grafts in situ. The PL
bundle is partially obscured by the AM bundle.
permitted by the CPM is achieved for 2 consecutive days.
This is usually after 1 to 2 weeks. The brace is unlocked at
1 week, and crutches are maintained until quadriceps con-
trol is reestablished, typically in 4 to 6 weeks. The accelerated
rehabilitation protocol described by Irrgang is implemented
with return to contact sports at 6 months with a brace after
successful function testing.19
Complications
We have had three graft failures, all occurring after return-
ing to sport. Two were sustained during contact injuries
FIG. 25-15 Crossing pattern of anteromedial (AM) and posterolateral (PL) bundles. A, Parallel in extension.
B, Crossed in flexion. LFC, Lateral femoral condyle.
176
while playing collegiate football. The third occurred in a
noncompliant patient 3 months after reconstruction when
she returned to playing high-school basketball without a
brace. Four patients have undergone staple removal for
symptomatic hardware. To date, after 192 double-bundle
ACL reconstructions, we have had no fractures and no
radiographic signs of femoral condylar avascular necrosis or
tunnel widening.
Results
Several in vivo functional biomechanical studies demon-
strate that the kinematics are not completely restored with
single-bundle reconstruction.5,6 Amis15 has demonstrated
that even if the femoral tunnel is placed in a lower position
than the traditionally described location, the kinematics
are still not normal with regard to rotational stability. In
contrast, Yagi et al14 published their results of double-bun-
dle ACL reconstruction in a cadaveric model in which rota-
tional stability was restored.
Clinical results of double-bundle ACL reconstruc-
tion surgery are still evolving (Table 25-1).12,20–25 In
1987, Zaricznyj12 published the first clinical results for
double-bundle ACL reconstruction. Twelve of the fourteen
patients had excellent results. In 1999, Muneta et al24 pub-
lished preliminary results suggesting that the double-bundle
procedure showed a better trend with respect to anterior sta-
bility. In 2001, Hamada et al22 published a 2-year follow-up
on 160 consecutive patients who underwent single or
bisocket ACL reconstructions, demonstrating no statistical
significant difference between the two techniques for
IKDC, KT measurements, or thigh muscle strength.
A trend for better anterior stability was observed in the
 Anatomical Double-Bundle Reconstruction of the Anterior Cruciate Ligament 25
TABLE 25-1 Clinical Results Following Anatomical Double-Bundle Anterior Cruciate Ligament Reconstruction
Surgeon Patients Postoperative Anterior/Posterior Translation Postoperative Pivot Functional Outcome

Adachi 108 KT: all <3 mm side–side difference Not reported 100% NL

Hamada 106 KT: all <3 mm side–side difference Not reported IKDC: 96% NL/near NL

Muneta 54 KT: 2 pts >5 mm Not reported Lyshom: 94.5
5.3

Yasuda 57 KT: 49 <3 mm; 8 were 3–5 mm 0: 56 pt; 1þ: 1 pt Noyes: 47.5

Zaricznyj 14 Negative Lachman: 11 pts; 1þ Lachman: 3 pts 0: 14 pt Marshall: 12 good/excellent; 2 fair

Aglietti (unpublished) 50 KT: all <3 mm side–side difference 0: 40 pt IKDC: 96% NL/near NL

Yagi 20 KT average: 1.3 mm side–side difference 0: 17 pt IKDC: 95% NL/near NL

Fu (unpublished) 192 KT average: 1.2 mm side–side difference 0: 105 pt; 1þ: 6 pt 93% NL; 6% near NL; 1% fair

NL, Normal.

double-bundle group. No assessment of rotatory stability earlier better range of motion at 1 week, 4 weeks, and
was mentioned. Furthermore, in 2004, Adachi et al20 per- 12 weeks postoperative follow-up (Table 25-2).
formed a randomized prospective study of 108 patients
(55 single bundle; 53 double bundle) with an average of
32 months of follow-up (24 to 36 months). No statistically CONCLUSION
significant difference was noted with regard to knee joint
stability (KT-2000) or to proprioception. There was a sta- ACL reconstruction is one of the most common orthopae-
tistically significant difference with regard to a decreased dic procedures performed in the United States. Single-
incidence of notchplasty for the double-bundle group com- bundle ACL reconstruction that is focused mainly on the
pared with the single-bundle group. The authors did not AM bundle remains the “gold standard” that has enjoyed
obtain IKDC results or assess for rotatory stability. Aglietti great success and returned many athletes to their sports.
et al21 have an unpublished series of 75 patients (25 single However, several authors have demonstrated that rotational
bundle, 50 double bundle) that demonstrates a lower side- instability persists. The goal of anatomical double-bundle
to-side KT difference, a lower number of patients with ACL reconstruction is to address this issue and better
a postoperative pivot shift, and better IKDC functional restore kinematics to normal. It is hoped that this will
results for patients who underwent double-bundle ACL decrease the rate of degenerative changes, but long-term
reconstruction. In contrast, Yagi et al23 also have an unpub- clinical outcome studies are imperative. Regardless of
lished series of 60 prospectively randomized patients whether a double-bundle reconstruction technique is
(20 double bundle, 20 AM reconstruction, 20 PL recon- chosen, knowledge of the underlying anatomy of the indi-
struction). At 1 year, there were no statistically significant vidual bundles will make one a better ACL reconstruction
differences regarding side-to-side KT measurements, IKDC surgeon.
functional results, or patients with a postoperative pivot
shift.
The senior author has performed a total of 186 pri-
mary double-bundle ACL reconstructions to date. The TABLE 25-2 Range of Motion Following Anatomical Double-Bundle and
Single-Bundle Anterior Cruciate Ligament Reconstruction*
average follow-up is 12 months. The average postoperative
side-to-side KT measurement difference is 1.2 mm. Six 1 Week 4 Weeks 12 Weeks
patients had a 1þ pivot shift and the remainder demon- PE AF PE AF PE AF
strated no pivot. In addition, we have recently compared
Double bundle 2 41 1 5 1 2
our double-bundle ACL reconstruction, early range-of-
motion data with a cohort of single-bundle reconstructions Single bundle 3 70 3 23 2 9
performed by the senior author. The comparison demon-
All numbers are in degrees.
strated with statistical significance that the double-bundle *Noninvolved minus involved side-to-side difference in passive extension (PE) and
ACL reconstruction patients have consistently achieved active flexion (AF).

177
 Anterior Cruciate Ligament Reconstruction
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1. Griffin LY, Agel J, Albohm MJ, et al. Non-contact anterior cruciate
ligament injuries: risk factors and prevention strategies. J Am Acad
Orthop Surg 2000;8:141–150.
2. Freedman KB, D’Amato MJ, Nedeff DD, et al. Arthroscopic
anterior cruciate ligament reconstruction: a metaanalysis comparing
patellar tendon and hamstring tendon autografts. Am J Sports Med
2003;31:2–11.
3. Yunes M, Richmond JC, Engels EA, et al. Patellar versus hamstring
tendons in anterior cruciate ligament reconstruction—a meta-analysis.
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4. Fithian DC, Paxton EW, Stone ML, et al. Prospective trial of a treat-
ment algorithm for the management of the anterior cruciate ligament-
injured knee. Am J Sports Med 2005;33:335–346.
5. Ristanis S, Stergiou N, Patras K, et al. Excessive tibial rotation during
high-demand activities is not restored by anterior cruciate ligament
reconstruction. Arthroscopy 2005;21:1323–1329.
6. Tashman S, Collon D, Anderson K, et al. Abnormal rotational knee
motion during running after anterior cruciate ligament reconstruction.
Am J Sports Med 2004;32:975–983.
7. Palmer I. On the injuries to the ligaments of the knee joint. Acta Chir
Scand 1938;91:282.
8. Harner CD, Baek GH, Vogrin TM, et al. Quantitative analysis of
human cruciate ligament insertions. Arthroscopy 1999;15:741–749.
9. Odensten M, Gillquist J. Functional anatomy of the anterior cruciate
ligament and a rationale for reconstruction. J Bone Joint Surg Am
1985;67:257–262.
10. Gabriel MT, Wong EK, Woo SL, et al. Distribution of in situ forces
in the anterior cruciate ligament in response to rotatory loads. J Orthop
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11. Mott HW. Semitendinosus anatomic reconstruction for cruciate liga-
ment insufficiency. Clin Orthop Relat Res 1983;172:90–92.
12. Zaricznyj B. Reconstruction of the anterior cruciate ligament of
the knee using a doubled tendon graft. Clin Orthop Relat Res
1987;220:162–175.
13. Mae T, Shino K, Miyama T, et al. Single- versus two femoral socket
anterior cruciate ligament reconstruction technique—biomechanical
analysis using a robotic simulator. Arthroscopy 2001;17:708–716.
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14. Yagi M, Wong EK, Kanamori A, et al. Biomechanical analysis of an
anatomic anterior cruciate ligament reconstruction. Am J Sports Med
2002;30:660–666.
15. Fu FH: Rupture pattern of the anteromedial and the posterolateral
bundle of the anterior cruciate ligament. Personal communication.
16. Amis AA. Persistence of the mini pivot-shift after anatomically placed
anterior cruciate ligament reconstruction. Clin Orthop Relat Res
2007;457:203–209.
17. Aglietti P, Giron F, Buzzi R, et al. Anterior cruciate ligament recon-
struction: bone-patellar tendon-bone compared with double semiten-
dinosus and gracilis tendon grafts. A prospective, randomized clinical
trial. J Bone Joint Surg Am 2004;86:2143–2155.
18. Jonsson H, Riklund-Ahlstrom K, Lind J. Positive pivot shift
after ACL reconstruction predicts later osteoarthrosis—63 patients
followed 5–9 years after surgery. Acta Orthop Scand 2004;75:594–599.
19. Irrgang JJ. Modern trends in anterior cruciate ligament rehabilitation:
nonoperative and postoperative management. Clin Sports Med
1993;12:797–813.
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ciate ligament—single versus double-bundle multistranded hamstring
tendons. J Bone Joint Surg Br 2004;86:515–520.
21. Aglietti P. Double-bundle ACL reconstruction: single versus double
incision. Personal communication.
22. Hamada M, Shino K, Horibe S, et al. Single- versus bi-socket anterior
cruciate ligament reconstruction using autogenous multiple-stranded
hamstring tendons with Endobutton femoral fixation: a prospective
study. Arthroscopy 2001;17:801–807.
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and postero-lateral ACL reconstructions—quantitative evaluation of
the pivot shift test. In press.
24. Muneta T, Sekiya I, Yagishita K, et al. Two-bundle reconstruction of
the anterior cruciate ligament using semitendinosus tendon with
Endobuttons: operative technique and preliminary results. Arthroscopy
1999;15:618–624.
25. Yasuda K, Kondo E, Ichiyama H, et al. Anatomic reconstruction
of the anteromedial and posterolateral bundles of the anterior cru-
ciate ligament using hamstring tendon grafts. Arthroscopy 2004;20:
1015–1025.
 SUB PART III NOTCHPLASTY AND NAVIGATION
The intercondylar notch is the open space that
lies between the medial and lateral femoral con-
dyles of the distal femur and houses the substance
of both the anterior and posterior cruciate
ligaments. The anterior medial wall serves as the
insertion point of the posterior cruciate ligament
(PCL), and the posterior lateral wall serves as the
insertion point of the anterior cruciate ligament
(ACL). The intercondylar notch plays an impor-
tant role in the incidence of ACL injuries and is
an important technical factor to consider when
optimizing the surgical technique of ACL
reconstructions. The purpose of this chapter is
to review the fundamental anatomy of the
intercondylar notch, to understand its impact on
both the risk of ACL injuries and the optimiza-
tion of ACL reconstructions, to develop a better
understanding regarding when a notchplasty
is indicated and to what extent it should be
performed, to review techniques and pearls
in performing notchplasty, and to recognize
potential complications or risks associated with
notchplasty so that they can be avoided.
ANATOMY
The subtle anatomy of the intercondylar notch
in three dimensions plays an important role in
the incidence of ACL injuries as well as in opti-
mizing surgical techniques of notchplasty and
the ultimate outcome of reconstructions. Several
investigators1–5 have shown that a small notch
width or a small notch width index (notch
width divided by condylar width) is directly
Notchplasty
26
CHAPTER
correlated to increased risk of ACL injuries, Mark R. Hutchinson
especially in women (Fig. 26-1). A debate has
surfaced that it is not a small notch width alone
that leads to an increased risk of injury but
rather a smaller ligament within the notch that
may play a role. Shelbourne et al6 showed when
reconstruction is performed with the same size
of graft, regardless of notch width or gender,
the success rates were similar. Anderson et al7
compared magnetic resonance imaging (MRI)
of groups of male and female basketball players
and found smaller ligaments in the female
athletes as well as differences in notch width.
Charlton et al8 found gender variations in both
notch width and ACL volume in the groups
they compared. Regardless of the debate, it is
clear that radiographic findings of a small notch
is predictive of ACL injury. In addition, the
shape of the notch on an anteroposterior (AP)
notch view may also play a role regarding
ACL injury risk, with an A-framed notch being
relatively more stenotic and leading to increased
risk of injury compared with a wider and
forgiving inverted U-shaped notch. It should
be emphasized that no one is currently promot-
ing prophylactic notchplasty in athletes with an
intact ACL who incidentally have been found
to have a small notch.
While the AP perspective is clearly
important when evaluating the intercondylar
notch, the lateral perspective may be as or more
important for preoperative planning. On a lateral
radiograph, Blumensaat’s line represents the
roof of the intercondylar notch. The slope
(angular orientation relative to the femur),
179
 Anterior Cruciate Ligament Reconstruction
FIG. 26-1 The notch width index can be measured on radiographic tunnel
views or magnetic resonance imaging scans and represents the ratio of the
width of the notch (dotted arrows) to the intercondylar width at the level of
the popliteus indentation (large bold arrows).
position (anterior/posterior translational position relative to
the central axis of the femur), and trueness (absolutely straight
or curved at the ends) are highly variable among patients
(Fig. 26-2). Numerous authors have demonstrated an
increased risk of ACL reconstruction failure or postoperative
extension loss if graft roof impingement is apparent on the
lateral perspective.9,10 Howell et al10–13 have been instru-
mental in increasing the surgical community’s awareness of
the importance of identifying potential graft roof impinge-
ment preoperatively to guide either tunnel placement or the
extent of notchplasty intraoperatively. A preoperative lateral
radiograph should be routinely obtained in full extension.
If the slope of the roof of the notch is acute or its relative
position is too posterior, either the tibial tunnel should be
placed more posteriorly to avoid impingement14–16 or an
aggressive roofplasty needs to be performed.16,17 Failure to
recognize this impingement will lead to an increased risk of
graft failure.
Review of the preoperative lateral radiograph should
also assess the trueness of Blumensaat’s line. Is it a straight
line from front to back with sharp corners or edges at the inlet
and outlet of the notch, or is it rounded at the ends with
bumps or curves in the middle that may affect femoral tunnel
selection? The roof of the notch is rarely perfectly flat; it usu-
ally has a slight curve at the inlet (anterior aspect of the notch)
and the outlet (the over-the-back) position. Anteriorly, the
gentle transitioning curve or blending of the femoral groove
and femoral condyles into the articular surface prevents a
sharp edge or corner cutting into the anterior aspect of the
180
ACL in full extension. Posteriorly within the notch, a change
in slope occurs approximately 1 cm anterior to the true over-
the-back position. This change of slope is usually located at
the anterior edge of the leading aspect of the ACL insertion
onto the lateral femoral condyle and has been termed the
“resident’s ridge” by Clancy18 (Fig. 26-3). Preoperative or
intraoperative awareness of the resident’s ridge is essential
for optimal placement of the femoral tunnel and successful
outcome of the reconstruction. If the change of slope is acute
and mistaken for the true over-the-back position, the femoral
tunnel will be placed too far anteriorly and lead to one of the
most common causes of failure for ACL reconstructions. At
the time of notchplasty, a prominent resident’s ridge should
be taken down with a bur or osteotome to confirm optimal
placement of the femoral tunnel guide and ensure proper
positioning of the femoral tunnel. Finally, the true outlet of
the notch or over-the-back position on the femur is frequently
gently curved, making it difficult to lock in the extended
tongues of the femoral guides designed to offset the tunnel
position relative to the posterior cortex. This edge may need
to be flattened or a preliminary concavity created at the site
of the femoral tunnel to allow the guide to be properly seated.
INDICATIONS AND POTENTIAL RISKS
Although some controversy exists regarding the necessity or
extent of a notchplasty, a few fundamentals related to notch-
plasty cannot be debated. First, the space within the intercon-
dylar notch must be adequate to avoid impingement on the
ACL graft. Second sharp edges, osteophytes, spurs, or corners
that could irritate the graft must be removed. Third, and
probably most importantly, the femoral tunnel must be opti-
mally positioned in the posterior quartile of the notch along
the lateral femoral condyle. For most surgeons, notchplasty,
at least to a minimal degree, allows for optimally arthroscopic
visualization to ensure that proper tunnel placement occurs.
Historically, more aggressive notchplasties were neces-
sary to avoid roof impingement due to the relatively anteriorly
placed tibial tunnels based on the original description of
reconstruction by Clancy.19 Over time, aggressive notchplas-
ties for routine ACL reconstructions have become less com-
monplace in favor of tibial tunnels placed onto the posterior
edge of the tibial ACL footprint, which allows for less risk
of impingement and minimal notchplasty. In these cases
notchplasty is performed primarily to optimize visualization
of the femoral tunnel placement. Devices have been devel-
oped to base the tibial tunnel off the notch roof, virtually guar-
anteeing the absence of impingement in full extension and
potentially obviating the need for any notchplasty at all.20
In addition to primary or revision ACL reconstruction
in which notchplasty is performed as an adjunct to the
 Notchplasty 26

FIG. 26-2 On a lateral radiograph with the leg in full extension, Blumensaat’s line (A) (solid white arrows)
represents the roof of the notch. The slope of the roof can be measured by the femoral roof angle (B) and is an
important preoperative assessment for planning tibial tunnel placement. An assessment of the “trueness” of the
roof of the notch (C) may also prevent intraoperative complications. Sharper inlet and outlet corners (straight
arrow) allow better application of the over-the-back femoral guides but may contribute to anterior impingement.
Gently sloped or curved inlet and outlet edges (curved arrows) may make it more difficult for the tongue of an
over-the-back femoral guide to lock into position but protects the graft anteriorly against impingement.

181
 Anterior Cruciate Ligament Reconstruction

FIG. 26-3 The “resident’s ridge” is a change in the slope of the roof and lateral wall of the notch that occurs just
anterior to the femoral anterior cruciate ligament (ACL) footprint. Cross-sectional view of a cadaveric femur (A)
shows the resident’s ridge” (black arrow) to be just anterior to the ACL footprint (black triangles) and almost 10 mm
anterior to the true over-the-back position represented by the posterior cortex of the femur and capsule
(white arrow). The probe identifies a resident’s ridge on the arthroscopic view (B).

procedure, notchplasty may be indicated as the primary
procedure itself. As noted previously, no one is currently
recommending prophylactic notchplasties to reduce the risk
of ACL injuries; however, in patients who have postoperative
extension loss or arthrofibrosis, notchplasty may be the
procedure of choice. Shelbourne and Johnson21 performed
arthroscopic débridement of scar tissue and manipulation under
anesthesia with notchplasty in this population with good success
in regaining motion in selected patients. Clearly, prevention is
the best treatment, and initial adequate notchplasty may help
prevent future extension loss. Tonino et al and Millet et al in
separate papers22,23 agree that inadequate notchplasty or space
available for the ACL graft at the time of initial surgery was a
common cause of arthrofibrosis, and adequate notchplasty
might have prevented the complication.
One might argue that notchplasty is a benign proce-
dure and therefore an aggressive notchplasty is indicated in
everyone. This may not be true. LaPrade et al24 found that
aggressive notchplasty, in a canine model, led to early degen-
erative changes in the patellofemoral joint. Jarvela et al25
correlated their clinical findings of postoperative patellofe-
moral arthritis 7 years after ACL reconstruction with a large
notchplasty. In contrast, Morgan et al26 failed to show abnor-
mal pressure changes (in vitro using pressure-sensitive
film) on the patellofemoral joint after notchplasty. Another
potential risk of aggressive notchplasty is alteration of the
biomechanical effects of the ACL reconstruction itself.
Markolf et al27 showed increased graft forces, particularly
with the knee flexed at 90 degrees after notchplasty, and
surmised that this could lead to an increased risk of graft
failure. Anatomically, the ACL is meant to fill the notch
and lie gently on the roof of the notch in full extension. This
serves as an added buttress versus anterior displacement in
addition to the tension along the fibers of the ligament itself.
With aggressive notchplasty, this normal relationship may
not occur.
TECHNIQUES AND AVOIDING COMPLICATIONS
Preoperative planning continues to play an important role
when considering the necessity and extent of notchplasty.
Preoperative notch and lateral radiographs may reveal rela-
tive notch stenosis, spurs, or osteophytic overgrowth.28
These can be related to gender, genetics, degeneration, or
the chronicity of the ACL injury. Nonetheless, when recog-
nized preoperatively, it allows the surgeon to be more
aggressive at the time of surgery to ensure the postoperative
notch will be adequate to house the new ligament without
impingement. When preoperatively evaluating the lateral
view, it is very important to obtain the image with the knee
in full extension, which allows careful interpretation of the
slope and relative anterior/posterior position of the roof of
the notch. This interpretation may indicate either a more
aggressive notchplasty or the need to move the tibial tunnel
more posteriorly to avoid notch roof impingement.

182

The notchplasty itself can be performed either arthros-
copically or via a mini-open incision. The two primary goals
are (1) to avoid impingement and graft irritation and (2) to
optimize visualization for femoral tunnel placement. With
the advent of central tibial tunnel placement 7 to 10 mm ante-
rior to the PCL, it is rarely necessary to perform an aggressive
notchplasty to avoid graft impingement. Proper tibial tunnel
placement obviates impingement unless secondary osteophy-
tic overgrowth has occurred due to chronicity of injury. For
nonchronic reconstructions, the most important goal is
adequate visualization for placement of the femoral tunnel,
avoiding mistaking the resident’s ridge for the real over-the-
back position, and careful visualization of the posterior cortex
of the femoral condyle. Currently, we use only a minimal
notchplasty in virtually all of our primary reconstructions.
Notchplasty begins with débridement of soft tissue
and remnant ACL from within the notch and on the sur-
face of the medial wall of the lateral femoral condyle. The
shaver placed on an alternating setting is effective for
removing large loose fragments, and the shaver set at high
speed removes tissues adherent to the medial wall of the
notch. If the remnant ACL is adherent to the PCL or rem-
nant ACL stump and if the posterior capsule is present pos-
teriorly in the notch, an arthroscopic biter can macerate the
tissue, making it easier for the shaver to be effective. Many
surgeons use thermal ablation probes to accomplish this
step. Special care should be used when débriding soft tissues
posterior and medial to the PCL because numerous bleeders
Notchplasty 26
are present and one could enter the popliteal artery. In
general, we avoid débriding the tissue just adjacent to the
12-o’clock position. This avoids bleeding and allows us to
complete 90% of our notchplasties without a tourniquet. If
bleeding is encountered, it can be controlled with arthro-
scopic electrocautery or by inflating the tourniquet. The lig-
ament of Humphrey, the anterior meniscofemoral ligament,
lies obliquely just anterior to the PCL and is frequently
damaged at the time of soft tissue débridement or tibial tun-
nel reaming. There are no data that support poor outcomes
secondary to the sacrifice of the ligament of Humphrey;
nonetheless, it is probably best to leave it intact as a second-
ary rotational stabilizer if possible.
Bony notchplasty usually begins anteriorly and pro-
gresses posteriorly. Arthroscopically, a subtle pink color
change can be visualized at the entrance of the femoral notch
where the articular surface of the lateral femoral condyle thins
and curves acutely into the surface of the wall of the notch
(Fig. 26-4). This subtle change is usually about 1 to 2 mm
onto the articular surface and marks our initial site of anterior
notchplasty. This edge can be taken down with a small osteo-
tome or a high-speed bur/shaver (Fig. 26-5). Once the lead-
ing edge is removed, the high-speed bur/shaver is used to
flatten the remaining wall to the same depth in a front-to-
back direction. The goal is to create a smooth flat surface
that does not irritate the graft and allows direct visualization
to the posterior outlet (over-the-back position) of the notch.
In general, the extent of this minimal notchplasty is effective

FIG. 26-4 Arthroscopic view of the inlet of the notch revealing the presence of the posterior cruciate ligament
(PCL) and absence of the anterior cruciate ligament (ACL). A, The subtle pink color change is noted where the
articular cartilage of the lateral condyle transitions, becoming thin and curving into the roof of the notch (identified
by spinal needle) (B). Minimal notchplasty will begin by removing this 1 to 2 mm of articular surface and working
posteriorly to flatten the roof and lateral wall. In acute ACL reconstructions, it is rare to require more aggressive
notchplasty to provide space for the reconstruction or visualize the true over-the-back position.

183
 Anterior Cruciate Ligament Reconstruction
FIG. 26-5 Initiation of notchplasty can be performed using a small osteotome (A, B) or simply by using
mechanical arthroscopic devices such as an arthroscopic shaver set on high speed or an arthroscopic bur.
for visualization of the over-the-back position in most
patients.
Approximately, two-thirds to three-quarters of the
way back, the bur frequently becomes more erratic and is
difficult to maintain on the surface of the wall of the notch.
This is due to a change in slope that occurs within the notch
and a change in density of the bone itself. This is the resi-
dent’s ridge.18 The change in slope occurs immediately
anterior to the ACL insertion onto the femur. The erratic
nature of the bur is secondary to the increased cortical thick-
ness of the ACL insertion itself. The resident’s ridge should
be carefully flattened with the bur to match the entire flat
surface of the wall of the notch. This will allow excellent
visualization of the true over-the-back position on the femur
and allow optimal placement of the femoral over-the-back
guide. Indeed, at the time of notchplasty, we will usually
make a small “prehole” or concavity where we expect the
tunnel placement to be. This allows the over-the-back guide
to slide more securely in place over the back of the lateral
femoral condyle. It should be noted that leaving the cortical
edge on the most posterior aspect of the notch is important
during notchplasty and guide placement. Notchplasty that is
too aggressive on the posterior wall of the notch can make
proper positioning of the over-the-back guide difficult.
Although notchplasties for primary reconstructions
performed in a timely fashion are generally straightforward,
notchplasties can be particularly challenging in cases of revi-
sions, chronic reconstructions, and patients who suffered
from postoperative loss of extension or arthrofibrosis. In revi-
sion cases, the previous surgeon may have débrided relative
landmarks. In chronic cases, significant osteophytic over-
growth can virtually close off the entire entry into the notch
184
or can leave spurs posteriorly that throw off the over-the-back
guides. Ultimately the goal in these complex cases is the same:
full extension, adequate space available for the ligament, and
excellent visualization for reconstructions.
Technically, the surgeon must work stepwise from
known to unknown and from front to back in the notch.
Débridement of soft tissue is usually straightforward; how-
ever, care must be taken to avoid viable anatomical structures
including previous reconstructed ligaments. If a Cyclops
lesion is present (scar tissue anteriorly in the notch, frequently
with an adherent fat pad), flexing and extending the knee
under arthroscopic visualization may help to identify the
ACL so that the surgeon can target the scar tissue itself. In
some cases it may be necessary to remove even the recon-
structed ligament to regain full extension. Fortunately,
débridement and notchplasty in post-ACL patients with
arthrofibrosis are usually successful in regaining motion and
normal gait as well as returning to athletic activities.29,30 In
patients with significant bony overgrowth, the surgeon
should begin by carefully taking down obvious osteophytes
under direct visualization and then working posteriorly.
Osteophytes are usually softer than the native bone and are
removed easier by the bur/shaver. In revision cases in which
osteophytes may be present posteriorly, we recommend
obtaining intraoperative radiographs to confirm femoral
tunnel placement prior to drilling to ensure optimal position.
In conclusion, knowledge of notch anatomy and tech-
nical pearls in performing an appropriate notchplasty when
indicated are essential skills in routinely obtaining successful
outcomes of ACL reconstructions. Currently, only minimal
notchplasty is usually necessary to assist in optimizing visu-
alization of femoral tunnel placement.

References
1. Souryal TO, Moore HA, Evans JP. Bilaterality in anterior cruciate lig-
ament injuries in athletes: associated with intercondylar notch stenosis.
Am J Sports Med 1988;16:449–454.
2. Souryal TO, Freeman TR. Intercondylar notch size and anterior cru-
ciate ligament injuries in athletes: a prospective study. Am J Sports Med
1993;21:535–539.
3. Schickendantz MS, Weiker GG. The predictive value of radiographs
in the evaluation of unilateral and bilateral anterior cruciate ligament
injuries. Am J Sports Med 1993;21:110–113.
4. LaPrade RF, Burnett QM. Femoral intercondylar notch stenosis and
correlation to anterior cruciate ligament injuries: a prospective study.
Am J Sports Med 1994;22:198–203.
5. Houseworth SW, Mauro VJ, Mellon BA, et al. The intercondylar
notch in acute tears of the anterior cruciate ligament: a computer gra-
phics study. Am J Sports Med 1987;15:221–224.
6. Shelbourne KD, Davis TT, Klootwyck TE. The relationship between
intercondylar notch width of the femur and the incidence of anterior
cruciate ligament tears: a prospective study. Am J Sports Med
1998;26:402–408.
7. Anderson AF, Dome DC, Gautam S, et al. Correlation of anthropo-
metric measurements, strength, anterior cruciate ligament size, and
intercondylar notch characteristics to sex differences in ACL tear rates.
Am J Sports Med 2001;29:58–66.
8. Charlton WPH, St John TA, Ciccotti MG, et al. Differences in fem-
oral notch anatomy between men and women: a magnetic resonance
imaging study. Am J Sports Med 2002;30:329–333.
9. Feagin JA, Cabaud HD, Curl WW. The anterior cruciate ligament:
radiographic and clinical signs of successful and unsuccessful repairs.
Clin Orthop 1982;164:54–58.
10. Howell SM, Taylor MA. Failure of reconstruction of the anterior cru-
ciate ligament due to impingement by the intercondylar roof. J Bone
Joint Surg 1993;75A:1044–1055.
11. Howell SM. Arthroscopic roofplasty: a method for correcting exten-
sion deficit caused by roof impingement of an anterior cruciate liga-
ment graft. Arthroscopy 1992;8:375–379.
12. Howell SM, Barad SJ. Knee extension and its relationship to the slope
of the intercondylar notch. Implications for positioning the tibial tun-
nel in anterior cruciate ligament reconstructions. Am J Sports Med
1995;23:288–294.
13. Howell SM, Gittins ME, Gottlieb JE, et al. The relationship between
the angle of the tibial tunnel in the coronal plane and loss of flexion
and anterior laxity after ACL reconstruction. Am J Sports Med
2001;29:567–574.
14. Miller MD, Olszewski AD. Posterior tibial tunnel placement to avoid
anterior cruciate ligament graft impingement: an in-vitro and in-vivo
study. Am J Sports Med 1997;25:818–822.
Notchplasty 26
15. Morgan CD, Kalman VR, Grawl DM. Definitive landmarks for
reproducible tibial tunnel placement in anterior cruciate ligament
reconstruction. Arthroscopy 1995;11:275–288.
16. Berns GS, Howell SM. Roofplasty requirements in vitro for different
tibial hole placements in anterior cruciate ligament reconstruction.
Am J Sports Med 1993;21:292–298.
17. Tanzere M, Lenczner E. The relationship of intercondylar notch size
and content to notchplasty requirement in anterior cruciate ligament
surgery. Arthroscopy 1990;6:89–93.
18. Hutchinson MR, Ash SA. Resident’s ridge: assessing the cortical
thickness of the lateral wall and roof of the intercondylar notch.
Arthroscopy 2003;19:931–935.
19. Clancy WG, Nelson DA, Reider B, et al. Anterior cruciate ligament
reconstruction using one-third of the patellar ligament, augmented by
extra-articular tendon transfers. J Bone Joint Surg 1982;64A:352–359.
20. Howell SM, Lawhorn KW. Gravity reduces the tibia when using a tibial
guide that targets the intercondylar roof. Am J Sports Med
2004;32:1702–1710.
21. Shelbourne KD, Johnson GE. Outpatient surgical management of
arthrofibrosis after ACL surgery. Am J Sports Med 1994;22:192–197.
22. Tonino P, Risinger RJ, Garcia M, et al. Arthrofibrosis following ACL
reconstruction. In Freedman KM (ed): Complications in orthopaedics:
ACL surgery, American Academy of Orthopaedic Surgeons: Rose-
mont, IL, 2005, pp 35–40.
23. Millet PJ, Wickiewicz TL, Warren RF. Motion loss after ligament
injuries to the knee. Part 1: causes. Am J Sports Med 2001;29:664–675.
24. LaPrade RF, Terry GC, Montgomery RD, et al. The effects of
aggressive notchplasty on the normal knee in dogs. Am J Sports Med
1998;26:193–200.
25. Jarvela T, Paakkala T, Kannus P, et al. The incidence of patellofemoral
osteoarthritis and associated findings 7 years after ACL reconstruction
using bone-patellar tendon-bone autograft. Am J Sports Med
2001;29:18–24.
26. Morgan EA, McElroy JJ, DesJardins JD, et al. The effect of intercon-
dylar notchplasty on the patellofemoral articulation. Am J Sports Med
1996;24:843–846.
27. Markolf KL, Hame SL, Hunter M, et al. Biomechanical effects of
femoral notchplasty in anterior cruciate reconstruction. Am J Sports
Med 2002;30:83–89.
28. Miller MD, Olszewski AD. The appearance of roofplasties on lateral
hyperextension radiographs. Am J Sports Med 1999;27:513–516.
29. Shelbourne KD, Johnson GE. Outpatient surgical management of
arthrofibrosis after ACL surgery. Am J Sports Med 2006;22:192–197.
30. Watanabe BM, Howell SM. Arthroscopic findings associated with
roof impingement of an anterior cruciate ligament graft. Am J Sports
Med 1995;23:616–625.
185
27
CHAPTER
Computer-Assisted Navigation for Anterior
Cruciate Ligament Reconstruction
Jason Koh Computer-assisted navigation for anterior cruci-
ate ligament (ACL) reconstruction can increase
precision in tunnel placement and also provide
valuable outcome information such as rotational
stability.1–8 This is accomplished by registering
anatomical landmarks and tracking the location
of instruments and the tibia and femur in three-
dimensional (3D) space on what is essentially a
3D map in the computer. Values such as the
location of instruments and measures of impin-
gement and isometry, as well as the location of
the femoral and tibial tunnels, are calculated
and shown to the operating surgeon in real
time. Computer-assisted navigation has been
demonstrated to improve accuracy and decrease
laxity of the ACL reconstructed joint.5
RATIONALE
Computer assistance for precision navigation
has been increasingly common in everyday appli-
cations such as the global positioning system
(GPS) for drivers and sailors and has spread into
surgical applications such as total knee replace-
ment, pedicle screw placement, stereotactic brain
surgery, and otolaryngology. In orthopaedic sur-
gery, computer-assisted navigation has repeat-
edly been demonstrated to improve accuracy of
total knee replacement components, not only in
reducing outliers but also in correcting consistent
repeated errors made by experienced sur-
geons.9,10 Similarly, improved accuracy in the
placement of total hip components has also been
demonstrated.11 Clinical outcomes have been
186
shown to be comparable between navigated and
nonnavigated groups.2,5
NEED FOR PRECISION IN TUNNEL
PLACEMENT
Clinical outcomes in ACL reconstructed patients
are significantly related to accurate tunnel place-
ment. Although there may not be a clear consen-
sus on where tunnels should be placed, ample
evidence exists that certain tunnel positions will
result in mechanical problems with the graft
and/or produce inappropriate kinematics. Multi-
ple authors have indicated that incorrect tunnel
placement can result in pain, laxity, synovitis, loss
of range of motion, graft impingement, and graft
failure.12–23 In longer-term follow-up, errors in
tunnel placement result in an increased risk of
arthritis.18 Although shorter-term studies may
not demonstrate substantial differences, there
remains a significant risk of arthritis following
ACL reconstruction, and this is likely to related
in part to tunnel placement.
CURRENT ACCURACY WITHOUT
NAVIGATION
Multiple authors have recommended techniques
and anatomical landmarks for accurate tunnel
placement; however, few studies have been per-
formed to assess the accuracy of surgeons in
reproducibly creating accurate tunnels. Part of
the difficulty in assessment is the difficulty in

accurately assessing intraarticular distance with the mono-
cular, angled arthroscope and limited ability to place measur-
ing devices in the joint in appropriate orientation. In addition,
it is difficult to assess isometry or the projection of the inter-
condylar notch or other sources of impingement in the knee.
Clinically, accuracy of ACL reconstruction techniques
can be assessed by the number of revision ACL reconstruc-
tions performed each year. Recent reports suggest that
approximately 10% to 20% of all cases are revised.24,25 The
vast majority of the failures are related to technical errors, spe-
cifically tunnel placement.24–26 The most common error is
excessive anterior femoral tunnel placement, which can
decrease rotational stability and may result in a graft that is
lax in extension and tight in flexion.22,24 Among experienced
surgeons, it has been noted that the tibial tunnel can be placed
too far posterior in order to avoid notch impingement.2–4
This can result in posterior cruciate ligament (PCL) impinge-
ment with the knee in flexion and subsequent loss of knee
flexion or strain on the graft. In addition, the graft will tend
to be more vertically oriented and contribute less rotational
stability.24
Several studies have been performed under various
conditions to assess the accuracy of ACL tunnel placement.
The Pittsburgh group evaluated tunnel placement by two
experienced ACL surgeons in 20 foam knee models using
standard arthroscopic guides. Actual tibial tunnel placement
was a mean of 4.9 mm from the ideal tunnel site. Actual
femoral tunnel placement was a mean of 4.2 mm from the ideal
tunnel site. These differences were believed to be significant.6
Another study from the same group demonstrated the
variability of tunnel placement by surgeons with 100 to 3500
cases of experience. Two fellows and two experienced surgeons
each drilled 10 tunnels in foam knees. Tibial placement by
experienced surgeon 1 varied by 2 mm; experienced surgeon
2, 3.4 mm; fellow 1, 2.1 mm; and fellow 2, 2.4 mm. On the
femoral side, variability was less for experienced surgeons:
experienced surgeon 1, 2.3 mm; experienced surgeon 2,
3.0 mm; fellow 1, 4.5 mm; and fellow 2, 4.1 mm. Clearly,
substantial variability was observed.27
Surgeon accuracy in tunnel placement has also been
evaluated in cadavers.28 In an advanced arthroscopy course,
instructors placed tunnels in 24 specimens. The tunnel
placement was then evaluated. Fifty percent (12/24) of the
femoral tunnels and 25% (6/24) of the tibial tunnels were
“unacceptable.” Similar results have been anecdotally noted
by instructors at other training courses.
Evaluation of tunnel placement in vivo has also been
performed in several centers. Harner recently reported on a
series of 30 patients in which the tibial guide pin placement
was evaluated by the use of intraoperative fluoroscopy.29 Tib-
ial pins were placed using standard arthroscopic landmarks:
namely, 7 mm anterior to the PCL, the medial tibial
Computer-Assisted Navigation for Anterior Cruciate Ligament Reconstruction 27
eminence, the anterior horn of the lateral meniscus, and the
center of the visualized ACL tibial footprint. After reviewing
the pin placement, Harner believed that it was necessary to
reposition the pin 43% of the time. Typically, the tendency
was for the experienced ACL surgeon to place the tibial
tunnel too posterior (13/14 cases). In addition, repositioning
of the pin was as frequent in the last 10 cases (5/10) as in the
first 10 cases (5/10).
Similar results were found for a series of 24 patients in
which tunnel position was evaluated postoperatively by radio-
graphs.30 Two experienced ACL surgeons performed ACL
reconstructions and recorded their perceptions of femoral
and tibial tunnel placement. These were then correlated with
actual tunnel placement by a blinded observer. The femoral
tunnel demonstrated excellent (perfect) correlation coefficient
(R2 ¼ 1) on the anteroposterior (AP) radiograph (medial-
lateral placement) between perceived and actual position.
Good correlation (R2 ¼ 0.55) was found for the lateral radio-
graph (AP position). However, the ability of the surgeons to
describe medial-lateral tibial tunnel position was poor
(R2 ¼ 0.14), and the true AP position of the tibial tunnel
had no correlation (R2 ¼ 0.07, P ¼ 0.36) to the surgeons’
perception. The authors concluded that four tunnels
(12.5%) “were in very different positions than that expected
by the surgeon.”
Other authors have noted that radiographic analysis of
tunnel placement demonstrated too-posterior placement
of the tibial tunnel and a relatively vertically oriented (the
11- or 1-o’clock position) femoral tunnel using standard
arthroscopic instrumentation.2,4
The evidence suggests that there is room for improve-
ment in the accuracy of ACL tunnel placement, even
among the more experienced surgeons who typically parti-
cipated in these studies. Accuracy among less experienced
surgeons would likely be lower.
TECHNIQUES OF COMPUTER-ASSISTED
NAVIGATION
Essential elements of computer-assisted navigation for ACL
reconstruction include the ability to register and accurately
track the relative positions of the tibia and femur as well as
the intraarticular landmarks that guide correct tunnel place-
ment. This can be accomplished by several methods, but most
current solutions involve markers on rigid bodies attached to
the tibia and femur with pins or screws. These are tracked
intraoperatively by use of a binocular infrared camera attached
to a computer that can calculate the relative position of the
femur and tibia to less than 1 mm and less than 1 degree of
precision1 (Fig. 27-1). Some systems require the use of pre-
operative computed tomography (CT) scans or intraoperative
187
 Anterior Cruciate Ligament Reconstruction
FIG. 27-1 Infrared camera.
fluoroscopy (Brainlab, Westchester, IL). Other systems are
“image-free,” such as the Orthopilot (Aesculap, Center Val-
ley, PA) and do not require the use of preoperative or intrao-
perative radiographic imaging.
Most navigation protocols follow a similar progression
of registration of intraarticular and extraarticular landmarks.
The following description is of the workflow of the Ortho-
pilot Navigation System (Aesculap), which functions to
record kinematic and anatomical data and calculates critical
values of concern to the surgeon.
The navigation camera and display screen are set up
opposite to the operative side of the patient, positioned
opposite the knee and next to the arthroscopy tower or
screen (Fig. 27-2). The initial data screens are filled in with
the basic demographic data such as the name of the patient
and physician (Fig. 27-3). This is followed by the optional
input of preoperative radiographic information if desired
by the surgeon. Clinically in the author’s practice, this has
not been found to be necessary to obtain accurate and pre-
cise results. This part of the setup may be completed by
ancillary personnel prior to the initiation of the case.
Following appropriate graft harvest and preparation
and the preparation of the knee to drill tunnels, the tracking
devices are attached to the knee. Typically, prior to the
placement of the trackers, the ACL stump is removed and
a notchplasty is performed if desired by the surgeon, and
other intraarticular pathologies such as meniscal or chondral
Arthroscopy screen
Patient
Navigation screen
and camera Surgeon
FIG. 27-2 Arthroscopy screen.
188
injuries are addressed. This minimizes the potential interfer-
ence of the tracking devices during preparation of the knee.
The trackers for ACL reconstruction are then attached
by either two Kirschner wires (K wires) (Fig. 27-4) or a screw
to the tibia and femur. The Orthopilot system uses trackers
that can be attached by K wire fixation to bone, unlike other
systems that use a significantly larger screw, which could be
a potential stress riser. The K wires are placed percutaneously
through small stab incisions on the anterior tibia and medial
epicondyle of the femur. This minimizes morbidity associated
with the placement of the trackers. We do not recommend the
placement of the femoral tracker through the quadriceps
mechanism because this can cause pain and potentially
quadriceps weakening.
We use a “passive” rather than an “active” tracking
system. This system involves using reflected light from mar-
kers rather than actively emitted light from small diodes.
The advantage is less weight and no cords intraoperatively.
However, it is important to keep the reflective balls clean
and dry intraoperatively.
Following attachment of the trackers to the femur and
tibia, tibial extraarticular landmarks are registered, including
the tibial tubercle, the anterior tibial crest, and the medial and
lateral borders of the tibia (Fig. 27-5). This is performed by
palpating the identified landmarks using a pointer with
attached reflective markers and clicking a foot pedal that
serves as a mouse button. This step is followed by kinematic
evaluation of knee motion by recording the relative positions
of the femur and tibia in full extension and flexion.
Acquisition of landmarks and kinematic testing takes
approximately 90 seconds.
The relative motion of the femur and tibia is then
assessed by the surgeon in a chosen degree of flexion, usually
30 degrees. Absolute anterior and posterior translation in
millimeters is recorded. In addition, the arc of internal and
external rotation is recorded (Fig. 27-6). This is a measure-
ment that cannot be accurately obtained without this sys-
tem. The values are then written to a permanent file. Of
note, any screen can be recorded to the computer memory
at any step in the program.
At this point, the arthroscope is introduced into the
knee, and the usual tibial intraarticular landmarks are identified
and palpated with the pointer, similar to palpation with a
probe. These include the PCL, the anterior horn of the
lateral meniscus, and the medial tibial spine. Following this,
the anterior margin of the intercondylar notch, the femoral
ACL origin, and the posterior edge of the intercondylar notch
are palpated. Of note, one of the most valuable pieces of infor-
mation is a real-time measurement of the intercondylar notch
length (Blumensaat’s line; Fig. 27-7). The average length is
30 mm; a measurement of 25 to 26 mm suggests that the true
over-the-top position has not been reached and the proposed

FIG. 27-3 Patient information screens.
position is not correct. At our institution, this has been partic-
ularly useful in providing additional feedback for residents in
training.
Following the acquisition of intraarticular landmarks,
the tibial guide is placed as usual into the knee and placed
in the proposed location for the tibial tunnel. The guide
FIG. 27-4 Trackers attached with K wires.
Computer-Assisted Navigation for Anterior Cruciate Ligament Reconstruction 27
has reflective markers attached, permitting the precise
identification of the location of the tibial guide pin with
respect to the PCL, the intracondylar notch, and other
intraarticular and extraarticular landmarks (Fig. 27-8). This
allows the surgeon to choose the appropriate coronal and
sagittal angles and distance from the PCL, as well as to
189
 Anterior Cruciate Ligament Reconstruction

FIG. 27-5 Extraarticular landmarks.

FIG. 27-6 Knee stability Test-Preoperative.

190

FIG. 27-7 Notch length. This is an excellent check of whether the true
over-the-top position has been reached.
FIG. 27-8 Tibial tunnel guidance.
avoid impingement on the roof or wall of the intercondylar
notch.
Following selection and recording of the tibial tunnel,
the proposed femoral tunnel location is evaluated by
placing the pointer tip at the location of the femoral guide
pin (Fig. 27-9). This tells the surgeon where the location
of the proposed tunnel site is from the posterior femoral
cortex and the location on the “clock face” (i.e., the position
of the graft laterally). In addition, information is provided
on the amount of isometry of the graft and where and
by how many millimeters the graft will impinge on the
intercondylar notch.
Finally, after securing the graft, the final measure-
ments of AP translation and internal and external rotation
are obtained (Fig. 27-10).
Computer-Assisted Navigation for Anterior Cruciate Ligament Reconstruction 27
FIG. 27-9 Femoral tunnel guidance.
FIG. 27-10 Postoperative screenshot.
RESULTS
The results of computer-assisted navigation for ACL recon-
struction have demonstrated consistent improvements in
tunnel placement and clinically measured laxity. The
improvements have been observed in both relatively inexpe-
rienced surgeons and surgeons who have conducted multiple
ACL reconstructions. In the laboratory setting, DiGioa
demonstrated improved accuracy in tunnel placement in
foam knees when compared with standard manual instru-
mentation. This was shown first with experienced surgeons
and then with novices.6
Koh reported that navigation improved the accuracy
of tibial tunnel placement.2 Forty-two navigated knees
demonstrated a more anatomical, slightly more anterior tib-
ial tunnel without impingement compared with nonnavi-
gated knees. The variability of tunnel placement was
191
 Anterior Cruciate Ligament Reconstruction
extremely low in both the navigated and nonnavigated knee
groups. After an initial learning curve, minimal extra time
was needed for the navigated knees.
Eichorn reported substantially better accuracy both for
inexperienced surgeons (fellows)3 and for his own4 tunnel
placement. Inexperienced surgeons demonstrated extremely
low variability and accurate femoral and tibial tunnel place-
ment using navigation.3 Navigated ACL reconstructions
performed by a very experienced surgeon demonstrated
improved tunnel placement on the lateral wall (the 10-
o’clock versus the 10:30 position) and a more accurate ante-
rior placement of the tibial tunnel (more anterior without
impingement).4
A French group recently published results of navi-
gated ACL reconstructions in patients randomized to either
navigated or nonnavigated knees.5 Twenty-two nonnavi-
gated and 26 navigated knees were compared. Nineteen of
the 22 nonnavigated knees had a portion of the tibial tunnel
placed anterior to the roof of the notch versus none of the
navigated knees. The variability of laxity was substantially
less, and less than 2 mm of laxity was seen in 96.7% of
navigated knees versus 83% of nonnavigated knees. The
initial additional time for use of the system was 25 minutes
but with experience decreased to less than 10 minutes.
DISCUSSION
ACL reconstructions performed with computer-assisted nav-
igation have demonstrated improved accuracy in tunnel
placement and improved measurements of clinically assessed
laxity in patients when compared with nonnavigated
knees.1–6 Following an initial learning curve of a few cases,
the additional time required for this increased precision is
minimal. At this time, a moderate cost is associated with the
initial acquisition of the machine; however, most of the navi-
gation systems can be used for other procedures such as joint
replacement. In addition, the high cost of revision surgery
may be avoided if tunnel position is more accurate. The ben-
efits of navigation have been demonstrated both for relatively
less experienced and more experienced surgeons. Less experi-
enced surgeons typically will have less variable results in
addition to improved accuracy with navigation.3 More experi-
enced surgeons, who are often quite consistent in tunnel
placement, will typically shift tunnel placement to a more ana-
tomical position.2,4,5
Computer-assisted navigation for ACL reconstruction
will provide a more precise method of accurately placing
tunnels and will be likely to reduce the rate of ACL failures.
In the future, accurate pinless systems (currently under
development) will be able to acquire anatomical information
about the knee without the user having to actively register
192
points. These systems will be able to provide valuable
information to the surgeon for ligament, cartilage, and bony
reconstruction.
References
1. Koh JL. Computer-assisted navigation and anterior cruciate liga-
ment reconstruction: accuracy and outcomes. Orthopaedics 2005;10:
s1283–s1287.
2. Koh JL, Koo S. Leonard J, Kodali P. ACL tunnel placement: A radio-
graphic comparison between navigated versus manual ACL recon-
struction. Orthopedics 2006;10:S122–S124.
3. Eichhorn J. Three years of experience with computer navigation-
assisted positioning of drilling tunnels in anterior cruciate ligament
replacement (SS-67). Arthroscopy 2004;20:31–32.
4. Eichhorn J. Three years of experience with computer-assisted
navigation in anterior cruciate ligament replacement. http://www.
aclstudygroup.com/Powerpoint-pdf02/Eichhorn.pdf.
5. Plaweski S, Cazal J, Rosell P, Merloz P. Anterior cruciate ligament
reconstruction using navigation: A comparative study on 60 patients.
Am J Sports Med 2006;94:542–552.
6. Picard F, DiGioia AM, Moody J, et al. Accuracy in tunnel placement
for ACL reconstruction. Comp Aid Surg 2001;6:279–289.
7. Klos TV, Habets RJ, Banks AZ, et al. Computer assistance in
arthroscopic anterior cruciate ligament reconstruction. Clin Orthop
1998;354:65–69.
8. Degenhart M. Computer-navigated ACL reconstruction with the
OrthoPilot. Surg Technol Int 2004;12:245–251.
9. Stulberg SD, Loan P, Sarin V. Computer-assisted navigation in total
knee replacement: Results of an initial experience in thirty-five
patients. J Bone Joint Surg Am 2002;84:S90–S98.
10. Berry DJ. Computer-assisted knee arthroplasty is better than a con-
ventional jig-based technique in terms of component alignment.
J Bone Joint Surg Am 2004;86:2573.
11. Parratte S, Argenson JNA. Validation and usefulness of a computer-
assisted cup-positioning system in total hip arthroplasty. A pros-
pective, randomized, controlled study. J Bone Joint Surg Am
2007;89:494–499.
12. Aglietti P, Buzzi R, Giron F, et al. Arthroscopic-assisted anterior cru-
ciate ligament reconstruction with the central third patellar tendon.
A 5–8-year follow-up. Knee Surg Sports Traumatol Arthrosc
1997;5:138–144.
13. Howell SM, Clark JA, Farley TE. Serial magnetic resonance study
assessing the effects of impingement on the MR image of the patellar
tendon graft. Arthroscopy 1992;8:350–358.
14. Howell SM, Clark J. Tibial tunnel placement in anterior cruciate
ligament reconstructions and graft impingement. Clin Orthop
1992;283:187–195.
15. Howell SM, Taylor MA. Failure of reconstruction of the anterior cru-
ciate ligament due to impingement by the intercondylar roof. J Bone
Joint Surg 1993;75A:1044–1055.
16. Howell SM, Wallace MP, Hull ML, Deutsch ML. Evaluation of the
single-incision arthroscopic technique for anterior cruciate ligament
replacement. A study of tibial tunnel placement, intraoperative graft
tension, and stability. Am J Sports Med 1999;27:284–293.
17. Ikeda H, Muneta T, Niga S, et al. The long-term effects of tibial drill
hole position on the outcome of anterior cruciate ligament reconstruc-
tion. Arthroscopy 1999;15:287–291.
18. Jarvela T, Paakkala T, Jarvela K, et al. Graft placement after the ante-
rior cruciate ligament reconstruction: A new method to evaluate the
femoral and tibial placements of the graft. Knee 2001;8:219–227.
19. Khalfayan EE, Sharkey PF, Alexander AH, Bruckner JD, Bynum
EB. The relationship between tunnel placement and clinical results
after anterior cruciate ligament reconstruction. Am J Sports Med
1996;3:335–341.

20. Romano VM, Graf BK, Keene JS, Lange RH. Anterior cruciate liga-
ment reconstruction. The effect of tibial tunnel placement on range of
motion. Am J Sports Med 1993;3:415–418.
21. Muneta T, Yamamoto H, Ishibashi T, et al. The effects of tibial tun-
nel placement and roofplasty on reconstructed anterior cruciate liga-
ment knees. Arthroscopy 1995;1:57–62.
22. Sommer C, Friederich NF, Muller W. Improperly placed anterior cru-
ciate ligament grafts: correlation between radiological parameters and
clinical results. Knee Surg Sports Traumatol Arthrosc 2000;8:207–213.
23. Yaru NC, Daniel DM, Penner D. The effect of tibial attachment site
on graft impingement in an anterior cruciate ligament reconstruction.
Am J Sports Med 1992;2:217–220.
24. Allen CA, Giffin JR, Harner CD. Revision anterior cruciate ligament
reconstruction. Orthop Clin N Am 2003;34:79–98.
25. AOSSM institutes multi-center revision ACL study. In Matava MJ,
Boden BP (eds). AOSSM Sports Medicine Update 2005; March-April: 5.
Computer-Assisted Navigation for Anterior Cruciate Ligament Reconstruction 27
26. Getelman MH, Friedman MJ. Revision anterior cruciate ligament
surgery. J Am Acad Orthop Surg 1999;7:189–198.
27. Burkart A, Debski RE, McMahon PJ, et al. Precision of ACL tunnel
placement using traditional and robotic techniques. Comput Aided Surg
2001;6:270–278.
28. Kohn D, Beusche T, Caris J. Drill hole position in endoscopic anterior
cruciate ligament reconstruction. Results on an advanced arthroscopy
course. Knee Surg Sports Traumatol Arthrosc 1998;6:S13–S15.
29. Cha PS, West RV, Harner CD. The results of using intraoperative
fluoroscopy for ideal tibial tunnel position during anterior cruciate lig-
ament reconstruction. 11th ESSKA Congress, May 8, 2004.
30. Sudhahar TA, Glasgow MM, Donell ST. Comparison of expected vs.
actual tunnel position in anterior cruciate ligament reconstruction.
Knee 2004;11:15–18.
193
 PART E FIXATION BIOMECHANICS
28
CHAPTER
Biomechanics of Intratunnel Anterior
Cruciate Ligament Graft Fixation
Neal C. Chen INTRODUCTION
Charles H. Brown, Jr.
In 1983, Lambert1 first introduced the technique
of intratunnel anterior cruciate ligament (ACL)
graft fixation by securing a vascularized bone–
patellar tendon–bone (BPTB) ACL graft with
6.5-mm AO cancellous screws. General accep-
tance of interference screw fixation of BPTB
ACL grafts came about in large part due to the
biomechanical study of Kurosaka et al.2 This
study demonstrated that fixation of a 10-mm
BPTB ACL graft in human cadaveric knees
with a custom-designed, headless, 9-mm, fully
threaded interference screw had superior strength
and stiffness compared with fixation with a
6.5-mm AO cancellous screw, staple fixation, or
sutures tied over a button.2 Because of the many
biomechanical studies demonstrating superior
initial fixation properties and clinical outcomes
studies demonstrating a high rate of success,
interference screw fixation of BPTB grafts is
now considered the standard against which all
ACL graft fixation techniques are compared.3,4
Based on the success of interference screw
fixation of BPTB ACL grafts, Pinczewski5 in
1993 introduced the use of blunt threaded metal
interference screws to fix four-strand hamstring
tendon ACL grafts. This fixation technique
has subsequently been extended to the use of
nonmetallic bioabsorbable interference screws.
Rigid initial graft fixation is critical to the
success of any ACL reconstruction. Attainment
of rigid initial graft fixation minimizes elongation
and prevents failure at the graft attachment sites
194
during cyclical loading of the knee prior to
biological fixation of the ACL graft. The advan-
tages of early joint motion, early weight bearing,
and closed chain exercises following ACL sur-
gery have been well documented. However, these
activities place greater demands on initial ACL
graft fixation. In order to maintain joint stability
and prevent the development of progressive joint
laxity while the knee is being subjected to
the stresses of an accelerated rehabilitation pro-
gram, it is important to choose ACL graft fixa-
tion methods that provide rigid mechanical
fixation from time zero until biological fixation
at the graft fixation sites occurs. One of the still-
unanswered questions regarding ACL graft
fixation is, “How strong and stiff do the initial
graft fixation methods need to be to allow use
of an accelerated ACL rehabilitation program?”
In the late 1960s, Morrison,6,7 using force
plate and gait analysis, estimated the forces
experienced by the ACL during activities of daily
living to range from 27 N to 445 N. Noyes et al8
estimated that the ACL is loaded to approxi-
mately 454 N during activities of daily living.
However, at the present time the forces placed
on the ACL with rehabilitation exercises
performed in the early postoperative period or
during activities of daily living are unknown. In
vitro mechanical studies have demonstrated that
the initial strength and stiffness of BPTB and
four-strand hamstring grafts far exceed the
estimated loads on the ACL.8–10 However,
compared with ACL grafts, all current ACL graft
fixation methods demonstrate inferior initial

tensile properties.11 Therefore mechanical fixation of the
ACL graft in the bone tunnels is the weak link in the early
postoperative period. Consequently, initial graft fixation
properties are of great relevance in determining the success
of ACL reconstruction in the early postoperative period.
In this chapter we will discuss some limitations of
in vitro biomechanical studies and review variables that
influence the tensile properties of intratunnel fixation
methods for bone–tendon–bone (BTB) and soft tissue
grafts. For an exhaustive review of the subject matter, the
University of Tampere academic dissertations of Janne
T. Nurmi and Petteri Kousa are highly recommended.
LIMITATIONS OF BIOMECHANICAL STUDIES
In vitro biomechanical studies are most commonly used to
evaluate initial ACL graft fixation properties.12,13 However,
in vitro biomechanical studies have inherent limitations. First,
the use of different research models and biomechanical testing
protocols make it difficult to compare the results of one study
with another. Ideally, human specimens are used for bio-
mechanical testing; however, the material properties of corti-
cal and cancellous bone, tendons, and ligaments can vary
greatly among specimens. Because of the lack of availability
of human cadaveric specimens in the age range of patients
typically undergoing ACL reconstruction, specimens from
older donors are often used or the same specimen is tested
multiple times. As demonstrated by Brown et al,14 the use
of specimens from older human donors underestimates the
fixation strength of fixation devices that rely on cancellous
bone for fixation strength. In this study, the initial fixation
strength of BPTB grafts fixed with metal interference screws
in the distal femur of bovine cadavers, young human cadavers
(mean age 41 years, range 33–52 years), and elderly human
cadavers (mean age 73, range 68–81 years) was compared.
There was no significant difference in the failure load of the
bovine (799
261 N) and young human specimens (655

186 N); however, the failure load of the elderly human
specimens (382
118 N) was significantly lower than the
young human and bovine specimens. Based on these findings
the authors concluded that elderly human cadavers are not an
appropriate model for ACL reconstruction fixation studies.
Performing multiple tests in the same specimen will introduce
carryover effects that may affect the fixation properties of
subsequent fixation techniques after the first fixation method
has been tested. Beynnon and Amis12 suggest testing male
specimens younger than 65 years old and female specimens
younger than 50 years old to minimize these problems.
Due to the paucity of suitable human cadaveric
specimens, animal models are often used. Animal models
have the advantage of eliminating the potential variability
Biomechanics of Intratunnel Anterior Cruciate Ligament Graft Fixation 28
introduced because of the large differences in bone mineral
density (BMD) that exist in human specimens, and their avail-
ability eliminates the need to perform multiple tests using the
same specimen. However, because of the differences in BMD
and tensile properties of bone that exist between human and
animal specimens, the results of biomechanical tests performed
using animal models cannot be directly compared with studies
performed using human specimens.15 Aerssens et al15 have
shown that human female femoral specimens (age range 30–
60 years) demonstrate lower BMD and failure stress compared
with specimens from dogs, pigs, cows, or sheep. In this study
the pig femur came closest to matching the BMD and failure
stress of the human femur. Because of the higher BMD and
tensile properties of animal specimens, biomechanical tests
performed in animal models tend to overestimate initial fixa-
tion properties.16,17 This is particularly true for devices such
as interference screws and cross-pins that rely on cancellous
bone for fixation strength.
Another limitation of in vitro biomechanical studies is
that they simulate the time zero period prior to biological
fixation of the ACL graft. These studies fail to account for
the progressive healing of the ACL graft to the bone tunnel
walls, which shifts the weak link from the ACL graft–fixa-
tion–bone tunnel interface to the bone–ligament interface
and eventually to the intraarticular part of the ACL graft.18
Although the healing response does not affect graft fixation
properties in the early postoperative period, bony or soft tissue
healing in the bone tunnels will alter graft fixation properties
over time. Few studies document the time frame for healing
to occur at the ACL graft fixation sites. Based on the studies
of Clancy et al18 and Walton,19 it appears that the bone blocks
of BTB grafts heal to the bone tunnel wall by 6 weeks.
Compared with BTB grafts, soft tissue grafts take longer to
heal to bone. In a dog model, Rodeo et al20 demonstrated the
formation of Sharpey’s fibers connecting the periphery of a soft
tissue graft to the bone tunnel wall at 6 weeks. However,
mechanical fixation was not achieved until 12 weeks.
Two types of biomechanical tests are commonly used to
evaluate the mechanical behavior of ACL ligament fixation
techniques.12,13 The first and most commonly used is the sin-
gle-cycle load to failure (single LTF) test. Single LTF tests
attempt to simulate the response of the graft fixation tech-
nique to a sudden mechanical overload event such as a slip
or fall. The load-displacement curve can be analyzed to deter-
mine the ultimate failure load, yield load, linear stiffness, and
displacement at failure. Advantages of single LTF testing are
that the weak link in the fixation system can be easily identi-
fied, the mode and site of the fixation failure are well defined,
and an upper limit of the strength of the graft-fixation con-
struct is established. Because failure testing attempts to repli-
cate traumatic loading conditions, a high rate of elongation,
typically 100% per second, is used.
195
 Anterior Cruciate Ligament Reconstruction
The second testing method involves cyclical loading
of the bone–ACL graft–fixation complex. Cyclical testing
evaluates the ability of the bone–ACL graft–fixation com-
plex to resist elongation or slippage under repetitive sub-
maximal failure loads over time. Cyclical testing attempts
to approximate the loading conditions associated with reha-
bilitation exercises or activities of daily living in the early
postoperative period prior to biological fixation of the graft.
Most commonly a load control test is performed, in which
the upper and lower loads are controlled and displacement
over time of the ACL graft relative to the bone is measured.
By determining the distance between markers on the bone
and the ACL graft at the beginning and end of the test,
elongation or slippage of the ACL graft with respect to
the bone can be measured. At the present time there is little
agreement on the force limits or the number of cycles that
should be performed, making it difficult to compare data
among studies. Beynnon and Amis12 have recommended
force limits between 150 N and –150 N and 1000 load
cycles. One thousand cycles approximates 1 week of flex-
ion-extension loading of the knee.13 The number of cycles
is limited by the ability to keep the specimen moist during
testing and the thawing of the freeze clamps that are com-
monly used to grip soft tissue ACL grafts.
Despite these limitations, in vitro biomechanical labo-
ratory testing can provide useful information on the perfor-
mance of ACL ligament fixation techniques. In summary,
single LTF testing evaluates the initial strength and stiffness
of the bone–ACL graft–fixation complex, whereas cyclical
testing provides information on slippage and progressive
elongation at the graft fixation sites that occur as a result of
rehabilitation exercises or activities of daily living in the early
postoperative period before biological healing has occurred.
BONE MINERAL DENSITY
Because intratunnel fixation methods depend on the graft
fixation device generating friction between the bone tunnel
wall and the ACL replacement graft, BMD is perhaps the
most important variable that influences initial fixation
strength and stiffness and resistance to slippage during
cyclical loading. It is well known that BMD in humans
decreases with age and that the BMD of females is less than
that of males. Cassim et al21 found that the fixation strength
of BPTB grafts fixed with metal interference screws in
human specimens with a mean age of 79 years resulted in
a 42% decrease in failure load compared with specimens
with a mean age of 35 years. There are also significant dif-
ferences in the BMD of the human distal femur and proxi-
mal tibia.22 The BMD of the proximal tibia is significantly
lower than that of the distal femur.22 The lower BMD of
196
the proximal tibia, along with the fact that tibial fixation
devices must resist shear forces applied parallel to the axis
of the tibial bone tunnel, combine to make tibial fixation
the weak link in ACL graft fixation.
Although BMD is a critical factor, other variables
correlate with initial fixation properties. In a BPTB model,
Brown et al14 found that insertion torque, an indirect measure
of BMD, was linearly correlated with pullout force but with
weak significance. Using elderly human cadaveric knees,
Brand et al22 found that BMD measured using dual-energy
x-ray absorptiometry and screw insertion torque was strongly
correlated to the fixation strength of doubled semitendinosus
and gracilis tendons fixed with bioabsorbable interference
screws in the distal femur and proximal tibia of human speci-
mens. In this study, the variables of insertion torque and
BMD explained 77% of the ultimate failure load observed.
The R2 value for the relationship between ultimate failure
load and BMD was 0.65, indicating that BMD explained
65% of the ultimate failure load. This study found that
BMD of 0.6 gm/cm2 resulted in better initial fixation proper-
ties. Using the proximal tibia of human cadaveric specimens
(mean age 40
11 years, range 17–54 years) and doubled
tibialis tendons fixed with a tapered bioabsorbable screw,
Jarvinen et al23 found that insertion torque was linearly
correlated to fixation strength (R2 ¼ 0.54) and was the most
strongly associated variable in their study for predictors of
fixation strength. Unfortunately, despite the correlation,
insertion torque was a poor predictor of cyclical loading failure
or single LTF. Clearly, other secondary factors influence the
properties of intratunnel graft fixation. The remainder of this
chapter is aimed at understanding the role and importance of
these other variables.
BONE–PATELLAR TENDON–BONE FIXATION
Interference screw fixation of BTB ACL grafts has been
well studied and documented over the past 20 years. The
fixation properties of interference screw fixation of BTB
grafts depend on the generation of friction between the
bone block and bone tunnel wall. Friction is generated by
compression of the bone block into the bone tunnel wall
and engagement of the screw threads into the bone block
and bone tunnel wall. As illustrated in Fig. 28-1, factors
that influence the initial tensile properties of interference
screw fixation of BTB ACL grafts include the following:
1 Screw diameter
2 Gap size
3 Screw length
4 Screw divergence
 Biomechanics of Intratunnel Anterior Cruciate Ligament Graft Fixation 28

C D

E
FIG. 28-1 Factors that influence the initial tensile properties of interference screw fixation of bone–tendon–bone
anterior cruciate ligament grafts: (A), screw diameter, (B), gap size, (C), screw length, (D), short screw length, and
(E), screw divergence.
197
 Anterior Cruciate Ligament Reconstruction
Overlap exists between the effects of screw diameter
and gap size on initial fixation properties. In the study of
Kurosaka et al,2 custom-made 9.0-mm screws demonstrated
higher ultimate failure loads compared with 6.5-mm AO
cancellous screws. However, the researchers reported that
making the size of the patellar and tibial bone blocks close
to the size of the bone tunnels was extremely important “in
obtaining a solid fixation.”2 Using a porcine experimental
model, Reznik et al24 demonstrated that gap size significantly
influenced the ultimate failure load of BTB grafts fixed in
10-mm bone tunnels with 7-mm screws. When the gap
between the bone block and bone tunnel wall was 4 mm or
more, increasing the screw diameter to 9 mm increased the
failure load by 97%. However, when the gap was less than
4 mm and a 9-mm screw was used, the results were inferior
to those seen with a 7-mm screw and a gap of less than
4 mm. Kohn and Rose,25 using human cadaveric knees (mean
age 30 years), reported that both femoral and tibial fixation
using 9-mm screws were stronger than with 7-mm screws.
Based on their findings, they recommended against using
7-mm screws for tibial fixation.
However, Hulstyn et al,26 using a bovine femur–
BPTB–tibia model found no significant difference in fixation
strength between 7- and 9-mm screws. Using elderly human
cadaveric specimens, Brown et al27 found no significant
difference in the fixation strength of BPTB grafts fixed in
the distal femur using endoscopically inserted 7-mm screws
and 9-mm screws inserted using a rear-entry technique.
Brown et al14 also found no difference in femoral fixation
between 7- and 9-mm screws. The influence of screw diame-
ter on initial fixation properties is probably most relevant
when a significant size discrepancy exists between the bone
block and the bone tunnel wall. This difference is often
referred to as gap size.
After studying various fixation methods, Kurosaka
2
et al hypothesized that the gap size between the bone block
and bone tunnel was a critical factor in interference screw
fixation. Cassim et al21 demonstrated the interrelationship
between gap size and screw diameter in determining fixation
strength in BPTB reconstruction. When the gap size was less
than 1 mm and a 9-  30-mm screw was used, the mean
ultimate failure load was 1060 N. Butler et al28 found that
with a gap size of 3 to 4 mm, increasing the screw diameter
size from 7 to 9 mm significantly increased the load at which
failure occurred. A number of authors have suggested using
larger screws as the gap size increases.29
Screw length probably does not have a large influence on
the initial fixation properties of BPTB grafts fixed with inter-
ference screws. Brown et al27 found no significant difference
in fixation strength between 7-  20-mm and 7-  30-mm
screws or between 9-  20-mm and 9-  30-mm screws fixed
in the distal femur of human specimens. Black et al30 compared
198
9-  12.5-mm, 9-  15-mm, and 9-  20-mm interference
screws in a porcine tibia model. No significant difference in
insertion torque, failure load, stiffness, or displacement to fail-
ure was found between the different lengths of screws.
Pomeroy et al31 also found no significant effect of screw length
on fixation strength for a given screw diameter. These findings
may be explained by the fact that the length of the bone block is
limited, and increasing the length of the screw does not lead to
an increase in the number of screw threads in contact with the
bone block and bone tunnel wall.
Divergence of the interference screw from the bone
block and the axis of the bone tunnel can occur with both
rear-entry and endoscopic techniques. The incidence of screw
divergence is more common with the endoscopic technique
(femur > tibia).32 Based on clinical studies, screw divergence
less than 30 degrees does not seem to have a significant effect
on the clinical outcome.33 Using a porcine model, Jomha
et al34 reported no significant difference in femoral fixation
strength with endoscopically inserted interference screws with
divergence up to 10 degrees. However, there was a significant
drop in femoral fixation strength with screw divergence at 20
degrees. Pierz et al,35 using porcine tibiae, demonstrated that
interference screws inserted to simulate a rear-entry femoral
fixation technique or fixation of a tibial bone block resulted
in a significant decrease in fixation strength from 0 to 15
degrees and 15 to 30 degrees of divergence. Interference
screws inserted to simulate an endoscopic technique resulted
in a significant decrease in fixation strength only at 30 degrees
of screw divergence. These authors concluded that optimal
interference screw fixation occurs when the screw is placed
parallel to the bone block and bone tunnel. Due to the
creation of a wedge effect, screw divergence has a lesser effect
on endoscopically inserted femoral screws. However, due to
the in-line direction of pull, minor degrees of divergence will
affect the fixation strength of femoral screws inserted
through a rear-entry technique and tibial fixation screws.
Metal interference screws can distort MRI images, lacer-
ate the graft during insertion, and complicate revision ACL
surgery. Bioabsorbable interference screws have been pro-
posed as a method to eliminate these potential complications.36
Several biomechanical studies have compared the initial
fixation strength of bioabsorbable interference screws and
conventional metal interference screws in animal and human
cadaveric models. Weiler et al37 used a calf proximal tibia
model to test the single LTF of six different biodegradable
interference screws compared with that of a titanium inter-
ference screw. Five of the six bioabsorbable screws had failure
loads and stiffness comparable with the metal screw. Similar
results have been reported by Kousa et al,38 who found no sig-
nificant difference in the tensile properties of BPTB
grafts fixed with metal and bioabsorbable screws evaluated
by single LTF and cyclical testing in a paired porcine model.

Concerns with bioabsorbable interference screws have
focused largely on the issues of screw breakage and biocom-
patibility. Screw breakage has largely been addressed by
designing screws and screwdrivers that allow the insertion
torque to be distributed along the entire length of the screw
and decreasing the insertion torque by notching the bone tun-
nel wall. To prevent breakage, it is important that the screw-
driver be fully engaged during insertion of the screw.
In summary, based on review of the literature, gap size
is probably the most important factor influencing the initial
fixation properties of interference screw fixation of BTB
grafts. Gap size is also the one factor that can be easily
measured intraoperatively and controlled by the surgeon.
Improvements in initial graft fixation can be achieved by
increasing the diameter of the screw to compensate for the
gap size. Increasing screw length appears to offer minimal
improvements in initial graft fixation properties.
GUIDELINES AND RECOMMENDATIONS FOR
INTRATUNNEL FIXATION OF BONE–TENDON–
BONE GRAFTS
Femoral Fixation: Two-Incision Technique
Use 8- or 9-mm-diameter metal screws with a length of 20 to
25 mm. Bioabsorbable screws can be used; however, the
higher insertion torque generated by insertion of the screw
against the hard cortex of the distal femur may result in a
higher incidence of screw breakage compared with bioabsorb-
able screws inserted using an endoscopic technique. In situa-
tions where the gap between the bone block and bone tunnel
wall is greater than 4 mm, suture/post or plastic button fixa-
tion should be considered.
Femoral Fixation: Endoscopic Technique
Use 7- or 8-mm-diameter metal or bioabsorbable screws with a
length of 20 to 25 mm. For bioabsorbable screws, review and
use the manufacturer’s guidelines regarding tapping or notch-
ing the bone tunnel wall to minimize the risk of screw breakage.
Use the Endobutton-CL in situations where the gap size is
greater than 4 mm, in cases of grafts with long tendon lengths
to prevent graft-tunnel mismatch, and in cases involving blow-
out of the posterior wall of the femoral tunnel.
Tibial Fixation
Avoid use of 7-mm-diameter screws. Use 8- or 9-mm-
diameter screws with a length of 20 to 25 mm. For gap sizes
greater than 4 mm, consider suture/post or button fixation.
Biomechanics of Intratunnel Anterior Cruciate Ligament Graft Fixation 28
In soft bone or situations where low insertion torque is
encountered, consider backing up the interference screw
fixation by tying sutures around a fixation post.
SOFT TISSUE GRAFTS
Interference screw fixation of soft tissue grafts depends on
many of the same factors as fixation for BPTB grafts; how-
ever, the importance of each of these factors differs.39 Similar
to BTB grafts, the initial fixation properties depend on the
fixation device generating friction between the soft tissue graft
and the bone tunnel wall. Friction is generated by compres-
sion of the soft tissue graft against the bone tunnel wall. How-
ever, because the soft tissue graft is more compressible than
the bone blocks of BTB grafts, the amount of compression
generated between the screw and bone tunnel wall for a given
diameter of screw is less. The amount of friction contributed
by engagement of the screw threads in the bone tunnel wall
and soft tissue graft is also significantly lower due to the lack
of engagement of the screw threads into the soft tissue graft.
As illustrated in Fig. 28-2, factors that may contribute
to the initial fixation properties of soft tissue grafts with
interference screws include the following:
1 Screw geometry (length and diameter)
2 Tendon fit
3 Tunnel impaction or dilation
4 Screw placement (concentric versus eccentric)
Unlike interference screw fixation of BTB grafts, screw
length seems to have a greater effect on the initial fixation
properties of soft tissue grafts fixed with interference screws.
Because of the lower BMD of the proximal tibia, screw length
has a greater influence on tibial fixation properties.22 Screw
length may have a more significant effect on the fixation prop-
erties of soft tissue grafts because the area over which friction
is generated between the bone tunnel wall and soft tissue graft
is determined by the screw length rather than by the length of
a bone block, which is typically 20 to 25 mm. In a bovine
proximal tibia model, Weiler et al40 found that 23-mm screws
had lower pullout strengths than 28-mm screws with equiva-
lent diameters. This study also found that increasing screw
length had a greater influence on failure load than increasing
the screw diameter. Selby et al,41 using human tibias (age
range 24–45 years), demonstrated significantly higher ulti-
mate failure loads for 35-mm versus 28-mm screws. Harvey
et al42 have investigated the effect of screw length and position
using a bovine tibia model under cyclical loading conditions.
Although not statistically significant, 45-mm-long metal
screws demonstrated less slippage and “more consistent
behavior” compared with 25-mm-long screws. Placement
199
 Anterior Cruciate Ligament Reconstruction
A B
Tendons
D
C
FIG. 28-2 Factors that may contribute to the initial fixation properties of soft tissue grafts with interference screws:
(A), screw geometry (length and diameter), (B), tendon fit, (C), tunnel impaction or dilation, and (D), screw
placement (concentric versus eccentric).
of the screw such that it engaged the cortex of the tibia allowed
significantly less slippage compared with screw insertion that
engaged only cancellous bone. Based on their findings, the
authors recommend that the screw head be placed such that
it engages the tibial cortex.
Few studies have examined the influence of screw
diameter on the initial fixation properties of soft tissue ACL
grafts with interference screws. Using human hamstring
tendon grafts and bovine proximal tibiae, Weiler et al40
found that increasing the diameter of a 23-mm-long bio-
absorbable interference screw from 7 to 8 mm increased
the mean pullout force from 367 N to 479 N.
The fit of the soft tissue graft in the bone tunnel appears
to have a significant influence on the initial fixation properties
of interference screw fixation of soft tissue grafts. Using a
human cadaveric model, Steenlage et al43 demonstrated that
four-strand hamstring tendon grafts fixed in the distal femur
with a bioabsorbable screw resulted in a significantly higher
ultimate failure load if the bone tunnel was sized within
0.5 mm of the graft diameter versus within 1 mm of the
measured size of the graft.
200
Screw Tendons
Because BMD has such a significant effect on the initial
tensile properties of interference screw fixation of soft tissue
grafts, compaction drilling or bone tunnel dilation has been
proposed as a method of creating increased bone density along
the bone tunnel walls. It has been speculated that this will lead
to an improvement in initial fixation properties. Using human
male cadaveric knees, Rittmeister et al44 demonstrated that
serial dilation did not improve the initial fixation strength of
four-strand hamstring tendon grafts fixed in the tibia with
metal interferences screws. Nurmi et al45 investigated the
effects of compaction drilling versus conventional drilling on
the initial fixation strength of four-strand hamstring tendon
grafts fixed with bioabsorbable screws in the proximal tibia
of human specimens (mean age 41
11 years, range 17–49
years). The biomechanical testing protocol consisted of
cyclical loading followed by a single LTF test. They found
no significant difference in initial stiffness or displacement
between the two drilling methods during cyclical testing. In
the single LTF test, there was no significant difference in
yield load, displacement at yield load, or stiffness between
the two drilling methods. The authors concluded that

compaction drilling does not increase the initial fixation
properties of hamstring tendon grafts.
In a second biomechanical study, Nurmi et al46 investi-
gated the effect of tunnel compaction by serial dilators versus
conventional drilling on the initial fixation strength of dou-
bled anterior tibial tendons fixed in the proximal tibia of
human specimens (mean age 40
11 years, range 17–54
years) using bioabsorbable interference screws. The speci-
mens were tested under cyclical loading followed by a single
LTF test. They found no significant difference in stiffness
or displacement between the two techniques during cyclical
testing. However, the number of failures during cyclical
loading of the extraction drilling group was twice that of the
serially dilated group. In the subsequent single LTF test, there
was no significant difference in failure load or stiffness
between the two groups. One of the limitations of this study
was that the size of the tibial bone tunnel was not matched
to the size of the soft tissue grafts, and a 10-mm-diameter
bone tunnel was created in all specimens.
The only study to demonstrate a beneficial effect of tun-
nel dilation on the fixation strength of soft tissue ACL grafts
was performed by Cain et al47 using paired human cadaveric
knees (average age 42 years, range 29–47 years). Four-strand
hamstring tendon grafts were fixed with bioabsorbable screws
in 0.5-mm matched femoral and tibial tunnels. The tibial tun-
nel was created using smooth tunnel dilators in one knee of the
pair and conventional extraction drilling in the opposite knee of
the pair. The femur-hamstring ACL graft–tibia complex was
tested to failure using anterior tibial translation with the knee
positioned in 20 degrees of flexion as previously described by
Steiner et al.48 This method of testing attempts to mimic the
Lachman test. All specimens failed due to the graft pulling
out of the tibial tunnel. However, the ultimate failure load
was reported to be significantly higher for the dilated tibial
tunnels. Testing methodology makes it difficult to compare
the results of this study with earlier studies; however, based
on the literature, the benefits of compaction drilling or serial
dilation seem to be marginal at best and probably do not
justify the extra costs and operating time.
Although it is generally agreed that interference screws
should be inserted on the cancellous side of BTB grafts, contro-
versy exists regarding placement of tibial interference screws
used to fix multistrand hamstring tendon grafts. Soft tissue
grafts may be fixed by inserting the screw on the side (eccentri-
cally) or down the center (concentrically) of the graft strands.
Concentric screw placement maximizes contact between the
graft strands and the bone tunnel wall, providing a greater
surface area for healing. Simonian et al49 investigated the effect
of screw eccentric versus concentric placement on initial fixa-
tion properties using human hamstring tendon grafts fixed in
a polyurethane foam model. There were no differences in the
ultimate failure load or slippage between the two screw
Biomechanics of Intratunnel Anterior Cruciate Ligament Graft Fixation 28
positions. Shino and Pflaster50 investigated the effect of
eccentric versus concentric screw placement on the initial
fixation properties of four-strand hamstring tendon grafts fixed
in the proximal tibia of paired human cadaveric knees (average
age 51 years, range 49–54 years). There were no significant
differences in stiffness, yield load, ultimate failure load, or
slippage between the two screw positions.
Unlike BTB grafts in which the bone tunnel size and
dimensions of the bone blocks are standardized, there are
large variations in the diameter and length of soft tissue
grafts, making it difficult to arrive at definitive recommen-
dations regarding selection of interference screw fixation.
Nevertheless, our interpretation of the literature has led to
the following conclusions:
1 Because of the lower BMD and the fact that the line of
applied force is parallel to the axis of the tibial tunnel,
tibial fixation is weaker, less stiff, and more likely to slip
under cyclical loading compared with the femoral fixation
site.
2 Screw length has a more significant effect on the initial
fixation properties of interference screw fixation of soft
tissue ACL grafts compared with BTB ACL grafts.
3 Longer screws seem to result in higher ultimate failure
loads and stiffness and less slippage.
4 Fixation properties are improved by having the screw
head engage the tibial cortex.
5 The effect of screw diameter on initial fixation properties
is unclear, making it difficult to establish clear guidelines
for screw sizing.
6 Matching the size of the bone tunnel to within 0.5 mm
of the measured size of the graft seems advisable.
7 Compaction drilling or serial dilation does not seem to
significantly improve initial fixation properties.
ALTERNATIVE INTRATUNNEL TIBIAL FIXATION
TECHNIQUES
The stimulus for the development of alternative intratunnel
tibial fixation techniques for soft tissue ACL grafts arose
from the desire to decrease slippage and the high rate of fix-
ation failure reported with interference screws under cyclical
loading conditions, to eliminate or reduce the need for sup-
plemental tibial fixation, and to improve soft tissue–to-bone
healing at the graft fixation sites.39,42,51 The IntraFix
(DePuy Mitek, Norwood, MA) was designed to individu-
ally capture each of the four strands of a soft tissue graft
in a separate compartment using a plastic sheath and to
achieve direct compression of each of the graft strands
201
 Anterior Cruciate Ligament Reconstruction
against the bone tunnel wall by the insertion of a tapered
screw into the central chamber of the plastic sheath.52 In a
porcine tibia model using human hamstring tendon grafts,
Kousa et al53 demonstrated that the IntraFix had the high-
est load failure load (1309
302 N) and stiffness (267

36 N/mm) and the least amount of slippage (1.5 mm) after
cyclical loading compared with two cortical fixation techni-
ques and three other interference screw fixation techniques.
The GTS System (Graft Tunnel Solution) (Smith &
Nephew Endoscopy, Andover, MA) is an intratunnel tibial
fixation technique that positions a poly-L-lactic acid
(PLLA)-tapered, fine-pitch screw concentrically within the
four-strand soft tissue graft.54 The screw features a tapered
design and shorter thread distance, which enhances compres-
sion of the soft tissue graft in cancellous bone. The Graft Sleeve
is a three-lumen, woven, nonabsorbable polypropylene (PPE)
mesh graft sleeve that organizes the four-strand soft tissue graft
in the tibial tunnel. The Graft Sleeve prevents graft twisting
during screw insertion, which helps maintain equal tension in
the four graft strands; maximizes bone-tendon contact, which
enhances healing; and provides better compression of each lig-
ament strand against the bone tunnel wall while protecting the
graft strands from screw damage. Cyclical testing followed by
single LTF testing of the Graft Sleeve and Tapered Screw
and IntraFix has been performed using human doubled gracilis
and semitendinosus tendon grafts (DGST) in the proximal
tibia of calf bone (2 years or younger) with BMD similar to
that of the proximal tibia in young humans. There were no
significant differences in slippage, ultimate failure load, or
stiffness between the two devices.
FUTURE DIRECTIONS
The ideal ACL graft fixation method would provide imme-
diate rigid fixation that is sufficiently strong and stiff and
able to resist slippage such that permanent elongation does
not develop with the stresses of rehabilitation and activities
of daily living. The fixation method should be low profile
and should not require later removal because of local irrita-
tion and pain. Ideally, the device should be replaced by can-
cellous bone and result in the development of a normal
histological ligament–bone attachment site.
Future improvements in intratunnel ACL graft fixa-
tion will depend on better understanding the in vivo forces
experienced by the ACL with rehabilitation exercises and
activities in the early postoperative period and the biology
of fixation site healing. Osteoconductive or osteoinductive
materials that will stimulate the development of normal
osseous tissue are currently under development. Bone
cement, which will provide immediate rigid fixation and
then be eventually replaced by bone, may be developed.
202
There is ongoing basic science research directed at promot-
ing and accelerating healing of soft tissue to bone. Ultra-
sound, bone morphogenic proteins (BMPs), and biological
growth factors are currently being investigated as possible
methods to promote and accelerate tendon-to-bone healing.
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hamstring tendon autograft with direct RCI interference screw fixation.
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6. Morrison JB. Function of the knee joint in various activities. Biomed
Eng 1969;4:573–580.
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for reconstruction of the anterior cruciate ligament: biomechanical
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11. Brand JC, Weiler A, Caborn DNM, et al. Graft fixation in cruciate
ligament reconstruction. Am J Sports Med 2000;28:761–774.
12. Beynnon BD, Amis AA. In vitro testing protocols for the cruciate
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Techn Orthop 1999;14:14–21.
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composition, density, and quality: potential implications for in vivo
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16. Magen HE, Howell SM, Hull ML. Structural properties of six tibial
fixation methods for anterior cruciate ligament soft tissue grafts. Am
J Sports Med 1999;27:35–43.
17. Nurmi JT, Sievanen H, Kannus P, et al. Porcine tibia is a poor substi-
tute for human cadaver tibia for evaluating interference screw fixation.
Am J Sports Med 2004;32:765–771.
18. Clancy WG, Jr, Narechania RG, Rosenberg TD, et al. Anterior and
posterior cruciate ligament reconstruction in rhesus monkeys. A histo-
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19. Walton M. Absorbable and metal interference screws: comparison of
graft security during healing. Arthroscopy 1999;15:818–826.

20. Rodeo SA, Arnoczky SP, Torzilli PA, et al. Tendon-healing in a bone
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Surg 1993;75A:1795–1803.
21. Cassim A, Lobenhoffer P, Gerich T, et al. The fixation strength of
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22. Brand JC, Jr, Pienkowski D, Steenlage E, et al. Interference screw fix-
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Med 2000;28:705–710.
23. Jarvinen TL, Nurmi JT, Sievanen H. Bone density and insertion
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for cruciate ligament reconstruction. Trans Orthop Res Soc 1990;15:519.
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26. Hulstyn M, Fadale PD, Abate J, et al. Biomechanical evaluation of
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27. Brown CH, Hecker AT, Hipp JA, et al. The biomechanics of interfer-
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repair and reconstruction. Oper Tech Orthop 1992;2:63–70.
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31. Pomeroy G, Baltz M, Pierz K, et al. The effects of bone plug length
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32. Lemos MJ, Albert J, Simon T, et al. Radiographic analysis of femoral
interference screw placement during ACL reconstruction: endoscopic
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33. Dworsky BD, Jewell BF, Bach BR. Interference screw divergence in
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1996;12:45–49.
34. Jomha NM, Raso VJ, Leung P. Effect of varying angles on the pullout
strength of interference screw fixation. Arthroscopy 1993;9:580–583.
35. Pierz K, Baltz M, Fulkerson J. The effect of Kurosaka screw diver-
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36. Barber FA, Elrod BF, McGuire DA, et al. Preliminary results of an
absorbable interference screw. Arthroscopy 1995;11:537–548.
37. Weiler A, Windhagen HJ, Raschke MJ, et al. Biodegradable interfer-
ence screw fixation exhibits pull-out force and stiffness similar to tita-
nium screws. Am J Sports Med 1998;26:119–128.
38. Kousa P, Järvinen TL, Kannus P, et al. Initial fixation strength of
bioabsorbable and titanium interference screws in anterior cruciate
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ligament reconstruction: biomechanical evaluation by single cycle and
cyclic loading. Am J Sports Med 2001;29:420–425.
39. Brand JC, Caborn DNM, Johnson DL. Biomechanics of soft-tissue
interference screw fixation of anterior cruciate ligament reconstruction.
Orthopedics 2003;26:432–439.
40. Weiler A, Hoffmann RF, Siepe CJ, et al. The influence of screw
geometry on hamstring tendon interference fit fixation. Am J Sports
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41. Selby JB, Johnson DL, Hester P, et al. Effect of screw length on
bioabsorbable interference screw fixation in a tibial bone tunnel. Am
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42. Harvey AR, Thomas NP, Amis AA. The effect of screw length and
position on fixation of four-stranded hamstring grafts for anterior
cruciate ligament reconstruction. Knee 2003;10:97–102.
43. Steenlage E, Brand JC, Jr, Johnson DL, et al. Correlation of bone tun-
nel diameter with quadrupled hamstring graft fixation strength using a
biodegradable interference screw. Arthroscopy 2002;18:901–907.
44. Rittmeister ME, Noble PC, Bocell JR, Jr, et al. Interactive effects of
tunnel dilation on the mechanical properties of hamstring grafts fixed
in the tibia with interference screws. Knee Surg Sports Traumatol
Arthrosc 2001;9:267–271.
45. Nurmi JT, Kannus P, Sievänen H, et al. Compaction drilling does not
increase the initial fixation strength of the hamstring tendon graft in
anterior cruciate ligament reconstruction in a cadaver model. Am
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46. Nurmi JT, Kannus P, Sievänen H, et al. Interference screw fixation of
soft tissue grafts in anterior cruciate ligament reconstruction: part 1.
Effect of tunnel compaction by serial dilators versus extraction drilling
on the initial fixation strength. Am J Sports Med 2004;32:411–417.
47. Cain EL, Phillips BB, Charlebois SJ, et al. Effect of tibial tunnel dila-
tion on pullout strength of semitendinosus-gracilis graft in anterior
cruciate ligament reconstruction. Orthopedics 2005;28:779–783.
48. Steiner ME, Hecker AT, Brown CH, Jr, et al. Anterior cruciate liga-
ment graft fixation: comparison of hamstring and patellar tendon
grafts. Am J Sports Med 1994;22:240–246.
49. Simonian PT, Sussmann PS, Baldini TH, et al. Interference screw
position and hamstring graft location for anterior cruciate ligament
reconstruction. Arthroscopy 1998;14:459–464.
50. Shino K, Pflaster DS. Comparison of eccentric and concentric screw
placement for hamstring graft fixation in the tibial tunnel. Knee Surg
Sports Traumatol Arthrosc 2000;8:73–75.
51. Magen HE, Howell SM, Hull ML. Structural properties of six tibial
fixation methods for anterior cruciate ligament soft tissue grafts. Am
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52. Sklar JH, Brown CH, Jr. Soft tissue anterior cruciate ligament
reconstruction with the IntraFix tibial fastener. Tech Orthop
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53. Kousa P, Jarvinen TL, Vihavainen M, et al. The fixation strength of six
hamstring tendon graft fixation devices in anterior cruciate ligament
reconstruction. Part II: tibial site. Am J Sports Med 2003;31:182–188.
54. Brown CH, Jr, Darwich N. Anterior cruciate ligament reconstruction
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2005;20:290–296.
203
29
CHAPTER
High-Stiffness, Slippage-Resistant Cortical
Fixation Has Many Advantages over
Intratunnel Fixation
Stephen M. Howell INTRODUCTION
This chapter explains why the fixation properties of
high stiffness and resisting slippage are the two
critical factors in restoring anterior laxity to a knee
reconstructed with an anterior cruciate ligament
(ACL) graft. Definitions and examples of high-
and low-stiffness fixation are provided, along with
evidence that high-stiffness cortical fixation placed
away from the joint line restores anterior laxity as well
as intratunnel fixation with an interference screw,
even though the graft is a few centimeters longer.
Resisting slippage, the most important fixation
property, goes hand-in-hand with stiffness. A fixa-
tion device that resists slippage also provides high
stiffness; however, the reverse relationship does not
hold true. A discussion is included of the extensive
biological and mechanical advantages of the use of
high-stiffness, slippage-resistant cortical fixation over
intratunnel fixation, including a more rapid, stronger,
and stiffer tendon–tunnel biological bond; a stronger,
stiffer, and more slippage-resistant mechanical
fixation; and less tunnel widening. A rationale for
selecting a soft tissue fixation device is presented.
The surgeon reading this chapter should find these
basic engineering principles useful when designing
his or her own ACL reconstruction technique.
FIXATION STIFFNESS AND SLIPPAGE:
CRITICAL FACTORS IN RESTORING
ANTERIOR LAXITY
An ACL graft construct is composed of the
ACL graft and the two fixation devices at either
204
end (Fig. 29-1). Anterior laxity in the knee of
the athlete returning to sport is determined by
the stiffness of the ACL graft construct and
the length of the ACL graft, not by the strength
of the graft and the tension in the graft.1–4
The stiffness of the ACL graft construct
determines anterior laxity, the firmness of the
Lachman test, and the quality of the “endpoint.”
The stiffness of the ACL graft construct is
increased more by the use of stiffer fixation
devices than by the use of a shorter graft. A
short graft with elastic fixation does not restore
anterior laxity as well as a longer graft with stif-
fer fixation.5,6 The concept that shortening the
graft increases the stiffness of the ACL graft
construct, as proposed by some studies,7–9 is
incorrect when high-stiffness, slippage-resistant
cortical fixation devices are used.4 The most
effective way to construct a stiff ACL graft
and restore a firm Lachman test is to use
high-stiffness, slippage-resistant cortical fixation
devices on both ends of the graft.1,3,5,6
A determinant of anterior laxity that is as
equally determinant as the stiffness of the ACL
graft construct is maintenance of the length of
the ACL graft set at the time of fixation. Main-
taining the initial set length of the ACL graft
after implantation requires the use of fixation
devices that resist slippage during cyclical load-
ing and exercise. Fortunately, there are fixation
devices that do resist slippage and provide high
stiffness; however, they are applied at the distal
end of the tunnels and engage cortical bone,
which is 30 times stronger than cancellous
bone.5,10–12 The use of intratunnel devices such
 High-Stiffness, Slippage-Resistant Cortical Fixation Has Many Advantages over Intratunnel Fixation 29

Bone Mulch Screw

EZLoc

Bone
graft

Bone
graft

WasherLoc

FIG. 29-1 An anterior cruciate ligament (ACL) graft construct is composed of the ACL graft and the fixation
devices used on the femur and tibia. The anterior laxity is determined by the stiffness of the ACL graft construct
and the ability of the fixation devices to prevent slippage of the graft during cyclical exercise and early exercise.
Intratunnel devices such as the interference screw and IntraFix are stiff but slip readily under cyclical load. Examples
of high-stiffness fixation devices that also resist slippage and are used in the femur include the EZLoc and Bone
Mulch Screw with bone graft. Examples of high-stiffness fixation that resist slippage and are used at the distal end
of the tibial tunnel include the WasherLoc, with or without bone dowel.

as the interference screw and IntraFix (DePuy Mitek,
Norwood, MA) do not resist slippage, and the ACL graft
readily elongates under cyclical load.5,13–15 Therefore the
use of high-stiffness, slippage-resistant cortical fixation that
purchases cortical bone is the best strategy for maintaining
the initial length of the ACL graft and compensating for
the obligatory loss in tension from cyclical movement of
the knee and exercise (Fig. 29-2).2,3
DEFINITION AND EXAMPLES OF HIGH- AND
LOW-STIFFNESS FIXATION
High-stiffness fixation can be arbitrarily defined as a fixation
stiffness that is greater than 400 N/mm when tested in young
human bone. The WasherLoc with bone dowel (stiffness of
565 N/mm), the WasherLoc alone (506 N/mm), and tandem
screws and washers placed on the cortex distal to the tibial
tunnel (414 N/mm) all provide stiffness greater than 400 N/
mm in young human bone (see Fig. 29-1). On the femoral
side, the EZLoc (infinite stiffness) and Bone Mulch Screw
(575 N/mm) are high-stiffness fixations because they pur-
chase cortical bone, which is 30 times stronger than cancellous
bone. Each of these high-stiffness cortical fixation devices
resists slippage well during cyclical loading.5,6,11,16–20
In contrast, low-stiffness fixation provides less than
400 N/mm in young human bone (Fig. 29-3). The interfer-
ence screw (340 N/mm), double staples placed in the cortex
distal to the tibial tunnel (174 N/mm), sutures tied to a post
(70 N/mm), closed loop Endobutton (79 N/mm), IntraFix
(49 N/mm), and sutures tied to an Endobutton (25 N/mm)
are all examples of fixation devices that provide low stiffness.
None of these low-stiffness intratunnel and cortical fixation
devices resists slippage well during cyclical loading.*
COMMENT ABOUT INTRATUNNEL FIXATION
WITH AN INTERFERENCE SCREW
The location of fixation of an ACL graft with respect to the
joint line has been a topic of debate.17,22–24 Proponents of
*
References 2, 5, 6, 12, 13, 21.

205
 Anterior Cruciate Ligament Reconstruction
FIG. 29-2 The loss of intraarticular graft tension (IAT) and increase in anterior laxity (maximal anterior translation)
with low-stiffness double staple fixation is shown after a series of treatments designed to simulate exercise.
All the tension in the graft was lost after cyclical loading of the knee 20 times to a maximum tensile load in the
graft of 170N.
fixation of an ACL graft at the level of the joint line with an
interference screw base their opinion on two studies.7,9 The
seminal study showed that anterior laxity was better restored
with intratunnel fixation with an interference screw than
with double staples applied distal to the tibial tunnel in por-
cine knees.7 A subsequent study showed that anterior laxity
was better restored with intratunnel fixation with an inter-
ference screw than with sutures tied to a post in human
knees.9 The explanation offered for the better restoration
of anterior laxity with intratunnel fixation with an interfer-
ence screw versus cortical fixation with double staples and
FIG. 29-3 Examples of low-stiffness cortical fixation that poorly resist
slippage include the double staples (belt buckle) and sutures tied to a post.
These fixation devices, along with the intratunnel devices such as the
interference screw and IntraFix, slip readily under cyclical loading, and their
use with aggressive rehabilitation should be approached cautiously.
206
sutures tied to a post was that intratunnel fixation shortens
the effective length of the graft, which increases the stiffness
of the knee.7–9
More recent studies have questioned the use of double
staples, sutures tied to a post, and porcine knees to study the
effect of the level of fixation on anterior laxity and knee stiff-
ness. Double staples (174 N/mm) and sutures tied to a post
(70 N/mm) are low-stiffness fixation devices (i.e., <200 N/
mm), whereas distal tibial fixation devices such as tandem
screws and washers (414 N/mm), WasherLoc (506 N/mm),
and WasherLoc and bone dowel (565 N/mm) are high-stiff-
ness fixation devices (i.e., >400 N/mm).5,17 Furthermore,
these high-stiffness cortical fixation devices provide greater
stiffness than interference screw fixation (340 N/mm) as well
as greater strength and less slippage.5,9,16–18 Two studies have
concluded that a porcine knee is not a reasonable surrogate
for a human knee for evaluating the fixation structural prop-
erties of the interference screw in ACL reconstructions.5,15
Porcine bone overestimates the stiffness of the interference
screw (476 N/mm) in comparison to young human tibia
(340 N/mm) and overestimates the strength and underesti-
mates slippage as well.5 Because the fixation structural proper-
ties of each of these high-stiffness cortical fixation devices are
superior to those of the interference screw, they each might
restore anterior laxity and knee stiffness in a human knee, even
though the effective length of the graft is longer.5,17,18
A more contemporary study that used high-stiffness,
slippage-resistant cortical fixation has dispelled the dogma
that intratunnel fixation with an interference screw provides
more acute stability to the reconstructed knee (Fig. 29-4).4
This in vitro cadaver study using human bone evaluated the
anterior laxity and knee stiffness provided by tandem screws
 High-Stiffness, Slippage-Resistant Cortical Fixation Has Many Advantages over Intratunnel Fixation 29

Tandem screws Interference WasherLoc WasherLoc and

and washers screw bone dowel
FIG. 29-4 The dogma that intratunnel fixation with an interference screw restores the acute stability of the
reconstructed knee better than cortical fixation was dispelled by a more contemporary study, which used high-
stiffness, slippage-resistant cortical fixation instead of low-stiffness cortical fixation with double staples and suture.
Tandem screws and washers, WasherLoc, and WasherLoc and bone dowel restored anterior laxity and knee
stiffness as well as intratunnel fixation with an interference screw.

and washers placed distal to the tibial tunnel, WasherLoc
placed at the end of the tibial tunnel, and WasherLoc and
bone dowel compared with an interference screw placed to
the level of the joint line. Anterior laxity normalized to the
intact knee with these three cortical fixation techniques of
tandem washers, WasherLoc, WasherLoc and bone dowel.
Each restored anterior laxity as well as intratunnel fixation
with an interference screw. The additional stiffness provided
by the cortical fixation device compensated for the slight
reduction in ACL graft stiffness caused by the added length,
which enabled the cortical fixation to restore anterior laxity
as well as intratunnel fixation with an interference screw.
This finding is in contrast to Ishibashi’s study7 in por-
cine bone in which an interference screw placed at the joint
line distal in the tibial tunnel provided better stability than
staples placed distal to the tibial tunnel. One reason for these
different findings in Ishibashi’s study compared with the
study that used high-stiffness cortical fixation5 is that the
interference screw provides 598 N/mm in porcine bone but
only 350 N/mm in human bone. The cancellous bone has a
higher density in a porcine knee than in a knee from a young
individual, which overestimates the stiffness and strength and
underestimates slippage of interference screw fixation when
compared with young human tibia.5,15 Another reason for
these different findings is that Ishibashi’s study underesti-
mated the performance of the cortical fixation because it eval-
uated one of the least stiff cortical fixations—the double
staples (174 N/mm)—instead of a high-stiffness, slippage-
resistant cortical fixation. The overestimation of the perfor-
mance of the interference screw in porcine bone suggests
Ishibashi et al’s findings (i.e., that the level of fixation in
porcine bone affects anterior laxity) should not be applied to
a knee in young individuals.4
A second study by Sheffler et al confirmed Ishibashi
et al’s findings by showing that low-stiffness cortical fixation
does not restore anterior laxity as well as intratunnel fixation
with an interference screw in human bone. Again, the
authors underestimated the performance of the cortical fixa-
tion because they used the least stiff cortical fixation, which
is a suture tied to a post (74 N/mm).9
In conclusion, high-stiffness, slippage-resistant cortical
fixation devices restore anterior laxity and knee stiffness as
well as intratunnel fixation with an interference screw
fixation. This is different from the use of low-stiffness cortical
fixation, which does not restore anterior laxity as well as
intratunnel fixation with an interference screw. This leads to
the principle that anterior laxity and knee stiffness are deter-
mined by the stiffness of the fixation device and not the loca-
tion of the fixation device with respect to the joint line.1,4,6
EXAMPLE OF STIFFNESS PRINCIPLE
The importance of including the stiffness of the fixation
device when determining the effect of the fixation device on
the anterior laxity of the knee can be illustrated by the follow-
ing example (Fig. 29-5). Consider a knee reconstructed with a
soft tissue graft in which the femoral fixation is a rubber (low-
stiffness) cross-pin placed near the joint line, and the tibial
fixation is high-stiffness, slippage-resistant cortical fixation
with a WasherLoc and bone dowel. Compare the anterior lax-
ity with a low-stiffness rubber cross-pin placed at the joint line
to a knee with a high-stiffness steel cross-pin placed farther
from the joint line. The stiffness of the knee with the rubber
cross-pin is extremely low even though the effective length
of the graft is short. The stiffness of the knee with the metal
cross-pin is high even though the effective length of the graft
is long. Anterior laxity is better restored in the knee with the
metal cross-pin and the longer effective graft length because
the added stiffness provided by the fixation device more than

207
 Anterior Cruciate Ligament Reconstruction
Joint Line Fixation Distal Fixation
High-stiffness
metal
cross-pin
Low-stiffness
rubber
cross-pin
FIG. 29-5 Intratunnel fixation with a low-stiffness fixation device near the
joint line, such as a rubber cross-pin, does not restore anterior laxity and
knee stiffness as well as more distal fixation with a metal cross-pin, even
though the graft is shorter. The stiffness of the fixation is a more important
determinant of the anterior laxity and stiffness of the knee than the
location of the fixation device with respect to the joint line.
compensates for the small increase in the effective length of
the graft and because the graft is generally stiffer than the
fixation device. 1,3–6
BIOLOGICAL AND MECHANICAL ADVANTAGES
OF CORTICAL FIXATION OVER INTRATUNNEL
FIXATION
The biological advantages of high-stiffness, slippage-resistant
cortical fixation over intratunnel fixation with an interference
screw include better healing because of the longer tunnel, cir-
cumferential healing of all sides of the graft to the tunnel wall,
and the ability to bone graft the tunnel (Fig. 29-6). The
biological bond between the tendon and tunnel wall is signif-
icantly stiffer and stronger in a longer tunnel than in a shorter
tunnel because there is more bone surface area for the tendon
to heal.27 Cortical fixation also allows circumferential biologic
healing so that all sides of the tendon within the tunnel can
heal to the bone. The interference screw blocks or “interferes”
with healing on one side of the tendon, which causes a reduc-
tion of stiffness, slippage, and loss of strength 4 weeks after
implantation that does not occur with cortical fixation.24
The use of high-stiffness, slippage-resistant fixation also
allows bone grafting of the tibial tunnel.17 Bone grafting
increases the snugness of fit between the tendon and tunnel
208
FIG. 29-6 A tibialis allograft is fixed at the end of the femoral tunnel with
the EZLoc and the end of the tibial tunnel with a WasherLoc and bone
dowel. Long, snug tunnels promote tendon healing and allow the tendon
to heal circumferentially to the tunnel wall. The addition of the bone dowel
can be seen filling the anterior half of the distal half of the tibial tunnel. The
use of an intratunnel device such as the interference screw and IntraFix
“interferes” with tendon healing by decreasing the contact area between
the tendon and tunnel wall.
wall and, as a biologically active component, may promote
tendon tunnel healing.17,27,28
The mechanical advantage of cortical fixation over
intratunnel fixation is that the cortical fixation device grips
cortical bone instead of cancellous bone.10 Cortical bone is
30 times stronger than cancellous bone and is not as affected
by other variables such as disuse, gender, age, alcohol, and
smoking. Cortical fixation is stiffer, slips less, and is stronger
than cancellous fixation with devices such as the interference
screw or IntraFix.5,6,10,12,13 Cortical fixation permits bone
grafting of the tunnel, which increases the stiffness 58 N/
mm on the tibial side and 41 N/mm on the femoral side.6,17
PREFERRED FIXATION TECHNIQUE
Based on these observations of these various studies and the
“stiffness principle,” we prefer to fix a soft tissue graft with
high-stiffness, slippage-resistant cortical fixation that pur-
chases cortical bone (Fig. 29-7). On the femoral side, the
EZLoc rigidly suspends the graft from the cortex, which
moves the fixation point from the cortical surface to inside
 High-Stiffness, Slippage-Resistant Cortical Fixation Has Many Advantages over Intratunnel Fixation
FIG. 29-7 The EZLoc in the femur and WasherLoc with bone dowel in the
tibia are examples of high-stiffness, slippage-resistant, strong cortical
fixation that grip cortical bone. The rigid fixation of the EZLoc in the femur
without micromotion allows bone ingrowth around the implant (arrows),
and there is no tunnel widening. On the tibial side, the bone dowel
(arrows) has reduced the tunnel diameter, preventing tunnel widening.
the femoral tunnel. This tends to shorten the graft length but
also preserves 25 to 30 mm of graft in the femoral tunnel so
that circumferential biological healing can take place.
Slippage of this construct does not occur because the lever
arm sits directly on cortical bone and the graft is looped within
a rigid metal slot. On the tibial side, the WasherLoc engages
cortical bone and allows access to the tibial tunnel for the
addition of a bone dowel or bone graft. The WasherLoc
placed at the end of the tibial tunnel also preserves 30 to
35 mm of graft in the tunnel and allows circumferential
tendon tunnel healing to take place.
CONCLUSION
This chapter emphasizes the importance of choosing fixation
devices that provide high stiffness and resist slippage under
cyclical load and exercise. Fixation devices with these proper-
ties purchase cortical bone at the end of the femoral and tibial
tunnels. These cortical fixation devices restore anterior laxity
and knee stiffness as well as intratunnel fixation, even though
the effective length of the graft is a few centimeters longer.
29
Intratunnel fixation with an interference screw or IntraFix,
although stiff, does not resist slippage, interferes with tendon
tunnel healing, and loses its effectiveness as cancellous bone
softens. Choosing the stiffness of the two fixation devices is
a more important determinant in restoring anterior laxity
and knee stiffness than trying to shorten the effective length
of the graft.
References
1. Eagar P, Hull ML, Howell SM. How the fixation method stiffness
and initial tension affect anterior load-displacement of the knee
and tension in anterior cruciate ligament grafts: a study in cadaveric
knees using a double-loop hamstrings graft. J Orthop Res
2004;22:613–624.
2. Grover DM, Howell SM, Hull ML. Early tension loss in an anterior
cruciate ligament graft. A cadaver study of four tibial fixation devices.
J Bone Joint Surg 2005;87A:381–390.
3. Karchin A, Hull ML, Howell SM. Initial tension and anterior load-
displacement behavior of high-stiffness anterior cruciate ligament graft
constructs. J Bone Joint Surg 2004;86A:1675–1683.
4. Liu-Barba D, Howell SM, Hull ML. High stiffness cortical fixation
restores anterior laxity and knee stiffness as well as intratunnel fixation
with an interference screw: a cadaveric study of human knees recon-
structed with a soft tissue anterior cruciate ligament graft. In press.
5. Magen HE, Howell SM, Hull ML. Structural properties of six tibial
fixation methods for anterior cruciate ligament soft tissue grafts. Am
J Sports Med 1999;27:35–43.
6. To JT, Howell SM, Hull ML. Contributions of femoral fixation
methods to the stiffness of anterior cruciate ligament replacements at
implantation. Arthroscopy 1999;15:379–387.
7. Ishibashi Y, Rudy TW, Livesay GA, et al. The effect of anterior cru-
ciate ligament graft fixation site at the tibia on knee stability: evalua-
tion using a robotic testing system. Arthroscopy 1997;13:177–182.
8. Morgan CD, Stein DA, Leitman EH, et al. Anatomic tibial graft fix-
ation using a retrograde bio-interference screw for endoscopic anterior
cruciate ligament reconstruction. Arthroscopy 2002;18:E38.
9. Scheffler SU, Sudkamp NP, Gockenjan A, et al. Biomechanical com-
parison of hamstring and patellar tendon graft anterior cruciate liga-
ment reconstruction techniques: the impact of fixation level and
fixation method under cyclic loading. Arthroscopy 2002;18:304–315.
10. Amis AA. The strength of artificial ligament anchorages. A compara-
tive experimental study. J Bone Joint Surg Br 1988;70:397–403.
11. Bailey SB, Grover DM, Howell SM, et al. Foam-reinforced elderly
human tibia approximates young human tibia better than porcine tibia:
a study of the structural properties of three soft tissue fixation devices.
Am J Sports Med 2004;32:755–764.
12. Kousa P, Jarvinen TL, Vihavainen M, et al. The fixation strength of
six hamstring tendon graft fixation devices in anterior cruciate liga-
ment reconstruction. Part I: femoral site. Am J Sports Med
2003;31:174–181.
13. Caborn DN, Brand JC Jr, Nyland J, et al. A biomechanical compari-
son of initial soft tissue tibial fixation devices: the IntraFix versus a
tapered 35-mm bioabsorbable interference screw. Am J Sports Med
2004;32:956–961.
14. Giurea M, Zorilla P, Amis AA, et al. Comparative pull-out and cyclic-
loading strength tests of anchorage of hamstring tendon grafts in anterior
cruciate ligament reconstruction. Am J Sports Med 1999;27:621–625.
15. Nurmi JT, Sievanen H, Kannus P, et al. Porcine tibia is a poor substi-
tute for human cadaver tibia for evaluating interference screw fixation.
Am J Sports Med 2004;32:765–771.
16. Coleridge SD, Amis AA. A comparison of five tibial-fixation systems
in hamstring-graft anterior cruciate ligament reconstruction. Knee Surg
Sports Traumatol Arthrosc 2004;12:391–397.
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17. Howell SM, Roos P, Hull ML. Compaction of a bone dowel in the
tibial tunnel improves the fixation stiffness of a soft tissue anterior
cruciate ligament graft: an in vitro study in calf tibia. Am J Sports
Med 2005;33:719–725.
18. Kousa P, Jarvinen TLN, Vihavainen M, et al. The fixation strength
of six hamstring tendon graft fixation devices in anterior cruciate
ligament reconstruction. Part II: tibial site. Am J Sports Med
2003;31:182–188.
19. Roos PJ, Hull ML, Howell SM. Lengthening of double-looped
tendon graft constructs in three regions after cyclic loading: a study
using Roentgen stereophotogrammetric analysis. J Orthop Res
2004;22:839–846.
20. Smith CK, Hull ML, Howell SM. Lengthening of a single-loop tibia-
lis tendon graft construct after cyclic loading: a study using roentgen
stereophotogrammetric analysis. J Biomech Eng 2006;128:437–442.
21. Hoher J, Livesay GA, Ma CB, et al. Hamstring graft motion in the
femoral bone tunnel when using titanium button/polyester tape fixa-
tion. Knee Surg Sports Traumatol Arthrosc 1999;7:215–219.
22. Brown CH Jr, Wilson DR, Hecker AT et al. Graft-bone motion and
tensile properties of hamstring and patellar tendon anterior cruciate
210
ligament femoral graft fixation under cyclic loading. Arthroscopy
2004;20:922–935.
23. Ma CB, Francis K, Towers J, et al. Hamstring anterior cruciate liga-
ment reconstruction: a comparison of bioabsorbable interference screw
and endobutton-post fixation. Arthroscopy 2004;20:122–128.
24. Singhatat W, Lawhorn KW, Howell SM, et al. How four weeks of
implantation affect the strength and stiffness of a tendon graft in a
bone tunnel: a study of two fixation devices in an extraarticular model
in ovine. Am J Sports Med 2002;30:506–513.
25. Morgan CD, Kalmam VR, Grawl DM. Isometry testing for anterior cru-
ciate ligament reconstruction revisited. Arthroscopy 1995;11:647–659.
26. Weiler A, Hoffmann RF, Stahelin AC, et al. Hamstring tendon fixa-
tion using interference screws: a biomechanical study in calf tibial
bone. Arthroscopy 1998;14:29–37.
27. Greis PE, Burks RT, Bachus K, et al. The influence of tendon length
and fit on the strength of a tendon-bone tunnel complex. A biomechan-
ical and histologic study in the dog. Am J Sports Med 2001;29:493–497.
28. Kyung HS, Kim SY, Oh CW, et al. Tendon-to-bone tunnel healing in a
rabbit model: the effect of periosteum augmentation at the tendon-to-
bone interface. Knee Surg Sports Traumatol Arthrosc 2003;11:9–15.
 Tibial Fixation for Anterior Cruciate
Ligament Hamstring Grafts: 10 Techniques
that Improve Fixation
INTRODUCTION
Tibial fixation during hamstring anterior cruciate
ligament (ACL) reconstruction has long been
considered the “weak link” of fixation. Surgeons
must provide an environment that optimizes the
ability of the cancellous bone to grow into the graft
and create strong connective tissue attachments.
The fixation method must be secure enough in
the first 2 months to allow the progression from
mechanical fixation to biological fixation without
graft elongation.
There are many reasons why tibial fixation is
more challenging than femoral fixation. Bone
mineral density (BMD) is higher in the distal
femur than it is in the metaphyseal region of the
tibia.1 Higher BMD provides more rigid fixation
for soft tissue fixation devices such as interference
screws and posts. Femoral fixation may include
suspensory devices and posts that can provide
more than twice the ultimate load to failure
(LTF) compared with commonly used interfer-
ence screws. Interference screws are more com-
monly used on the tibial side of the graft.2 Posts
can also be used on the tibial side of the ACL graft,
but this entails tying heavy sutures over the post or
screw that is drilled into the tibia distal to the tun-
nel. The “weak link” then becomes the interface
between the tendons and the sutures. When posts
are used for femoral fixation, the grafts are draped
over the posts and fail due to the post pulling
through the cancellous bone. Tibial fixation is also
more difficult because the reconstructed ACL
forces are parallel to the tibial tunnel,3 requiring
30
CHAPTER
either a fixation point orthogonal to the tunnel Lonnie E. Paulos
(screw or WasherLoc distal to the tunnel) or an
inner-tunnel fixation device that will provide
enough wedge fit and compression to secure the
graft from slippage and failure under cyclical
loading. When inner-tunnel fixation or inter-
ference screws are used, they are inserted in a
direction opposite to the tension being pulled on
the ACL graft, which may squander valuable
tension.4 This, coupled with management and
equal tensioning of four separate whipstitched
tendons, makes tibial fixation technically difficult.
Potential pitfalls in fixation include graft
malposition, slippage or micromotion, tunnel
widening, and lengthening of the graft after it
has been positioned within the knee. We
describe here 10 tibial fixation techniques that
significantly improve fixation of hamstring
grafts for ACL surgery. All techniques are used
in all of our ACL reconstructions.
TECHNIQUE 1: GRAFT PREPARATION
Whipstitch each tendon strand along the entire
length of the part of the tendon that is occupy-
ing the tibial tunnel.
Hamstrings can be harvested one of several
ways. Many surgeons harvest the semitendinosus
and gracilis tendons by making an incision
between the tendons as they insert on the pes
anserinus. The tendons are then retrieved proxi-
mally, where they are more distinct from each
other. Extra length may be achieved by using
211
 Anterior Cruciate Ligament Reconstruction
some of the periosteum near the anterior crest of the tibia
where the tendons attach.5 An equally popular way to harvest
the hamstrings involves making a horizontal incision over the
superior margin of the gracilis tendon, starting at the tibial
crest and extending 2 to 3 cm medially. This is followed by
an incision along the anterior margin of the tibia, creating a
trapdoor by which the pes anserinus is reflected from the peri-
osteum. The semitendinosus and gracilis tendons are easily
visualized and dissected from the sartorius fascia. This
technique better preserves the sartorius fascia that acts as
a scaffold for later hamstring tendon regeneration. It also
allows better visualization of the infrapatellar branch of
the saphenous nerve, which is important to protect while
harvesting hamstrings and performing meniscus repair.
A provisional heavy nonabsorbable suture is passed
several times through the end of the semitendinosus tendon
to use for traction as the tendon is freed of soft tissue attach-
ments and eventually stripped from its muscle belly. This
traction suture is removed by an assistant, who then
prepares the graft with whipstitches. If an assistant is not
available, one can whipstitch the tendon prior to stripping
while it is still attached to the muscle. A 6-inch curved Kelly
clamp is used to hold the very tip of the tendon as a #2
Ethibond or orthocord suture is whipstitched up one side
of the tendon and then down the other.
Once the tendon ends have been secured with the
traction suture or the whipstitch configuration, the suture and
tendons are fed into a stripper with a circumferential opening.
The stripper is gently advanced in line with the semitendinosus
tendon and muscle. A slight figure-four position with the knee
bent to 90 degrees may facilitate passage of the stripper. If
resistance is encountered, the stripper is removed and the
tissue around the tendon is probed for soft tissue attach-
ments. The most commonly encountered adhesions are the
attachments from the medial head of the gastroc tendon.
Once these are released, the stripper is advanced again.
The semitendinosus, being the broader and longer of
the two tendons, is harvested first. Most surgeons harvest in
this order in case the stripper accidentally damages the tendon
that is not being stripped. Another potential reason for
harvesting the semitendinosus first is the possibility that the
semitendinosus may be long enough to be quadrupled,
providing all four strands of the reconstruction. Preservation
of the gracilis tendon may protect knee flexion strength;
however, this is controversial.6 The gracilis is harvested in
the majority of our ACL reconstructions.
After tendon harvest, the sartorius fascia and pes
anserinus are repaired to their origins using a #1 Vicryl suture.
This protects the majority of the sartorius fascia from inadver-
tent destruction during tibial tunnel reaming. Gracilis and
semitendinosus grafts are gently removed of their musculoten-
dinous muscle attachments using a small key elevator. A #2
212
Ethibond or orthocord nonabsorbable suture is used to
whipstitch each of the four arms of the tendon grafts. Usually,
a running whipstitch up and down each side of the strand
provides enough security for later tensioning. Occasionally
one end of the graft may not have robust-enough tissue, and
a locking whipstitch can be used as described by Krackow.7
Graft tunnels are measured accurately, and whipstitches are
made along each arm of the four bundled graft such that the
whipstitches will extend up the entire distance of the tibial
tunnel (Fig. 30-1). By using whipstitches along the entire
length of the graft that is occupying the tibial tunnel, fixation
pullout is increased by approximately 15%.8 The tendons are
then placed over a suture and drawn through an appropriately
sized soft tissue guide or measuring device to determine the
width of the tunnels.
TECHNIQUE 2: PRETENSION AND CYCLING OF
THE GRAFTS
Tendons, when at rest, are in a crimped, wavy state. When
tensioned, the fibers line up in a parallel fashion and the
tendon elongates by 2% to 4%, depending on where
the tensioning is taking place on the stress–strain curve.
Once the “toe” region of the stress–strain relationship curve
has been exceeded, any further stress makes the graft stiffer
and therefore makes the knee tighter.9 By preloading the graft
and tensioning with 30 lb over 3 dozen cycles and/or 30 min-
utes of time, the graft is stiffened and the relaxation that
occurs immediately after fixation is reduced (Fig. 30-2)
Grafts inserted after pretensioning and cycling are much
stiffer than grafts that have not undergone this technique.
By placing a stiffer graft and using stiffer fixation, less load
FIG. 30-1 Whipstitches extend up the entire distance of the tibial tunnel.
FIG. 30-2 Preloading the graft by tensioning 30 lb for 20 minutes or 3
dozen cycles under tension after implanting increases graft stiffness and
performance significantly.
 Tibial Fixation for Anterior Cruciate Ligament Hamstring Grafts: 10 Techniques that Improve Fixation
can be placed on the graft, ultimately resulting in a tighter
knee.10
Recently, static tensioners have been developed to
tension the graft while it is already fixed in the femoral tunnel.
As the knee is cycled with the grafts under tension, the graft
elongates and the grafts are retensioned prior to insertion of
the interference screws.11 When using a static tensioner, we
place no more than 15 lb on the graft, to be distributed equally
among the four arms of the four-bundle graft (Fig. 30-3).
Yasuda et al tested their ACL hamstrings grafts ten-
sioned to 20N and 80N at the time of surgery, 2 years later
the grafts tensioned at 20N had significantly more laxity
than the 80N group: 2.2 mm versus 0.6 mm, respectively.12
However, it is important to remember that grafts continue
to elongate despite pretensioning. A recent study demon-
strated that the viscoelastic properties of tendons cannot
be completely eliminated. Hamstring and anterior tibialis
allografts underwent no preconditioning, cyclical precondi-
tioning, or isometric preconditioning, and the tension of
the grafts was measured over 1 hour. The grafts continued
to elongate for the entire 60 minutes. In all groups the grafts
lost approximately 60% of their original tension over the
1-hour period.13 This has important implications for
hamstring reconstruction physical therapy protocols. We
recommend and the literature supports a less aggressive
regimen in the first 2 months after reconstruction.
TECHNIQUE 3: MAXIMIZE LENGTH OF THE
TIBIAL TUNNEL
Increasing the length of the tunnel maximizes the surface area
available for healing of tendons to bone. It also provides more
room for a longer fixation device and therefore improved
fixation. In a dog model, pullout strength of a soft tissue
FIG. 30-3 Static tensioner.
30
tendon was 153.7N in a 1-cm tunnel versus 265.5N in a
2-cm tunnel.14 However, the important healing itself occurs
in the first 8 to 10 mm of the proximal tibial tunnel, and thus
tibial healing is not enhanced by longer tunnels. Longer
tunnels allow longer interference screws, which provide more
rigid fixation when using interference screw techniques. In
addition to using longer tunnels, the author’s clinic under-
sizes the tibial tunnel by 1 mm, allowing for a better press
fit. This also enhances healing of the graft in the tunnel.
Location of the tibial tunnel is extremely important in
terms of neutralizing rotation (pivot-shift) and preventing
early failures due to impingement. If the tunnel is too anterior
in the sagittal plane, the risk of impingement is high and the
graft may stretch out because it is too tight in flexion. If the
graft tunnel is too posterior, it will fail to neutralize anterior
translation of the tibia when the knee is in full extension.15
We currently use a high-angle tibia guide designed by
Dr. Steve Howell. The guide is designed to place the tibial
tunnel into a position in which impingement on the ham-
string graft cannot occur. The guide directs the guide pin into
the tibia at approximately 65 degrees.16 The guide has a wide,
golf club (driver)–shaped tip that is inserted into the notch,
and the knee is taken into full extension. The bulky tip of
the guide is forced posterior in relation to the anterosuperior
edge of the femoral notch. This ensures that the graft will stay
behind Blumensaat’s line when the knee is in full extension,
eliminating anterior impingement on the graft. The high
angle created by the guide also creates a longer tibial tunnel
that will enable more surface area for fixation and healing.17
In our technique, we perform only a lateral wall
notchplasty and only enough to allow safe graft passage.
There must be enough room between the posterior cruciate
ligament (PCL) and the lateral wall for the large diameter of
the Howell guide. Once there is enough room for the tip of
the guide, the knee is brought into full extension. A Kirschner
wire (K wire) is placed through the arm of the guide in order
to align the guide to a 45-degree angle in relation to the tibial
plateau. This prevents the graft from being placed in a
too-vertical position. ACL grafts that are too vertical have
more rotational instability and tend to pivot-shift after
reconstruction.18 After the guide pin is placed in the proximal
tibia, we check its position in the posterior aspect of the ACL
footprint. Other landmarks that are used to check position are
the anterior horn of the lateral meniscus, the PCL, and the
medial tibial intercondylar eminence.19 The most useful of
these landmarks is the PCL. Our pin should be within 5 to
6 mm of the anterior border of the PCL. When using this
guide, one should pay close attention to the position of the
guide pin as it enters the tibia. It is usually more posterior than
in traditional placement techniques that aim for the midpoint
between the anterior and posteromedial aspect of the tibia.
Often the guide pin is very close to the anterior border of
213
 Anterior Cruciate Ligament Reconstruction
the superficial medial collateral fibers. If the guide pin sits
within the fibers of the medial collateral ligament, then a more
traditional location for the tunnel should be used to avoid
damaging the ligament.
Traditionally surgeons have reamed with a broad,
cannulated reamer. We use a trephine bone harvesting
system, also known as a coring reamer.20 This creates a long
bone dowel or plug that is later used as bone graft in the tibial
tunnel (discussed later). Matching the tunnel size to the graft
size is very important. Steenlage et al showed that even a
0.5-mm difference in tunnel sizes could reduce ultimate LTF
of tibial fixation from 308N to 221N.21 We make sure that
our hamstring grafts fit snugly in their tunnels. Sometimes
we even undersize the tibial tunnel by 0.5 to 1.0 mm to
enhance this fit. Cain et al tested hamstring grafts in tunnels
that were reamed to the correct size versus tunnels that were
under-reamed by 2 mm and then dilated by smooth dilators
to the same diameter as the controls. The pullout strength of
the dilated group was 616N versus 453N for the reamed-alone
group.22
TECHNIQUE 4: LIMITED DÉBRIDEMENT OF
ARTICULAR EDGE OF TIBIAL TUNNEL
After reaming is complete, there are usually small pieces of
bone and cartilage debris present near the opening of the
tibial tunnel into the knee joint. We remove any pieces that
might cause tearing of our graft by placing the shaver up the
tibial tunnel. The posterior edge of the tunnel concerns us
the most. Rarely do we débride the anterior aspect of the
tunnel. By débriding only the necessary pieces of articular
cartilage and bone, we preserve valuable soft tissue that
can help form the seal between the joint and the tunnel,
which can accelerate healing.
TECHNIQUE 5: DISTAL TUNNEL FIXATION
Location of the fixation device will determine the ultimate
fixation strength of the ACL graft. The bone closest to the
cortex of the proximal tibia has the tighter trabecular pattern
and higher BMD.23 The cortex at the distal aspect of the tibial
tunnel provides better fixation than the cancellous middle
portion of the tibial tunnel. The very proximal part of the tun-
nel can provide good fixation, but the fixation device should
not interfere with bone completely encompassing the graft.
This must be balanced with the knowledge that fixation
points farther away from the joint may produce more tunnel
widening.24 In theory, this may hinder bone attachment to
the hamstring tendons. Phillips et al demonstrated in human
cadavers that the greatest amount of screw insertional torque
214
was at the most distal aspect of the tibial tunnel.25 The inser-
tional torque at the distal aspect of the tunnel measured
8.7 inches per pound versus 4.7 and 4.3 inches per pound in
the middle and proximal thirds of the tibial tunnel, respec-
tively. This relates directly to pullout strength and further
justifies a fixation point close the cortex of the tibia.
We prefer a short, broad interference screw that
provides good fixation at the distal aspect of the tibial
tunnel. This allows the graft to heal in the proximal aspect
of the tibial tunnel without the disturbance of an interfer-
ence screw. This also provides space in the proximal aspect
of the tunnel for bone graft material.
TECHNIQUE 6: BONE GRAFTING OF TIBIAL
TUNNEL
The author has bone grafted the tibial tunnel using autograft
and allograft bone for the past several years. By impacting
bone between the tendons to the proximal portion of the tibial
tunnel, the healing of the graft to the tunnel is enhanced in a
circumferential way. As mentioned earlier, the trephinated
reamer produces an excellent core of cancellous bone. This
also increases pullout strength significantly.19 The bone graft
is placed in the tibial tunnel prior to placing the interference
screw (Fig. 30-4). The interference screw then further
compacts the graft and pushes it into the proximal portion
of the tibial tunnel. The surgeon must exercise care so as not
to push bone into the joint itself. The only way to ensure that
bone has not been pushed into the joint is to insert the
arthroscope back into the knee and visualize the graft
and notch area. If trephinated reamers are not available,
one can use allograft bone chips or OBI bone substitute
(Osteobiologics, San Antonio, TX).
FIG. 30-4 Bone graft placed in the tibial tunnel prior to fixation.
 Tibial Fixation for Anterior Cruciate Ligament Hamstring Grafts: 10 Techniques that Improve Fixation 30
TECHNIQUE 7: RIGID INTEROSSEOUS Kousa et al tested six different tibial fixation devices in
human cadavers.4 The study included two screw-and-washer
COMPRESSION WITH INTERFERENCE SCREW fixation devices and four interference screw devices including
IntraFix. Single-cycle LTF testing as well as 1500-cycle load
The goal of any fixation should be to limit motion as much as
testing were performed on the specimens. IntraFix had the
possible. Rigid fixation creates an environment in which bone
highest single-cycle LTF threshold at 1332N, which was
healing to the tendons is more likely to occur. Interference
357N stronger than the next closest device, the WasherLoc
screws when used with a protective sleeve can provide this
(975N). After cyclical load testing, the residual displacement
rigid fixation (i.e., IntraFix, Mitek, Norwood, MA). The
of the IntraFix averaged 1.5 to 0.3 mm, which was the
IntraFix has several advantages over other fixation devices
lowest displacement of the six devices. WasherLoc had 3.2
(Fig. 30-5). The sleeve protects the graft from laceration
to 1.5 mm of residual displacement, which was the next-best
during insertion while at the same time pressing the four
recorded value.
hamstring strands firmly into the cancellous bone of the tibia.
If two assistants are available, we prefer to have the arms of the
graft pulled in the direction of the tunnel, and then without
TECHNIQUE 8: CROSS-PIN FIXATION OF
losing tension, we lay the grafts down on the edge of the tibia
in four separate directions. The tunnel is first expanded with INTERFERENCE SCREW SYSTEM
the IntraFix expander. We then place our bone graft in the
Early failure of the soft tissue graft to cycling occurs when the
tunnel and again use the expander to ensure that there is
interference screw and/or fixation device slips or loosens. The
enough room for the sleeve and screw. The grafts are again
author has described and tested a bioabsorbable Interlock pin
pulled in the direction parallel to the tunnel and the grafts
(Stryker Orthopedics, Kalamzoo, MI) that is constructed
are laid down in opposite directions on the tibia, similar to
with polylactic acid (PLA).26 After the IntraFix device is
the spokes on a wheel. The sleeve is inserted, followed by
deployed, a hole is drilled through the cortex of the proximal
the screw. The screw is advanced until it is nearly flush with
tibia and perpendicular to the long axis of the bioabsorbable
the tibia. Further advancement past the cortical bone will
interference screw. The smooth PLA pin is placed across
sacrifice fixation strength, as explained earlier. The author’s
the bone and the interference screw (Figs. 30-6 and 30-7).
clinic purposely use an interference screw that is equal to or
This prevents early slippage and improves fixation by as much
larger than the diameter of the tunnel drilled for the graft.
as 30% when tested by cyclical pullout.27 By placing an
We typically use the shorter of the two screws to ensure that
our interference screw does not “interfere” with bone healing
to tendon near the joint surface.

FIG. 30-6 The smooth polylactic acid (PLA) pin is placed across the bone
FIG. 30-5 IntraFix device (Mitek Products, Norwood, MA). and through the fixation screw to increase resistance to cycling stresses.

215
 Anterior Cruciate Ligament Reconstruction
FIG. 30-7 Rigid fix device.
Interlock pin perpendicular to the interference screw, the
need for an extracortical fixation device is obviated. This also
prevents reoperation in a significant number of cases wherein
extracortical devices protrude and create palpable tenderness
and/or kneeling pain (see Fig. 30-2).
TECHNIQUE 9: UTILIZATION OF
BIOABSORBABLE MATERIALS
Within the past few years, the author’s clinic has adopted
bioabsorbable materials that have been enhanced for bone
ingrowth. Several products have been introduced to the
market that use either hyaluronic acid and/or phosphorus
products embedded or molded into the poly-l-lactic acid
(PLLA) device to enhance bone healing and device absorp-
tion. (Biosteon, Stryker Endoscopy, San Jose, CA, and
Milagro, Mitek Products, Norwood, MA). By the use of
these materials, tunnel widening should be minimized and
there should be direct bone replacement of the device and
the graft itself.
Although bioabsorbable screws have been well studied in
patellar tendon ACL reconstructions, there is relatively less
information about the devices in hamstring ACL reconstruc-
tions. Bioabsorbable screws have been compared with titanium
screws human cadavers and hamstring ACL reconstructions.
Brand et al demonstrated that there was no statistical difference
in pullout strengths between the metal versus bioabsorbable
screws.28 On the femoral side of fixation, they did observe a
much higher rate of graft laceration with the titanium screws.
Robinson et al evaluated bone tunnel enlargement with PLLA
screws versus screws mixed with PLLA and hydroxyapatite
(HA).29 Tunnel widening was observed in 29.9% of the com-
bined PLLA/HA versus 46% in the group with PLLA alone.
TECHNIQUE 10: MODIFIED PHYSICAL THERAPY
FOR THE FIRST 2 MONTHS AFTER SURGERY
The first 8 to 12 weeks after hamstring ACL reconstruction
are the most important in terms of forming bonds between
the bone and the hamstring tendons. From our knowledge
216
of what happens to grafts in vitro, we discourage any physi-
cal therapy activity that will aggressively cycle the graft.
However, we do allow early weight bearing with a hinged
brace as well as full range of motion as soon as possible. Sta-
tionary bicycling is not allowed until the ninth postoperative
week. In a cohort study, Hantes et al demonstrated that
early motion after hamstring ACL reconstruction resulted
in an average of 48.14% tunnel widening versus 24.47%
widening in patients with delayed motion.30 We do not
allow our patients to take antiinflammatory medications
postoperatively because we believe these may disrupt heal-
ing of bone to tendon in the tibial tunnel.
References
1. Brand JC Jr, Pienkowski D, Steenlage E, et al. Interference screw fix-
ation strength of a quadrupled hamstring tendon graft is directly
related to bone mineral density and insertional torque. Am J Sports
Med 2000;28:705–710.
2. Brown CH Jr, Wilson DR, Hecker AT, et al. Graft-bone motion and
tensile properties of hamstring and patellar tendon anterior cruciate
ligament femoral graft fixation under cyclic loading. Arthroscopy
2004;20:922–935.
3. Malek MM, DeLuca JV, Verch DL, et al. Arthroscopically assisted
ACL reconstruction using central third patellar tendon autograft with
press fit femoral fixation. Instr Course Lect 1986;45:287–295.
4. Kousa P, Jarvinen TLN, Vihavainen M, et al. The fixation strength of
six hamstring tendon graft fixation devices in anterior cruciate ligament
reconstruction. Part II: tibial side. Am J Sports Med 2003;31:182–188.
5. Pagnini MJ, Warner JP, O’Brien SO, et al. Anatomic considerations
in harvesting the semitendinosus and gracilis tendons and a technique
of harvest. Am J Sports Med 1993;21:565–571.
6. Carofino B, Fulkerson J. Medial hamstring tendon regeneration fol-
lowing harvest for anterior cruciate ligament reconstruction: fact,
myth, and clinical application. Arthroscopy 2005;21:1257–1265.
7. Krackow KA, Thomas SC, Jones LC. A new stitch for ligament-ten-
don fixation. J Bone Joint Surg 1986;68A:764–766.
8. Paulos LE, Ellis B. ACL fixation pullout studies. Orthopedic Biome-
chanics Institute. Salt Lake City, 1998.
9. Kannus P, Jozsa L, Jarvinen M. Basic science of tendons. In
Garrett WE, Jr, Speer KP, Kirkendall DT (eds). Principles and practice
of orthopaedic sports medicine. Philadelphia, 2000, Lippincott, Williams
& Wilkins, pp. 21–37.
10. Vachtsevanos JG, Lamberson KA, Paulos LE. Anterior cruciate graft
tensioning. Tech Knee Surg 2003;21:125–136.
11. Paulos L. Personal communication, 2007.
12. Yasuda K, Tsujino J, Tanabe Y, et al. Effects of initial graft tension on
clinical outcome after anterior cruciate ligament reconstruction.
Autogenous double hamstring tendons connected in series with poly-
ester tapes. Am J Sports Med 1997;25:99–106.
13. Nurmi JT, Kannus P, Sievanen H, et al. Interference screw fixation of
soft tissue grafts in anterior cruciate ligament reconstruction and after
screw insertion. Part 2: effect of preconditioning on graft tension dur-
ing and after screw insertion. Am J Sports Med 2004;32:418–424.
14. Greis PE, Burks RT, Bachus K, et al. The influence of tendon length
and fit on the strength of tendon-bone tunnel complex. A biomechanical
and histologic study in the dog. Am J Sports Med 2001;29:493–497.
15. Fineberg MS, Zarins B, Sherman OH. Practical considerations in ante-
rior cruciate ligament replacement surgery. Arthroscopy 2000;16:715–724.
16. Simmons R, Howell SM, Hull ML. Effect of the angle of the femoral
and tibial tunnels in the coronal plane and incremental excision of the
posterior cruciate ligament on tension of an anterior cruciate ligament
graft (an in vitro study). J Bone Joint Surg 2006;85A:1018–1029.
 Tibial Fixation for Anterior Cruciate Ligament Hamstring Grafts: 10 Techniques that Improve Fixation
17. Cuomo P, Edwards A, Giron F, et al. Validation of the 65 degrees
Howell guide for anterior cruciate ligament reconstruction. Arthroscopy
2006;22:70–75.
18. Lee MC, Seong SC, Jo H, et al. Outcome of anterior cruciate liga-
ment reconstruction using quadriceps tendon autograft. Arthroscopy
2004;20:795–802.
19. Jackson D, Gasser S. Tibial tunnel placement in ACL reconstruction.
Arthroscopy 1994;10:124–131.
20. Howell SM, Roos P, Hull ML, et al. Compaction of a bone dowel in
the tibial tunnel improves the fixation stiffness of a soft tissue anterior
cruciate ligament graft: an in vitro study in calf tibia. Am J Sports Med
2005;33:719–725.
21. Steenlage E, Brand JC Jr, Johnson DL, et al. Correlation of bone tun-
nel diameter with quadrupled hamstring graft fixation strength using a
biodegradable interference screw. Arthroscopy 2002;18:901–907.
22. Cain EL, Phillips BB, Charlebois SJ, et al. Effect of tibial tunnel dila-
tion on pullout strength of semitendinosis graft in anterior cruciate lig-
ament reconstruction. Orthopedics 2005;28:779–783.
23. Klein SA, Nyland J, Caborn DN, et al. Comparison of volumetric
bone mineral density in the tibial region of interest for ACL recon-
struction. Surg Radiol Anat 2005;27:372–376.
30
24. Fauno P, Kaalund S. Tunnel widening after hamstring anterior cruci-
ate ligament reconstruction is influenced by the type of graft fixation
used: a prospective randomized study. Arthroscopy 2005;21:1337–1341.
25. Phillips BB, Cain EL, Dlabach JA, et al. Correlation of interference
screw insertional torque with depth of placement in the tibial tunnel
using a quadrupled semitendinosus-gracilis graft in anterior cruciate
ligament reconstruction. Arthroscopy 2004;20:1026–1029.
26. Berg TL, Paulos LE. Endoscopic ACL reconstruction using Stryker
Biosteon cross-pin femoral fixation and Interlock cross-pin tibial fixa-
tion. Surg Technol Int 2004;12:239–244.
27. Stryker Endoscopy data, 2002, Study performed by Frontier
Biomedical. Logan, UT.
28. Brand JC Jr, Nyland J, Caborn DN, et al. Soft-tissue interference fixation:
bioabsorbable screw versus metal screw. Arthroscopy 2005;21:911–916.
29. Robinson J, Huber C, Jaraj P, et al. Reduced bone tunnel enlargement
post hamstring ACL reconstruction with poly-l-lactic acid/hydroxyap-
atite bioabsorbable screws. Knee 2006;13:127–131.
30. Hantes ME, Mastrokalos DS, Yu J, et al. The effect of early motion
on tibial tunnel widening after anterior cruciate ligament replacement
using hamstring tendon grafts. Arthroscopy 2004;20:572–580.
217
 PART F FIXATION DEVICES AND METHODS OF SOFT-TISSUE GRAFT
FEMORAL FIXATION
31
SUB PART I SUSPENSORY CORTICAL
Endobutton Anterior Cruciate Ligament
Reconstruction Femoral Fixation
CHAPTER
Chadwick C. Prodromos INTRODUCTION
The Endobutton (EB) is the most widely used
femoral fixation device worldwide that is
designed specifically for soft tissue grafts. Pio-
neered by Dr. Thomas Rosenberg and intro-
duced around 1990, it was the first device
specifically designed to hold soft tissue grafts.
As originally designed, the surgeon would tie a
Dacron tape connecting the button to the ten-
don. In the past 5 years, this technique has been
largely supplanted by use of the EB-CL (contin-
uous loop), which obviates the need to tie knots.
Due to the longevity of the device, there is a
much greater literature concerning it than any
of the other newer, soft tissue–specific devices.
BIOMECHANICS
Numerous studies have analyzed the pullout
strength and stiffness of this device.1–7 Much was
made at one point about a so-called “bungee
effect,” in which the device’s fixation on the
cortex and not in the tunnel supposedly resulted
in lower stiffness. However, it has subsequently
been shown that the greater stiffness resulting from
cortical anchorage dwarfs the slightly reduced stiff-
ness from the greater length of the construct.7
Also, as described elsewhere in the text, stiffness
has no bearing on ultimate stability. This is because
the stiffness of all grafts is independent of their
mode of fixation once tunnel healing has occurred
at about 2 months postoperatively. After this time,
load is borne by the healed fibers that connect the
218
graft to the tunnel, not by the device. Because the
fixation device is not load bearing after this time,
its stiffness is irrelevant. However, even before that
time, stiffness is less important because the stiffness
represents only elastic deformation of the graft. It is
only plastic deformation, not elastic deformation,
that will result in greater ultimate clinical laxity.
In fact, reduced stiffness, or greater elasticity, in
the graft-fixation construct will diminish the forces
that tend to displace the fixation device in cyclical
loading. This reduction in stiffness diminishes
these forces by partially dissipating them in tempo-
rary elastic deformation of the graft. Therefore,
ultimately, stability may actually be enhanced by
protecting the construct from plastic deformation
or fixation device slippage while tunnel healing is
occurring.
CLINICAL RESULTS
In the largest meta-analysis of anterior cruciate
ligament reconstruction (ACLR) autografts, the
EB-hamstring combination was found to have
the highest stability rates of any graft-fixation
construct when paired with modern tibial fixa-
tion.8–14 Morbidity has been minimal.15–18 In
our experience,8 the EB has proven to be
extremely reliable. After 13 years of continuous
use, as well as follow-up of more than 80% of
all implanted EBs, we have had no graft failures
(see Chapter 69). Approximately 86% of grafts
have had IKDC normal stability. We have had
no hardware complications and no displaced
EBs, and we have not had to remove an EB.

SURGICAL TECHNIQUE
Principle
The EB is a small oval button that anchors the graft against
the outer femoral cortex. It is passed up from within without
a second femoral incision.
Materials
The EB-CL (continuous loop) is now the standard implant.
It comes with fabric loops already attached to the EB in
5-mm increments, with 15 mm being the shortest. A standard
ACL tray is used, although a special 4.5-mm drill bit, available
only from Smith & Nephew (Andover, MA), must be used.
Femoral-Tunnel Formation
Principles of Femoral-Tunnel Drilling
Two femoral tunnels are necessary in sequence with each
other, as will be described. They are drilled transtibially. A
laser-marked, long transtibial guide pin with markings every
2 mm is used to drill the femoral tunnel at a 65-degree coro-
nal angle. It is important to drill the tunnel such that the exit
is in the femoral metaphysis rather than the femoral condyle
if possible so that the tunnel will have adequate length. It has
recently become apparent that a femoral-tunnel entry lower
down at the 10 o’clock position rather than the 11 o’clock
position (for a left knee) will improve rotational stability.
This lower entry will, however, also result in a shorter tunnel
because the exit will tend to be from the narrower condyle,
which is lower down than the wider metaphysis. To compen-
sate for this, the knee needs to be more flexed during drilling
to 90 degrees or more in order to redirect the tunnel upward
toward the metaphysis. The following is our technique for
femoral-tunnel formation and EB fixation.
Notchplasty
We always perform a lateral notchplasty, but not roofplasty,
of about 3 mm for visualization. All soft tissue should be
removed from the tunnel so that the over-the-top position
can be clearly seen. It should also be probed to make sure
the surgeon knows where the back of the notch is.
Basic Technique
With the leg hanging free at its usual angle of about 75
degrees, a 1-mm deep indentation is made with the tip of
the drill pin at the 10 o’clock position, and about 3 mm dis-
tal to (forward from) the over-the-top position. The tunnel
entry point is found in this fashion because visualization is
easiest at this degree of knee flexion. We then pull the pin
Endobutton Anterior Cruciate Ligament Reconstruction Femoral Fixation 31
back and make sure the location for the tunnel is satisfac-
tory. The knee is then flexed to at least 90 degrees and usu-
ally to about 100 degrees. The pin is then reinserted into the
indentation, and the tunnel is slowly drilled, taking care to
stop when the resistance of cortical bone is reached. This
is easily felt if the tunnel is drilled slowly and with a light
touch. Cortex will usually be reached at 30 to 40 mm, as
seen on the laser-marked pin.
Minimum Tunnel Length
Our minimum acceptable tunnel length is 30 mm, which,
when the 15-mm continuous loop length is subtracted,
leaves 15 mm of graft in the tunnel. The cortex is 3 to
5 mm thick. Thus we make sure that the laser pin shows
at least 27 mm inserted into the condyle before reaching
the femoral cortex to ensure that the total channel length
will be at least 30 mm after drilling through the cortex.
Redrilling if the First Tunnel Is too Short
If the tunnel is less than 27 mm we withdraw the pin, relax the
knee to 75 degrees or so, and make a new pilot indentation at
about the 10:30 position and about 5 mm distal to over-the-
top position (i.e., slightly higher and more distal or forward
than the original hole). We then flex the knee to 5 or 10 degrees
more than on the first pass, at least 95 degrees, and redrill the
hole. The new tunnel should be significantly longer. The
changes in tunnel location, along with the greater knee
flexion, yield longer tunnels and will still result in a tunnel in
a very acceptable location. If the knee is adequately flexed the
first time, however, a second pass will rarely be necessary.
Finishing the Femoral Tunnel
Once a satisfactory tunnel has been found, the laser pin is
further drilled through the cortex. We observe the laser
markings when giving way is achieved, which indicates the
pin has burst through the cortex, so we have a good idea
of the total channel length. Next, the appropriate acorn
reamer is inserted over the pin. This is drilled nearly to
the cortex, as measured from the laser pin. If high resistance
is felt before the anticipated point is reached, drilling should
be stopped to avoid breaking through the opposite cortex.
Generally the acorn reamer will be drilled 1 to 2 mm shorter
than the laser pin length indication of where the cortex was
reached. The socket will usually be about 6 mm shorter than
the total channel length. It must be within 9 mm of the
length of the total tunnel to allow a 15-mm EB-CL to be
used. This is because at least 6 mm of extra length is needed
to allow a turning radius for the EB as it sits outside the
femoral cortex (i.e., 6 þ 9 ¼ 15 mm). Once the socket is
drilled, the acorn drill bit is withdrawn and a 4.5-mm bit
is inserted and drilled through the outer cortex with the
guide pin still in place (Fig. 31-1). After the 4.5-mm tunnel
219
 Anterior Cruciate Ligament Reconstruction

multiple of 5, then the next-largest number that is a multiple

of 5 is selected. For example, if the total channel is 34 mm
and the socket is 27 mm, the difference would be 7 mm.
7 þ 6 ¼ 13. The next-largest number that is a multiple of
5 is 15, so a 15-mm EB-CL is selected. In this case, 34 – 15
¼ 19, so 19 mm of graft would be in the femoral tunnel.

Preparing the Endobutton/Graft Construct

The EB-CL is positioned in the holder on the Graftmaster
board. The graft is then passed through the fabric loop attached
FIG. 31-1 The 4.5-mm drill bit is drilled through the cortex over the to the EB (Fig. 31-3). A violet #3–0 or 4–0 monofilament
previously drilled, laser-marked, long guide pin after the socket has been
absorbable suture is then sewn across the graft (Fig. 31-4) at a
drilled.
distance from the EB that is 2 mm greater than the total chan-
nel length, as identified on the Graftmaster board on which the
is drilled, the guide pin is removed with the 4.5-mm drill
construct is positioned. In the earlier example, the total channel
bit. Next, the long-depth gauge is used to measure the total
length was 34 mm, so the suture would be placed at 36 mm
channel length (Fig. 31-2). If it exceeds the socket length
from the EB. This will provide arthroscopic evidence that the
by more than 9 mm, the guide pin and then the acorn drill
graft has been passed to the proper depth later in the procedure.
bit should be reinserted over the guide pin, and the socket
This area should also be marked with a marking pin. This
should be drilled a little farther so that it is within 6 to
9 mm of the total length. If the far wall of the cortex is
accidentally violated, this can be easily salvaged with an
Xtendobutton, as will be described.

Calculating Endobutton–Continuous Loop Length

The socket length is subtracted from the total channel length
and 6 or 7 mm are added for a turning radius. If that number
is a multiple of 5, then that is the EB-CL used. If it is not a

FIG. 31-3 The prepared graft is passed through the fabric loop until each
arm of the graft is the same length.

FIG. 31-2 The total channel length is measured with the long-depth FIG. 31-4 The colored absorbable monofilament suture locks the graft to
gauge while viewing the femoral-tunnel entry point arthroscopically. prevent sliding and also marks the entry point for the femoral tunnel.

220

absorbable colored suture also locks the graft in place, preven-
ting it from sliding on the fabric loop. A #5 suture is then
passed through one eyehole and a #2 suture through the other
eyehole of the EB. All four suture ends are then passed through
the eye of the long passing pin (Fig. 31-5), and a hemostat is
applied to the four suture ends near their tips to lock the graft
onto the pin.
Endobutton Anterior Cruciate Ligament Reconstruction Femoral Fixation 31
sure the graft cannot be pulled back out (Fig. 31-8). We then
wrap the sutures around the smooth shank of the tibial screw
and hold very strong tension while fully flexing and extending
the knee three times. This serves to eliminate slack from the
graft. Equally importantly, this will serve to pull the graft
out of the knee if the EB has not been seated. For this reason,

Passing the Graft

th
The long pin with the graft and sutures attached is then

ng

an ion
le
passed into the tibial tunnel into the knee, where it is visua-

sp ect
el
nn

nn
lized with the arthroscope. The knee should be flexed during

ha

Co
lc
ng on
this passage to the same degree as when the femoral tunnel

ta
To

le rti
th
se
was drilled. The pin is then inserted into the femoral

In
tunnel and passed proximalward out through a puncture in
the soft tissue, where it is pulled free of the passing sutures
(Fig. 31-6). Sometimes the pin must be redirected subtly
within the femoral socket before it finds the smaller 4.5-mm
tunnel and makes its way into the soft tissue. The two #5
sutures are then grasped with a Kocher clamp. The sutures
are wound onto the closed Kocher jaws like a spool. The
Kocher with wound sutures is then strongly pulled until
the graft can be felt to pass into the femoral socket and
become fully seated. The previously inserted violet suture
and ink markings on the graft are visualized arthroscopically
just outside the femoral-tunnel opening, which confirms that
the graft is in proper position. If the graft is not fully seated,
the Kocher can be wound like a windlass to pull in the graft.
Cycling of the knee may also help.

Seating the Endobutton

The two #2 sutures are then pulled to flatten the EB on the
external femoral surface. After slack is taken up, a slight tog-
gling should be felt (Fig. 31-7). Strong retrograde tension
should be applied to the whipstitches as they dangle out the
tibial incision while the knee is flexed and extended to make A

FIG. 31-5 All four sutures—two #5 and two #2 sutures—are passed FIG. 31-6 A,B, The long guide pin is passed into the knee and out
through the eye of the long passing pin. through the soft tissue with the graft construct attached.

221
 Anterior Cruciate Ligament Reconstruction
FIG. 31-7 The #2 sutures are used to flatten the Endobutton, seating it on the femoral cortex after the graft has
been pulled into the socket with the #5 sutures.
this step is very important. We have had the graft withdraw in
this fashion two or three times and have successfully reseated
it each time (see “Troubleshooting”). We have never had a
graft pull out later. However, if this step had been omitted,
later loosening could have occurred in these cases. The tibial
screw or other tibial fixation method is then tightened.
Removing the Passing Sutures
After the EB is flattened and tibial fixation has been applied,
the passing sutures should be pulled out from the EB. The #2
suture should be tried first, making sure that it slides freely
(if not, see problem 3 in “Troubleshooting”). If it does slide
freely, cut one limb off at skin level, and pull the other end
out and discard it. This is repeated with the #5 suture.
TROUBLESHOOTING
In this section, we list all the EB problems that we have
either encountered or theorized but not encountered. In all
222
cases the difficulty was dealt with, the surgery was finished
with only a minor delay, and a good result was obtained.
In 13 years of continuous use we have never had an EB-
related complication, EB failure, or migration. We have
never had to remove an EB nor had a graft fail when
fixated with an EB.8 Rarely, however, one of the following
problems may arise. If the surgeon is prepared, these
problems should pose no difficulty. The EB has proven to
be remarkably trouble free over the most extended use of
any soft tissue femoral fixation device.
Problem 1: What if the Endobutton Will not
Flatten and the Graft Pulls back through
and into the Knee?
Cause 1
The total channel length was measured too short, and hence
the EB-CL is too short, so it is not emerging outside the
femoral cortex where it can be flattened.

FIG. 31-8 Strong retrograde tension fails to dislodge the graft when the knee is cycled once the Endobutton has
been properly seated.
Comment
This is a rare occurrence that was slightly more likely to
happen in the past, when tunnels were placed higher and
channels were longer than at present. The lower tunnel place-
ments currently used result in relatively short tunnels, which
are easier to measure. Also, initially the long guide pin did
not have laser markings. At our urging, Smith & Nephew
began fabricating marked guide pins and has now included
laser length markings on all long guide pins, which allows
the surgeon to closely estimate the femoral-tunnel length
while drilling before measuring with the depth gauge.
Remedy
If the EB will not flatten and seat and catch, it should be
passed a second time. If it still will not seat, then the femoral
tunnel should be remeasured. If a longer measurement is
indeed obtained, a longer EB-CL should be attached, and
the EB should now flatten and catch appropriately. If the total
channel was measured accurately and if the difference
between the total channel length and the socket is 8 or 9 mm
such that the turning radius of the EB is only 6 or 7 mm, then
the socket should be drilled another 2 or 3 mm if possible.
This allows a greater turning radius for the EB of 8 to
10 mm and should facilitate seating.
Cause 2
The lateral cortex was damaged by the socket reamer, effec-
tively enlarging the 4.5-mm tunnel such that the EB does
not hold and falls back into the joint.
Endobutton Anterior Cruciate Ligament Reconstruction Femoral Fixation 31
Comment
If this occurs, you will usually know when you burst through
with the socket reamer (or at least suspect it), but it is pos-
sible to damage the cortex and not realize it until the EB
will not hold.
Remedy 1
A second incision of 3 cm in length near the exit of the
femoral tunnel can be made. A #5 suture can be substi-
tuted for the #2 suture and tied 2
2 with the other
already inserted #5 suture around a 6.5-mm, two-thirds
threaded unicortical cancellous screw and washer inserted
about 1.5 cm away from the exit of the femoral tunnel.
Remedy 2
Currently, this problem could be more easily salvaged without a
second incision by attaching the larger, recently introduced
Xtendobutton to the EB and then passing the graft again. This
larger button will hold in a socket-sized larger tunnel up to at
least 10 mm. The surgeon should make sure an Xtendobutton
is present at surgery in case it is required.
Cause 3
The two passing sutures are tangled.
Comment
When the graft is pulled back, the entanglement that pre-
vents the thinner flattening suture from functioning should
be clearly visible arthroscopically.
223
 Anterior Cruciate Ligament Reconstruction
Remedy
Separate the #5 and #2 sutures from each other, and pass
the graft again without withdrawing the sutures from their
exit out of the thigh.
Problem 2: What if the Endobutton Flattens
Initially but Is Pulled Back out when the
Graft is Tensioned?
Cause 1
Excessive tensioning pressure was applied to the graft on the
tibia, and the EB was pulled back without apparent cause.
Comment
We have had this occur on only one occasion for no appar-
ent reason, except that we were probably excessively tension-
ing the graft during range of motion of the knee prior to
tying around the tibial screw. There was a palpable “thunk”
when it happened, as though a minor knee subluxation had
taken place. We then noticed mild slack on the construct
and slight withdrawal arthroscopically.
Remedy
Repass and flatten the EB. If it holds, as it did during our
case, take a radiograph before applying tibial fixation with
fluoroscopy to make sure the position is satisfactory. If so,
proceed to finish tibial fixation. Nothing further needs to
be done, although we would recommend a repeat radio-
graph at 3, 7, and 14 days postoperatively to verify EB posi-
tion. Repeat radiographs in our clinic showed no migration,
and excellent stability ultimately resulted.
Cause/Remedy 2
See Problem 1, Cause 2.
Problem 3: What if the Passing Sutures
cannot be Pulled out of the Endobutton
After Fixation?
Cause
Entanglement or entrapment in soft tissue.
Comment
This is less likely to happen if the knee is flexed to the same
degree for passing suture removal as during graft passage.
Remedy
The surgeon should slide one of the passing sutures a few
millimeters to make sure it is free. If it will not slide one way
easily, it often will do so in the opposite direction. If it still will
not slide, the soft tissue of the thigh should be compressed
224
downward and the ends cut. The recoil of the soft tissue will
ensure that the ends retract well below the dermis. We have
had this happen once. No sequela occurred as a result of the
suture being left in the soft tissue. We prefer this to forcing
the suture to come out, which we fear might displace the
EB into the tunnel.
Problem 4: What if the Endobutton-CL Is so
Long that There Is too Little Graft in the
Femoral Tunnel?
Cause
Mismeasurement of the tunnel or miscalculation with selec-
tion of an EB-CL that is too long.
Comment
We have never had this happen, but the surgeon should be
prepared in case it does occur.
Remedy
Even if there were less graft in the tunnel than we had
planned, we would leave it alone if there were at least
15 mm of graft in the tunnel. Studies19,20 and the experience
of ourselves and others have shown this to be adequate. If less
than 15 mm were in the tunnel and the fabric loop were visible
through the arthroscope, we would recommend cutting the
loop arthroscopically and then using the 4.5-mm bit to push
the EB outward into the soft tissue. The tunnel would then
be remeasured, and another EB-CL of more appropriate
length would be used. If the fabric loop were not visible
arthroscopically or could not be cut and if less than 15 mm
of graft were in the tunnel, we would make a small second
incision to either remove the EB or feed it back into the tunnel
so that it could be removed from below. We would then
remeasure the tunnel and use an appropriately shorter EB so
that satisfactory graft remained in the tunnel.
Problem 5: What if the Far Femoral Cortex
Is Blown out with the Socket Reamer such
that a 4.5-mm Tunnel Cannot Be Drilled?
See Problem 1, Cause 2. Problem 5 is the same problem but
with earlier recognition that it has occurred.
THE XTENDOBUTTON
Recently released, the Xtendobutton is a larger button that
attaches to the standard EB (Fig. 31-9), effectively enlarg-
ing its profile as described earlier. It can be used routinely
to eliminate the need to drill the narrower 4.5-mm tunnel.
This larger profile can be used with larger tunnels up to at
 Endobutton Anterior Cruciate Ligament Reconstruction Femoral Fixation 31
continuous use. However, it is likely that the use of the
Xtendobutton will prove to be just as reliable. Xtendobutton
use eliminates the calculations involved with two tunnels,
which may facilitate the procedure for the occasional user.
As described earlier, the Xtendobutton is of great value if
the surgeon penetrates out the far femoral cortex with the
larger socket reamer such that the standard EB is too
small to use. Before the introduction of the Xtendobutton
a second incision would have had to be made over the femur
for insertion of a femoral screw. The Xtendobutton allows
the procedure to be completed in the usual fashion without
a second femoral incision (Fig. 31-10).

FIG. 31-9 The Xtendobutton fits over the Endobutton so that it is large
enough to hold outside a 10-mm femoral tunnel. CONCLUSIONS
1 Stability: Unsurpassed stability rates have been reported
least a 10-mm tunnel. We still use the smaller 4.5-mm tun-
using the EB.
nel in conjunction with the larger socket because we believe
the smaller bone removal may be beneficial and because we 2 The bungee effect: The bungee effect is either nonexistent
are comfortable with this technique after 13 years of or clinically insignificant.

FIG. 31-10 In this revision case, the Xtendobutton was used to anchor the graft on the outside of a 9-mm femoral
tunnel.

225
 Anterior Cruciate Ligament Reconstruction
3 Technique: The most important technical point is to flex
the knee to or beyond 90 degrees during femoral-tunnel
drilling to ensure a tunnel of at least 30 mm in length.
4 Morbidity: The complication rate has been virtually
nonexistent, with only a few reported cases (and none in
our experience), despite the highest level of use of any
noninterference screw femoral fixation device.
5 Xtendobutton: The Xtendobutton provides salvage
without making a femoral incision if the far cortex is
blown out. It also simplifies the procedure for the
occasional user.
6 Ease of use: The method is straightforward and easily
learned.
References
1. Ahmad CS, Gardner TR, Groh M, et al. Mechanical properties of
soft tissue femoral fixation devices for anterior cruciate ligament recon-
struction. Am J Sports Med 2004;32:635–640.
2. Brand J Jr, Weiler A, Caborn DNM, et al. Graft fixation in cruciate
ligament surgery. Am J Sports Med 2000;28:761–774.
3. Brand J Jr, Hamilton D, Selby D, et al. Biomechanical comparison of
quadriceps tendon fixation with patellar tendon bone plug interference
fixation in cruciate ligament reconstruction. Arthroscopy 2000;16:805–812.
4. Brown CH, Wilson DR, Hecker A, et al. Comparison of hamstring and
patellar tendon femoral fixation: cyclic load. Presented at the 1999
Meeting of the American Orthopaedic Society for Sports Medicine,
Traverse City, MI, June, 1999.
5. Rowden NJ, Sher D, Rogers GJ, et al. Anterior cruciate ligament graft
fixation: initial comparison of patellar tendon and semitendinosus
autografts in young fresh cadavers. Am J Sports Med 1997;25:472–478.
6. Scheffler SU, Sudkamp NP, Gockenjan A, et al. Biomechanical com-
parison of hamstring and patellar tendon graft anterior cruciate liga-
ment reconstruction techniques: the impact of fixation level and
fixation method under cyclic loading. Arthroscopy 2002;18:304–315.
7. To JT, Howell SM, Hull ML. Contributions of femoral fixation
methods to the stiffness of anterior cruciate ligament replacements at
implantation. Arthroscopy 1999;15:379–387.
226
8. Prodromos CC, Han YS, Keller BL, et al. Stability of hamstring ante-
rior cruciate ligament reconstruction at two- to eight-year follow-up.
Arthroscopy 2005;21:138–146.
9. Gobbi A, Mahajan S, Zanazzo M, et al. Patellar tendon versus qua-
drupled bone-semitendinosus anterior cruciate ligament reconstruc-
tion: a prospective clinical investigation in athletes. Arthroscopy
2003;19:592–601.
10. Gobbi A, Tuy B, Mahajan S, et al. Quadrupled bone-semitendinosus
anterior cruciate ligament reconstruction: a clinical investigation in a
group of athletes. Arthroscopy 2003;19:691–699.
11. Cooley VJ, Deffner KT, Rosenberg TD. Quadrupled semitendinosus
anterior cruciate ligament reconstruction: 5-year results in patients
without meniscus loss. Arthroscopy 2001;17:795–800.
12. Feller JA, Webster KE. A randomized comparison of patellar tendon
and hamstring tendon anterior cruciate ligament reconstruction. Am J
Sports Med 2003;31:564–573.
13. Yasuda K, Kondo E, Ichiyama H, et al. Anatomic reconstruction of
the anteromedial and posterolateral bundles of the anterior
cruciate ligament using hamstring tendon grafts. Arthroscopy
2004;20:1015–1025.
14. Prodromos CC, Joyce BT, Shi K, et al. A meta-analysis of stability
after anterior cruciate ligament reconstruction as a function of ham-
string versus patellar-tendon graft and fixation type. Arthroscopy
2005;21:1202–1208.
15. Karaoglu S, Halici M, Baktir A. An unidentified pitfall of Endo-
button use: case report. Knee Surg Sports Traumatol Arthrosc
2002;10:247–249.
16. Simonian PT, Behr CT, Stechschulte DJ Jr, et al. Potential pitfall of
the Endobutton. Arthroscopy 1998;14:66–69.
17. Muneta T, Yagishita K, Kurihara Y, et al. Intra-articular detachment
of the Endobutton more than 18 months after anterior cruciate
ligament reconstruction. Arthroscopy 1999;15:775–778.
18. Brucker P, Zelle BA, Fu FH. Intraarticular Endobutton displacement
in anatomic anterior cruciate ligament double-bundle reconstruction: a
case report. Op Tech Orthop 2005;15:154–157.
19. Zantop T, Brucker P, Bell K, et al. The effect of tunnel-graft length on
the primary and secondary stability in ACL reconstruction: a study in a
goat model. Presented at the 2006 meeting of the European Society
of Sports Traumatology, Knee Surgery, and Arthroscopy, Innsbruck,
Australia, May, 2006.
20. Yamazaki S, Yasuda K, Tomita F, et al. The effect of intraosseous
graft length on tendon-bone healing in anterior cruciate ligament
reconstruction using flexor tendon. Knee Surg Sports Traumatol
Arthrosc 2006;14:1086–1093.
Cortical Screw Post Femoral Fixation Using
Whipstitches, Fabric Loop, or Endobutton:
The Universal Salvage
BACKGROUND
Importance
We believe that every surgeon performing ante-
rior cruciate ligament reconstruction (ACLR)
would benefit by being able to perform at least
one of the variants of cortical screw post femoral
fixation described here. Although probably not
their primary techniques, they are the universal
“bail-out” methods for rescuing more exotic and
complicated single-incision techniques gone awry
on the femoral side. The ability to troubleshoot
is arguably the most important skill a surgeon
can possess, and these techniques not only
troubleshoot all other femoral methods (and
all grafts), but they also can be accomplished with
materials that are present in every orthopaedic
surgical suite.
History
Whipstitch cortical screw post was perhaps the
most popular method of soft tissue ACL graft
fixation when two-incision methods were
commonly used. There are many reports of high
stability using this method.1–6 However, the
advent of the Endobutton and then the various
cross-pins that did not require a formal second
incision relegated the two-incision method
to a secondary role. More recently it has
become apparent that a second incision for
outside-in drilling can facilitate the lower femoral
tunnel placement that is now recognized as
32
CHAPTER
biomechanically preferable, and more Chadwick C. Prodromos
two-incision methods are now being described.
BIOMECHANICS
The technique uses rigid cortical bone for
anchorage. This has been shown to be the most
important factor in producing high-stiffness
fixation.7 The stiffness is reduced slightly by the
length of the construct, but the rigidity of
the cortical bone7 has been shown to more than
compensate. A fabric or suture interface has been
associated with high-stability ACLR,8–11 as have
whipstitches if properly implanted.12–14 Both are
described here in conjunction with cortical screw
post fixation.
Advantages
We no longer use the femoral screw post
through a second incision as a primary method
because we have had success using the one-inci-
sion Endobutton method. However, we still
believe that the two-incision technique has a
number of advantages.
1 It is useful in revision cases where single-
incision techniques may be problematic or
impossible.
2 It is useful in difficult primary cases,
particularly those with small distal femora
resulting in short femoral tunnels as a backup
to single-incision techniques if the surgeon
blows out the back wall.
227
 Anterior Cruciate Ligament Reconstruction
3 It allows odd-numbered strand grafts such as triple
semitendinosus (3ST), 3ST/1 gracilis (Gr), and 3ST/
2Gr,2 grafts that cannot be looped as a quadruple graft
with the use of cross-pins.
4 We believe that due to the small learning curve, it is a
more reliable method than some complicated single-
incision techniques for the surgeon who performs a small
volume of ACL reconstructions.
5 It allows the most precise proximal-distal positioning of
the graft in the tunnels and knee of any method. This is
useful with shorter grafts where malposition in the
proximal-distal direction may result in too little graft
length in one of the tunnels.
6 No other fixation method has resulted in higher stability
rates.2
7 Most importantly, as mentioned earlier, it can
troubleshoot any problem that occurs with a femoral
fixation device, femoral tunnel, or femoral graft.
The only disadvantage to this technique is that it
requires a second incision. However, this disadvantage is
usually primarily in the mind of the surgeon. We, and others,
have never found the use of a small second incision to be of
concern to the patient (see Chapter 49). Furthermore, the
incision does not need to be large. Some may dislike the fact
that a nonbioabsorbable and nonradiolucent screw remains
in the patient. However, we have never seen one of these
screws back out, nor have we ever seen one bother the patient2
because the screw sits flush on cortical bone under a thick
muscular layer. Plus, because they are metadiaphyseal, they
are far enough from the joint to not interfere with subsequent
magnetic resonance images (MRIs).
SURGICAL TECHNIQUE
Materials
A standard 6.5-mm, two-thirds threaded cortical screw with a
smooth washer is usually used. ACL tibial fixation posts can
also be used as follows: There are two 4.5-mm screws without
washers with which we are familiar, one made by Smith &
Nephew (Andover, MA) and one by Arthrex (Naples, FL).
If these washerless screws are used, the screw must be slightly
angled away from the femoral tunnel to prevent suture or
fabric loop slippage. Linvatec (Largo, FL) has a good
6.5-mm screw, which is used with a washer. Arthrex also
has a 6.5-mm screw that is used with a washer, but it uses a
smaller (2.5-mm) hex screwdriver. In the past we had
occasional instances of breakage of the smaller screwdriver
when it encountered high torque with the large screw.
228
Whipstitches should be put in using either standard #5
braided, nonabsorbable polyester sutures such as Ethibond
(Ethicon, Somerville, NJ), Tevdek (SybronEndo, Orange,
CA), or Mersilene (Ethicon) or one of the newer stronger
#2 sutures such as Fiberwire (Arthrex) or Ultrabraid (Smith
& Nephew). The surgeon may also pass a 5- or 6-mm Dacron
tape through a quadruple graft and tie it around the cortical
screw instead of using whipstitches. A 2- or 3-mm tape is
not strong enough. The best loop, however, is the fabric loop
that is attached to the Endobutton-CL, which comes in
5-mm increments with 15 mm being the smallest.
Incision
The lateral femoral incision should be made with the knee
flexed. The posterior border of the lateral femoral condyle
should be palpated and the incision made over the middle of
the lateral femoral metaphysis at the flare of the condyle. In
a lean patient this incision is about 2 cm long. It will need to
be larger in larger patients. The iliotibial band is longitudi-
nally split, and the lateral femoral metaphysis is exposed.
Femoral Screw Insertion Technique
The femoral screws should be inserted unicortically as with
tibial screw posts for three reasons.
1 As mentioned earlier, we have never had one back out, so
bicortical insertion is unnecessary.
2 They are cancellous screws, and if they are inserted
bicortically, they may be impossible to remove later if
needed.
3 Also, they can toggle if they are tied under tension before
final tightening, with the tip moving slightly away from
the predrilled hole in the opposite cortex. This may make
it impossible for the tip of the screw to enter this hole at
final tightening, resulting in the screw remaining proud
and potentially irritating the patient. Unicortical insertion
prevents this problem.
Attaching the Graft to the Femoral Post
There are four methods by which this may be successfully
accomplished, all of which we have used. We prefer number
four. Numbers one and four require an Endobutton-CL to
be available. If it is not available, then method two or three
may be used, and both are very satisfactory.
1. Endobutton-CL Fabric Loop Passed around the
Femoral Post
This is the most difficult technique for properly positioning
the graft, but it does have the advantage of being the only
 Cortical Screw Post Femoral Fixation Using Whipstitches, Fabric Loop, or Endobutton: The Universal Salvage
technique of the four described that does not require the
tying of knots for those who perceive a knot as a possible
weak link (which we have not found it to be). The femoral
tunnel should be drilled in the appropriate location by an
inside-out or outside-in technique. The 3.2-mm drill bit
for the femoral screw should be drilled a distance of at least
1.5 cm from the femoral tunnel. This will result in at least
a 1-cm bone bridge between the femoral tunnel and the
screw when the 6.5-mm cancellous screw and smooth
washer are screwed in. The screw should be angled slightly
away from the femoral tunnel to further prevent the loop
from slipping over the washer and screw. The two-thirds
threaded screw should be advanced until all threads are
buried into the femur, leaving only smooth screw shank
exposed.
At the back table or Mayo stand, the graft should be
placed through the Endobutton-CL loop and then #5 braided
nonabsorbable sutures passed through the Endobutton eyelets.
These sutures are used to pass the construct through the
knee and out of the femoral tunnel into plain view. The
loop is passed over the screw head and washer, and the screw
is tightened down. The Endobutton will lie between the
screw and the femoral tunnel and will not interfere with
fixation.
The length of the loop should be calculated in
advance to allow the graft to sit where desired in the knee
in a proximal-distal direction. This must take into account
the size of the bone bridge between the shank of the screw
and the opening of the femoral tunnel as well as the diame-
ter of the screw. Added to this should be the amount of
length the surgeon wishes the graft to be recessed within
the femoral tunnel from its outer opening. The graft should
be clearly marked circumferentially before implantation at a
distance of 2 cm from each end with a marking pen. As long
as these marks are not visible arthroscopically the surgeon
can be sure there is at least 2 cm of graft in each tunnel.
The graft should also be marked with a 3-O or 4-O,
violet-colored, absorbable monofilament suture that is used
to tie the strands together in the middle of the graft.
This suture serves the dual purpose of preventing the graft
from sliding along the loop when tensioning and tibial
fixation are carried out and also allows the surgeon a
visible guide point for what should be the approximate
intraarticular midpoint of the graft.
With a long 2ST/2Gr graft this method is highly
satisfactory because there is enough length to have more
graft than is needed in each tunnel; usually 3 cm in each
tunnel is a reasonable goal. If the measurements are off
slightly after the graft is tightened down, the graft does
not need to be adjusted. If the end result is too little graft
in one of the tunnels by the surgeon’s standards, then the
graft can be withdrawn out the tibial tunnel and passed
32
through again using a shorter or longer Endobutton-CL
loop. With the shorter 4ST graft this method is still usu-
ally satisfactory but requires more precision. A minimal
length of 15 mm of graft in the tunnels appears to be
adequate.15,16
2. Fabric Tape Tied Around the Femoral Post
If a Dacron tape was used to pass the graft up into the tibial
tunnel and out the femoral tunnel, it should be discarded, as
it may be frayed, and a new tape should be used for fixation.
The surgeon should watch the intraarticular portion of the
graft on the video screen, with the assistant holding
the arthroscope as the surgeon ties the 5- or 6-mm Dacron
tape around the post. The tape ends should be passed once
around the shank of the screw, crossed around the opposite
side of the shank, and then brought back to the near side of
the screw for tying.
By this means the surgeon controls the proximal-dis-
tal position of the graft. The tape is tied to a length that
will provide optimal lengths of tissue in each tunnel.
Before the surgeon ties, the assistant should exert mild
tension on the tibial end of the graft to remove gross slack
from the graft, which further ensures proper positioning.
The screw and washer should then be finally tightened.
The graft should be marked with both a marking pin and
a cross-suture near the proposed femoral aperture, as
described previously.
3. Whipstitch Technique
In this technique the four-strand graft, if it is used, may be
made into four single strands of graft of equal length. #2
braided, nonabsorbable whipstitches are then woven into
each of the eight ends as described in Chapter 42.
It is of paramount importance that all the sutures are
woven in very tightly with strong tension after every pass or
every other pass of the suture to maximally tighten the
weave so that no tightening of the weave will occur later.
Again, the graft should be marked with both a marker
and suture, as in method 1. The sutures are then tied,
two by two, around a cancellous screw and washer
(Fig. 32-1) as follows: Each double suture strand is
brought up to the smooth screw shank and crossed around
the far side of the screw. These ends are then pulled back
and tied two by two, such that the knot is on the graft side
of the screw for the first two graft limbs. The process is
repeated for the other two graft limbs. This will result in
two knots in the femoral post. It is important to keep track
of which sutures correspond to which graft segment either
by using different color sutures or marking or knotting the
suture ends before passing the graft segments.
229
 Anterior Cruciate Ligament Reconstruction
FIG. 32-1 A and B, Two-thirds threaded femoral cancellous screw and washer used as fixation post for
whipstitches from four-strand hamstring graft tied around it.
4. Graft Passed Through the Endobutton-CL Loop
and Sutures Used to Tie the Endobutton to the
Femoral Post
This is our preferred technique. Rather than tying a fabric loop
around a cancellous screw, the surgeon can pass the graft
through a short Endobutton loop and then pass a #5 braided
nonabsorbable suture through each end of the Endobutton.
These sutures can then be used to tie the Endobutton (and
hence the loop and graft) to the screw as described in the previ-
ous paragraph. We prefer this technique if the Endobutton-CL
is available because of the known strength of the fabric loop
attached to the Endobutton. It also obviates the need to put
whipstitches in the femoral end. Generally the surgeon will pre-
fer to use the shortest loop, which is 15 mm. The Endobutton
will be closely juxtaposed to the screw (Fig. 32-2) but is suffi-
ciently low in profile to allow secure attachment to the screw
without being in the way. A washer should be used on the screw.
Again, the graft should be marked with both a marker
and suture as in method 1.
230
Fixating Single Strands of Graft and Odd
Numbers of Strands
Double-length strands that are looped over a femoral fixa-
tion device are now the mainstay of autograft and allograft
ACL soft tissue femoral fixation. However, single strands
may also be used in combination with double strands or
other single strands to fashion a variety of grafts. The goal
is to have a graft of sufficient strength to provide good
stability using the available tissue. Reports of excellent sta-
bility now exist for three-, four-, five-, six-, and eight-strand
grafts (see Chapter 17). These variegated grafts may be
used with any of the four fixation methods described
earlier. For an added single strand of graft, whipstitches of
braided #2 nonabsorbable suture should be implanted.
Then the two ends can be tied one to one either around
the Endobutton-CL fabric loop (methods 1 and 4), the
Dacron tape (method 2), or the femoral screw itself
(method 3).
 Cortical Screw Post Femoral Fixation Using Whipstitches, Fabric Loop, or Endobutton: The Universal Salvage
FIG. 32-2 A and B, Sutures through the Endobutton eyelets are tied around the femoral screw post. The graft is
looped through the Endobutton-CL fabric loop.
Radiography
We use C-arm fluoroscopy after the screw is tightened
down to document its satisfactory position. Fluoroscopy is
not needed during implantation. We have never found a
screw to be intraarticular or otherwise malpositioned. The
screw will generally lie in the distal femoral metaphysis,
but it can be placed adjacent to wherever the femoral tunnel
emerges on the external femoral surface.
THE FEMORAL POST TECHNIQUE CAN SALVAGE
THE FOLLOWING SITUATIONS
1 Lateral cortex blowout with Endobutton fixation:
Conversion is easy, and the Endobutton can still be used
for fixation by taking advantage of the fabric loop.
2 Proximal tunnel wall blowout: This is not a problem for
femoral cortical suspensory fixation such as the
Endobutton or EZLoc but is a problem for interference
fixation. It is easily remedied with the femoral post
32
technique, as a circumferential bone tunnel is not
required. It is, however, important that the graft be pulled
distalward against the distal tunnel wall and the screw be
inserted distal to the exit area of the femoral tunnel. This
will compress the graft against the distal wall. If the screw
is put in proximal to the exit area of the femoral tunnel,
the graft could potentially be pulled out of the femoral
tunnel, as this tunnel is now really a “notch” and not a
tunnel.
3 Revision surgery in which a new proximal tunnel partially
overlaps with the old more distal tunnel: The surgeon may
need to bone graft the old tunnel in this case. However,
a semicircular notch in the femur (indenting in from the
over-the-top position) can often be created lower down
on the femur, which will produce a very biomechanically
sound graft and save the patient both the pain of a bone
graft and a second procedure. This tunnel may tighten a
little more than usual toward extension, which should be
taken into account when tensioning.
4 Fixation device breakage: The breakage or lack of
availability of another device should allow conversion
to one of the previously described techniques.
231
 Anterior Cruciate Ligament Reconstruction
5 Harvesting a short semitendinosus or gracilis: If one
tendon is cut too short during harvest to use as a loop
(i.e., less than 14 cm) but the other tendon is at least
21 cm, then the longer tendon can be tripled and
combined with the shorter tendon as a single strand
as described earlier (i.e., the surgeon can use either a
3ST/1Gr or 1ST/3Gr). Both of these grafts are strong
enough to substitute for the torn ACL, especially the
3ST/1Gr (in fact, 3ST alone should be sufficient).
Because some femoral fixation systems would have
difficulty with these grafts, the surgeon may use femoral
screw post fixation instead, thus obviating the need to
make an unplanned switch to allograft, which might
otherwise be necessary.
CONCLUSIONS
1 Stability: Femoral post fixation provides unsurpassed
stability.
2 Morbidity: Morbidity is minimal. The use of a second
incision is necessitated; however, this is usually well
tolerated by patients. Screw removal is virtually never
necessary.
3 Ease of use: The method is straightforward and uses
techniques familiar to every surgeon. If whipstitches are
used, they must be inserted carefully and tightened
maximally.
4 Equipment: Although the Endobutton-CL is useful,
it is certainly not necessary. Every operating suite will
have a 6.5-mm, partially threaded screw and smooth
washer and #5 braided nonabsorbable sutures, and
probably 5- or 6-mm Dacron tape as well. Also,
4.5-mm cancellous screws with washer can be used
with care.
5 The universal salvage: In the increasingly complex world
of ACLR in which high-tech techniques can go awry, it
is a great comfort to have the ability to perform this
technique, which can salvage virtually any ACLR-related
problem on the femoral side.
232
References
1. Prodromos CC, Joyce BT. In Five-strand hamstring ACL reconstruc-
tion: a new technique with better long-term stability than four-strand.
Presented at the 2006 meeting of the Mid-America Orthopaedic
Association, San Antonio, TX, April, 2006.
2. Prodromos CC, Joyce BT. In Five-strand hamstring ACL reconstruc-
tion: a new technique with better long-term stability than four-strand.
Presented at the 2006 meeting of the Arthroscopy Association of
North America, Hollywood, FL, May, 2006.
3. Goradia VK, Grana WA. A comparison of outcomes at 2 to 6 years
after acute and chronic anterior cruciate ligament reconstructions using
hamstring tendon grafts. Arthroscopy 2001;17:383–392.
4. Howell SM, Deutsch ML. Comparison of endoscopic and two-inci-
sion techniques for reconstructing a torn anterior cruciate ligament
using hamstring tendons. Arthroscopy 1999;15:594–606.
5. Hamada M, Shino K, Horibe S, et al. Preoperative anterior knee laxity
did not influence postoperative stability restored by anterior cruciate
ligament reconstruction. Arthroscopy 2000;16:477–482.
6. Maeda A, Shino K, Horibe S, et al. Anterior cruciate ligament recon-
struction with multistranded autogenous semitendinosus tendon. Am J
Sports Med 1996;24:504–509.
7. To JT, Howell SM, Hull ML. Contributions of femoral fixation
methods to the stiffness of anterior cruciate ligament replacements at
implantation. Arthroscopy 1999;15:379–387.
8. Prodromos CC, Han YS, Keller BL, et al. Stability of hamstring ante-
rior cruciate ligament reconstruction at two- to eight-year follow-up.
Arthroscopy 2005;21:138–146.
9. Cooley VJ, Deffner KT, Rosenberg TD. Quadrupled semitendinosus
anterior cruciate ligament reconstruction: 5-year results in patients
without meniscus loss. Arthroscopy 2001;17:795–800.
10. Gobbi A, Mahajan S, Zanazzo M, et al. Patellar tendon versus
quadrupled bone-semitendinosus anterior cruciate ligament recon-
struction: a prospective clinical investigation in athletes. Arthroscopy
2003;19:592–601.
11. Gobbi A, Tuy B, Mahajan S, et al. Quadrupled bone-semitendinosus
anterior cruciate ligament reconstruction: a clinical investigation in a
group of athletes. Arthroscopy 2003;19:691–699.
12. Feller JA, Webster KE. A randomized comparison of patellar tendon
and hamstring tendon anterior cruciate ligament reconstruction. Am J
Sports Med 2003;31:564–573.
13. Howell SM, Deutsch ML. Comparison of endoscopic and two-inci-
sion techniques for reconstructing a torn anterior cruciate ligament
using hamstring tendons. Arthroscopy 1999;15:594–606.
14. Goradia VK, Grana WA. A comparison of outcomes at 2 to 6 years
after acute and chronic anterior cruciate ligament reconstructions using
hamstring tendon grafts. Arthroscopy 2001;17:383–392.
15. Zantop T, Brucker P, Bell K, et al. In The effect of tunnel-graft length
on the primary and secondary stability in ACL reconstruction: a study in a
goat model. Presented at the 2006 meeting of the European Society of
Sports Traumatology, Knee Surgery, and Arthroscopy, Innsbruck,
Australia, May, 2006.
16. Yamazaki S, Yasuda K, Tomita F, et al. The effect of intraosseous
graft length on tendon-bone healing in anterior cruciate ligament
reconstruction using flexor tendon. Knee Surg Sports Traumatol
Arthrosc 2006;14:1086–1093.
 EZLoc Femoral Fixation of a Soft Tissue
Graft
ABSTRACT
The EZLoc (Arthrotek, Warsaw, IN) is a cortical
femoral fixation device for a soft tissue anterior
cruciate ligament (ACL) reconstruction that com-
bines superior fixation properties (high resistance
to slippage, infinite stiffness, and 1427N strength)
with a simple surgical technique. The EZLoc con-
sists of a deployable lever arm connected to an axle
in a slotted body through which the ACL graft is
looped. The EZLoc comes sterilely package with
a sharp-tip passing pin that is secured in the slot-
ted body with a suture tied under tension. The
passing pin is passed through the tunnels, the gold
lever arm is positioned lateral, and the soft tissue
graft is looped through the slot in the EZLoc.
The graft is pulled into the femoral tunnel. When
the lever arm clears the femoral tunnel, the suture
is cut, the passing pin is removed, the suture is ten-
sioned, and the lever arm is deployed, which fixes
the EZLoc on cortical bone. The EZLoc can be
used with both the one- and two-tunnel ACL
reconstruction techniques, and it is available in
three diameters and three lengths. The EZLoc
femoral fixation resists slippage and is stiffer and
stronger than other femoral fixation techniques
currently in use with a soft tissue ACL graft. The
EZLoc is an ideal fixation for the skeletally imma-
ture knee.
INTRODUCTION
Fixation of the looped end of a soft tissue ACL
graft to the femur poses different challenges than
33
CHAPTER
fixation of the free ends to the tibia. Metal cross- Stephen M. Howell
pin devices such as the Bone Mulch Screw and
Transfix have set the standard for femoral fixation
because of their superior slippage resistance,
stiffness, and strength.1–4 Although these metal
cross-pin devices work extremely well, their surgi-
cal techniques consists of multiple challenging
steps and a lateral incision through the iliotibial
band, which can damage the lateral collateral
ligament.5 Prominent seating of the head of the
cross-pin causes iliotibial band pain,6 and counter-
sinking below the cortex complicates and may
prevent hardware removal at the time of revision
surgery (Fig. 33-1).
The design of the EZLoc femoral fixation
device (Arthrotek) replicates the superior fixation
of the metal cross-pins while simplifying the
surgical procedure. The use of the EZLoc does
not require a lateral incision, and the lever arm
seats on cortical bone so that it is neither promi-
nent nor countersunk, which facilitates revision
surgery. Both the high-volume and occasional
ACL surgeon should find the EZLoc to be
simpler, quicker, and easier to use than other
femoral fixation techniques including the cross-
pins. Brace-free, aggressive rehabilitation is safe
because the EZLoc provides superior slippage
resistance, stiffness, and strength.
Design, Diameter, Length,
Packaging, and Mechanism
of the EZLoc
The EZLoc is a cortical fixation device that
consists of a deployable lever arm connected to
233
 Anterior Cruciate Ligament Reconstruction

FIG. 33-1 Radiographs of a two-stage revision in which the cross-pin was buried beneath the cortical bone on the
femur and could not be removed at the time of hardware removal and bone grafting of the originally misplaced femoral
and tibial tunnels (denser bone). At the second stage, the tibial tunnel was placed at an angle of 60 to 65 degrees in the
coronal plane, which moved the femoral tunnel farther down the sidewall, which prevented posterior cruciate ligament
impingement, and more posterior in the sagittal plane, which prevented roof impingement. The EZLoc sits low in profile
but is still easy to find at the time of revision surgery because the lever arm rest on cortical bone.

an axle in a slotted body through which the ACL graft is soft tissue graft in the femoral tunnel is computed by
looped. The lever arm grips cortical bone on the anterolat- subtracting 22 mm from the length of the lateral wall of the
eral side of the femur, which provides superior slippage femoral tunnel. The short version is used in a femoral tunnel
resistance, high stiffness, and strong cortical fixation. The that is shorter than 35 mm, and the length of the graft in
lever arm provides rigid fixation that is better than that of
a cross-pin because the lever arm seats on cortical bone on
the anterolateral femur, which is 50 times stronger than
cancellous bone7 (Fig. 33-2).
The EZLoc is available in three diameters (5/6, 7/8,
9/10) and three lengths (short, standard, long). The diameter
of the EZLoc is selected to match the diameter of the femoral
and tibial tunnels. The 7/8 EZLoc is used with a 7- and
8-mm diameter tunnel, and the 9/10 EZLoc is used with
a 9- and 10-mm diameter tunnel. The 5/6 EZLoc is used in
the posterolateral tunnel with the two-tunnel technique,
and the 7/8 EZLoc is used in the anteromedial tunnel.
The EZLoc comes in different lengths, which control
the length of the graft in the femoral tunnel and ensure that
enough graft extends beyond the tibial tunnel for secure fixa-
tion. The most commonly used EZLoc length is the standard FIG. 33-2 The EZLoc is a cortical femoral fixation device consisting of a
version. The standard version is used in a femoral tunnel from gold-colored lever arm (a) connected to a slotted body (b) by an axle (c).
35 to 50 mm in length, which provides 22 to 37 mm of soft The lever arm provides slippage-resistant, stiff, and strong fixation similar to
a cross-pin because it seats on cortical bone (circle). The lever arm prevents
tissue graft in the tunnel, promoting rapid, stiff, and strong
proximal and distal micromotion, and the body prevents anteroposterior
tendon tunnel healing.8–10 The long version is used in a fem- and medial lateral micromotion. The slot in the body accepts both one-
oral tunnel that is longer than 50 mm, and the length of the and two-strand soft tissue anterior cruciate ligament grafts.

234

FIG. 33-3 The EZLoc comes in a sterile package with a passing pin and
suture. The dull end of a 16-inch-long, sharp-tip passing pin is secured in
the proximal end of the slotted body by a suture tied under tension. The
passing pin is used to orient the lever arm laterally and to pull the anterior
cruciate ligament (ACL) graft into place. In the special situation when the
EZLoc is used in the posterolateral femoral tunnel in a two-tunnel ACL
reconstruction technique and the posterolateral femoral tunnel is not in
the same axis as the tibial tunnel, the passing pin is removed from the
EZLoc and the suture is used to pull the graft.
FIG. 33-4 Radiograph showing two EZLocs fixing the graft in the femur in
the two-tunnel technique. A 5/6 short EZLoc fixes a single loop of gracilis
tendon in the posterolateral femoral tunnel. A 7/8 standard EZLoc fixes a
single loop of semitendinosus tendon in the more vertical anteromedial
femoral tunnel.
EZLoc Femoral Fixation of a Soft Tissue Graft 33
the tunnel is computed by subtracting 7 mm from the length
of the lateral wall of the femoral tunnel.
For ease of use, each EZLoc comes preassembled on a
16-inch-long, sharp-tip passing pin that is secured by a suture
tied under tension and is sterile (Figs. 33-3 and 33-4). The
suture has two functions: to keep the passing pin in the body
of the EZLoc during passing of the graft and to deploy the lever
arm once the lever arm clears the femoral tunnel. The suture
passes through a hole in the lever arm and through two holes
at the sharp end of the passing pin. The suture is tied under ten-
sion, which keeps the dull end of the passing pin inside the
EZLoc and keeps the lever arm undeployed. The lever arm is
positioned laterally, tension is applied to the pin, and the
EZLoc and soft tissue graft are pulled across the knee. Once
the ACL graft is pulled into the femoral tunnel, the suture is
cut, the passing pin is removed, the suture is tensioned, and
the lever arm deploys.
Fixation Properties of the EZLoc
A successful ACL reconstruction with a soft tissue graft
depends on the use of a femoral fixation device that has
superior fixation properties and enhances biological healing
of the tendon to the tunnel wall. The fixation properties
of the femoral fixation device should provide high strength
and high stiffness, be resistant to slippage, and allow cir-
cumferential healing of the tendon to the tunnel
wall.4,9,11–13 Because a soft tissue graft takes longer to heal
to the tunnel than a bone plug, the femoral fixation of a soft
tissue graft should be more slippage resistant, stiffer, and
stronger than the femoral fixation of a bone plug graft.14
The use of the EZLoc to fix a soft tissue graft in the
femur is a sound choice because its fixation properties are
second to none and the device allows circumferential
healing. The strength of the EZLoc is 1427N, which is
stronger than the closed-loop Endobutton (1086N) and the
cross-pins (Bone Mulch Screw, 1112N; Transfix, 1303N;
RigidFix, 868N).2,15 The stiffness of the lever arm of the
EZLoc on cortical bone is infinitely high compared with
the stiffness of the more elastic soft tissue graft. A benefit of
using a high-stiffness femoral fixation device such as the
EZLoc is that the tension applied to the graft to restore ante-
rior laxity is lowered4,12,13,16 and the risk of developing
anterior laxity during early motion is lessened.11 The slippage
resistance of the EZLoc under cyclical loading has not been
measured; however, the slippage with a metal lever arm on
cortical bone should be at least as small as a cross-pin because
the mechanism of looping the graft over a metal post is
identical in both types of fixation methods.17 The EZLoc
promotes healing of the tendon to the tunnel wall better
than an interference screw because the soft tissue graft fixed
with the EZLoc heals circumferentially to the tunnel wall.9
235
 Anterior Cruciate Ligament Reconstruction
The combination of the EZLoc with the WasherLoc
and bone dowel tibial fixation device creates a graft-fixation
device construct with superior fixation properties that allow
an early, aggressive, and brace-free rehabilitation.18 With
this fixation technique and correct tunnel placement,
the majority of patients regain sufficient function and
confidence in their knee to return to preinjury activity level
4 months after reconstruction, similar to femoral fixation
with the Bone Mulch Screw.19
RELIABLE SURGICAL TECHNIQUE WITH
MINIMAL STEPS
Important considerations of a femoral fixation device are
reliable insertion, consistent fixation performance, minimal
surgical steps and instruments, and easy use for both the
high-volume and occasional ACL surgeon and the experi-
enced and inexperienced surgical team. The reliability of the
EZLoc insertion depends on correct sizing of the soft tissue
ACL graft, the type of femoral reamer, the width of the slot-
ted body, and the broad surface of the lever arm. The ACL
graft is correctly sized when the diameter of the tunnel
matches the diameter of the smallest sleeve that can be
“thrown” rather than pushed over the looped end of the graft.
The use of a 1-inch femoral reamer creates a smoother tunnel
than the acorn-tip reamer, preventing the EZLoc and graft
from “hanging up” during passage across the knee. The wide-
ness of the slotted body blocks the EZLoc from getting
caught in the lateral thigh musculature. The broad surface of
the lever arm easily catches the cortical edge of the femoral
tunnel, providing a solid feel when the EZLoc is seated.
The EZLoc provides consistent fixation in bone
affected by a variety of conditions. Softening of the cancellous
bone in the femur from injury, disuse, increased age, smoking,
and alcohol use does not affect the fixation properties because
the EZLoc is seated on cortical bone. A posterior wall
blowout or a thin, 1-mm back wall to the femoral tunnel,
which is required so that the tension in the graft matches that
of the intact ACL,20 does not affect the fixation performance
of the EZLoc in contrast to the interference screw, which
requires excessive anterior placement of the femoral tunnel
to provide fixation.
The surgical steps and instruments for fixing a soft
tissue ACL graft to the femur are simple and few. The
diameter of the tibial and femoral tunnel is chosen from the
smallest cylinder that freely passes over the ACL graft when
it is looped through a sizing stick (described later). The length
of the lateral wall of the femoral tunnel is measured with a
depth gauge. The tip of the passing pin is inserted across the
tibial and femoral tunnel and through the skin of the
236
anterolateral thigh. The passing pin is rotated until the lever
arm faces laterally. The soft tissue graft is passed through
the slot in the EZLoc, and the length of the femoral tunnel
is marked on the graft by measuring from the distal tip of
the lever arm. The passing pin is pulled until the mark on
the graft enters the femoral tunnel. The suture is cut, the pass-
ing pin is removed, the suture is tensioned, and the lever arm
is deployed. The end of the graft exiting the tibial tunnel is
tensioned, which seats the lever arm on the anterolateral
cortex of the femur. Passing the graft and rigidly fixing the
graft to the femur are accomplished confidently and reliably
in essentially the same step. The high-volume and occasional
ACL surgeon and the experienced and inexperienced
surgical team can easily master the EZLoc femoral fixation
technique.
Surgical Technique
The surgical technique for fixing a soft tissue ACL graft to
the femur with the EZLoc using a single-tunnel, transtibial
technique can be viewed in streaming video online (http://
www.drstevehowell.com/ezloc_video.cfm) as well as in the
DVD and website that accompany this textbook.
Prepare and Size the Hamstring or
Tibialis Allograft
Regardless of whether an autogenous hamstring graft or
a tibialis allograft is used, the preparation of the tendons
requires no special suturing or tensioning for use with the
EZLoc. Sew a #1 suture to each end of each tendon. Use
the 7- to 8-mm and 9- to 10-mm sizing sticks to determine
the diameter of the graft. Loop the graft in the slot of
the sizing stick. Pass sleeves of different diameters over the
graft. Choose the diameter of the smallest sleeve that can
be “thrown” rather than pushed over the looped end of the
graft to drill the femoral and tibial tunnels. Store the graft
inside the sizing sleeve in a saline basin to keep it moist
and to prevent swelling until it is used (Fig. 33-5).
Place the Tibial Tunnel without Posterior Cruciate
Ligament and Roof Impingement
The EZLoc is most easily inserted with use of the transti-
bial technique, in which the femoral tunnel is drilled
through the tibial tunnel (see Chapter 21). Correct place-
ment of the tibial tunnel ensures correct placement of
the femoral when the tibial tunnel is drilled with the
Howell 65-degree tibial guide (Arthrotek). The 65-degree
tibial guide places the ACL graft without posterior cruci-
ate ligament (PCL) and roof impingement. A wallplasty
is performed until the width between the lateral femoral
condyle and PCL exceeds the width of the graft by
 EZLoc Femoral Fixation of a Soft Tissue Graft 33
leaves ridges that can block the passage of the EZLoc.
Use a cannulated 1-inch femoral reamer (Arthrotek) that
matches the diameter of the ACL graft, and drill the femo-
ral tunnel through the anterolateral cortex of the femur.
Draw the reamer in and out along the entire length of the
femoral tunnel, including the cortex, two to three times to
smooth the tunnel (Fig. 33-6). The EZLoc does not hang
up when the femoral tunnel is drilled with the 1-inch fem-
oral reamer.

Measure the Femoral Tunnel and Choose the

FIG. 33-5 The double-looped semitendinosus and gracilis autograft and Length of the EZLoc
the tibialis allograft require no special suturing for use with the EZLoc. The
graft should be submerged in a saline basin and stored inside a sizing Insert the depth gauge through the tibial tunnel into the
sleeve to keep it moist and to prevent swelling until it is used. femoral tunnel. Hook a tip of the depth gauge on the lateral
cortex of the femur. Read the length of the lateral wall of
the femoral tunnel at the point where the depth gauge
1 mm. The tibial tunnel is angled 60 to 65 degrees with the enters the femoral tunnel (Fig. 33-7). Choose a standard
medial joint line, which positions the lateral edge of the tib- EZLoc when the femoral tunnel length is between 35 and
ial tunnel such that it passes through the apex of the lateral 50 mm, a short EZLoc when the femoral tunnel length is
tibial spine in the coronal plane to avoid PCL impingement. less than 35 mm, and a long EZLoc when the femoral
Because the tibial tunnel is drilled with the knee in full tunnel length is greater than 50 mm.
extension and the guide references off the intercondylar roof,
the center of the tibial tunnel is placed 5 to 6 mm posterior Fix the Soft Tissue Graft to the Femur
and parallel to the intercondylar roof with the knee in maxi- The first step in fixing the soft tissue ACL graft to the femur
mum hyperextension in the sagittal plane, which avoids roof is to insert the passing pin attached to the EZLoc through the
impingement without performing a roofplasty.20–24 tibial tunnel, intercondylar notch, femoral tunnel, and skin
overlying the anterolateral thigh. Rotate the passing pin until
Place and Adjust the Length of the Femoral Tunnel the gold lever arm faces laterally. Loop the soft tissue ACL
Place the femoral tunnel with a 1-mm back wall using a size-
specific femoral aimer (Arthrotek) that matches the diameter
of the graft. Insert the femoral aimer through the tibial tunnel,
and hook it over the posterior edge of the intercondylar notch.
Select the 2.4-mm drill tip guidewire with marks at 35 and
50 mm (Arthrotek). Make a pilot hole in the femur by drilling
the guidewire through the femoral aimer. Remove the guide-
wire and femoral aimer, and flex the knee to 90 degrees.
Reinsert the guidewire through the tibial tunnel and into the
pilot hole on the femur. Drill the guidewire until the tip of
the guidewire stops at the anterolateral cortex of the femur,
and then check the marks. If the 35-mm mark is inside the
femur but the 50-mm mark is not, then the length of the
femoral tunnel will be between 35 and 50 mm and a standard
EZLoc will be used. If the 50-mm mark is inside the
femur, then the length of the femoral tunnel will be greater
than 50 mm and a long EZLoc will be used. The surgeon
can adjust the length of the femoral tunnel by redrilling the
guidewire with the knee in different degrees of flexion.

Drill the Femoral Tunnel with a 1-Inch

Femoral Reamer FIG. 33-6 The femoral tunnel should be drilled with a 1-inch reamer rather
than an acorn reamer. The 1-inch reamer creates a smooth femoral tunnel,
The use of a 1-inch femoral reamer is recommended rather whereas the acorn reamer leaves ridges. The EZLoc passes more reliably in
than an acorn-tip reamer because the acorn-tip reamer a smooth femoral tunnel.

237
 Anterior Cruciate Ligament Reconstruction
FIG. 33-7 The length of the lateral wall of the femoral tunnel is measured
with a depth gauge inserted through the tibial and femoral tunnels. The tip
of the depth gauge is hooked on the lateral cortex of the femur. The length
of femoral tunnel in this subject is 45 mm and is measured at the opening
of the femoral tunnel into the notch.
graft through the slot in the body of the EZLoc, and tie
together the sutures at the end of each tendon. Mark the
length of the femoral tunnel on the graft by measuring from
the tip of the lever arm (Fig. 33-8). Pull the passing pin prox-
imally until the lever arm enters the notch, and confirm that
the lever arm is still facing laterally. Pull the passing pin until
the mark of the graft enters the femoral tunnel. Cut the
suture, remove the passing pin, and tension the suture, which
deploys the lever arm. Pull on the distal end of the graft until
the sudden, firm grip of the lever arm on cortical bone is felt.
The lever arm rests laterally and in low profile on the antero-
lateral cortex of the femur (see Fig. 33-1).
Tibial Fixation
Fix the graft to the tibia with the knee in maximal exten-
sion. We prefer to use the WasherLoc with compaction of
a bone dowel, which is described in detail in Chapter 29
in this textbook.
EZLOC AND THE SKELETALLY
IMMATURE PATIENT
ACL reconstruction with a soft tissue graft is considered
the treatment of choice in the skeletally immature patient to
prevent uncorrectable injury to the menisci and articular
238
FIG. 33-8 The gold lever arm on the EZLoc faces laterally (arrow). The soft
tissue graft is looped through the slot in the body of the EZLoc. A ruler is
placed at the distal tip of the gold lever arm, and the length of the femoral
tunnel is marked on the graft (blue line). The graft is pulled across the knee
until the mark enters the femoral tunnel.
cartilage.25 The EZLoc is designed to function without
causing a growth plate arrest in the skeletally immature
patient in contrast to the interference screw and cross-pin
(Fig. 33-9). The EZLoc grips the femoral cortex several
centimeters proximal to the growth plate. The body of
the EZLoc is centered in the femoral tunnel and does
not purchase bone on either side of the growth plate;
therefore interference with growth is unlikely. In contrast
to the EZLoc, the placement of an interference screw across
the growth plate seems unwise, and oblique placement of
the cross-pin has caused valgus angulation.26
EZLOC AND DRILLING THROUGH THE
FEMORAL CORTEX
Drilling a 7- to 10-mm diameter tunnel through the lateral
femoral cortex to pass the EZLoc produces a temporary stress
riser that has not been reported to cause a femur fracture.
Drilling through the lateral femoral cortex with a soft tissue
graft and looping the graft around a fixation post outside the
tunnel was the standard femoral fixation technique from the
 EZLoc Femoral Fixation of a Soft Tissue Graft 33

FIG. 33-9 The EZLoc can be used with concern of a growth plate (arrow) arrest in the skeletally immature patient
because it does not cross the growth plate. The anteroposterior and lateral radiographs (upper left and right images,
respectively) and MRI (lower images) show the EZLoc several centimeters proximal to the growth plate (arrows).

1970s to early 1990s.27,28 During that time period, there were
no published reports of femoral fracture around the drill hole.
One reason that drilling the femoral tunnel across the femur
did not cause a reportable femoral fracture is that the bone
remodels along the length of the tunnel. Remodeling is
especially rapid with the EZLoc because the titanium
body encourages bone ingrowth that obliterates the tunnel
within 4 to 6 months (Fig. 33-10).
REVISION SURGERY WITH THE EZLOC
Because of the rapid growth of bone around the EZLoc,
revision surgery may seem to be a challenge. Surprisingly,
removal of the EZLoc is straightforward because the lever
arm sits on the cortical bone and is easily located through
a small anterolateral incision (Fig. 33-11). First, the distal
end of the EZLoc should be freed by removing the remnant
of the soft tissue ACL graft from the femoral tunnel with
either a reamer on slow speed or a tissue ablation device.
Next, a small curved gouge is used around the periphery of
the proximal end to separate the ingrowth of cortical bone
from the EZLoc. A small towel clip is used to grab the lever
arm, and the EZLoc is pulled free of the tunnel. If the fem-
oral tunnel was positioned correctly, and because we believe
there is no tunnel widening with the EZLoc, the same tun-
nel and a new EZLoc can then be used to place and fix the
revision ACL graft.

239
 Anterior Cruciate Ligament Reconstruction

that the EZLoc is too tight in the femoral tunnel, then

FIG. 33-10 Drilling the femoral tunnel through the anterolateral cortex
does not produce a clinically relevant stress riser. Bone grows rapidly
around the EZLoc (arrows) because the device is made of titanium. The
rapid ingrowth and lack of tunnel widening is a testament to the rigid
fixation provided by the EZLoc.
TROUBLESHOOTING THE EZLOC
Difficulty in passing the EZLoc up the femoral tunnel can
result in premature deployment of the EZLoc inside the
femoral tunnel, but this can be prevented. Prevention is
based on sensing that the EZLoc and graft slide easily up
the tibial tunnel but are tighter in the femoral tunnel, which
is best detected by the surgeon and not an assistant pulling
the EZLoc into the femoral tunnel. If the surgeon senses
the graft and passing pin should be removed and the diam-
eter of the femoral reamer should be checked. If the diame-
ter of the reamer was too small, then redrill with the correct
1-inch reamer. If the reamer diameter was correct but an
acorn-tip reamer was used, then redrill with a reamer
1 mm larger in size. If the reamer was correct and a 1-inch
reamer was used, then redrill the femoral tunnel, pistoning
the reamer up and down the tunnel and through the lateral
cortex several times to be sure that all ridges are removed.
Pistoning the 1-inch reamer to remove ridges should be
routinely done in young subjects because the hard bone
causes small deviations in the path of the reamer. If the
EZLoc does prematurely deploy, then check the location
of the deployment inside the femoral tunnel intraoperatively
with a radiograph. If the deployment occurs at the proximal
end of the femoral tunnel and the lever arm is in the cancel-
lous bone, then the EZLoc can be left in place because it
has not been shown to move. If the deployment occurs at
the distal end of the femoral tunnel, then use a blunt scope
trocar to push the EZLoc and graft up the femoral tunnel
and out through the cortex. As in any complication, the best
way to get out of it is to never get into it—prevention is the
key.
CONCLUSION
The EZLoc is a femoral fixation device for soft tissue ACL
reconstruction that is simple and reliable for both the high-
volume and occasional ACL surgeon and surgical team. The

FIG. 33-11 Removal of the EZLoc is straightforward because the lever arm, which seats on the cortex of the
anterolateral femur, is easily palpated through a small skin incision (left). The cortical bone that has grown in and
around the proximal end of the EZLoc is freed with a small curved gouge. A small towel clip is used to grab the
lever arm, and the EZLoc is removed (center).27,28 Dense bone has grown into the titanium EZLoc (right).

240

EZLoc combines superior fixation properties (1427N
strength, 8 N/mm stiffness, and high resistance to slippage)
and allows circumferential healing of the tendon graft to the
tunnel wall, which allows aggressive rehabilitation without
a brace and return to sport at 4 months.19,27,29 The EZLoc
works well in patients with hard and soft bone and in
the skeletally immature knee. Revision is straightforward,
although a small anterolateral incision is required to identify
and remove the EZLoc.
References
1. Brown CH, Jr, Wilson DR, Hecker AT, et al. Graft-bone motion and
tensile properties of hamstring and patellar tendon anterior cruciate
ligament femoral graft fixation under cyclic loading. Arthroscopy
2004;20:922–935.
2. Kousa P, Jarvinen TL, Vihavainen M, et al. The fixation strength of
six hamstring tendon graft fixation devices in anterior cruciate liga-
ment reconstruction. Part I: femoral site. Am J Sports Med
2003;31:174–181.
3. Kudo T, Tohyama H, Minami A, et al. The effect of cyclic loading on
the biomechanical characteristics of the femur-graft-tibia complex after
anterior cruciate ligament reconstruction using Bone Mulch screw/
WasherLoc fixation. Clin Biomech (Bristol, Avon) 2005;20:414–420.
4. To JT, Howell SM, Hull ML. Contributions of femoral fixation
methods to the stiffness of anterior cruciate ligament replacements at
implantation. Arthroscopy 1999;15:379–387.
5. Pujol N, David T, Bauer T, et al. Transverse femoral fixation in ante-
rior cruciate ligament (ACL) reconstruction with hamstrings grafts: an
anatomic study about the relationships between the transcondylar
device and the posterolateral structures of the knee. Knee Surg Sports
Traumatol Arthrosc 2006;14:724–729.
6. Pelfort X, Monllau JC, Puig L, et al. Iliotibial band friction syndrome
after anterior cruciate ligament reconstruction using the transfix
device: report of two cases and review of the literature. Knee Surg
Sports Traumatol Arthrosc 2006;14:586–589.
7. Amis AA. The strength of artificial ligament anchorages. A compara-
tive experimental study. J Bone Joint Surg 1988;70B:397–403.
8. Greis PE, Burks RT, Bachus K, et al. The influence of tendon length
and fit on the strength of a tendon-bone tunnel complex. A bio-
mechanical and histologic study in the dog. Am J Sports Med
2001;29:493–497.
9. Singhatat W, Lawhorn KW, Howell SM, et al. How four weeks of
implantation affect the strength and stiffness of a tendon graft in a
bone tunnel: a study of two fixation devices in an extraarticular model
in ovine. Am J Sports Med 2002;30:506–513.
10. Zacharias I, Howell SM, Hull ML, et al. In vivo calibration of a fem-
oral fixation device transducer for measuring anterior cruciate ligament
graft tension: a study in an ovine model. J Biomech Eng
2001;123:355–361.
11. Grover DM, Howell SM, Hull ML. Early tension loss in an anterior
cruciate ligament graft. A cadaver study of four tibial fixation devices.
J Bone Joint Surg 2005;87A:381–390.
12. Karchin A, Hull ML, Howell SM. Initial tension and anterior load-
displacement behavior of high-stiffness anterior cruciate ligament graft
constructs. J Bone Joint Surg 2004;86A:1675–1683.
EZLoc Femoral Fixation of a Soft Tissue Graft 33
13. Magen HE, Howell SM, Hull ML. Structural properties of six tibial
fixation methods for anterior cruciate ligament soft tissue grafts.
Am J Sports Med 1999;27:35–43.
14. Tomita F, Yasuda K, Mikami S, et al. Comparisons of intraosseous
graft healing between the doubled flexor tendon graft and the bone-
patellar tendon-bone graft in anterior cruciate ligament reconstruction.
Arthroscopy 2001;17:461–476.
15. Becker R, Voigt D, Starke C, et al. Biomechanical properties of qua-
druple tendon and patellar tendon femoral fixation techniques. Knee
Surg Sports Traumatol Arthrosc 2001;9:337–342.
16. Eagar P, Hull ML, Howell SM. How the fixation method stiffness
and initial tension affect anterior load-displacement of the knee and
tension in anterior cruciate ligament grafts: a study in cadaveric knees
using a double-loop hamstrings graft. J Orthop Res 2004;22:613–624.
17. Roos PJ, Hull ML, Howell SM. Lengthening of double-looped
tendon graft constructs in three regions after cyclic loading: a study
using Roentgen stereophotogrammetric analysis. J Orthop Res
2004;22:839–846.
18. Matsumoto A, Howell SM. WasherLoc and bone dowel: a rigid slippage-
resistant tibial fixation device for a soft tissue anterior cruciate ligament
graft. Tech Orthop 2005;20:278–282.
19. Howell SM, Deutsch ML. Comparison of endoscopic and two-
incision techniques for reconstructing a torn anterior cruciate ligament
using hamstring tendons. Arthroscopy 1999;15:594–606.
20. Simmons R, Howell SM, Hull ML. Effect of the angle of the femoral
and tibial tunnels in the coronal plane and incremental excision of the
posterior cruciate ligament on tension of an anterior cruciate ligament
graft: an in vitro study. J Bone Joint Surg 2003;85A:1018–1029.
21. Cuomo P, Edwards A, Giron F, et al. Validation of the 65 degrees
Howell guide for anterior cruciate ligament reconstruction. Arthroscopy
2006;22:70–75.
22. Howell SM, Barad SJ. Knee extension and its relationship to the slope
of the intercondylar roof. Implications for positioning the tibial tunnel
in anterior cruciate ligament reconstructions. Am J Sports Med
1995;23:288–294.
23. Howell SM, Clark JA, Farley TE. A rationale for predicting anterior
cruciate graft impingement by the intercondylar roof. A magnetic res-
onance imaging study. Am J Sports Med 1991;19:276–282.
24. Howell SM, Lawhorn KW. Gravity reduces the tibia when using a
tibial guide that targets the intercondylar roof. Am J Sports Med
2004;32:1702–1710.
25. Aichroth PM, Patel DV, Zorrilla P. The natural history and treatment
of rupture of the anterior cruciate ligament in children and adoles-
cents. A prospective review. J Bone Joint Surg 2002;84B:38–41.
26. Koman JD, Sanders JO. Valgus deformity after reconstruction of the
anterior cruciate ligament in a skeletally immature patient. A case
report. J Bone Joint Surg 1999;81:711–715.
27. Howell SM, Taylor MA. Brace-free rehabilitation, with early return to
activity, for knees reconstructed with a double-looped semitendinosus
and gracilis graft. J Bone Joint Surg 1996;78A:814–825.
28. Howell SM, Taylor MA. Failure of reconstruction of the anterior cru-
ciate ligament due to impingement by the intercondylar roof. J Bone
Joint Surg Am 1993;75A:1044–1055.
29. Aglietti P, Giron F, Buzzi R, et al. Anterior cruciate ligament recon-
struction: bone-patellar tendon-bone compared with double semiten-
dinosus and gracilis tendon grafts. A prospective, randomized clinical
trial. J Bone Joint Surg 2004;86A:2143–2155.
241
 SUB PART II CROSS-PIN
34
CHAPTER Stratis ST Femoral Fixation System
Paul Re INTRODUCTION
Tony Wanich
It has been estimated that approximately
Russell F. Warren 200,000 anterior cruciate ligament (ACL) injuries
occur annually, with approximately 100,000
patients per year undergoing reconstruction.1
Over the past decade, ACL reconstruction
utilizing soft tissue grafts, such as hamstring auto-
graft or tibialis anterior allograft, has gained
increased popularity compared with bone–
patellar tendon–bone (BPTB) autograft due to the
decreased morbidity of hamstring harvesting,
excellent clinical results, and availability of a
variety of soft tissue allograft constructs. There
remains continued controversy regarding graft
options for ACL reconstructions. Of the graft
choices available, the two most commonly used
are autologous BPTB grafts and autologous
hamstring tendon grafts. Even more perplexing
is the number of fixation methods currently
available.
For many surgeons, BPTB autograft
remains the gold standard. Several long-term
studies have demonstrated good outcomes with
the use of this graft.2,3 Due to the morbidity
associated with BPTB autograft, the use of ham-
string tendon autograft has become increasingly
popular. A number of prospective clinical trials
comparing patellar tendon versus hamstring
tendon have demonstrated comparable clinical
results after 2-year follow-up.4–9 Additional stud-
ies, including a study by Feller and Webster,10
have demonstrated increased laxity based on KT-
1000 in ACL reconstructions with hamstring
242
tendon compared with patellar tendon. How-
ever, this difference was not clinically significant
because patients in both groups demonstrated
similar clinical scores and functional outcomes.
One of the primary advantages of using
hamstring tendon in ACL reconstruction
appears to be less donor site morbidity compared
with patellar tendon. Namely, there is a lower
incidence of anterior knee pain and a decreased
risk of extension deficits, although some authors
have found flexion deficits in patients with
ACL reconstruction using hamstring tendon
grafts.11,12 The weakness in extension or flexion
following either patellar tendon or hamstring
tendon harvest appears to be most pronounced
early on, with differences diminishing between
groups over time.13 Another concern regarding
the use of hamstring tendon grafts is the phe-
nomenon of tunnel widening associated with
early forms of femoral fixation.14 With improve-
ments in surgical technique and advances in
femoral fixation devices, the differences in
tunnel widening between hamstring and patellar
tendon grafts have been reduced.15
The earliest forms of fixation for soft tis-
sue grafts included post and washer and staple
fixation. This required a significant lateral
femoral dissection for the over-the-top or out-
side-in femoral guide, as well as placement of
the devices used. Although the fixation
strength was acceptable, the issues surrounding
this technique included the surgical dissection
and the rehabilitation consequences and the
occurrence of painful hardware necessitating a

second procedure for hardware removal and the so-called
“bungee and windshield wiper effect.” Although bio-
mechanical studies have shown that hamstring autografts
have an ultimate yield strength greater than the native
ACL and a stiffness curve more similar to the native
ACL, the distally fixed construct placed these grafts at a
disadvantage.16,17
The femoral fixation is more than 50 to 70 mm from
the intraarticular origin of the femoral tunnel, which essen-
tially triples the length of the working graft when compared
with the native ACL, whose average intraarticular length is
about 25 mm. This results in tripling the creep and decreas-
ing the stiffness, making the construct feel more elastic.
Because creep is dependent on the overall length of the
graft, shortening the functional length of the graft will result
in less stretch to the graft at follow-up.
The distal fixation also acts as a pivot point about
which the graft moves during knee flexion and extension
until the graft–femoral tunnel interface matures. This results
in a cone-shaped tunnel widening at the articular femoral
origin. Although the effect of tunnel widening on clinical
outcome remains unclear, there is concern that this may
affect healing of the graft–femoral tunnel interface and also
create problems in the revision setting.18,19
To address these issues, different fixation devices have
been devised and used. Suspensory anterior-lateral femoral
cortical fixation devices have had great clinical success. They
eliminate the need for a secondary lateral dissection and
have good pullout strength.20 They do, however, suffer the
consequences of elongation resulting from excessive length
of the functional graft due to the distance of femoral cortical
fixation. The use of interference screws has addressed the
issue of aperture fixation at the femur. However, the con-
cern regarding the damage the screw threads cause to the
graft, as well as the less-than-optimal pullout strength, has
limited their use. In addition, interference screws take up
most of the space within the femoral tunnel, pushing the
soft tissue graft to one side and limiting its contact with
the femoral tunnel, which raises concerns of impaired graft
tunnel healing.
Recently, transverse femoral tunnel pinning (transfe-
moral) fixation has been introduced and is gaining in popu-
larity. These devices either spear the graft or drape the graft
over a fixation pin in an anteroposterior orientation. The
different designs have resulted in improved fixation and
pullout strength.21,22 However, for each design there are
concerns regarding graft damage and passage of the graft
into the tunnel by pulling either axially or perpendicular to
the tunnel, which often necessitates making a wider femoral
tunnel to aid in graft passage.
Any construct that spears the graft compromises its
integrity and secondarily subjects it to increased creep. This
Stratis ST Femoral Fixation System 34
increased creep is due to the fact that the collagen fibers in
the graft run longitudinally in bundles with limited cross-fiber
bundle strength. If these bundles are speared and pulled, the
graft essentially tears along these fiber bundle lines.
Other transfemoral fixation devices require that a flex-
ible wire be drilled across the femoral tunnel and out the
other side; the wire is then retrieved down the tunnel, across
the joint, and out the tibial tunnel. Here the graft is draped
across the wire and pulled back up into the tunnel by pulling
on the limbs of the wire exiting medially and laterally. Once
pulled back up, the fixation pin or device is then passed.
Axially pulling any graft is mechanically harder than push-
ing a graft into the femoral tunnel. These transfemoral fixa-
tion devices are even more mechanically disadvantaged
because the force vector to pull the graft up into the tunnel
is perpendicular to the axis through which the graft is
passed. This weaker pull makes it difficult to pass the graft,
often requiring surgeons to oversize the tunnel to ease pas-
sage. This oversizing results in less graft compression within
the tunnel, which could ultimately impair healing.
Anatomical studies show that the femoral footprint of
the ACL is oriented in anteromedial (AM) and posterolat-
eral (PL) bundles. These transfemoral tunnel devices orient
the bundles in an anterior and posterior position rather than
the correct anatomical orientation.
DESIGN RATIONALE OF THE STRATIS ST
With the knowledge gained by devices and techniques that
preceded it, the Stratis ST (Scandius Biomedical, Littleton,
MA) was designed to address the major points and goals
that define the ultimate soft tissue fixation device. Any clin-
ically successful device needs to (1) not compromise graft
integrity, (2) have excellent pullout strength, (3) have aper-
ture fixation with graft tunnel compression and optimized
graft tunnel contact, (4) be pushed into the femoral tunnel,
and (5) orient graft limbs in the correct anatomical orienta-
tion. These qualities are discussed in detail in this section.
The Stratis ST femoral fixation system consists of a
graft block and a ribbed transverse locking pin (Fig. 34-1).
The graft block and pin are available in nonabsorbable
polymer and absorbable poly-L-lactic-acid (PLLA).
The graft block is available in 25-mm and 35-mm
lengths and diameters of 8, 9, and 10 mm. The graft block
has a suture eyelet most proximally, followed by a locking
portal that receives the transverse pin, followed next by the
graft portal, which receives the soft tissue graft. The graft
block tapers distally into a 2-mm biconcave fin, which
receives the draped soft tissue graft and provides graft tunnel
compression and distal aperture fixation. At the distal tip of
the graft block is the docking station for the insertion tool.
243
 Anterior Cruciate Ligament Reconstruction
FIG. 34-1 Stratis ST femoral fixation graft block and transverse locking pin.
The transverse locking pin is 40 mm long, of which
28 mm is smooth and 4 mm in diameter, with the remaining
12 mm being ribbed and 6 mm in diameter. The ribbed
portion stops the pin from moving too far medially through
the graft block and also locks it into the lateral femoral
condyle, stopping the pin from backing out. The transverse
pin was designed with the locking portion being ribbed
instead of screw threaded because mechanical studies show
that screw-threaded devices are more prone to back out
under cyclical loading than are ribbed devices.
1. Do Not Compromise Graft Integrity
The Stratis ST femoral fixation system is designed for use
with any soft tissue graft, with the quadrupled hamstring ten-
don being the most common autograft and tibialis anterior
being the most common allograft used. The graft is passed
through the distal graft portal and draped distally (Fig. 34-2).
This hole is tapered smooth and contoured to deliver the
graft to the distal biconcave compression fins. The transverse
locking pin does not compromise or contact the soft tissue
graft in any way. Instead, it locks the graft block within the
femoral tunnel by docking with and traversing the more prox-
imal locking portal. This ensures graft integrity and allows for
a stiffer construct.
2. Have Excellent Pullout Strength
With the locking pin engaged in the graft block, it forms a
“fixed T” construct that yields superior biomechanical
244
FIG. 34-2 Stratis ST femoral fixation system with soft tissue graft.
characteristics. Pullout studies have shown an ultimate fail-
ure load of up to 1250N depending on which graft block
is used. Cyclical loading studies of 50N to 250N showed
no evidence of any creep, failure, or pin backout after
250,000 cycles.23 The locked fixed T construct also gives a
theoretical decreased rotation moment because it is harder
to rotate a fixed T construct through bone than it would
be a simple transverse pin.
3. Have Aperture Fixation with Graft
Tunnel Compression and Optimized Graft
Tunnel Contact
The graft block is seated no less than 5 mm from the
femoral tunnel origin. This placement allows the fin of the
graft block to provide rigid fixation at the tunnel aperture.
In addition, the 2-mm-thick fin provides graft compression
to the tunnel wall with more than 90% graft tunnel inter-
face23 (Fig. 34-3).
4. Be Pushed into the Femoral Tunnel
It is mechanically easier to push a graft into a tunnel than it is
to pull the same-sized graft through the same-sized tunnel.
Devices that rely on axially (or worse, perpendicularly) pulling
the graft into the femoral tunnel are at a mechanical disadvan-
tage. This disadvantage often requires oversizing the femoral
tunnel to ease graft passage, which secondarily decreases graft
tunnel compression and can interfere with graft tunnel
healing.

FIG. 34-3 Implanted view of Stratis ST femoral fixation system.
At the distal tip of the Stratis ST graft block is a docking
station at which the insertion tool locks into place (Fig. 34-4).
Once connected, the soft tissue graft–graft block construct
can be delivered into the femoral tunnel. This locked con-
struct allows the surgeon to better aim and guide the graft
construct into the tunnel and then, once it is engaged with
the tunnel, to push it into position with a mechanical advan-
tage. This allows the surgeon to take full advantage of the
compression fin and, if desired, oversize the graft but not
the tunnel.
Another advantage of not having to pull the graft into
the femoral tunnel is that the guidewire does not have to
breach the femoral cortex, nor does it have to traverse the
quadriceps muscle and the skin. Therefore the wire and
(secondarily) the graft-pulling suture are not there to dam-
age the quadriceps. In addition, because there is no hole in
the femoral cortex, no direct conduit exists from the intraar-
ticular space and the anterior muscular compartment. This
FIG. 34-4 Stratis ST femoral fixation system insertion tool.
Stratis ST Femoral Fixation System 34
limits fluid extravasation from the knee into the muscular
compartment, further limiting damage to the quadriceps.
5. Orient the Graft Limbs in the Correct
Anatomical Orientation
Anatomical studies show that the femoral ACL footprint
consists of an anteromedial (AM) and a posterolateral (PM)
bundle orientation. The design of the graft portal, which is
parallel to the transverse pin, and the technique of insertion
position the graft bundles into the correct anatomical orienta-
tion. This orientation, although probably not truly important
to single-bundle reconstruction, plays an important role in
anatomical single femoral tunnel, double-tibial tunnel, hybrid
ACL reconstruction.24
TECHNIQUE
Tendon Harvest
Soft tissue autografts and allografts can be used with the
Stratis ST system. We most commonly use the Stratis ST
system for fixation of hamstring autografts. The technique
we use for harvesting hamstring tendons is outlined in a
paper by Solman and Pagnani.25
Briefly, make a longitudinal or oblique incision appro-
ximately 2 cm medial to the tibial tubercle and 4 cm distal
to the joint line (Fig. 34-5). Dissect the subcutaneous tissue
to expose the sartorius fascia. Incise the rolled edge of the
sartorius fascia to expose the gracilis and semitendinosus
tendons, which are covered by the sartorius (Fig. 34-6).
Separately isolate each tendon with a 90-degree snap and
deliver each under the sartorius (Fig. 34-7). Take care to cut
all projecting bands and adhesions from each tendon, and
bluntly dissect to the adductor hiatus. Sharply release the
FIG. 34-5 Incision for hamstring harvest.
245
 Anterior Cruciate Ligament Reconstruction
FIG. 34-6 Hamstring tendon.
FIG. 34-7 Isolation of gracilis and semitendinosus tendons.
tendons from their attachment to the tibia. Whipstitch the
ends with a sturdy suture (usually #2 nonabsorbable).
With the knee bent roughly 40 degrees, place the ten-
don. Manually palpate around the tendon to confirm that
the facial bands have been released. Using a blunt tendon
stripper, release the muscular attachment. Firmly pass the
tendon stripper through the adductor hiatus and aim it
toward the ischial tuberosity. Deliver the released tendon,
and safely place it on the preparation table.
Graft Preparation
Pinch the harvested tendon between the ends of a forceps
and subsequently pull it through repeatedly in order to
remove any remaining muscle. Alternatively, use a Cobb
elevator or the back end of a ruler. Whipstitch the ends with
a sturdy suture (usually #5 nonabsorbable). Fold the two
grafts over a #5 suture (Fig. 34-8).
246
FIG. 34-8 Prepared hamstring autograft.
Arthroscopic Preparation
Pull the graft bundle through a graft-sizing block to deter-
mine the diameter. The diameter selected should be one
through which the graft bundle fits tightly but still passes.
Débride the ACL stump as necessary, and perform a lateral
femoral notchplasty to visualize the over-the-top position as
per the standard technique.
Creation of Tibial and Femoral Tunnels
When using a transtibial approach, care should be taken
because the position of the tibial tunnel influences the position
of the femoral tunnel. The standard starting position of the
tibial tunnel is just in front of the medial collateral ligament
(MCL) and 1 cm proximal to the superior aspect of the
sartorius fascia. This will create an appropriately angled tibial
tunnel, which should be 30 degrees to the sagittal axis of the
tibia. If the starting point is too lateral, then the graft position
may be too vertical. If the starting point is too medial, then
the ability to get far back in the femoral notch is compromised.
The intraarticular entry point of the tibial tunnel is located
in the posterior medial aspect of the ACL footprint. It is
important not to be too anterior to avoid graft impingement.
Using a tibial drill guide, advance a 2.25-mm, drill-
tipped guidewire into the intraarticular space. After appro-
priate guidewire position is confirmed, overdrill it with the
appropriately sized cannulated drill bit.
Clear the tunnel of bone debris, and chamfer it as
necessary. With the knee typically bent to 90 degrees, posi-
tion an appropriately sized over-the-top guide. With the
appropriate position confirmed, drill the graduated guide-
wire until it engages the femoral cortex. Note the measured
depth (Fig. 34-9). Typically a 25-mm-long graft block
implant is used. However, a 35-mm graft block may be used

FIG. 34-9 Measure depth of femoral tunnel.
if the guidewire hits the cortex at a depth of 50 mm or
more. Advance the appropriate-diameter acorn drill over a
guidewire and into the femur to a depth equal to the graft
block to be used plus 5 mm; typically this will be 30 mm
deep (Fig. 34-10).
Creation of Transverse Tunnel
Select the tunnel guide that corresponds to the diameter of
the femoral tunnel. Attach the transverse drill guide to the
tunnel guide. Insert the assembled tunnel guide/transverse
guide through the tibial tunnel until it is fully seated in
the femoral tunnel (Fig. 34-11). The gradations on the tun-
nel guide should indicate a depth that corresponds to the
drilled femoral tunnel depth.
Orient the system so that the transverse guide is
roughly 10 degrees posterior to the epicondylar axis. Alter-
natively, position the guide so that it is roughly parallel to
the patellar plane.
FIG. 34-10 Create femoral tunnel.
Stratis ST Femoral Fixation System 34
FIG. 34-11 Assembled tunnel guide/transverse guide.
Insert the drill sleeve and obturator into the opening
on the distal end of the transverse guide. Make a 1-cm inci-
sion at the point where it engages skin. Using a snap to
spread the iliotibial band, dissect down to the lateral femoral
cortex. Advance the drill sleeve and obturator to the lateral
femoral cortex (Fig. 34-12, A and B). Take care to ensure
that no tissue is trapped between the sleeve and the cortex.
When advancing the drill sleeve, hold the tunnel
guide handle (rather than the transverse guide) and apply
steady, light force to the drill sleeve; avoid applying excessive
torque to the system. Use the locking nut to secure the drill
sleeve to the transverse guide.
Markings on the proximal aspect of the drill sleeve
indicate the distance from the lateral cortex to the lateral wall
of the femoral tunnel (see Fig. 34-12, A). To provide adequate
purchase for the barbed end of the fixation pin, confirm that
a minimum of 15 mm lateral distance is available.
Remove the obturator from the drill sleeve. Advance
the transverse drill through the drill sleeve and into the
femur to the same depth as noted on the sleeve to create
the transverse tunnel (Fig. 34-13).
Run a sterile medical marking pen along the trans-
verse guide to mark the skin on the lateral side of the knee,
showing the orientation of the system.
Remove the transverse drill, and insert the switching
stick through the sleeve and into the tunnel. Take care to
orient the switching stick in the same axis as the sleeve.
Do not force the switching stick; it should slide through
the sleeve and tunnel easily. Remove the transverse drill
sleeve. Withdraw the tunnel guide; the slot in the distal
end of the transverse guide will allow the switching stick
to remain in the transverse tunnel. Note that if the switch-
ing stick is inserted too far at first, it will engage the
tunnel guide and lock it in place, not allowing it to be
removed.
247
 Anterior Cruciate Ligament Reconstruction
FIG. 34-12 A and B, Assembled tunnel guide/transverse guide with drill sleeve in place.
FIG. 34-13 Insert drill to create transverse tunnel.
Preparation of the Graft
Block–Graft Construct
Choose the appropriate Stratis implant set. The set will
contain a graft block and a fixation pin. Insert the prepared
soft tissue graft into the lower eyelet of the graft block
(Fig. 34-14).
Place the graft block/graft construct onto the appro-
priate graft block inserter. Attach the transverse guide onto
the graft block inserter (Fig. 34-15, A and B). Wrap the
graft suture ends around the lock nut. Temporarily insert
the drill sleeve into the distal end of the transverse guide,
confirming that it lines up with the upper eyelet in the graft
block and that the correct inserter has been selected.
Remove the drill sleeve after confirming.
248
FIG. 34-14 Prepared graft placed through lower eyelet of graft block.
Additionally, the graft may be marked with a sterile
marking pen prior to insertion to facilitate confirmation of
insertion depth. Passage of the graft block–graft construct
into the tibial and femoral tunnels may be facilitated by
first conditioning the construct with the Stratis graft
sizing/conditioning block. This will condition the construct
diameter to within 0.2 mm of the tunnel diameter, easing
passage while still proving tissue compression in the tunnel.
Insertion of the Graft Block
Proper orientation is necessary to ensure that the fixation
pin will align with the transverse tunnel. Use of the trans-
verse guide and markings on the lateral side of the knee
can facilitate proper orientation.

FIG. 34-15 A, Graft block–graft construct attached to graft inserter with
transverse guide. B, Graft block–graft construct attached to graft inserter
with transverse guide.
Advance the inserter–graft block construct through
the tibial tunnel and fully into the femoral tunnel. Note that
you may have to back out the switching stick to allow the
graft block to fully seat.
During this step, the switching stick should pass
through the slot in the distal end of the transverse guide
(Fig. 34-16). With the inserter/construct in position, advance
the drill sleeve over the switching stick and to the cortex;
secure it in place (Fig. 34-17). Make note of the depth
measurements on the drill sleeve; these should be roughly
the same as the previous measurements.
To verify engagement, fully insert the switching stick;
the stepped end should engage with the implant. After this
is done, traction applied to the distal end of the graft will
verify that the switching stick is engaged with the implant.
Stratis ST Femoral Fixation System 34
FIG. 34-16 Switching stick through distal end of graft block.
FIG. 34-17 Drill sleeve advanced over switching stick.
During this step, take care to maintain orientation of
the switching stick along the axis of the transverse tunnel
and to limit knee movements. This assists in maintaining
correct tunnel alignment and helps preserve tunnel quality
(off-axis insertion forces can compromise the tunnel,
particularly in patients with poor bone quality).
Femoral Fixation
Place the fixation pin on the fixation pin inserter (Fig. 34-18).
Remove the switching stick. Advance the fixation pin
inserter/fixation pin through the drill axis in the same
fashion as the switching stick. Do not apply force; insertion
through the sleeve and tunnel should encounter minimal
resistance. Applying excessive off-axis force could damage
the fixation pin.
Confirm the depth by reading the measurements on
the shaft of the fixation pin inserter (Fig. 34-19). These
249
 Anterior Cruciate Ligament Reconstruction
FIG. 34-18 Fixation pin loaded onto inserter.
should be roughly the same as those drilled with the trans-
verse drill and measured on the drill sleeve.
The fixation pin will engage the upper eyelet of the
graft block, providing device-to-device fixation and preserv-
ing graft integrity (Fig. 34-20). The graft block offers
enhanced tissue-to-tunnel compression in a more anatomi-
cal mediolateral orientation. This compression provides
rigid fixation at the joint line of the femur.
Remove the fixation pin inserter by applying gentle
lateral traction. Remove the drill sleeve. Apply traction to the
graft to confirm rigid fixation. Remove the transverse guide
nut, and unloop the sutures. Rock the graft block inserter
anterior to posterior while pulling distally to dislodge the graft
block and remove the inserter/transverse guide assembly.
Using the tip of a finger, palpate the lateral transverse
tunnel hole opening to confirm that the fixation pin is well
seated.
FIG. 34-19 Fixation pin advanced through upper eyelet of graft block.
250
FIG. 34-20 Close-up view of implant graft block with fixation pin.
REMOVAL OF IMPLANT
If removal of the Stratis implant is necessary, locate the
transverse tunnel in which the fixation pin has been
implanted. Insert the threaded end of the fixation pin
removal tool at the angle used to insert the pin; engage
the threads. Once engaged, gently turn the fixation pin
removal tool clockwise until the tool is seated in the fixation
pin. Pull the fixation pin straight out with firm lateral trac-
tion. The pin’s ribbed press fit design will provide some
resistance when being removed. Once the fixation pin is
removed, gently pull on the graft ends to deliver the graft
block into the joint. If the graft block cannot be delivered
through the tibial tunnel, grab the distal end of the graft
block with a snap inserted through the medial portal. Once
firmly grasped, the graft block and graft can be delivered
from the intraarticular space through the medial portal with
gentle traction while turning the graft block clockwise or
counter-clockwise.
PEARLS AND PITFALLS
1 The choice of the size of the graft block is entirely up to
the surgeon. Most surgeons use the 25-mm block and
drill between 30 and 35 mm (we prefer 32 mm). This
ensures at least 20 mm of graft in the femoral tunnel.
Note that the amount of graft needed in the femoral
tunnel was based on initial studies of bone–tendon–bone
and interference screws. It was not based on healing of
the graft, but rather on pullout strength. Because this
device’s pullout strength is not based on length of the
femoral tunnel, we believe that 20 mm of graft in the
tunnel is more than biologically appropriate for healing.

If you decide to drill deeper or use the 35-mm device,
note that as you drill deeper, you lose more lateral wall
depth due to the flare of the femur. This may affect the
amount of depth available for the transverse locking pin.
2 If you are drilling the femoral tunnel through the tibial
tunnel (i.e., transtibial) we suggest that you flex the knee
to 90 degrees. This accomplishes two things: First, it
brings the point at which the transverse drill engages the
lateral femoral cortex closer toward the mid-longitudinal
axis, thereby maximizing lateral depth and limiting the
chance of drill skiving. Secondly, it makes the drill more
likely to engage the femoral flare and thereby increases
lateral wall depth. Due to the unique anatomy of the
distal femur, the more the knee is flexed, the more lateral
depth is gained as you move the contact point off the
femoral shaft and onto the femoral flare. In addition the
anterior aspect of the femoral flare has more lateral wall
depth than the posterior.26
3 Because the average intraarticular length of the ACL is
about 25 mm, if the 35-mm graft block is used, you may
encounter difficulty transferring the graft block through
the tibial tunnel, across the joint, and into the femoral
tunnel, as the tunnels may not perfectly align. If this
occurs, flex the knee to 70 degrees and begin to insert the
graft block into the femoral tunnel; once it is inserted
5 mm or so, you can extend the knee back to 90 degrees
and insert the graft block fully. This technique may also
be used for insertion of the tunnel guide.
4 When inserting the transverse drill sleeve onto the
outrigger, it should be slid down firmly but easily. Hold
on to the colored handle and not the outrigger when
doing this. If you hold the outrigger and push it in with
your thumb (syringe technique), you have the very slight
possibility of splaying the outrigger like a wishbone and
causing it to go off-axis. Although this has not occurred
clinically, its theoretical possibility suggests the avoidance
of this technique.
5 The transverse drill is stepped in design to accommodate
the shape of the transverse locking pin. The tip of the
drill has a sharp, brad point. When drilling, use
high RPMs and low pressure (standard trauma
technique). The first part of the drill will go quickly, and
then the stepped portion engages the lateral cortex. Be
patient, slightly increase your pressure, and keep up the
RPMs; it will then capture and seat. Remove the drill
with the power on. Do not pump back and forth
within the tunnel because you do not want to
inadvertently enlarge it. The drilling of the transverse
tunnel, although meticulously described, takes about
10 seconds.
Stratis ST Femoral Fixation System 34
6 The pin inserter has a snug fit onto the transverse pin.
Once the pin is inserted, pull down on the graft and graft
block inserter to lock the transverse pin in place. A mallet
can be used to back-tap the base of the pin inserter,
quickly disengaging the assembly. After removing the pin
inserter, a blunt tap can be used to push the pin to the
correct depth.
7 We have performed the Stratis ST femoral fixation using
the standard transtibial as well as medial portal femoral
techniques and have noted that in the latter technique,
there is sufficient lateral wall depth to capture the locking
pin. Once again, this is a result of the unique shape of the
distal femur in the hyperflexed position.
8 After we drill the transverse tunnel, we partially insert the
switching stick. Once the tunnel guide/outrigger is
removed, we fully seat the switching stick. Next, we use
the arthroscope to look up the femoral tunnel to confirm
the drilling. We leave the switching stick across the
tunnel as we insert the graft–graft block construct. As we
insert it farther into the femoral tunnel, the graft block
hits the switching stick. We then back out the switching
stick about 1.5 cm, fully seat the graft block, and then
fully reinsert the switching stick to confirm alignment.
9 When preparing the graft, the ends are whipstitched and
subsequently passed through the lower eyelet of the graft
block. However, the end of the prepared graft may be too
large to easily pass through the eyelet due to the added
bulk of the whipstitched end. Therefore we recommend
passing the graft one limb at a time through the eyelet
and then preparing the ends of the graft with a
whipstitch.
References
1. Owings MF, Kozak LJ. Ambulatory and inpatient procedures in the
United States, 1996. Vital Health Stat 1998;139:1–119.
2. Shelbourne KD, Gray T. Anterior cruciate ligament reconstruction
with autogenous patellar tendon graft followed by accelerated
rehabilitation. A two- to nine-year follow up. Am J Sports Med
1997;25:786–795.
3. Buss DD, Warren RF, Wickiewicz TL, et al. Arthroscopically assisted
reconstruction of the anterior cruciate ligament with use of auto-
genous patellar-ligament grafts. Results after twenty-four to forty-two
months. J Bone Joint Surg 1993;75A:1346–1355.
4. Aglietti P, Giron F, Buzzi R, et al. Anterior cruciate ligament
reconstruction: bone-patellar tendon-bone compared with double
semitendinosus and gracilis tendon grafts. J Bone Joint Surg
2004;86A:2143–2155.
5. Aune AK, Holm I, Risberg MA, et al. Four-strand hamstring tendon
autograft compared with patellar tendon-bone autograft for anterior
cruciate ligament reconstruction. Am J Sports Med 2001;29:722–728.
6. Ejerhed L, Kartus J, Sernert N, et al. Patellar tendon or semitendino-
sus tendon autografts for anterior cruciate ligament reconstruction? A
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Med 2003;31:19–25.
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 Anterior Cruciate Ligament Reconstruction
7. Jansson KA, Linko E, Sandelin J, et al. A prospective randomized
study of patellar versus hamstring tendon autografts for anterior cruci-
ate ligament reconstruction. Am J Sports Med 2003;31:12–18.
8. Laxdal G, Kartus J, Hansson L, et al. A prospective randomized com-
parison of bone-patellar tendon-bone and hamstring grafts for anterior
cruciate ligament reconstruction. Arthroscopy 2005;21:34–42.
9. Shaieb MD, Kan DM, Chang SK, et al. A prospective randomized
comparison of patellar tendon versus semitendinosus and gracilis ten-
don autografts for anterior cruciate ligament reconstruction. Am
J Sports Med 2002;30:214–220.
10. Feller JA, Webster KE. A randomized comparison of patellar tendon
and hamstring tendon anterior cruciate ligament reconstruction. Am
J Sports Med 2003;31:564–573.
11. Beynnon BD, Johnson RJ, Abate JA, et al. Treatment of anterior
cruciate ligament injuries, part I. Am J Sports Med
2005;33:1579–1602 [review].
12. Marder R, Raskind J, Carroll M. Prospective evaluation of arthrosco-
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don versus semitendinosus and gracilis tendons. Am J Sports Med
1991;19:478–485.
13. Herrington L, Wrapson C, Matthews M, et al. Anterior cruciate liga-
ment reconstruction, hamstring versus bone-patella tendon-bone
grafts: a systematic literature review of outcome from surgery. Knee
2005;12:41–50 [review].
14. Simonian PT, Erickson MS, Larson RV, et al. Tunnel expansion after
hamstring anterior cruciate ligament reconstruction with 1-incision
EndoButton femoral fixation. Arthroscopy 2000;16:707–714.
15. Roe J, Pinczewski LA, et al. A 7-year follow-up of patellar tendon and
hamstring tendon grafts for arthroscopic anterior cruciate ligament
reconstruction: differences and similarities. Am J Sports Med
2005;33:1337–1345.
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16. Hamner DL, Brown CH Jr, Steiner ME, et al. Hamstring tendon
grafts for reconstruction of the anterior cruciate ligament: biomechan-
ical evaluation of the use of multiple strands and tensioning techni-
ques. J Bone Joint Surg Am 1999;81:549–557.
17. Noyes FR, Butler DL, Grood ES, et al. Biomechanical analysis of
human ligament grafts used in knee-ligament repairs and reconstruc-
tions. J Bone Joint Surg 1984;66A:344–352.
18. Fahey M, Indelicato PA. Bone tunnel enlargement after anterior cru-
ciate ligament replacement. Am J Sports Med 1994;22:410–414.
19. Fauno P, Kaalund S. Tunnel widening after hamstring anterior
cruciate ligament reconstruction is influenced by the type of graft
fixation used: a prospective randomized study. Arthroscopy
2005;11:1337–1341.
20. Barrett GR, Papendick L, Miller C. Endobutton button endoscopic
fixation technique in anterior cruciate ligament reconstruction.
Arthroscopy 1995;11:340–343.
21. Kousa P, Jarvinen TL, Vihavainen M, et al. The fixation strength of
six hamstring tendon graft fixation devices in anterior cruciate
ligament reconstruction. Part I: femoral site. Am J Sports Med
2003;31:174–181.
22. Fabbriciani C, Mulas PD, Ziranu F, et al. Mechanical analysis of
fixation methods for anterior cruciate ligament reconstruction with
hamstring tendon graft. An experimental study in sheep knees. Knee
2005;12:135–138.
23. Studies on file. Littleton, MA, Scandius Biomedical.
24. Frank DA, Altman GT, Re P. Hybrid anterior cruciate ligament
reconstruction: introduction to a new technique for anatomic anterior
cruciate ligament reconstruction. Arthroscopy 2007; In Press.
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tomic relationships and avoiding pitfalls. Orthop Clin N Am 2003;34:1–8.
26. Re P. Unpublished data.
 Pinn-ACL CrossPin System for Femoral
Graft Fixation
INTRODUCTION
Graft fixation has been considered the weak link
in the early postoperative period, especially
with the soft tissue grafts. Initial fixation requires
sufficient fixation strength during the rehabilita-
tion period while the graft incorporates into the
bone tunnels. Several techniques have been used
for fixing hamstring grafts. Interference screw
fixation for quadrupled hamstring grafts has fail-
ure strengths that may not be adequate for daily
activities and a modern rehabilitation program1;
suspension techniques are related to tunnel enlar-
gement and the so-called “bungee effect.”2–4
A recent study demonstrated that four-bundle
hamstring grafts fixed with modern techniques
produced higher stability rates than bone–patellar
tendon–bone (BPTB) reconstructions.5
Transfixation pin fixation techniques were
developed to improve femoral graft fixation;
these techniques put a pin across the femur tra-
versing the femoral tunnel. Within the transverse
femoral tunnel, the pins either penetrate the
graft, as with Rigidfix (Mitek, Ethicon, West-
wood, MA); the two bundles of the hamstring
graft fold around the pin to create a quadrupled
graft, as with Bio-TransFix (Arthrex, Naples,
FL), Cross-Screw (Stryker, Kalamazoo, MI)
and Bone Mulch (Arthrotek, Warsaw, IN); or
the two bundles are looped through a graft har-
ness that a pin transverses to create a quadrupled
graft (ConMed-Linvatec, Largo, FL). Femoral
fixation of hamstring tendon grafts using trans-
fixing pins is an accepted technique that yields
35
CHAPTER
excellent biomechanical properties with failure Arturo Almazan
loads over 800N,1,6,7 which clearly surpasses the
Donald H. Johnson
500N accepted to adequately follow an aggressive
rehabilitation protocol8,9 and has demonstrated
results in clinical trials comparable with other fix-
ation methods.10–13
The ConMed-Linvatec Pinn-ACL Cross-
Pin System is designed to provide transverse
femoral fixation in anterior cruciate ligament
(ACL) reconstruction using a soft tissue graft.
With existing systems, transverse femoral
fixation was a blind procedure, but this surgical
technique and the implant’s innovative design
allow the surgeon to visualize the transverse
tunnel and exact point of femoral fixation. With
this system the graft is suspended in a harness
and the pin transfixes the harness, not the graft.
Laboratory testing has showed greater than
1700N pullout strength,14 which is superior to
that of other available designs.1,6,7
INSTRUMENTS AND IMPLANT DESIGN
The Pinn-ACL CrossPin system for femoral graft
fixation includes the implants and instrumenta-
tion to ensure accurate transverse fixation of the
graft. The implant consists of two parts, the graft
harness and the cross-pin implant (Fig. 35-1).
The graft harness is composed of self-
reinforced poly-L-lactic acid (PLLA), it has an
eyelet in which the cross-pin locks, it also has a
closed loop of high-strength Dyneema suture in
which the graft sits and folds, and in its proximal
aspect it has a lead suture for graft construct
253
 Anterior Cruciate Ligament Reconstruction
FIG. 35-1 CrossPin system: graft harness (purple) and cross-pin, both with
their leading sutures.
passing. The graft harness is available in 8- and 9-mm dia-
meters. The cross-pin implant is also composed of self-rein-
forced PLLA, is available in three different lengths (40, 45,
and 50 mm), and has a lead suture in its tip for implant pass-
ing. A disposable transverse cannula fits in the blue frame and
slides over the drill bit to maintain the entrance of the trans-
verse tunnel as opened and accessible. The U-Guide is an
external aimer with two components—the main blue frame
and the positioning rod, which fit in the tunnels—and is
available in 8 and 9 mm. A specially designed drill bit with
two different diameters is used to create the transverse tunnel.
This drill bit is the same for every procedure regarding the
cross-pin implant length. Being a transverse fixation system,
the tip of the drill bit engages in the tip of the positioning
rod to ensure the engagement of the implants (Fig. 35-2).
SURGICAL TECHNIQUE WITH HAMSTRING
TENDONS
Graft Harvesting and Preparation
The semitendinosus and gracilis tendons are harvested in the
usual fashion. Each tendon must be at least 20 cm long because,
FIG. 35-2 Cross-pin drill bit as it engages the positioning rod.
254
when folded, a 10-cm-long final graft construction is desired.
The free grafts are taken to the Grafix Prep Table for prepara-
tion. Both tendons are measured and cut to the desired length
(20 to 22 cm), and then muscle is removed with an osteotome
or a periosteal elevator. Once cut and cleaned, each end of the
individual graft tendon is whipstitched approximately 35 to
40 mm from the end with a #2 nonabsorbable suture. If the
surgeon plans to use the SE Graft Tensioner for tibial fixation,
the graft’s bundles must be identified. This is easily accom-
plished by applying one knot to the semitendinosus sutures
and two to the gracilis or by using a surgical marker pen.
Using the graft sizing block, the entire graft bundle
diameter is measured. It is important to take measurements
of the femoral and tibial ends (Fig. 35-3); these diameters will
determine the proper sizes of the cross-pin graft harness and
tunnel. The graft harness size (8 or 9 mm) should always be
selected based on the diameter of the femoral end of the graft.
Not infrequently, the entire graft size is not uniform;
usually the tibial end increases 1 mm because of the mor-
phology of the tendon and the placed sutures. If this is the
case, the cross-pin graft harness must match the femoral
graft diameter. For tunnel creation, two different drill bits
will be used, with the smaller drill bit for the femoral tunnel
and the larger for the tibial tunnel.
To load the graft strands into the graft harness
(Fig. 35-4), place the graft harness onto the harness holder
accessory and pass the graft strands individually through
the continuous suture loop on the graft harness.
Notchplasty and ACL Stump Removal
The ACL stump is removed with the shaver. The notch-
plasty is large enough to accommodate the graft; this is
FIG. 35-3 Measure the diameter of the femoral and tibial ends.
FIG. 35-4 Graft mounted in the harness.

usually possible by just removing the soft tissues on the
lateral wall of the notch with the shaver or a curette. Some-
times in chronic cases in which stenotic bone is found,
notchplasty will include some bone resection.
Tibial and Femoral Tunnel Creation
The Pinn-ACL tibial guide, set at 55 degrees, is inserted
into the knee through the medial working portal. The tip
of the guide is placed in the posterior aspect of the tibial
ACL stump following an imaginary line along the posterior
border of the lateral meniscus anterior horn and centered in
the midline of the joint. The guide pin should enter the
tibia 5 cm below the medial joint line and 2 to 3 cm medial
to the anterior tibial tuberosity in a position adjacent to the
medial collateral ligament; this alignment will create a tibial
tunnel that allows a more oblique femoral tunnel, usually
around the 65-degree angle.15,16 The guide pin is advanced
into the tibia, and arthroscopic visualization is used to check
the correct position of the guide pin in the joint. An
AccuDrill reamer corresponding to the graft’s tibial size is
used to create the tibial tunnel.
Select the correct Bullseye guide so to leave 1 to 2 mm
of cortical back wall in the femoral tunnel. This selection is
made according to the femoral end diameter of the folded
graft. The Bullseye guide is inserted into the joint through
the tibial tunnel. The knee is slightly extended, and the tip
of the guide is directed toward the posterior femoral cortex,
trying to aim to the 10-o’clock position for the right knee
and 2-o’clock position for the left knee. Once the tip of the
guide is hooked in the femoral back wall, the knee is bent to
90 degrees, and the graft-passing guide pin is inserted
through the handle of the Bullseye guide and drilled until it
exits the lateral portion of the femur and skin. Leaving the
graft-passing guide pin in place, the femoral Bullseye guide
is taken out, its tip is disengaged, and it is turned 90 degrees
toward the posterior cruciate ligament (PCL). A C-Reamer
or Badger drill of the appropriate size (8 or 9 mm) is used to
create the femoral tunnel. The tunnel length of the femoral
socket should be no less than 30 mm (35 mm is recom-
mended). The femoral drilling must be visualized with the
arthroscope to ensure the tunnel position and integrity of
the posterior back wall.
U-Guide Position and Cortical Length
Measurement
Based on the diameter of the femoral tunnel, select the appro-
priate positioning rod size (8 or 9 mm) and assemble it
onto the U-Guide. Slide the black disposable transverse
cannula, which is packaged with the graft harness, onto the
U-Guide body.
Pinn-ACL CrossPin System for Femoral Graft Fixation 35
With the U-Guide assembled, insert the positioning
rod over the graft-passing guide pin, through the tibial tun-
nel, and completely into the femoral socket. The positioning
rod has laser-etched marks to enable the surgeon to check
its penetration. If the positioning rod is fully inserted in
the femoral tunnel, the laser marks must match the tunnel
length; otherwise it is not fully inserted or the tunnel depth
was not accurate. Remove the graft-passing guide pin from
the femoral tunnel.
After the U-Guide is fully inserted into the tunnels,
rotate the U-Guide body until the black transverse cannula
that is mounted on the U-Guide body is directed toward
the lateral condyle. The transverse tunnel will be drilled
from the lateral to the medial condyle.
Cross-Pin Implant Selection
With the U-Guide body in the correct orientation, insert
the cross-pin drill bit into the drill guide aperture and iden-
tify the entrance point of the transverse tunnel. With the tip
of the cross-pin drill bit touching the skin, use a scalpel to
create a small, 3- to 5-mm incision to assist the passage of
the drill bit through the soft tissue in order to make contact
with lateral femoral cortex.
To identify the appropriate length of cross-pin to be
used, utilize the U-Guide and cross-pin drill bit as a caliper
to first determine the length of the cortical side of the transverse
tunnel (i.e., the distance from the lateral cortex of the femur to
the lateral wall of the femoral tunnel). To measure this distance,
firmly press the cross-pin drill bit against the cortical surface,
without drilling, and read the laser-etched depth markings
where the drill bit enters the drill guide aperture (Fig. 35-5).
This measurement is important in selecting the appropriate-
sized cross-pin implant for cortical side fixation.
FIG. 35-5 The measurement on the transverse drill bit indicates the
correct size of the cross-pin implant. (Courtesy of ConMed-Linvatec.)
255
 Anterior Cruciate Ligament Reconstruction
Each cross-pin has a cortical length designed to
occupy the cortical side of the transverse tunnel, the avail-
able cortical lengths being 15, 20, and 25 mm. The proper
length of the cross-pin is that in which the cortical length
is less than or equal to the measured cortical tunnel length.
After the measurement is taken, drill the transverse
tunnel until the drill bit stops against the U-Guide body.
As you pull out the drill from the tunnel by hand, push
the black transverse cannula into the transverse tunnel to
prevent soft tissues from entering the transverse tunnel
(Fig. 35-6). Note: The use of the transverse cannula is
optional. The purpose of the cannula is to maintain the
opening of the transverse tunnel in the event the transverse
opening cannot be located.
Before removing the U-Guide, reinsert the graft-
passing guide pin until it exits the lateral femur and skin,
and then remove the U-Guide from the knee by sliding
it over the guide pin as it exits the femoral and tibial
tunnels.
FIG. 35-6 The transverse cannula remains in the transversal tunnel,
facilitating instruments and device entrance. (Courtesy of ConMed-
Linvatec.)
256
Graft Passing
Draw the hamstring graft construct into the knee using the
graft-passing guide pin. Pass the lead suture of the graft
harness through the eyelet of the graft-passing guide pin
and, while maintaining lateral-to-medial alignment of the
axis of the eyelet in the graft harness, pass the graft con-
struct into the tibial tunnel. It is very important to maintain
the graft harness alignment; the eyelet on it must be parallel
to the transverse femoral drill (Fig. 35-7).
As the graft harness enters the joint space in the intra-
condylar notch, use an arthroscopic probe (if necessary) to
maintain the eyelet orientation lateral to medial as it passes
into the femoral tunnel (Fig. 35-8).
Pull firmly on the graft construct until it is fully seated
in the femoral socket.
Place a sheathed scope into the black transverse cannula
to view the full insertion and alignment of the axis of the graft
harness eyelet with the axis of the transverse tunnel (Fig. 35-9).
FIG. 35-7 The harness lead suture is mounted in the graft-passing guide
pin. (Courtesy of ConMed-Linvatec.)

FIG. 35-8 Arthroscopic view of the graft harness as it enters the femoral
tunnel.
Graft Fixation
With the graft fully seated in the femoral tunnel and the
graft harness adequately oriented, pass the graft-passing
guide pin through the black transverse cannula and the eye-
let of the graft harness into the medial portion of the trans-
verse tunnel by hand. When the graft-passing guide pin will
advance no further, drill the graft-passing guide pin until it
exits the medial femur and skin. To confirm proper place-
ment of the graft-passing guide pin, pull tension on the
graft construct to ensure the graft-passing guide pin
intersects the graft harness construct. Pass the lead suture
of the cross-pin implant through the eyelet of the graft-
passing guide pin. Remove the graft-passing guide pin from
the transverse tunnel by pulling by hand from the medial
side until it fully exits the knee. The lead suture of the
cross-pin implant should pass through the transverse tunnel
and the graft harness and exit on the medial side of the
knee.
FIG. 35-9 Use of an arthroscope in the transverse tunnel to verify that the
harness is centered in the tunnel. (Courtesy of ConMed-Linvatec.)
Pinn-ACL CrossPin System for Femoral Graft Fixation 35
A sheathed scope should be placed into the black
transverse cannula to view the lead suture passing through
the eyelet of the graft harness (Fig. 35-10).
Gently pull the cross-pin lead suture until it enters the
black transverse cannula and the tunnel opening. Insert the
cross-pin driver into the proximal end of the implant
(Fig. 35-11, A), and tap the driver with a mallet, advancing
the implant until it stops. After the cross-pin is fully seated,
disengage the driver and ensure the cross-pin implant is flush
with or slightly below the cortical surface (Fig. 35-11, B) by
palpating the proximal end of the cross-pin at the insertion site.
Apply tension to the graft construct by pulling the
tibial sutures to check femoral fixation.
Finally, pull on one end of the lead suture attached to
the cross-pin to remove the suture from the device. Addi-
tionally, pull on one end of the lead suture attached to the
graft harness to remove its suture (Fig. 35-12).
Tibial Fixation
The recommended tibial fixation is the ConMed-Linvatec
BioScrew Xtralok interference screw. Tensioning of graft
can be conducted using the ConMed-Linvatec SE Graft
Tensioner System.
TIPS AND TRICKS
The Pinn-ACL CrossPin system for femoral fixation, like
other transfixation devices, has a steep learning curve, but
the main advantage of this system is that it is the only one
providing endoscopic visualization of the exact point of
femoral fixation.
Several steps, which may be easily missed, facilitate
the procedure as follows:
 The positioning rod is only 8 and 9 mm; for 7-mm grafts,
use the 8-mm rod.
 When inserting the positioning rod in the femoral tunnel,
it is useful to gently tap it to ensure it is fully inserted.
FIG. 35-10 Use of an arthroscope in the transverse tunnel to verify that
the implant’s lead suture passes through the harness eyelet. (Courtesy of
ConMed-Linvatec.)
257
 Anterior Cruciate Ligament Reconstruction
FIG. 35-11 A, Tap the implant’s driver to insert the cross-pin into the
transverse tunnel. B, Insert the implant until it is flush with the lateral cortex
of the femur. (Courtesy of ConMed-Linvatec.)
The laser mark must match the previously drilled
depth.
 Always remove the graft-passing guide pin from the
femoral tunnel before transverse drilling; otherwise the
transverse drill bit may not pass through the U-Guide or,
if it does, a false way will be created.
 Do not forget to measure the length of the cross-pin implant
before drilling the transverse tunnel, as this measurement
will give you the proper size of the implant to use.
 The length measured in the transverse drill bit is the size
of the cross-pin implant to use.
 When drilling the transverse tunnel, ensure the black
transverse cannula is seated in the U-Guide, not in the
skin incision. If it is in the incision when the power drill
is activated, the black cannula will engage in the drill bit
spinning or braking.
258
FIG. 35-12 Final view of the femoral fixation. The cross-pin engages the
graft harness. (Courtesy of ConMed-Linvatec.)
 The transverse drill bit always must be removed by hand,
if the power drill is used; the black cannula will engage in
the drill bit spinning or braking.
 Before removing the U-Guide, reinsert the graft-passing
guide pin through the positioning rod.
 It is useful to introduce the shaver into the transverse
tunnel entrance to remove the soft tissues that may
interfere with scope visualization.
 Do not try to introduce the scope in the U-Guide if it is
not removed first. The distance between the lateral border
of the U-Guide and the transverse tunnel entrance is
larger than the scope tip.
 The shaver can be used to remove soft tissues from the
transverse tunnel; this maneuver may facilitate the
introduction of the transverse cannula.
 The clue for success with this technique is that the graft
harness eyelet must be parallel to the transverse tunnel.
To accomplish this, the eyelet must be oriented so that it
enters the tibial tunnel. It is extremely difficult to rotate it
when it is within the bone tunnels, but it is easy to
control rotation of the graft if the surgeon holds it in

hand with the bundles separated in two pairs
(Fig. 35-13). As the lead suture of the graft harness is
pulled out and the graft prepares to enter the tibial
tunnel, the surgeon can rotate the graft to match the
eyelet–transverse tunnel orientation. Tension in the lead
suture of the graft harness must be maintained while it
enters the tunnels as the surgeon controls graft rotation
by hand. Arthroscopic visualization is very helpful. If the
surgeon observes that the graft harness is slightly rotated
(less than 20 degrees), sometimes the harness can be
rotated using the arthroscopic probe. If it is badly rotated
(greater than 20 degrees), it is better to take the graft out
and correct alignment.
 Once the graft harness enters the femoral tunnel, change
the arthroscope to the transverse tunnel to visualize how
it sits up in the tunnel. The surgeon must observe that the
harness eyelet is centered in the transverse tunnel
(Fig. 35-14); this will allow the cross-pin device to fit
into the harness eyelet.
FIG. 35-13 Spreading the bundles of the graft helps control rotation as it
enters the tunnels.
FIG. 35-14 The graft harness eyelet is centered in the transverse tunnel.
Pinn-ACL CrossPin System for Femoral Graft Fixation 35
 If there is any doubt regarding whether the cross-pin was
fully inserted until flush with the femoral cortex, the
scope can be placed again through the skin incision to
check the cross-pin position.
TROUBLESHOOTING
During our learning curve with the CrossPin system, we had
only two intraoperative incidents. In one case we did not
remove the guide pin from the positioning rod, and the
cross-pin drill bit was forced and created a false way. When
this was recognized, the guide pin was removed; the drill bit
was introduced again, creating a correct transverse tunnel;
and the rest of the case followed with no problems. In the
second case, the cross-pin implant was sunken into the lateral
femoral condyle; to avoid this incident, we recommend prior
definite implant impaction to insert the driver through the
skin incision and sit it on the femoral lateral cortex, and then
put a mark in the driver using a marker pen. This mark will
assist in recognizing the exact depth of implant insertion.
The opposite can happen, leaving the implant too proud on
the lateral femoral cortex; both incidents have already been
reported with the use of transfixation pins.17,18
Our results with the CrossPin femoral fixation are
encouraging thus far; we have 6 months of follow-up and all
patients have full range of motion, no Lachman or pivot-shift
signs, KT-1000 manual maximum side-to-side differences
of 1 mm, and no radiological signs of tunnel enlargement.
VIDEO TECHNIQUE
A presentation of the CrossPin system technique is available
in the DVD that accompanies this textbook.
References
1. Kousa P, Jarvinen TL, Vihavainen M, et al. The fixation strength of
six hamstring tendon graft fixation devices in anterior cruciate liga-
ment reconstruction. Part I: femoral site. Am J Sports Med
2003;31:174–181.
2. Uchio Y, Ochi M, Sumen Y, et al. Mechanical properties of newly
developed loop ligament for connection between the EndoButton
and hamstring tendons: comparison with Ethibond sutures and
Endobutton tape. J Biomed Mater Res 2002;63:173–181.
3. Hoher J, Scheffler SU, Withrow JD, et al. Mechanical behavior of two
hamstring graft constructs for reconstruction of the anterior cruciate
ligament. J Orthop Res 2000;18:456–461.
4. Hoher J, Livesay GA, Ma CB, et al. Hamstring graft motion in the
femoral bone tunnel when using titanium button/polyester tape
fixation. Knee Surg Sports Traumatol Arthrosc 1999;7:215–219.
5. Prodromos CC, Joyce BT, Shi K, et al. A meta-analysis of stability
after anterior cruciate ligament reconstruction as a function of ham-
string versus patellar tendon graft and fixation type. Arthroscopy
2005;21:1202.
259
 Anterior Cruciate Ligament Reconstruction
6. Ahmad CS, Gardner TR, Groh M, et al. Mechanical properties of
soft tissue femoral fixation devices for anterior cruciate ligament recon-
struction. Am J Sports Med 2004;32:635–640.
7. Clark R, Olsen RE, Larson BJ, et al. Cross-pin femoral fixation: a
new technique for hamstring anterior cruciate ligament reconstruction
of the knee. Arthroscopy 1998;14:258–267.
8. Howell SM, Hull ML. Aggressive rehabilitation using hamstring ten-
dons: graft construct, tibial tunnel placement, fixation properties, and
clinical outcome. Am J Knee Surg 1998;11:120–127.
9. Noyes FR, Butler DL, Grood ES, et al. Biomechanical analysis of
human ligament grafts used in knee-ligament repairs and reconstruc-
tions. J Bone Joint Surg 1984;66A:344–352.
10. Wilcox JF, Gross JA, Sibel R, et al. Anterior cruciate ligament recon-
struction with hamstring tendons and cross-pin femoral fixation com-
pared with patellar tendon autografts. Arthroscopy 2005;21:1186–1192.
11. Harilainen A, Sandelin J, Jansson KA. Cross-pin femoral fixation ver-
sus metal interference screw fixation in anterior cruciate ligament
reconstruction with hamstring tendons: results of a controlled prospec-
tive randomized study with 2-year follow-up. Arthroscopy
2005;21:25–33.
260
12. Fabbriciani C, Milano G, Mulas PD, et al. Anterior cruciate ligament
reconstruction with doubled semitendinosus and gracilis tendon graft
in rugby players. Knee Surg Sports Traumatol Arthrosc 2005;13:2–7.
13. Wolf EM. Hamstring anterior cruciate ligament reconstruction using
femoral cross-pin fixation. Oper Tech Sports Med 1999;7:214–222.
14. ConMed-Linvatec, Pinn-ACL CrossPin System [company brochure]
ConMed-Linvatec; 2005.
15. Johnson D. Anterior cruciate reconstruction using hamstring grafts
fixed with bioscrews and augmented with the EndoPearl. Tech Orthop
2005;20:264–271.
16. Howell SM, Gittins ME, Gottlieb JE, et al. The relationship between
the angle of the tibial tunnel in the coronal plane and loss of flexion
and anterior laxity after anterior cruciate ligament reconstruction. Am
J Sports Med 2001;29:567–574.
17. Pelfort X, Monllau JC, Puig L, et al. Iliotibial band friction syndrome
after anterior cruciate ligament reconstruction using the Transfix
device: report of two cases and review of the literature. Knee Surg
Sports Traumatol Arthrosc 2006;14:586–589.
18. Marx RG, Spock CR. Complications following hamstring anterior
cruciate ligament reconstruction with femoral cross-pin fixation.
Arthroscopy 2005;21:762.e1–762.e3.
 TransFix Anterior Cruciate Ligament
Femoral Fixation
BACKGROUND
More than 100,000 anterior cruciate ligament
(ACL) reconstructions are estimated to be per-
formed annually in the United States.1,2 There
has been a tremendous amount of research on
both graft selection and fixation methods.3–5
The increased use of soft tissue grafts and the
concern regarding soft tissue interference screw
fixation (e.g., graft pullout, slippage, damage)
have led to the development and use of femoral
cross-pin fixation in ACL reconstruction. One
successful technique for cross-pin fixation is
the TransFix ACL reconstruction technique
(Arthrex, Naples, FL).
Unlike interference screw fixation, which
is dependent upon screw geometry, bone den-
sity, and interface gap, the fixation strength of
the TransFix is limited only by the strength
of the graft and the device itself (size, geometry,
and material composition). The mode of failure
of the TransFix pin during biomechanical
studies has consistently been bending and
breakage, unlike the evidence of graft slippage
for interference screw constructs.
BIOMECHANICAL AND CLINICAL
RESULTS
The Arthrex TransFix implant is made of
titanium, and the Bio-TransFix implant is
made of poly-L-lactic acid (PLLA), as shown
in Fig. 36-1. In vivo, the Bio-TransFix implant
hydrolyzes into lactic acid, which is then
36
CHAPTER
metabolized into CO2 and H2O. A proprietary Brian P. McKeon
degradation study of the Bio-TransFix demon-
strated that it does not lose shear strength
through 52 weeks.
Several studies have shown that the Trans-
Fix and Bio-TransFix have significantly better
structural properties for maximum load, stiffness,
strength, and slippage of soft tissue grafts as com-
pared with interference screw fixation and other
cross-pin fixation techniques. Also, because of
the fixation technique, the potential for tunnel
widening is significantly decreased and the
strength of the graft is compromised much less
than that from interference screw fixation.
Fabbriciani et al used the TransFix system
in conjunction with fresh, ovine, doubled Achil-
les tendons and ovine femurs.5 Cyclical loading
comparisons of bioabsorbable and metal RCI
screws (Smith & Nephew, Andover, MA), the
LINX HT (Mitek, Norwood, MA), and the
TransFix implant showed significantly lower
mean values of graft elongation for the TransFix
construct (1.5
0.1 mm) over 1000 cycles. The
maximum load to failure (LTF) for the TransFix
was 890N
175N, which, unlike the other
devices in the study, is comparable to that of the
intact ovine ACL (725N
77N).
Becker et al showed that the stiffness of the
TransFix construct (184 N/mm) approximates
the stiffness of the human ACL (242 N/mm,
as reported by Woo et al6) and provides signifi-
cantly greater ultimate strength than interference
screw fixation.7 This study compared three fixation
methods using a porcine femur model: (1) TransFix
fixation of a quadruple tendon, (2) 8-  20-mm
261
 Anterior Cruciate Ligament Reconstruction
FIG. 36-1 The Arthrex TransFix implant is made of titanium, and the
Bio-TransFix implant is made of poly-L-lactic acid (PLLA).
biodegradable interference screw fixation of a quadruple
tendon, and (3) 8-  20- mm titanium screw fixation of a patel-
lar tendon–bone graft using a porcine femur model. Interfer-
ence screw fixation of the patellar tendon and quadruple
tendon resisted only 59% and 37%, respectively, of the pullout
strength of the TransFix (1303N
282N). The TransFix
had significantly less construct displacement during cyclical
loading than the interference screw/quadruple graft construct.
Ahmad et al demonstrated that interference screw
fixation and the Rigidfix cross-pin technique were inferior
to the Bio-TransFix and the Endobutton for graft slippage
during cyclical loading and ultimate LTF.8 After 1000 cycles,
the graft displacement for the Bio-TransFix was 1.13 mm
compared with greater than 5 mm for the interference screw
and Rigidfix. This study also showed significantly greater
LTF of the Bio-TransFix (746N
119N) as compared with
the interference screw technique (539N
114N).
As these and other studies have demonstrated, the use of
the TransFix system offers considerable advantages compared
with other femoral fixation systems in terms of yield load,
stiffness, and deformation and elongation under cyclical
loading. These results offer stable fixation of the graft during
the postoperative period, before graft healing has occurred.
The inherent rigidity of the TransFix limits graft-tunnel
motion during physiological loading. Intratunnel motion has
been associated with tunnel widening.9 Fauno and Kaalund
reported a significant reduction in tunnel widening in the
femur when TransFix was used compared with Endobutton
fixation at 1-year follow-up for a prospective randomized
study.10 Unlike interference screw techniques, in which the
graft is squeezed and possibly damaged during screw insertion,
graft strength is maximized with the TransFix technique.
In 1998, Wolf11 reported his initial results with the
TransFix fixation. Eighty-eight percent of patients at follow-up
262
described their postoperative knees to be normal or near
normal. The 27 patients had a mean KT-1000 side-to-side
laxity difference of 1.5 mm at follow-up. (Ahmad reports that
greater than 5 mm may be considered clinical failure.8)
Recently, Harilainen et al12 showed no significant
difference in IKDC scores at 2-year follow-up for TransFix
cross-pin fixation versus metal screw fixation. In this controlled
prospective randomized study, 85% of the TransFix group and
73% of the screw patients were in the IKDC A or B categories.
SURGICAL TECHNIQUE
The TransFix technique requires that a 3-mm drill pin be
passed from lateral to medial. Although no neurovascular
complications have been reported, theoretically the medial
(and lateral) neurovascular structures are at risk. The author’s
lab has shown that a defined “safe zone” exists in which a
distal femoral cross-pin can be reliably placed without
damaging the local neurovascular structures.13 In this anato-
mical cadaveric study, the absolute neurovascular safe zone
during cross-pin guidewire placement is from þ20 degrees
(0 degrees equals “parallel to the floor” line) and –40 degrees
(lowering the guide more posteriorly) (Fig. 36-2).
The TransFix technique is designed for soft tissue
grafts such as hamstring autograft or tibialis tendon allo-
graft. The author prefers tibialis tendon allograft and has
performed more than 300 TransFix ACL reconstructions
with this particular graft. A stepwise approach is as follows:
1 Position the patient supine, and place the patient under
general anesthesia. Examine both knees, and place a
tourniquet and thigh holder on the consented extremity.
2 Perform routine diagnostic arthroscopy with a standard
two anterior portal technique. Complete all meniscal and
articular cartilage procedures prior to notchplasty.
3 Prepare the tibialis graft with a running or Krackow
locking stitch,14 and size it to the nearest-millimeter
diameter (Fig. 36-3).
Tip 1: Make sure the graft runs easily through the selected
diameter.
One advantage of a tibialis graft is that the surgeon can
select or trim the graft to the desired size. The completed
graft is placed in a moist sponge that has been soaked in
antibiotic solution.
4 Complete the tibial tunnel through a small anterior
medial tibial incision using a posterior cruciate ligament
(PCL) referencing guide (Fig. 36-4).
5 Place the foot in a sterile basin with the knee at about 90
degrees of flexion.

FIG. 36-2 The absolute neurovascular
“safe zone” during cross-pin guidewire
placement is from þ20 degrees (0
degrees equals “parallel to the floor”
line) to –40 degrees (lowering the
guide more posteriorly).
FIG. 36-3 Prepare the tibialis graft with a running or Krackow locking
stitch, and size it to the nearest-millimeter diameter.
Tip 2: The knee flexion angle must be maintained until the
TransFix is implanted.
6 Use a transtibial femoral ACL drill guide (TTG) to cre-
ate a 1- to 2-mm “back wall.”
Tip 3: The TTG should easily be placed in the over-the-
top position. If not, the tibial tunnel may be too anterior.
A Beath pin is drilled through the distal cortex but not
through the skin.
7 Complete the selected femoral tunnel, reaming to a
depth of 40 mm. In small patients, the author accepts
TransFix Anterior Cruciate Ligament Femoral Fixation 36
a depth of 30 mm to avoid reaming out through the
femoral cortex.
8 Remove the Beath pin. Insert the matched TransFix tunnel
hook through the tibial tunnel, and position it in the fem-
oral socket (Fig. 36-5). A small lateral stab incision through
the iliotibial band (ITB) allows for the guide pin sleeve to
be advanced directly to bone. If the guide pin’s laser line
is exposed, use a 50-mm TransFix pin. The author has used
a 50-mm pin only once in more than 300 cases.
Tip 4: Do not overtighten the drill guide on the lateral cor-
tex. This causes the sleeve to skive along the metaphysis
and throw off the alignment of the guide. The sleeve
should rest lightly on the bone.
9 Drill a 3-mm guide pin medially through the guide sleeve
and tunnel hook. In general, the guide pin should be
directed parallel to the floor or anteriorly.13
Tip 5: Do not push hard on the TransFix guide pin when
drilling. This can cause the trocar tip to skive along the
metaphysis and throw off the aim. The TransFix guide
pin is threaded and will ease across the femur.
Tip 6: The 3-mm guide pin should easily pass back and
forth, ensuring a smooth passage through the tunnel
263
 Anterior Cruciate Ligament Reconstruction

FIG. 36-6 Drill the 5-mm broach with a stop collar over the 3-mm
guidewire.

hook. Pass the guidewire back and forth several times

manually until it glides easily.
10 Drill the 5-mm broach with a stop collar over the 3-mm
guidewire (Fig. 36-6). Note: The calibration numbers
on the drill are used as a guide for subsequent implant
insertion depth. For example, if the calibration shows
3 cm, the depth markings on the implant impactor
FIG. 36-4 Complete the tibial tunnel through a small anterior medial tibial
should match at the time of final TransFix implantation.
incision using a posterior cruciate ligament referencing guide.
11 Pass and deliver the nitinol wire out of the tibial tunnel.
Pass the selected graft in a retrograde fashion (Fig. 36-7).
Tip 7: The nitinol wire should glide back and forth very
easily after seating the graft proximally. The kink in
the wire from graft passage should be pulled medially
to prevent capturing the implant on insertion. If the
graft–tunnel interface is too tight, the graft will not be
seated proximally. This will result in the nitinol wire
breaking on implant insertion. The knee flexion angle
at the time of reaming the femoral socket must be
maintained.
Tip 8: A blunt probe can be used to push the graft up the
femoral tunnel to assist in seating the graft completely
in the femoral socket.
Tip 9 (the most critical): The implant should be advanced
manually along the same direction as the nitinol wire.
An assistant should confirm smooth glide of nitinol wire
throughout the insertion. Hand-inserting the implant as
FIG. 36-5 Remove the Beath pin. Insert the matched TransFix tunnel hook far as possible allows for more surgeon/assistant feed-
through the tibial tunnel, and position it in the femoral socket. back. If resistance to glide is noted with the nitinol wire,

264

FIG. 36-7 Pass and deliver the nitinol wire out of the tibial tunnel. Pass the
selected graft in a retrograde fashion.
then the surgeon should immediately confirm proper
implant orientation.
12 Seat the implant at the appropriate depth (match the
calibration line to the reamer) with gentle taps using
a mallet only after smooth passage of the wire is
confirmed (Fig. 36-8).
13 Remove the nitinol wire in a medial direction.
FIG. 36-8 Seat the implant at the appropriate depth (match the calibration
line to the reamer) with gentle taps using a mallet only after smooth
passage of the wire is confirmed.
TransFix Anterior Cruciate Ligament Femoral Fixation 36
14 Cycle the construct, and correct any roof or lateral wall
impingement if necessary.
15 Secure the graft on the tibial side with a 35-mm delta-
tapered biointerference screw (Arthrex) (usually 2 mm
greater in diameter than the tibial tunnel).
If orifice fixation is desired, this can be achieved with
the addition of a cancellous bone block15 or 20-mm femoral
retroscrew (Arthrex) placed distal to the TransFix. Ishibashi
et al demonstrated that proximal fixation resulted in reduced
anteroposterior translation compared with more distal fixa-
tion.16 Anatomical fixation close to the joint line results in
increased knee stability and graft isometry. Fixation of the
graft in the tunnel by an interference screw or bone block
also may mitigate synovial fluid infiltration into the tunnel.
TROUBLESHOOTING AND COMMON PROBLEMS
The tunnel hook jig cannot be passed into the tibial/
femoral socket: Confirm the sizes of the tunnel and tunnel
hook. Always verify that the knee flexion angle is main-
tained after drilling the femoral socket. This ensures that
no resistance will be encountered while passing the graft
from the tibial to the femoral socket.
The graft will not seat properly in the femoral
socket: If the graft cannot be pushed up into the femoral
socket with a blunt probe while the assistant pulls the niti-
nol wire, then the surgeon should resize the graft. The graft
diameter is likely to be too large. Do not soak the graft in
saline after sizing; often swelling can increase graft diameter.
The graft can be trimmed, or in extreme cases, the femoral
tunnel can be reamed up one size. Always make sure that
the knee flexion angle is maintained after drilling the
femoral socket.
The nitinol wire does not glide very easily: Again,
always make sure that the knee flexion angle is maintained
after drilling the femoral socket. The graft is not seated
proximally (see earlier).
The TransFix implant is “trapping wire”: Confirm
that the implant insertion angle is identical to that of the niti-
nol wire. The graft may not be seated proximally (see earlier).
The nitinol wire breaks: This typically happens early
in the insertion phase. Broken ends of wire can easily be
removed from both medial and lateral directions. In general,
this is because the graft is not seated enough proximally or
the implant insertion angle is different from that of the
guide pin/nitinol wire. Resize the graft, and reconfirm the
correct angle of implant insertion. A portion of the wire will
be left in the femur/implant if the wire breaks after the
implant is seated. This situation is usually not a problem if
the graft is secure, but it will be obvious on radiographs.
265
 Anterior Cruciate Ligament Reconstruction
The graft is severed upon implant insertion: The
threads on the TransFix implant can injure the graft if it
is countersunk in bone too far. Use another allograft if avail-
able, or suture the graft together (tubularize) and convert to
using Endobutton fixation or soft tissue interference screw
fixation.
CONCLUSION
In summary, TransFix cross-pin fixation offers favorable
strength and stiffness values as well as excellent early clinical
results.
References
1. Brown CH, Carson EW. Revision anterior cruciate ligament surgery.
Clin Sports Med 1999;18:109–171.
2. Orthopedic soft tissue repair. Norwalk, CT, 2005, Windhover Information.
3. Brand J, Weiler A, Caborn D, et al. Current concepts: graft fixation in
cruciate ligament reconstruction. Am J Sports Med 2000;28:761–774.
4. Kousa P, Jarvinen TL, Vihavainen M, et al. The fixation strength of
six hamstring tendon graft fixation devices in anterior cruciate
ligament reconstruction. Part I: femoral site. Am J Sports Med
2003;31:174–181.
5. Kousa P, Jarvinen TL, Vihavainen M, et al. The fixation strength of six
hamstring tendon graft fixation devices in anterior cruciate ligament
reconstruction: part II: tibial site. Am J Sports Med 2003;31:182–188.
6. Woo SL, Hollis JM, Adams DF, et al. Tensile properties of the
human femur-anterior cruciate ligament-tibia complex. The effects
of specimen age and orientation. Am J Sports Med 1991;19:217–225.
266
7. Becker R, Voight D, Starke C, et al. Biomechanical properties of
quadruple tendon and patellar tendon femoral fixation techniques.
Knee Surg Sports Traumatol Arthrosc 2001;9:337–342.
8. Ahmad CS, Gardner TR, Groh M, et al. Mechanical properties of
soft tissue femoral fixation devices for anterior cruciate ligament
reconstruction. Am J Sports Med 2004;32:635–640.
9. L’Insalata JC, Klatt B, Fu FH, et al. Tunnel expansion following
anterior cruciate ligament reconstruction: a comparison of hamstring
and patellar tendon autografts. Knee Surg Sports Traumatol Arthrosc
1997;5:234–238.
10. Fauno P, Kaalund S. Tunnel widening after hamstring anterior
cruciate ligament reconstruction is influenced by the type of graft
fixation used: a prospective randomized study. Arthroscopy
2005;21:1337–1341.
11. Wolf EM. Semitendinosus and gracilis anterior cruciate ligament recon-
struction using the TransFix technique. Tech Orthop 1998;13:329–336.
12. Harilainen MD, Sandelin J, Jansson K. Cross-pin fixation versus
metal interference screw in ACL with hamstring tendons: results of
a controlled prospective randomized study with 2-year follow-up.
Arthroscopy 2005;21:25–33.
13. McKeon BP, Gordon M, Deconciliis G, et al. The “safe zone” for
femoral cross-pin fixation. An anatomical study. Am J Knee Surg;
In Press.
14. McKeon BP, Heming JD, Langeland R, et al. The Krackow stitch: a
biomechanical evaluation of changing the number of locking loops
versus the number of sutures. Arthroscopy 2006;22:33–37.
15. Hantes ME, Dailiana Z, Zachos VC, et al. Anterior cruciate ligament
reconstruction using the Bio-TransFix femoral fixation device and
anteromedial portal technique. Knee Surg Sports Traumatol Arthrosc
2006;14:497–501.
16. Ishibashi Y, Rudy T, Livesay G, et al. The effect of anterior cruciate
ligament graft fixation site at the tibia on knee stability: evaluation
using a robotic testing system. Arthroscopy 1997;13:177–182.
 Stryker Biosteon Cross-Pin Femoral
Fixation for Soft-Tissue Anterior Cruciate
Ligament Reconstruction
INTRODUCTION
In the past, soft-tissue anterior cruciate ligament
(ACL) reconstructions have had several distinct
disadvantages, despite the fact that multiple-
strand hamstring grafts have been shown to have
higher strength, stiffness, and cross-sectional
area compared with patellar tendon grafts.1–3
Soft-tissue healing into bone tunnels is consider-
ably slower than bone–bone healing (about three
times slower4) and probably takes as long as 10
to 12 months for mature healing with Sharpey’s
fibers to occur.5 Fixation points distant from the
intraarticular portion of the graft have resulted
in more motion of the graft within the tunnel,
creating additional problems with graft–tunnel
healing, as well as contributing to tunnel widen-
ing. Fixation has traditionally been the weak link
in soft-tissue reconstructions, with constructs that
both were weak initially and failed to withstand
extended cyclical loading, which would be neces-
sary to allow the additional time for soft-tissue–
bone healing to occur. However, the morbidity
of hamstring harvest seems to offer several signif-
icant advantages over that of patellar tendon
grafts, including issues such as extensor weak-
ness, anterior knee pain, patellar entrapment/
patella baja, and patella fracture. In short, the
conventional wisdom was that patellar tendon
grafts provided tighter knees with more secon-
dary problems, whereas hamstring grafts resulted
in increased laxity but less morbidity.
The challenge of the past several
years, therefore, has been to eliminate these
37
CHAPTER
disadvantages as much as possible while maximiz- John C. Anderson
ing the inherent advantages of soft-tissue ACL Lonnie E. Paulos
reconstruction. To that end, the Stryker Biosteon
Femoral Cross-Pin System was designed with
the following goals in mind:
1 Make it possible for the surgeon to shorten
the femoral tunnel and bring the fixation
point as close to the joint as possible, with the
only limitation being bone quality and
healing surfaces.
2 Provide rigid initial fixation that, in addition
to having excellent strength at time zero, is
also resistant to cycling, which would allow
aggressive early rehabilitation.
3 Use a bioabsorbable material (enhanced to
form bone) that will be readily incorporated
by the body, retain strength for an adequate
period of time, obviate the need for secondary
procedures such as hardware removal, and
facilitate revision surgery. Bioabsorbable
materials also have the advantage of a lack of
stress shielding compared with permanent
implants.6,7
4 Provide a press-fit of the graft against the
tunnel walls in addition to simply providing a
pin with high load to failure (LTF) and
pullout strength. More specifically, the goals
would be increasing bone/soft-tissue contact
area and contact pressure.
5 Allow anatomical (far posterior and lateral)
graft placement, without compromise of
fixation if the posterior wall is blown out.
267
 Anterior Cruciate Ligament Reconstruction
6 Minimize damage to the graft as the implant is placed, in
contrast to interference screw fixation.
Successful ACL reconstruction using hamstring auto-
graft requires stable initial graft fixation and, ultimately,
graft–bone healing. Hamstring reconstruction using femoral
cross-pin fixation has been shown to have excellent initial
mechanical properties, including pullout strength.8,9
Whereas femoral interference screw fixation requires a
slightly more anterior femoral tunnel that fails to reproduce
native ACL anatomy exactly, cross-pin fixation allows for
placement of the femoral tunnel in the far posterolateral
notch, a more anatomical position that provides improved
biomechanical properties. The Stryker Biosteon Femoral
Cross-Pin technique described in this chapter has the
mechanical advantage of achieving “press-fit” graft fixation
close to the knee joint and therefore increased graft stiffness,10
as well as the biological advantage of not interfering with bony
and soft-tissue–bone healing.
WHY HYDROXYAPATITE?
Hydroxyapatite has been widely investigated and used exten-
sively as a bone graft substitute, and it has a track record of
being safe and effective (references). The basic advantages
of this application are: (1) pH buffering, (2) the implant
material is replaced by bone, and (3) the modulus of elasticity
is matched to bone (i.e., no stress shielding). In terms of pH,
hydroxyapatite particles provide a buffering effect as the
poly-L-lactic acid (PLLA) is degraded into lactic acid.11
The material is therefore not subject to autocatalytic degra-
dation, which can result in formation of a sterile abscess.
This also serves to create a more controlled degradation
process, with more gradual loss of strength over an extended
period of time compared with PLLA alone (Fig. 37-1).
Dynamics of healing and strength retention profile of Biosteon®
in comparison with PLLA in-vivo
100
90
Strength Retention %
80
70
60
50
40 Ideal Biological
Healing Curve5
30
20
Poly Lactide
10 Biosteon®
0
0 4 8 12 16 20
Time (weeks in vivo)
FIG. 37-1 Rate of degradation of Biosteon versus poly-L-lactic acid (PLLA)
alone.
268
Osteoblasts bind preferentially to the surface of Bio-
steon as compared with poly-L-lactic acid (PLLA) alone
(Fig. 37-2). Hydroxyapatite is remodeled through cell-
mediated processes. Osteoblasts cultured on the surface of
hydroxyapatite express genes associated with the production
of osteocalcin and CBFA-1 (proteins involved in the process
of osteogenesis). With hydroxyapatite, a direct biological
bond is achieved through osteoconduction, with less of a
fibrotic reaction. It is therefore less likely that fixation will
be compromised by an interface consisting of fibrous tissue
that encapsulates the implant (Fig. 37-3). As far as modulus
of elasticity, Biosteon lies somewhere between the moduli of
cortical and cancellous bone (Fig. 37-4), thereby greatly
decreasing the risk of stress shielding, even prior to the
breakdown of the implant material. In short, hydroxyapatite
enhances the healing properties of PLLA while minimizing
many of the drawbacks.
SURGICAL TECHNIQUE
Initial Arthroscopy
The patient receives intravenous antibiotics preoperatively.
After induction of anesthesia, an exam under anesthesia is
performed. The patient is then positioned supine with the
operative leg in an arthroscopic leg holder and a tourniquet
on the upper thigh. The knee is routinely injected with
30 mL of 0.25% bupivacaine (Marcaine) at the beginning of
the case for purposes of preemptive analgesia. Diagnostic
arthroscopy is performed, and any chondral or meniscal pro-
cedures are performed at this time. A minimal lateral wall
notchplasty is performed for visualization purposes only; we
rely upon accurate graft placement rather than an aggressive
notchplasty to avoid impingement, as a débrided notch has
been shown to regrow.12 In addition, an overzealous notch-
plasty may have deleterious effects on the ACL reconstruction
by altering the femoral attachment site and increasing graft
forces, resulting in loosening.13,14 Furthermore, removal of
too much of the lateral condyle can change joint contact forces
significantly.15 Preservation of the integrity of the fat pad is
also of paramount importance because it reduces the risk of
patellar entrapment during recovery and rehabilitation.16,17
Placement of the anterolateral portal a few millimeters supe-
rior to the conventional position serves to avoid the fat pad
and will improve visualization without the need to débride
or excise any of the fat pad. We typically place the antero-
lateral portal at the level of the distal pole of the patella
(if patella alta is not present), immediately lateral to the
patellar tendon.
 Stryker Biosteon Cross-Pin Femoral Fixation for Soft-Tissue Anterior Cruciate Ligament Reconstruction 37
Area Coverage %

0 10 20 30 40 50 60 70 80

3 days

Culture Period

14 days

Biosteon PLLA
FIG. 37-2 Osteoconductive properties of hydroxyapatite. PLLA, Poly-L-lactic acid.

In vivo 6 months post-implantation

PLLA screw Titanium screw Biosteon screw

A fibrous layer is clearly visible New bone has formed in

between the screw and all the contours of the
the bone screw threads
FIG. 37-3 Biosteon encourages bony rather than fibrous healing. PLLA, Poly-L-lactic acid.

Modulus/MPa

0 50,000 100,000 150,000 200,000 250,000

Cancellous7
Biosteon

Cortical 8
Titanium

Stainless Steel

FIG. 37-4 Modulus of elasticity of Biosteon is closely matched to bone.

269
 Anterior Cruciate Ligament Reconstruction
Graft Harvest and Preparation
Graft harvest is discussed in detail in other chapters, but a
few points are worth mentioning. With hamstring grafts,
it is important to pull the graft into the tendon stripper,
rather than push the stripper up the thigh, to avoid ampu-
tating the graft prematurely. We harvest the semitendinosus
tendon first, and if the tendon is at least 28 cm long, it can
be quadrupled and used alone as the ACL graft. If the ten-
don is less than 28 cm, the gracilis is harvested as well.
Number 5 permanent sutures are whipstitched at the free
tendon end(s), leaving 55 mm of graft centrally and ensur-
ing that sutures will occupy the entire length of the tibial
tunnel. The tendons (with sutures in place) are then placed
under 30 pounds of tension for 20 to 30 minutes.
Tibial Tunnel Location and Preparation
The senior author’s current preference for tibial tunnel
placement is to use the Howell guide, which effectively pre-
vents placing the tunnel where the ACL would impinge on
the notch in full extension or the posterior cruciate ligament
(PCL) in flexion. The diameter of the tibial tunnel is deter-
mined by passing the bundle of harvested tendons through
various sizers and then choosing a reamer 0.5 mm smaller
than the smallest sizer through which the graft will pass.
Sizing in this way provides a tight fit and secure fixation
in the tunnel and limits micromotion and secondary tunnel
widening. We also like to use a trephine or coring reamer
rather than a traditional reamer, which allows the harvest
of cancellous bone for later use in grafting the tibial tunnel
between the strands of tendon graft, prior to interference
screw placement.
Femoral Tunnel Location and Preparation
The optimum location of the femoral tunnel is in the poster-
omedial footprint of the native ACL, 1 to 2 mm anterior to
the back wall and about 45 degrees of external rotation from
vertical (i.e., approximately 10 o’clock on a right knee). The
2.4-mm forked femoral guide pin is passed through the tibial
tunnel (or the anteromedial portal) with the knee flexed at
least 90 degrees. The tip is placed no more than 2 mm ante-
rior to the posterior femoral cortex in the appropriate position.
An offset guide, such as the Stryker Femoral Aimer, may be
used if desired. If such a guide is used, it is necessary to flex
the knee beyond 90 degrees to allow the guide to sit flush
against the bone of the back wall of the notch. It is important
to note that when a Biosteon cross-pin is used for femoral fix-
ation, the posterior femoral cortex can be breached without
compromising fixation. Therefore, there is no reason not
to place the femoral tunnel as far posteriorly as desired.
270
However, if the posterior wall is compromised, either inten-
tionally or unintentionally, there are two important consid-
erations. First, it is desirable to orient the cross-pin parallel
to the transepicondylar axis or perhaps angled slightly ante-
riorly so as to ensure adequate bony support posterior to the
cross-pin. Second, the surgeon should consider reaming the
femoral tunnel deeper, especially if the tunnel was at all short
to begin with, because this will effectively place the cross-pin
more anteriorly, thereby increasing the thickness of bone pos-
teriorly (although at the expense of graft length, as discussed
earlier).
The femoral pin is advanced into the femur, out the
anterolateral femoral cortex, and then through the skin of
the anterolateral distal thigh. The femoral tunnel is then
reamed to a depth of 20 to 30 mm, depending on the sur-
geon’s preference, using the appropriate diameter of reamer
based on graft size. It may be preferable to drill a shorter tun-
nel, both to bring the fixation point closer to the joint and to
leave more graft length distally to allow more flexibility in tib-
ial fixation. Drilling a shorter femoral tunnel will also make it
more likely that a quadrupled semitendinosus tendon will
provide adequate length.
We then broach the anterolateral femoral cortex using a
4.5-mm cannulated drill over the guide pin, although this step
is optional. This allows easier passing of heavy sutures or suture
tape (our preference) later in the case as the graft is passed and
seated. However, the tip of the forked femoral guide pin does
have a larger diameter than the rest of the pin, which accom-
plishes some of the same effect, although to a lesser extent.
Once this step is completed, the 2.4-mm forked femoral guide
pin in retracted into the femoral tunnel under direct arthro-
scopic visualization so that it sits just above the level of the
wider portion of the tunnel (just inside the 4.5-mm portion
of the tunnel). This is done to prevent interference with the
transverse drill guide. The femoral pin is then secured at
the skin proximally to prevent accidental pullout.
Femoral Fixation
A transverse femoral index guide equal in diameter to the
femoral tunnel (or slightly smaller) is selected, and the
transverse drill guide is assembled. The transverse drill guide
is inserted through the tibial tunnel and into the femoral
tunnel to the desired depth. This step may also be accom-
plished through the anteromedial portal with the knee
hyperflexed (especially if the double-bundle technique is
employed). As with any guide pin system, it is important
not to change the degree of knee flexion once the femoral
guide pin is in place. The same principle applies when the
transverse drill guide is in the femoral tunnel; otherwise,
tunnel or instrument damage may occur. It should be noted
that the transverse drill guide places the Biosteon cross-pin
 Stryker Biosteon Cross-Pin Femoral Fixation for Soft-Tissue Anterior Cruciate Ligament Reconstruction
8 mm inferior to the tip of the transverse femoral index
guide; this offset is built into the guide system and requires
no adjustments on the part of the surgeon. For example, a
25-mm femoral tunnel will place the center of the Biosteon
cross-pin 17 mm from the aperture of the femoral tunnel,
through the loop of hamstring graft.
The transverse drill guide is aimed parallel or slightly
anterior to the transcondylar axis to protect the neurovascular
structures in both the posterior and medial aspects of the knee
and to ensure sufficient posterior bone support for the Bio-
steon cross-pin, as detailed earlier. A stab incision is created
laterally, and the transverse guide bullet is advanced gently
to bone. It is important to avoid forcing the bullet into posi-
tion against the lateral femoral cortex, as this can torque the
guide and lead to significant problems in later steps due to a
malaligned guide pin. If in doubt, simply ensure that the bul-
let slides freely in the drill guide, without regard for whether
or not it is seated on bone, because the alignment of the guide
is the critical factor. The bullet can be advanced down to bone
after the guide pin is in place for measuring purposes (see later
discussion). Once the guide bullet is in place, the 2.7-mm
transverse threaded guide pin is advanced through the bullet
from lateral to medial until it exits the skin medially
(Fig. 37-5). Use gentle pressure rather than forcing the drill
FIG. 37-5 With the transverse drill guide in position, the transverse guide
bullet is advanced into position, taking care not to alter the trajectory by
forcing the bullet against soft tissues or the femoral cortex. The 2.7-mm
transverse threaded guide pin is then driven across the femur and oriented
properly, as described in the text.
37
so to avoid misdirecting the pin. The guide pin should emerge
at or slightly posterior to the medial epicondyle.
The transverse guide bullet is calibrated, allowing a
measurement to determine the correct length of the Biosteon
cross-pin; this number is read directly from the outside of the
transverse drill guide, without any conversion or addition/
subtraction. This measurement system is designed to deter-
mine the distance from the lateral femoral cortex to 10 mm
beyond the medial wall of the femoral tunnel (assuming a tun-
nel diameter of 10 mm), thus providing ample medial bony
support for the cross-pin. In practical terms, the authors use
a 50-mm cross pin in all but the smallest knees (a 40-mm
pin is also available).
Once the transverse threaded guide pin is in place, the
transverse drill guide is removed. Direct arthroscopic visualiza-
tion into the femoral tunnel (through the tibial tunnel) allows
the surgeon to confirm that the transverse guide pin passes
through the center of the femoral tunnel (Fig. 37-6). With
the arthroscope still in the femoral tunnel, the 5-mm fluted
reamer is advanced over the transverse guide pin into the
femoral tunnel. In most patients the drill is advanced to a depth
of approximately 10 mm less than the length of the Stryker
cross-pin being used. Under direct visualization, this usually
corresponds to drilling just a few millimeters into the lateral
wall of the femoral tunnel. In patients with less dense bone, it
may only be necessary to perforate the lateral femoral cortex.
The Flexwire is then secured to the lateral end of the
2.7-mm transverse threaded guide pin already in position in
the femur. The threaded guide pin is then pulled out of the
femur medially, pulling the Flexwire into the femur and
FIG. 37-6 The transverse drill guide assembly ensures that the cross-pin
will bisect the femoral tunnel; this is confirmed arthroscopically.
271
 Anterior Cruciate Ligament Reconstruction
across the femoral tunnel. The threaded guide pin is
detached medially, and the Flexwire is secured on both sides
of the knee. With the arthroscope again looking into the
femoral tunnel for direct visualization, the surgeon advances
the 2.4-mm forked femoral guide pin back down the
femoral tunnel toward the scope and captures the Flexwire
with the forked end of the pin. (This step is made easier if
the femur is reamed to 4.5 mm all the way out of the ante-
rolateral cortex, as described earlier, which allows the
surgeon to have some control of the direction of the forked
pin while attempting to capture the Flexwire.) The pin and
wire are then advanced by hand into the joint and out
through the tibial tunnel (Fig. 37-7). (We opt here to
detach the camera from the arthroscopic sleeve, retracting
the camera and advancing the pin and wire into the sleeve
under direct vision. This prevents twisting and soft-tissue
impingement as the pin, wire, and sleeve are retracted
together through the joint and out the tibial tunnel.) It is
critically important to keep the Flexwire from twisting at
all times, especially once is it out of the tibial tunnel distally.
Twisting the Flexwire can be disastrous if unrecognized,
causing at best abrasion and weakening of the graft as it is
pulled into the tunnel and the Flexwire untwists, and at
worst breakage of the Flexwire and/or amputation of the
graft if the Flexwire is not untwisted prior to impacting
the cross-pin into position.
FIG. 37-7 The forked femoral guide pin is used to capture the Flexwire in
the femoral tunnel and deliver it at the distal tibia.
272
With the Flexwire and the forked femoral guide pin
protruding from the distal end of the tibial tunnel, the ham-
string (or other soft tissue) graft is looped over the Flexwire,
again taking care not to twist either the graft or the wire.
Next, a loop of polyester tape (our preference) or #5 suture,
which has previously been passed through the loop of ham-
string graft, is threaded through the eyelet at the end of the
forked femoral guide pin (Fig. 37-8). The forked femoral
guide pin is then pulled proximally through the tibial and
femoral tunnels and out the skin of the anterolateral thigh,
delivering the polyester tape or suture to the surgical assis-
tant. The assistant applies tension to the tape, and the graft
is advanced into the femoral tunnel to the maximum depth,
while at the same time, even tension is applied to both ends
of the Flexwire to pull it back up into the femoral tunnel to
form a straight line again. These two actions are performed
simultaneously, but the suture or tape must perform the
work of pulling the graft into the femoral tunnel. If tension
on the Flexwire is used to seat the graft, abrasion of the graft
and/or tunnel may occur. Once the ACL graft is in place,
the Flexwire should glide easily medially and laterally with
FIG. 37-8 The graft is then looped over the Flexwire and advanced into
the joint using the suture tape, which is passed through the forked femoral
guide pin and brought out through the skin proximally.
 Stryker Biosteon Cross-Pin Femoral Fixation for Soft-Tissue Anterior Cruciate Ligament Reconstruction
minimal resistance; this confirms that there is free passage
through the transcondylar tunnel and the loop of graft.
However, this maneuver should only be performed once so
as to avoid abrasion of the graft. After graft position is con-
firmed, one end of the tape or suture is cut and the other
end is pulled out of the thigh. This is done to avoid trapping
the tape or suture when the stepped insertion pin and sub-
sequently the cross-pin itself are passed, and also to facilitate
their passage.
The stepped insertion pin is then attached to the Flex-
wire laterally and advanced into the femur and through the
loop of graft in the femoral tunnel, leaving enough of
the pin protruding laterally to guide the cross-pin into posi-
tion. The Flexwire can then be detached from the pin medi-
ally, although this step is not necessary. The surgeon can
test graft position by tensioning the distal sutures, confirming
that the graft is looped over the rigid guidewire in the femoral
tunnel. The Biosteon cross-pin is then passed over the lateral
end of the stepped insertion pin and advanced by hand until the
cross-pin is seated against the shoulder of the stepped insertion
pin. The cannulated tamp is placed against the cross-pin and
used to advance it over the insertion pin (and thereby under
the graft) with a mallet until it is seated (Fig. 37-9). The
cross-pin is fully seated into the lateral condyle when the
shoulder of the tamp is flush with the lateral femoral cortex.
The stepped insertion pin is then removed medially.
Tibial Fixation
This topic is likewise covered in detail elsewhere, but we
would again like to mention a few points. Once femoral
fixation is complete, the knee is cycled through a full arc of
FIG. 37-9 The Stryker Biosteon cross-pin is inserted over the guide pin.
37
motion 20 times while steady tension is maintained on the
individual graft strands distally. This should help to eliminate
graft kinking and creep and thus increase graft rigidity. In
addition, this helps set the sutures in the distal graft strands
and eliminate any areas of laxity, which again should result
in more predictable and reproducible tensioning. The senior
author’s current preference for tibial fixation is a Mitek Intra-
Fix sheath (bioabsorbable) with a Biosteon interference screw
and an Interlock bioabsorbable pin across the sheath/screw.
These implants should never be prominent or symptomatic,
thereby obviating the need for implant removal. Again, we
prefer to bone graft the tibial tunnel prior to distal fixation.
When using the previously mentioned implants, hardware
removal should never be necessary for symptomatic reasons.
POSTOPERATIVE CARE
A brace locked in full extension is applied in the operating
room. A physical therapist instructs the patient in the recov-
ery room in appropriate exercises such as quad sets and
straight leg raises to maintain quadriceps tone. The patient
is typically non–weight bearing and immobilized for the first
postoperative week for comfort. The brace is unlocked at 7
to 10 days postoperatively, and range of motion exercises
are begun according to our customized protocols. Because
of the stability of the fixation with the Stryker Biosteon
cross-pin and tibial fixation described earlier, the patient
may advance to full weight bearing by approximately post-
operative week 3. Patients may swim in the second month,
bike in the third, run straight ahead in the fifth, and return
to sport at 7 to 8 months.
273
 Anterior Cruciate Ligament Reconstruction

Our rehabilitation program is fairly aggressive for a
soft-tissue graft, due to the excellent initial stability provided
by the fixation. However, one should keep in mind that
soft-tissue–bone healing still takes considerably longer than
bone–bone healing.
BIOMECHANICAL PERFORMANCE OF STRYKER
BIOSTEON CROSS-PIN
The Biosteon cross-pin was tested for pullout strength and
mode of failure at an outside laboratory in a porcine model.
In the porcine model, the average maximum load was
1217.8N, whereas the average yield load was 1052.9N. This
compared favorably with the Arthrex Bio-TransFix (PLA)
pin, which had significantly lower values in both categories.
Displacement at yield load averaged 11.56 mm for the Stryker
implant, which was similar to the Arthrex implant. (Please see
Fig. 37-10 for full details.) Of note is the fact that a higher
percentage of the Arthrex ACL reconstructions failed via
graft failure at the proximal end, which could be attributed
to the fact that the Arthrex implant has a 5-mm diameter
compared with the 6-mm diameter of the Stryker implant,
which should create less of a stress riser on the graft as it
loops over the implant. In keeping with this trend, a greater
proportion of the Stryker implants actually broke, as opposed
to the grafts failing, although again this was at a higher load.18
RESULTS
The senior author performed 82 ACL reconstructions using
the Stryker cross-pin and reported early results (2- to 3.3-year
follow-up). Of the 82 patients, 30 had acute injuries and 52
had chronic ACL deficiency. The ACL was the only ligament
injured in 53 patients, whereas 20 patients also had a medial
collateral ligament (MCL) injury, six patients had concomi-
tant patella dislocation, and three patients had lateral
ligamentous injury as well. The average age was 28 years,
and 47 were male, whereas 35 were female. Patients followed
the postoperative protocol described earlier. Complications
included deep infection (1), superficial infection (2), deep
venous thrombosis (1), loss of motion requiring manipu-
lation (2), and saphenous nerve paresthesias (1). In terms of
graft stability and survival, one patient had traumatic
graft rupture, two patients had a positive pivot shift, and eight
patients had a positive pivot glide. KT-1000 measurements
showed an average translation with 20 pounds of force of
1.3 mm, with an average maximum translation of 1.7 mm.
Eighty-four percent of patients had a maximum KT-1000
translation of less than 3 mm, 16% had 4 to 5 mm, and 5%
had more than 5 mm. Range of motion results included an
average extension loss of 0 degrees (range –5 to 7 degrees) and
an average flexion loss of 8.2 degrees (range 0 to 10 degrees).
CONCLUSIONS
The Stryker Biosteon cross-pin achieves many of the previ-
ously unattainable goals in soft-tissue ACL fixation on the
femoral side. Rigid initial fixation, which is resistant to
cycling, is obtained. The fixation is placed relatively close
to the intraarticular portion of the graft, thereby effectively
shortening graft length and minimizing the potential for
creep and tunnel widening. A good press-fit is obtained,

1400
Stryker
1200 Arthrex

1000

800
N

600

400

200

0
Maximum load Yield load

Displ. @ Displ. @
Cross-pin Max load max load Yield load yield load
brand (N) (mm) (N) (mm)

Mean 1217.8 15.37 1052.9 11.56

Stryker
SD 234.4 2.94 296.7 2.73
Mean 934.5 11.53 890.6 10.27 FIG. 37-10 Data from testing in a
Arthrex
SD 177.8 2.43 212.8 2.49 porcine model.

274
 Stryker Biosteon Cross-Pin Femoral Fixation for Soft-Tissue Anterior Cruciate Ligament Reconstruction 37
TABLE 37-1 Potential Pitfalls and Solutions
Problem Solution

Posterior wall disruption No compromise in fixation, as long as cross-pin is oriented properly (parallel to
transepicondylar axis or angled slightly anteriorly). Consider making the femoral tunnel
slightly deeper to ensure adequate bone support posterior to the cross-pin.

Difficulty capturing Flexwire with forked femoral As part of femoral tunnel preparation, overdrill with a 4.5 reamer all the way through the
guide pin femur and out the anterolateral cortex, which will allow some control of the direction of the
forked guide pin while trying to capture the Flexwire.

Twisting of Flexwire (can cause breakage of Flexwire Prevent this by bringing the Flexwire down through the tibial tunnel under direct
and/or amputation of graft) visualization with the arthroscope. After the graft is pulled into the femoral tunnel, confirm
that no twist is present by checking that the Flexwire slides back and forth easily across the
femur (once only to avoid graft abrasion).

Damage to forked femoral guide pin (by either the Ensure the pin is withdrawn far enough proximally so that the tip is completely out of the
transverse threaded guide pin or the step drill) femoral tunnel but still in the femur (under direct arthroscopic visualization through the
tibial tunnel).

Difficulty passing stepped insertion pin and/or cross-pin
(implant)
When drilling with the step drill, make sure to penetrate all the way into the femoral tunnel,
and then touch the tip of the drill bit against the far (medial) side of the tunnel to create a
small divot to assist the stepped insertion pin, and later the actual implant, in finding the
path. If the stepped insertion still will not pass, you may tap gently with a mallet while
maintaining tension on the Flexwire from the medial side.

which should serve to promote graft–bone healing. A bioab-
sorbable implant material is used, which promotes bony
healing in addition to simplifying revision surgery. Finally,
anatomical graft placement is possible, and fixation is not
compromised by posterior wall blowout. We believe that
these factors represent a significant advancement in soft-tissue
ACL reconstruction, bringing it closer to the gold standard
of bone–patellar tendon–bone reconstruction in terms of
stability and healing while maintaining the advantages of less
morbidity (see Table 37-1 for pitfalls and solutions).
References
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15. Lowe WR, Noble P. Unpublished data.
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Anterior Cruciate Ligament Reconstruction
Utilizing the Rigidfix for Femoral-Sided
Fixation
BACKGROUND
Graft selection for anterior cruciate ligament
(ACL) reconstruction has been debated in the
literature.1 Historically, the debate has been
regarding the use of soft tissue grafts secondary
to increased laxity as compared with patellar ten-
don autografts.2 The point of concern occurred
at the site of graft fixation with soft tissue grafts,
and the issues were “suspensory” fixation and
creep with cyclical loading. Improved fixation
techniques have largely eliminated the historical
differences in laxity comparing quadrupled
hamstring tendon with bone–patellar tendon–
bone (BPTB) autografts.3 It has been well
documented in recent literature that the two
graft types have similar success rates.4–6 Some
potential advantages of soft tissue grafts include
decreased kneeling pain, decreased patellar
tendonitis, lower risk of postoperative patella
fracture, and improved cosmesis with a smaller
incision for harvest.1
The patellar tendon graft, with bone plugs
on each end, has classically been fixed with a
metal interference screw in the tibia and femur
with near-aperture fixation. This fixation was
sufficiently rigid to prevent significant graft slip-
page or creep. The patellar tendon graft became
the gold standard by which all other grafts and
graft fixation systems were compared.1 Despite
the increased laxity with hamstring tendon
reconstructions, this technique gained popular-
ity as patients complained of significant anterior
knee and kneeling pain with patellar tendon
38
CHAPTER
autografts. The potential for patellar fracture John Richmond
also exists. Hamstring tendon autografts have
Michael Kuhn
less morbidity, although they do demonstrate
some permanent hamstring weakness at high
flexion angles.7 The clinical significance of this
weakness remains unclear.
A quadrupled hamstring tendon graft has
two significant biomechanical advantages. First,
quadrupled hamstring grafts have a larger cross-
sectional area when compared with patellar tendon
grafts.7 The larger cross-sectional area results in
more collagen and thus a stronger graft. The ulti-
mate tensile strength of a quadrupled hamstring
autograft is 4140N with a stiffness of 807
N/mm. This is compared to the patellar graft at
2977N and 455 N/mm, respectively. The native
ACL has been tested at 2160N and 242 N/mm,
respectively.1 Second, hamstring tendon grafts
require smaller bone tunnels than do grafts with
bone plugs. These grafts heal circumferentially
to the tunnel wall if the interference screw is
eliminated. These advantages fueled the search
for better soft tissue graft fixation devices.
The historical poor performance of soft
tissue grafts cannot be compared with today’s
graft fixation. Initial studies compared doubled
hamstring tendons to patellar tendons. A qua-
drupled soft tissue graft is the optimal choice
when hamstring tendons are used. Studies of
soft tissue graft fixation preceded the use of
transfixion devices. Kousa et al8 tested the pull-
out strength of the soft tissue fixation devices
that are currently most used for hamstring
grafts. On the femoral side, the Bone Mulch
277
 Anterior Cruciate Ligament Reconstruction

Screw (Arthotek, Warsaw, IN) (1112N), Endobutton-CL
(Smith & Nephew, Endoscopy Division, Andover, MA)
(1086N), and Rigidfix (Depuy Mitek, Westwood, MA)
(868N) systems had the best fixation for soft tissue grafts.8
These were significantly stronger than patellar tendons
fixed with an endoscopic interference screw (588N). On
the tibial side, the fixation is much more secure. The Intra-
Fix (Depuy Mitek) (1332N) and WasherLoc (Arthrotek)
(975N) both had higher pullout strengths than a patellar
tendon bone plug fixed with a metal interference screw
(758N, 9-  30-mm screw). Interference screws for soft
tissue grafts are weaker, with pullout strengths from 201N
to 665N depending on the system.8
The improved fixation systems for hamstring tendons,
combined with strength and stiffness superior to the native
ACL, make this an attractive graft option. One must chal-
lenge any concept of a BPTB autograft as the gold standard.
Patient factors and desires and the surgeon’s preference
should dictate which graft is chosen. Surgeons completing
ACL reconstructions should be well versed in both techni-
ques. Allograft reconstruction offers an additional soft tissue
option. For those surgeons or patients desiring an allograft
source, the tibialis anterior tendon has an ultimate tensile
strength of 4122N and is an attractive alternative.9 We also
use the technique described here when an allograft tibialis is
selected.
tendons. This is palpable in most patients, but when not
palpable, the middle of the tibial tubercle can be used to
estimate its location. An oblique, skin-fold incision is used
for graft harvest. This incision parallels the gracilis tendon.
This incision is approximately 3 cm in length and is
centered over the anterior border of the medial collateral
ligament (Fig. 38-1). This is generally 4 to 5 cm medial to
the tibial tubercle. Both arthroscopic portals and the
harvest incision are injected with 5 to 10 mL of 1%
lidocaine with epinephrine for the hemostatic effect.10
After the skin incision is made and subcutaneous soft
tissues mobilized, the intersection of the anterior border of
the medial collateral and the superior border of the sartorius
fascia is marked with electrocautery (Fig. 38-2). The main
advantage of this starting point is that it allows a relatively
horizontal femoral tunnel in the coronal plane when the
femoral tunnel is drilled through the tibial tunnel. Vertical
grafts in the coronal plane have been associated with
increased anterior laxity and functional instability. In order
to locate this landmark later in the procedure, the electro-
cautery is used to make a cruciform periosteal incision that
exposes enough of the tibia for the tibial tunnel drill site.

SURGICAL TECHNIQUE
Patients undergoing ACL reconstruction are treated in the
outpatient surgical suite. General anesthesia is combined with
the intraarticular injection of a local anesthetic containing
epinephrine to obviate the need for a tourniquet. The leg
holder is positioned in as proximal a position on the thigh as
possible so as to allow more than 100 degrees of flexion during
graft tunnel preparation and graft passage if necessary.
A well-padded tourniquet is placed on the upper thigh. It is
not routinely inflated during the procedure in order to mini-
mize quadriceps inhibition postoperatively. An examination
under anesthesia is performed prior to final positioning.
The knee is initially prepped with povidone-iodine
(Betadine) and injected with 60 mL of 1% lidocaine with
epinephrine (1:100,000). The injection is performed later-
ally adjacent to the superior lateral portion of the patella.
During the injection, a fluid wave should be visualized
medially, which ensures that a fat pad injection has not
occurred. The hemostatic effect would largely be lost with
a fat pad injection. The knee is then prepped and draped
with standard arthroscopy drapes.
FIG. 38-1 Preparing the skin incision for graft harvest. An oblique incision
Surgical landmarks are identified and marked on the allows for easy harvest visualization, tunnel preparation, and a good
skin, including the superior border of the pes anserine cosmetic result.

278
 Anterior Cruciate Ligament Reconstruction Utilizing the Rigidfix for Femoral-Sided Fixation
FIG. 38-2 Cruciform periosteal incision marking the site of tibial tunnel
entry point.
The hamstring tendons are harvested after identifying the
gracilis and semitendinosus tendons. It is our preference to
used a closed loop tendon stripper to remove the tendons
after freeing all palpable slips to the gastrocnemius and
dissecting the tendon off the tibia, including Sharpey fibers.
Once the tendons are harvested, they are passed to the
back table for preparation. The gracilis and semitendinosus
tendons are looped on a suture, creating a four-bundled
graft (Fig. 38-3). The free ends of the tendons are sutured
with #2 Orthocord (Depuy Mitek) in Krackow-type suture
configuration. This is performed in the event that secon-
dary fixation is desired in the tibia. Graft length is generally
not an issue, but a minimum graft length of 10 cm, once
quadrupled, ensures adequate soft tissue for fixation and
ingrowth within the tibia and femur. The proximal end
is sutured together with #2 Orthocord for a distance of
3 cm. Each individual graft strand is incorporated to ensure
the creation of a single proximal mass. This is helpful to
FIG. 38-3 Graft preparation for Rigidfix. The proximal segment is sutured
between strands to ensure capture by the implant.
38
facilitate capture of the graft strands with the Rigidfix pins.
Once suturing is complete, the graft is sized using a closed
graft-sizing block, with 0.5-mm increments. The femoral
side should fit snugly through the sizing block. The tibial
side of the graft should freely pass through the sizing block.
This, with the additional material of the Krackow sutures,
often creates a 0.5 to 1.0 mm difference between the tibial
and femoral tunnels. Finally, the graft is marked with a
surgical pen 30 mm from the femoral tip of the graft. This
allows intraarticular visualization of proper graft seating
once it is passed. The graft should be kept under 12 to
15 pounds of tension on the back table until inserted.
Simultaneously with graft preparation, the joint is
examined and prepared. Two standard arthroscopic portals
are established. A diagnostic arthroscopy is performed,
treating any additional pathologic lesions that are encoun-
tered. The ACL stump and remnant tissue are removed,
clearly identifying the femoral and tibial footprints. Once
the soft tissue is removed from the notch, the need for a
notchplasty is assessed. A minimal notchplasty is performed
to identify the over-the-top position, widen the notch to
accommodate the graft, and ensure that the graft will not
impinge in full extension. Following completion of the
notchplasty, the posterior compartment can be more easily
visualized to ensure that no meniscal fragments or loose
bodies remain.
At this point, the ACL tibial guide is inserted. The
ideal position for the guide is on the lateral downslope of
the medial tibial spine, approximately 7 mm anterior to
the posterior cruciate ligament (PCL).5 Once the tip is
firmly seated, correct anteroposterior positioning can be
confirmed. The tunnel should be directly medial to the mid-
point between the insertions of the anterior and posterior
horns of the lateral meniscus. The tip of the “bullet” portion
of the guide is then placed on the previously marked
junction of the anterior border of the medial collateral
ligament and the superior border of the pes tendons on
the anteromedial flare of the tibia. The tunnel length is
noted and should be at least 30 mm in length. The angle
on the ACL tibial guide should be set at approximately 55
degrees. Care is taken not to allow the tip of the bullet to
move in a superior direction. If this occurs, an excessively
flat and short tibial tunnel will be created. This may
compromise both graft fixation and positioning of the
femoral tunnel using the endoscopic transtibial approach.
For this reason, the bullet is positioned within a few
millimeters of the superior border of the sartorius fascia.
A guide pin is drilled through the tibial tunnel guide.
Once the pin emerges through the tibial footprint, the drill
guide is removed and a hemostat is introduced through the
medial portal and clamped to the tibial pin. The tibial tun-
nel is drilled to the predetermined size while maintaining
279
 Anterior Cruciate Ligament Reconstruction
pressure on the guide pin in a posterior direction using the
hemostat. This prevents anterior migration of the intraarti-
cular entry point as the drill penetrates into the joint ante-
rior to the pin. The tunnel is then dilated 0.5 mm greater
in diameter than the graft, allowing smooth graft passage.
The posterior rim of the intraarticular tibial tunnel is
inspected. Soft tissue flaps and any bony fragments are dé-
brided to ensure a smooth surface for the graft in order to
minimize abrasion at the tunnel entrance into the joint.
The femoral over-the-top guide is selected. A 1-mm
posterior wall is desired. Thus the offset guide should be
1 mm larger than half the diameter of the femoral end of
the graft. The correct offset guide is placed through the
tibial tunnel and positioned in the over-the-top position.
The knee should be placed in 65 to 70 degrees of flexion
for drilling of the femoral tunnel. If the guide is not easily
positioned with the knee in this position, the knee may be
slightly extended for guide placement and then gently
flexed into desired position.
Graft positioning in the femur plays a large role in
successful reconstruction. The goal is to obtain as horizontal
a graft as possible in the coronal plane. The femoral guide
should be positioned as far from the 12-o’clock position as
possible. The ideal positions to aim for are the 10:00 to
10:30 positions (on the clock face) for a right knee or 2:00
to 2:30 position for a left knee (Fig. 38-4). If this cannot
be created through the tibial tunnel, the femoral guide can
be placed through the medial portal and the tunnel drilled
through this approach. If access through the medial portal
FIG. 38-4 Identify the femoral point, and make a tunnel through the tibial
tunnel when possible, reaching a depth of 30 mm. (Reproduced with
permission by Depuy Mitek.)
280
is required, the knee should be flexed to 110 degrees to
ensure adequate bone for the femoral socket. Care should
be taken to not allow the guide to slip anteriorly and to
ensure the post remains in the over-the-top position. If
anterior slippage were to occur, the femoral tunnel would
be placed too anterior, drastically increasing the risk of graft
failure. The Beath pin is drilled through the femoral guide
through both cortices, but not through the skin of the lateral
thigh. It should be palpable below the skin, allowing for easy
retrieval if necessary. An acorn drill is used to create the
femoral socket to a depth of 35 mm. This depth will allow
30 mm of the graft to be seated in the socket. In smaller
and female patients, the cortex may be encountered prior
to 35 mm. As long as the drill has penetrated 25 mm, we
accept that as the depth because two Rigidfix pins can still
be placed to engage the graft. Bone and soft tissue debris
are removed from the femoral socket and notch.
The appropriate-sized cannulated femoral rod is then
attached to the cross-pin frame from the Rigidfix system
and is inserted into the femoral tunnel over the Beath pin.
Once it is fully seated, the Beath pin is removed (Fig. 38-
5). If working through the tibial tunnel, the next step is to
determine the exact position of joint flexion that provides
the least resistance to rotation of the cross-pin guide frame.
This step is crucial because knee flexion has often changed
subtly since the femoral tunnel was drilled. Flexing and
extending the knee a few degrees while rotating the guide
frame permits the surgeon to determine which position of
the knee allows the cross-pin guide frame to rotate freely
and aligns the outrigger properly. This facilitates accurate
position of the cross-pin sleeves and decreases the chance
that one of the cross-pins will not penetrate the graft. If
the guide is properly aligned, it should be nearly parallel to
the floor.
FIG. 38-5 Position the Depuy Mitek Rigidfix femoral guide. Note that the
arm of the guide is positioned lateral to the knee. (Reproduced with
permission by Depuy Mitek.)
 Anterior Cruciate Ligament Reconstruction Utilizing the Rigidfix for Femoral-Sided Fixation 38

FIG. 38-6 Introduce the guide, and then drill the two cannulated sleeves.
(Reproduced with permission of Depuy Mitek.)

FIG. 38-7 Arthroscopic inspection of the location of the Rigidfix drill holes.
A cross-pin sleeve is then placed over the interlocking (Reproduced with permission of Depuy Mitek.)
trocar. The distal hole in the cross-pin frame is drilled first
(Fig. 38-6). The interlocking trocar is drilled until the cross- cylindrical tunnel and complete fill with a 30-mm graft. As
pin sleeve is fully seated in its hole on the cross-pin guide previously mentioned, a 25-mm tunnel (20 mm of graft) can
frame. A small mallet is then used to gently tap the drill to be accepted. The Rigidfix outrigger is designed with 11 mm
disengage the interlocking trocar from the cross-pin sleeve. of bone distal to the more caudal pin, allowing excellent fixa-
When it is disengaged, the user will see that the small inter- tion through a shorter socket. The first cross-pin is then
locking pin on the trocar is no longer engaged with the inserted using the stepped pin insertion rod and tapped with
sleeve. At this point, the trocar may be removed by spinning a small mallet until it is fully seated. Increased resistance
the drill. The observation of good fluid flow from the occurs as the pin is tapped across the graft. The proximal
sleeve indicates central positioning of the pin in the pin is inserted first. Once it is placed, distal tension of
tunnel. This process is repeated through the proximal slot approximately 25 pounds is applied across the graft. This
on the outrigger. ensures that both pins will share the load. The distal pin is
At this point, the cross-pin guide frame is disassembled then inserted (Fig. 38-8). The cross-pin sleeves are then
and removed. The arthroscope is removed from the portal and removed. It is crucial to cycle the knee to take up any
is inserted through the tibial tunnel into the femoral socket to
inspect the cross-pin holes. They should be centered in the
tunnel. Passage of guide pins or nitinol wires through the
sleeves should be preformed to identify their positions
(Fig. 38-7). If only one is centered, we accept this as an
acceptable fixation and insert both pins. If neither is correctly
placed, graft fixation may not be adequate. At this point, an
alternative type of femoral fixation should be employed. It is
our preference to use a Milagro bioabsorbable screw, 1 mm
over the diameter of the femoral socket. The Beath pin is
now reinserted through the femoral tunnel and out through
the skin on the lateral thigh. The suture on which the graft
was looped is then retrieved and used to pass the graft. The
cleft between the strands on the graft should be directed from
the anterior to the posterior planes so that the Rigidfix pins
will pierce all four arms of the quadrupled graft. The graft is
then pulled so that the 30-mm pen mark just enters the fem-
FIG. 38-8 Femoral fixation with two Rigidfix absorbable pins. The proximal
oral tunnel. The tunnel was ideally drilled to 35 mm because pin is inserted first and the distal pin second. (Reproduced with permission
the tip of the drill is tapered 5 mm, resulting in 30 mm of of Depuy Mitek.)

281
 Anterior Cruciate Ligament Reconstruction
creep that might occur. We routinely use 25 cycles from 0 to
90 degrees with 25 pounds of force using a tensioner.
The tibial side is then fixed using the IntraFix sheath
and screw device. The technique for this implant is covered
in Chapter 47. Once the graft is fixed on the tibial side, it is
again examined arthroscopically. It is placed through a range
of motion and checked in full extension to ensure a lack of
impingement. The graft is probed to visually check proper
tension.
TROUBLESHOOTING
Pitfalls may develop at any of several steps in the Rigidfix
technique.
The most common pitfall arises in placing the sleeves
into the femur using the outrigger guide. If the trocar pin
and sheath are drilled into the bone but will not advance to
seat fully, be sure that you have removed the Beath pin
because this prevents advancing the trocar through the guide.
If the Beath pin has been removed and the sheath and trocar
will not advance, it is likely that you have changed the angle
of the joint enough to slightly deform the guide. Oftentimes
the trocar tip will slide into the slot in the guide. Unfortu-
nately, it may also slide off the guide, making the hole for
the pin too eccentric to effectively capture the graft. If this
occurs and the sleeve has good purchase in the femur, as you
visualize the hole with the arthroscope inserted through
the tibial tunnel into the femoral socket, you can redirect the
trocar and sleeve to be more central in the socket. If this
cannot be done, you can remove the sleeves and replace
them after deepening the socket by 8 mm.
Removal of the femoral rod may sometimes be diffi-
cult. When this happens, it is usually caused by the step
between the shaft of the rod and the wider portion from
the femur catching on the tibial tunnel. Changing the flex-
ion angle of the knee to match the angle when the femoral
socket was drilled and pushing the tibia posteriorly will
allow the rod to slide out of the joint.
Two key points for optimal functioning of this system
are a snug fit (using 0.5 mm tolerance) of the graft and
sutures into the femoral socket and cycling the graft under
tension multiple times before fixing the tibial side in order
to reduce potential creep from this system. Because the graft
is not looped over the pins but rather is skewered by them
and compressed against the socket walls, there is the poten-
tial for excessive creep in the early postoperative course if
these steps are not followed.11 In this study, which was done
without cycling the graft prior to testing, 5 mm of creep was
found in the first 100 cycles, a large contrast to the manu-
facturer’s data indicating less than 2 mm of creep over
1000 cycles (assuming adherence to these details).
282
It is important to tension the graft at or near full
extension in order to ensure that the knee does come to full
extension in the operating room. The combination of these
fixation devices, Rigidfix and IntraFix, results in a construct
with very little creep under cyclical loading, and fixing
the tibial side with 30 degrees of flexion may lead to
overtensioning of the graft.
POSTSURGICAL CARE
Immediately postoperatively a hinge brace is applied, with
the hinges locked in extension. Icing is helpful for control of
pain and swelling. We stress early full extension and have
the patient keep the brace on, locked in extension at all times
during the first week, with the exception of 6 hours per day in
a continuous passive motion (CPM) machine. Ambulation
with weight bearing as tolerated is allowed from day 1, with
the brace locked in extension. We maintain this weight-
bearing protocol for a full 4 weeks after surgery but encou-
rage brace removal after week 1, at any time when the patient
is not weight bearing for motion and isometric strengthening.
The CPM is discontinued after the 1-week postoperative
visit, and formal physical therapy is begun. Quadriceps
strengthening is carefully progressed under the supervision
of the therapist for the first 4 months. Proprioceptive and
agility training are delayed to the 4-month mark, and unre-
stricted return to athletics is permitted when 6 months has
passed, if the thigh musculature is fully rehabilitated.
RESULTS
This system for soft tissue ACL reconstruction, Rigidfix
and IntraFix, reliably results in stable knees with 3 mm or
less increased translation by KT-1000 at maximal manual
pull in our early (2-year) follow-up. Endpoints on drawer
and Lachman tests are high pitched. This system offers
360 degrees of circumferential fixation, which is radiolucent
and absorbable. All these factors make soft tissue ACL
reconstruction an attractive and reproducible procedure.
References
1. Yunes M, Richmond JC, Engels EA, et al. Patellar tendon versus
hamstring tendons in ACL reconstruction: a meta-analysis. Arthros-
copy 2001;17:248–257.
2. Brand J, Weiler A, Carborn DN, et al. Graft fixation in cruciate liga-
ment reconstruction. Am J Sports Med 2000;28:761–774.
3. Pinczewski LA, Deehan DJ, Salmon LJ, et al. A five-year comparison
of patellar tendon versus four-strand hamstring tendon autograft for
arthroscopic reconstruction of the anterior cruciate ligament. Am J
Sports Med 2002;30:523–536.
 Anterior Cruciate Ligament Reconstruction Utilizing the Rigidfix for Femoral-Sided Fixation
4. Goldblatt JP, Fitzsimmons SE, Richmond JC, et al. Reconstruction of
the anterior cruciate ligament: meta-analysis of patellar tendon versus
hamstring tendon autograft. Arthroscopy 2005;21:791–803.
5. Fu FH, Bennett CH, Latterman C, et al. Current trends in anterior
cruciate ligament reconstruction. Part I: biology and biomechanics of
reconstruction. Am J Sports Med 1999;27:821–830.
6. Fu FH, Bennett CH, Ma CB, et al. Current trends in anterior cruciate
ligament reconstruction. Part II: operative procedures and clinical cor-
relations. Am J Sports Med 2000;28:124–130.
7. Spindler KP, Kuhn JE, Freedman KB, et al. Anterior cruciate liga-
ment reconstruction autograft choice: bone-tendon-bone versus ham-
string. Am J Sports Med 2004;32:1986–1995.
38
8. Kousa P, Jarvinen TL, Vihavainen M, et al. The fixation strength of six
hamstring tendon graft fixation devices in anterior cruciate ligament
reconstruction. Part I: femoral site. Am J Sports Med 2003;31:174–181.
9. Donahue TL, Howell SM, Hull ML, et al. A biomechanical evalua-
tion of anterior and posterior tibialis tendons as suitable single-strand
anterior cruciate ligament grafts. Arthroscopy 2002;18:589–597.
10. Raffo CS, Richmond JC. Hamstring anterior cruciate ligament recon-
struction with rigid, 360-degree, near-aperture fixation. Tech Orthop
2005;20:1–5.
11. Ahmad CS, Gardner TR, Groh M, et al. Mechanical properties of
soft tissue femoral fixation devices for anterior cruciate ligament recon-
struction. Am J Sports Med 2004;32:635–640.
283
 SUB PART III INTERFERENCE SCREW–BASED

39
CHAPTER
Hamstring Tendon Interference Screw
Fixation

Michael Wagner BIOMECHANICAL AND BIOLOGICAL
Andreas Weiler CONSIDERATIONS
The concept of interference screw fixation
involves the parallel insertion of the screw to the
graft in the tunnel, which allows compression of
the graft to the bony tunnel wall and biological
graft incorporation. Graft fixation using interfer-
ence screws presents the “gold standard” when
using a bone–patellar tendon–bone (BPTB)
graft. This type of fixation combines high initial
construct stiffness and early bony graft incor-
poration.1 These factors are generally required
to allow for an accelerated rehabilitation, which
has been demonstrated to improve clinical out-
come.2 Soft tissue grafts, however, do not provide
attached bone blocks for interference fit fixation.
Additionally, tendon–bone healing generally
takes longer for bony graft incorporation com-
pared with bone–bone healing (4 to 6 weeks ver-
sus 6 to 12 weeks).3–7 Thus fixation of soft tissue
grafts requires improved mechanical and
biological boundary conditions for graft fixation
compared with grafts with attached bone blocks.
Biomechanical Boundary
Conditions
Ideally, a graft fixation construct should be simi-
lar in strength and stiffness to the native human
anterior cruciate ligament (ACL). Current
fixation techniques demonstrate a wide range of
in vitro measured graft fixation loads (200N to
1200N). However, today evidence is still limited
regarding real in vivo requirements for initial
construct strength.8 Noyes et al calculated that
the ACL is loaded up to 454N during activities
of daily living,9 but other authors reported a high
amount of good and excellent results with
fixation types whose failure load is far below
that anticipated value.10–12 For soft tissue graft
fixation using biodegradable interference screws,
failure loads of 250N to 800N have been
demonstrated depending on screw length and
insertion torque.13–15
Graft fixation generally is divided into
anatomical (aperture or joint line fixation), non-
anatomical, and semi-anatomical (Fig. 39-1),
according to the location of fixation in relation
to the joint line. Graft fixation directly at the joint
line (site of the native ACL insertion) is called
anatomical, whereas an extracortical fixation
(e.g., staples, fixation buttons) is called non-
anatomical. For example, transfixation devices or
tibial interference screws that are not deeply
inserted provide an intraosseous and thus a
semi-anatomical mounting of the graft.
This classification is important because
the site of graft fixation determines the length of
the complete graft fixation construct. The length
of the native ACL is between 2.8 and 3.7 cm.
Reconstruction of the anteromedial bundle of the
ACL results in an intraarticular graft length of
only approximately 2.5 to 3.2 cm. Using femoral
and tibial nonanatomical fixation devices, the
length of the graft fixation construct can easily
reach 10 to 15 cm (see Fig. 39-1). In correlation
to the distance between the fixation devices,
reversible elastic longitudinal deformations of

284

A B C ligament insertion). The first zone comprises the ligament,
FIG. 39-1 A, Nonanatomical and indirect femoral and tibial fixation;
B, anatomical and direct femoral and semianatomical and direct tibial
fixation; C, anatomical and direct femoral and tibial fixation.
the graft have been demonstrated. This phenomenon also is
known as the “bungee-cord effect.” Furthermore, sagittal
intratunnel graft motion (reversible) might occur due to antero-
posterior translation of the graft during knee flexion and exten-
sion using a nonanatomical or semianatomical graft fixation
technique (“windshield-wiper effect”).15,16 Thus a long dis-
tance between the femoral and tibial fixation device results in
low construct stiffness and graft–tunnel motion.
Additionally, indirect and direct graft fixation should
be distinguished (see Fig. 39-1). The concept of indirect
graft fixation implicates the use of linkage material between
graft and fixation device (e.g., suture loop of Endobutton
fixation), whereas direct fixation means anchoring of the
graft without any additional material except the fixation
device itself (e.g., interference screws, staples, transfixation
devices). Longitudinal irreversible graft deformation might
occur using indirect fixation techniques due to stretch-out
of linkage material (e.g., suture loop of Endobutton fixa-
tion) or suture attachment at the graft tissue.13,17,18
Longitudinal and sagittal graft–tunnel motion inhibits
constant graft–tunnel contact at the tunnel entry site and
thus compromises bony graft incorporation at the site of
the native ACL insertion.5,19 Furthermore, graft–tunnel
motion might lead to graft laceration at the tunnel entry site
during dynamic loading20 and is a factor responsible for the
development of tunnel enlargement.16 Although current lit-
erature is not consistent concerning the correlation between
tunnel enlargement and postoperative knee stability16,21,22
in revision ACL reconstruction, tunnel enlargement is of
clinical importance and should therefore be prevented.
According to these considerations, interference screw
fixation offers high construct stiffness and prevents intra-
tunnel graft motion because it allows for direct and anato-
mical graft fixation at the level of the joint line combined
with adequate initial fixation strength.5,23 Recent clinical
data support the belief that clinical outcome can be
improved with anatomical joint line fixation using interfer-
ence screws for hamstring tendon grafts.24
Hamstring Tendon Interference Screw Fixation 39
Biological Boundary Conditions
In addition to correct tunnel placement, graft incorporation
represents the main factor for long-term survival of an ACL
reconstruction and is mainly influenced by the type of
fixation. The surgical target is to create biological (and
biomechanical) boundary conditions that allow for the resti-
tution of a native ACL insertion site anatomy.5 The normal
ACL insertion site consists of four zones (so-called direct
the second is characterized by fibrocartilage, the third zone
consists of a mineralized cartilage tidemark, and the fourth
is where the mineralized cartilage tidemark inserts into the
subchondral bone plate.5 The design of this complex insertion
anatomy allows distribution of longitudinal and shear forces
from the ligament into the subchondral bone plate. The
development of a direct ligament insertion at the level of the
joint line has been demonstrated histologically in an animal
model using anatomical soft tissue graft fixation with com-
pression at the tunnel entry site (interference screws).25
In contrast, the use of a nonanatomical fixation technique in
the same model showed the development of an indirect type
of ligament insertion or only a delayed formation of a direct
type of insertion.25 In indirect insertions, the surface of the
ligament connects with the periosteum whereas the deeper
layers connect to bone via Sharpey fibers (e.g., medial collat-
eral ligament). This is of inferior mechanical competence
compared with the direct ligament insertion.5
Thus it is reasonable to assume that neutralization of
graft-tunnel motions using anatomical and direct interfer-
ence screw fixation obviously improves osseous graft incor-
poration by means of the development of a native ACL
insertion anatomy.25
Interference Screws
Metallic interference screws initially were developed for
fixation of grafts with attached bone blocks. These screws are
threaded sharply to achieve good starting conditions for screw
insertion and secure graft fixation. The use of this type of inter-
ference screw for soft tissue graft fixation might lead to lacera-
tion of the graft tissue during screw insertion, especially if high
insertion torque is generated. Thus different round-threaded
interference screws have been developed for soft tissue graft fix-
ation.26,27 The first round-threaded metallic interference screw
for direct fixation of soft tissue grafts was developed by L. Pinc-
zewski, the round-headed cannulated interference screw
(RCI)10,26 (Fig. 39-2). More recently, biodegradable interfer-
ence screws have been developed and biomechanically as well
as clinically tested for fixation of BPTB and soft tissue
grafts.27,28 Soft tissue graft fixation using biodegradable inter-
ference screws was first described by Stähelin and Weiler.29
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 Anterior Cruciate Ligament Reconstruction

FIG. 39-2 Different interference screws. A, Early metallic interference screw, sharp threaded; B, Sysorb
biodegradable interference screw, round threaded; C, round-headed cannulated interference (RCI) screw, metallic,
round threaded; MegaFix biodegradable interference screws, sharp threaded at the tip (D) and round threaded at
the body (E). (A–C, From Weiler A, Hoffmann RF, Sudkamp NP, et al. Replacement of the anterior cruciate ligament.
Biomechanical studies for patellar and semitendinosus tendon fixation with a poly[D,L-lactide] interference screw.
Unfallchirurg 1999;102:115–123. D and E, By permission of KarlStorz, Tuttlingen, Germany.)

Biodegradable interference screws have been demon-
strated to be advantageous compared with metallic screws by
means of undistorted radiological imaging, uncompromised
revision surgery, and minimized risk of graft laceration.
However, one might consider that most currently available
biodegradable interference screws do not show complete
degradation and subsequent osseous replacement of the for-
mer implant site because they consist of slow degrading and
high-molecular poly-L-lactide.27 Thus the use of inter-
mediate degrading stereo-co-polymeric materials such as
poly-(L-co-D,L-lactide) are preferable.27,30
The newest screw generations are sharply threaded
just at the tip for easy starting conditions of the screw,
followed by a blunt threading to prevent tissue laceration
(see Fig. 39-2). Biodegradable as well as metallic
interference screws are distributed in different sizes (diame-
ter and length). Thus precise matching of graft and tunnel
diameters can easily be performed.
Mechanical studies have shown that a tight fit among
the screw, the graft, and the tunnel is essential for sufficient
fixation strength.13,31–33 When deciding to oversize a screw
to improve fixation strength (particularly at the tibial site),
an increased length has been demonstrated to be superior to
an increased diameter.13,34 Furthermore, an oversized screw
diameter increases the insertion torque in contrast to a longer
screw. We therefore recommend increasing screw length
instead of using massively oversized screws in diameter (e.g.,
Delta screws) to avoid violating the tendon tissue.
In summary, hamstring tendon interference screw
fixation offers the following advantages:

286


Anatomical and direct fixation

High stiffness of the graft fixation construct

Short graft, allowing the preservation of the gracilis
tendon (especially with hybrid fixation; see later
discussion)

No slippage under cyclical loading (improved by the use
of tibial and femoral hybrid fixation; see later discussion)

Neutralization of graft tunnel motions

Prevention of synovial inflow into the tunnel

Allowance for uncompromised revision surgery
(improved by using biodegradable screws)
TECHNICAL CONSIDERATIONS
Graft Preparation
Graft preparation is one of the essential surgical steps and
should be performed carefully. Possible configurations
include four-stranded grafts using a doubled semitendinosus
and doubled gracilis tendon or the quadrupled semiten-
dinosus tendon. Other possibilities are three- or five-
stranded grafts.
Because preservation of the gracilis tendon has been
demonstrated to be beneficial35,36 and due to the fact that
anatomical joint line fixation requires only a short graft (at
least 7 cm) (Fig. 39-3), the use of a four-stranded semiten-
dinosus tendon graft should be routinely achieved. To gain a
sufficient length of the semitendinosus tendon, the tendon
can be harvested including the periosteal distal insertion of
the tendon. In most cases this results in a tendon length
of at least 28 cm. If the semitendinosus tendon is very short
(less than 26 cm) or thin, one can additionally harvest the
gracilis tendon to create a four- or five-stranded semitendi-
nosus/gracilis tendon graft.
The four-stranded graft is prepared with the help of a
suture board while arthroscopic preparation of the knee is
performed. The proximal and distal endings of the
FIG. 39-3 Quadrupled semitendinosus tendon autograft with EndoPearl
attached to the femoral end.
Hamstring Tendon Interference Screw Fixation 39
semitendinosus tendon are armed with #2 polyester sutures
in a whipstitch fashion (Fig. 39-4). Care has to be taken to
pull all slack out of each suture pass. Then the construct
should be manually tensioned to allow potential slippage to
be taken out of the construct (Fig. 39-5). The tendon is then
looped over itself using the so-called “W-technique,” and a
polyester passing suture is brought through each loop
(Fig. 39-6). The looped tendons are then pulled through a
graft sizer (Fig. 39-7). The resulting diameter of the graft is
usually between 7 and 9 mm. A tight fit of the graft in the tun-
nel generally is required to improve fixation strength and graft
incorporation. The diameter of the graft is a given value,
which needs to be known before tunnel creation. When
hybrid fixation (see later discussion) is used, sizing of the graft
in increments of 1 mm is sufficient; if interference screw
fixation is used solely, we recommend sizing in increments
of 0.5 mm33 to allow for the required tight fit. A marking
suture using #0 absorbable suture has to be set 2 cm from
the femoral end of the graft to show the surgeon if the graft
is inserted deep enough into the femoral tunnel. The side
effect of the suture is that good passage of the graft in the
tunnel is ensured, and twisting of the graft around the screw
during its insertion is prevented (see later discussion; see
also Fig. 39-3).
If femoral hybrid fixation using the EndoPearl
(Linvatec, Largo, FL) device is desired, the pearl is tied to
the femoral end of the graft (see Fig. 39-3). It is important
that the knot fixing the pearl to the graft is not placed at the
side of the screw, which would result in an increased graft
diameter, possibly leading to problems during graft inser-
tion. The tibial end of the graft is sutured in a baseball-
stitch technique using #0 absorbable sutures to ease the
insertion of the tibial screw and to increase initial tibial
graft fixation strength (see Fig. 39-3).
Femoral Interference Screw Fixation
Tunnel Preparation
According to the current literature the femoral tunnel should
be drilled in the ten-o’clock position for right knees or in the
two–o’clock position for left knees.37–39 Arnold et al demon-
strated that this position cannot or can hardly be achieved
when using the conventional transtibial techniques (single
incision).40 Thus we routinely use the anteromedial portal
technique in all ACL reconstruction procedures because it
allows for an anatomical lateral tunnel placement.
In the anteromedial tunnel technique, we create the
femoral tunnel first in approximately 120 to 130 degrees of
flexion (Fig. 39-8). Thus tunnel direction is directed more
to the center of the bone and away from the posterior femoral
cortex, which prevents posterior breakage of the tunnel wall.
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 Anterior Cruciate Ligament Reconstruction
FIG. 39-4 Arming the tendon with #2 polyester sutures in whipstitch fashion.
FIG. 39-5 Manual tensioning of the armed tendon to prevent later slippage of the sutures.
FIG. 39-6 To prepare a quadrupled graft, the tendon is looped over itself
using the so-called “W-technique” and a polyester passing suture is laid
through each loop.
288
FIG. 39-7 Measuring the diameter of the graft.
As this amount of knee flexion only hardly can be achieved
when using a standard leg holder, we routinely use a lateral
support at the level of the thigh and put the leg on the
operating table in maximum knee flexion (Fig. 39-9).
In ACL reconstruction using hamstring tendons, the
graft diameter has to be known before tunnel creation to allow
for a tight fit between graft and tunnel wall, in contrast to
BPTB grafts for which 8- to 10-mm tunnels are routinely
used as determined by the size of the harvested bone blocks.

FIG. 39-8 In the anteromedial tunnel technique, the femoral tunnel is
created in approximately 120 to 130 degrees of flexion to prevent posterior
breakage of the tunnel wall. (By permission of KarlStorz, Tuttlingen, Germany.)
FIG. 39-9 Knee held in maximum flexion during creation of the femoral
tunnel via the anteromedial portal.
The standard sizing when using interference screw
fixation at the femoral site alone is:
Tunnel diameter ¼ Graft diameter ¼ Screw diameter
The length of the screw should be 23 to 25 mm to
achieve sufficient initial fixation strength.
Hamstring Tendon Interference Screw Fixation 39
Screw Insertion
During femoral screw insertion it is of great importance to
control knee flexion to prevent screw divergence, which
might result in decreased fixation strength, and to allow
for an easy screw start. If the anteromedial portal technique
is used, the knee flexion angle has to be exactly the same as
it was during tunnel creation. If the transtibial technique is
used, one needs to find the desired knee flexion angle for
proper screw insertion. In this situation a standardized flex-
ion of 120 degrees might not be appropriate. We therefore
recommend palpating the tunnel with a nitinol wire or the
tip of the screwdriver prior to screw insertion to ensure par-
allel screw placement.
In addition to correct direction of screw insertion,
other surgical details can ease femoral screw insertion:

A nitinol guidewire can be used to identify tunnel
direction and to secure correct screw placement by
insertion of the screw over the wire (cannulated
screwdriver necessary).

Tunnel direction can be verified using the screwdriver.
Furthermore, the place of screw insertion can be dilated a
little bit when the graft is already inserted using the
screwdriver or a small dilator (4 mm) (Fig. 39-10). This
technique preconditions the tunnel for screw insertion
and correct placement.

Notching of the femoral tunnel wall using a special
instrument (Fig. 39-11) eases screw insertion and secures
posterior positioning of the graft in the tunnel.
Concerning the depth of screw insertion into the femo-
ral tunnel, there is a main difference between metallic and bio-
degradable interference screws. Biodegradable interference
screws should be countersunk a few millimeters (2 to 3 mm)
below the surface to allow for overgrowth of connective tissue.
If metallic interference screws are advanced too deep, later
hardware removal (e.g., in case of revision reconstruction)
might be complicated. The use of round-headed interference
screws on the femoral site, as recommended in earlier years
for BPTB graft fixation, is not recommended anymore
because a prominent screw head might impinge with the
graft in full extension. If a metallic screw head is countersunk,
later revision reconstruction might be compromised because
screw removal can create large bone defects due to the head
of the screw needing to be exposed for removal.
Interference Screw Position
On the femoral site, screw position generally is anterior to
the graft to allow anatometric posterior placement of the
graft in the tunnel.
Problems in femoral hamstring tendon interference
screw fixation might occur if the graft tends to rotate around
289
 Anterior Cruciate Ligament Reconstruction

FIG. 39-10 Dilation of the screw site using a small dilator (4 mm), followed by screw insertion.

the screw during its insertion; this might lead to an undesired
position of the graft (Fig. 39-12). When using a standard
right-threaded screw in right knees, the graft might rotate
toward an anterolateral position, resulting in too-anterior
graft placement and lateral wall impingement. Thus Pinc-
zewski et al could show a difference of clinical outcome
between right and left knees after hamstring tendon interfer-
ence fit fixation.41 Subsequently, a reversed-threaded inter-
ference screw was developed for use in right knees.41
However, in a left knee with a conventional screw or in a right
knee with a reversed screw, the graft might rotate toward the
12-o’clock position, which might lead to compromised
control of knee rotation.40,42 We therefore recommend
preventing screw rotation completely.
Techniques to minimize the risk of graft rotation
during interference screw insertion include the following:

Tight suturing of the proximal end of the graft (see
Fig. 39-3). This decreases graft rotation by stabilizing the
bundles of the graft and preventing strands of the graft
from being caught by the surface of the screw.

Hybrid fixation. Femoral hybrid fixation using the
EndoPearl device allows undersizing of screw diameter,
resulting in decreased insertion torque without

290
 Hamstring Tendon Interference Screw Fixation 39

FIG. 39-11 Notching of the anterior edge of the femoral tunnel entry to facilitate screw insertion and anterior
placement of the screw. A, Schematic picture. B–G, Intraoperative views. (A, By permission of KarlStorz, Tuttlingen,
Germany.)

291
 Anterior Cruciate Ligament Reconstruction
FIG. 39-12 Rotation of the graft to an undesired 12-o’clock position in femoral hamstring tendon interference
screw fixation in a left knee.
compromising fixation strength. Decreased insertion
torque minimizes the risk of graft rotation during screw
insertion.

Notching the screw insertion site (see Fig. 39-11).

Bone wedge technique (Fig. 39-13). The use of this
technique prevents the graft from rotation during screw
insertion and allows for 360 degrees of bone contact
around the graft. At the anterosuperior tunnel aperture, a
thin (2 to 4 mm) bone wedge can be detached using a
special chisel (Fig. 39-14). The screw is then advanced
between the tunnel wall and the bone wedge. Care has to
be taken because a very large bone wedge might decrease
fixation strength; thus hybrid fixation is recommended.
Possible Problems During Screw Insertion
Normally the interference screw should start easily with only
low manual pressure. During further screw insertion, the
screw should find the way parallel to the graft without any
manual pressure, just by rotation of the screwdriver.
If the screw does not start correctly, the surgeon often
tends to push the screw against the graft with the risk of tis-
sue laceration. Because one of the main reasons for dis-
turbed screw insertion is a wrong knee flexion angle, the
screw should be removed and the flexion angle controlled
prior to inserting the screw again.
Furthermore, problems during screw insertion might
occur due to high bone density because very high insertion
torque might be created in this situation. If metal interfer-
ence screws are used, the danger of graft laceration during
screw insertion has to be considered. Therefore oversized
screws are not recommended on the femoral site. Another
problem might occur if the screw is too long (more than
25 mm) or the tunnel is too short (less than 25 mm).
In these cases, shorter screws (e.g., 19 mm) can be used or
the tunnel needs to be lengthened. When biodegradable
292
interference screws are used, high-insertion torque might
result in breakage of the screw. Thus the screw should be
changed to a smaller diameter if possible breakage is recog-
nized. If the screw is inserted already for two-thirds of its
length when it breaks, sufficient fixation strength can be
assumed if hybrid fixation is used.
In contrast, low insertion torque generally results in
low fixation strength. Different factors can be responsible
for a low insertion torque, as follows:

Low bone density or inappropriate matching of tunnel
diameter and screw. In these cases a bigger screw should
be chosen or a second screw can be inserted (sandwich
technique).

Posterior blowout of the femoral tunnel wall due to far
posterior tunnel placement. In these cases the fixation
technique has to be changed (e.g., Endobutton).

The screw is accidentally inserted into the posterolateral
recess. This problem might occur due to poor
intraarticular visualization and improper knee flexion
during screw insertion.
Femoral Hybrid Fixation
An important method that further minimizes graft–tunnel
motions and improves initial fixation strength as well as
construct stiffness is the so-called hybrid fixation.31,43 The
principle of hybrid fixation is to combine two fixation tech-
niques at one site.31 At least one of the devices used should
be able to achieve sufficient fixation strength alone. This
device is combined with a second technique in order to neu-
tralize its possible biomechanical and biological disadvan-
tages (e.g., graft–tunnel motion) (Table 39-1).
On the femoral site, graft fixation generally is more
forgiving compared with the tibia from a mechanical point
of view. However, disturbed biological incorporation is a
 Hamstring Tendon Interference Screw Fixation 39

FIG. 39-13 Bone wedge technique. At the anterosuperior position of the tunnel entry site, a thin bone wedge is
detached using a special chisel (A). The screw then is advanced between the tunnel wall and this bone wedge (B–D).

problem of femoral fixation due to the higher graft–tunnel
motions.25 We therefore recommend aperture fixation on
the femur to optimize biological boundary conditions. In
order to minimize possible problems of interference screw
fixation, such as tissue laceration and graft rotation, femoral
hybrid fixation allows for the use of an undersized screw to
solve these problems.
For femoral hybrid fixation with interference screws,
a biodegradable spherical device, the EndoPearl, has been
developed (see Fig. 39-3). The EndoPearl is tied to the
femoral end of the graft and achieves an internal locking
between the graft and the tip of the interference screw
(Fig. 39-15). Thus it increases initial fixation strength,
especially in cases of tunnel enlargement (revision recon-
struction) or low bone density. Clinically it has been shown
to improve knee stability compared with interference screw
fixation alone.44 If this type of femoral hybrid fixation is
used, the femoral tunnel should be created 1 cm deeper

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 Anterior Cruciate Ligament Reconstruction

FIG. 39-14 Specially designed chisel for the bone wedge technique. (By permission of KarlStorz, Tuttlingen,
Germany.)

TABLE 39-1 Possibilities for Hybrid Fixation

Type of Fixation Possible Methods
Femoral hybrid Interference screw and EndoPearl
fixation Suture button and interference screw
Suture button and cancellous bone plug
Transfixation and interference screw
Transfixation and cancellous bone plug
Tibial hybrid fixation Interference screw and suture to bony bridge
Interference screw and suture button
Interference screw and staples
Cancellous bone plug and suture button
Cancellous bone plug and suture to bony bridge
Cancellous bone plug and tying of sutures over
screw
than normally recommended (35 mm instead of 25 mm).
Additionally the chosen diameter of the screw can be 1 to
2 mm less than the tunnel diameter without compromising
fixation strength. This is advantageous because it decreases
the risk of tissue laceration (insertion torque) and reduces
screw rotation without compromising initial fixation
strength.
Thus the standard sizing when using femoral hybrid
fixation with the EndoPearl is:
Tunnel diameter ¼ Graft diameter ¼ Screw diameter  1mm
As an alternative, tunnel diameter can be increased and
screw size chosen according to the graft diameter when
hybrid fixation is used. This allows for hamstring tendon
interference screw fixation in revision cases as well.
As another alternative, a cortical bone plug can be tied to
the femoral end of the graft.45
Femoral hybrid fixation with interference screws also
can be achieved with the additional use of an Endobutton.
In these cases, especially if a continuous loop is used, the
screw acts only to neutralize graft tunnel motion and
prevent synovial inflow. Thus the use of small screws
(5 to 6 mm) is sufficient.
Tibial Interference Screw Fixation
Tunnel Preparation
The tibial tunnel is created in the standard fashion; we pre-
fer a posterior cruciate ligament (PCL)–referenced tibial
drill guide. The first drill bit is undersized approximately
2 mm to the desired tunnel diameter. This allows for later
correction of the tibial tunnel after impingement testing
and reduces the risk of a spine fracture or apical spine frag-
mentation. Furthermore, if the initially drilled tunnel is
undersized, the final steps can be dilated if low bone density
is recognized during drilling.
On the tibial site, screw position is routinely chosen to
be posterior to the graft (see Fig. 39-15). This position pre-
vents the screw from anterior graft impingement if it is acci-
dentally inserted too deep. The tibial screw can be
positioned anterior to the graft if the tibial tunnel is placed
slightly too far anterior to push the graft posteriorly and to
prevent a notch impingement.

294
 Hamstring Tendon Interference Screw Fixation 39

FIG. 39-15 A, Magnetic resonance image (MRI) demonstrating contact between the EndoPearl and the tip of
the interference screw (arrow) to achieve an internal locking. B, MRI demonstrating position of the tibial screw
posterior to the graft (arrow).

Matching of Tibial Tunnel and Screw Diameter Tibial Hybrid Fixation

When using interference screw fixation at the tibial site
alone, the diameter of the screw should be 1 mm larger than
the diameter of the tunnel. For the tibial site, a longer screw
(28 to 35 mm) is beneficial to avoid oversizing the screw
by 2 mm. However, today it is generally recommended
that hybrid fixation at the tibial site should always be
performed when using interference screw fixation of soft
tissue grafts.
Therefore, when using tibial hybrid fixation with
interference screws, the standard procedure is:
When interference screw fixation is used for soft tissue
grafts, some authors are concerned about a possible fixation
slippage at the tibial fixation site even though fixation
strength at the femoral site is considered sufficient.13,18,32,46
The risk of graft slippage on the tibial site can be nicely
compensated with oversized screws, or better, by using
hybrid fixation on the tibia, especially in females.34,47
An easy and safe method of tibial hybrid fixation is
to tie the holding sutures of the graft over a bony bridge

Graft diameter ¼ Tunnel diameter

¼ Screw diameter ðlonger screw ½e:g:; 28 mmÞ

If one prefers using interference screw fixation alone, the

following sizing is recommended:

Graft diameter ¼ Tunnel diameter

¼ Screw diameter ðlonger screw ½e:g:; 28 mmÞ
þ1 mm

Possible Problems during Screw Insertion

A specific problem at the tibial site is the “blind” insertion
of the screw. Thus the risk of inserting the screw not parallel
to the graft is increased compared with the femoral site.
Furthermore, it might easily happen that the screw is not
inserted between the graft and the tunnel wall but instead
pushes the graft forward during its insertion. To prevent
this accidental graft dislocation, the surgeon should hold
the holding sutures of the graft tightly during screw inser-
tion. After tibial screw insertion we recommend controlling
graft and screw placement by an intratunnel view using the FIG. 39-16 Intratunnel view to control tibial interference screw and graft
arthroscope (Fig. 39-16). position.

295
 Anterior Cruciate Ligament Reconstruction

FIG. 39-17 Tibial backup fixation by suturing the linkage material over a bony bridge. A, A monocortical hole is
prepared 2 cm distally from the tibial tunnel using the screwdriver. B, The cancellous bone is tunneled using a
curved clamp. C and D, A suture loop is passed from the distal to the proximal hole using a needle. E–I, One
strand of each attached suture is passed through the holes using the suture loop and tied over the created bony
bridge. J, The knot should be countersunk into the tibial tunnel to avoid the development of a subcutaneous
granuloma. t, Tibial tunnel. (A–D, By permission of KarlStorz Tuttlingen, Germany.)

after the tibial screw is inserted (Fig. 39-17). For this a
monocortical drill hole is created 2 cm distally of the
tibial tunnel exit site. Then one strand of each suture is
passed through the hole and tied over the created bony
bridge.48
In cases with a low insertion torque of the interference
screw, the use of a suture button instead of the suture over
bony bridge might be beneficial (Fig. 39-18). Manual
rotation of the button tightens the linkage material, thus
safely preventing graft slippage.

296
 Hamstring Tendon Interference Screw Fixation 39

FIG. 39-18 Tibial hybrid fixation using a suture. A–D, The tibial tunnel exit site first has to be prepared using a
special instrument. E–G, The sutures are passed through the holes of the fixation button and tied over the button.
H and I, Manual rotation of the button using a special instrument tightens the linkage material. (From Strobel
M. Manual of arthroscopic surgery. Berlin, 2001, Springer-Verlag.)

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gradable interference fit fixation: a prospective matched-group analy-
sis. Am J Sports Med 2005;33:1327–1336.
25. Weiler A, Unterhauser F, Faensen B, et al. Comparison of tendon-to-
bone healing using extracortical and anatomic interference fit fixation
of soft tissue grafts in a sheep model of ACL reconstruction. Trans
Orthop Res Soc 2002;48:173.
26. Scranton P, Pinczewski L, Auld M, et al. Outpatient endoscopic qua-
druple hamstring anterior cruciate ligament reconstruction. Operative
Tech Orthop 1996;6:177–180.
27. Weiler A, Hoffmann R, Stähelin A, et al. Current concepts: biode-
gradable implants in sports medicine—the biological base. Arthroscopy
2000;16:305–321.
28. Weiler A, Windhagen HJ, Raschke MJ, et al. Biodegradable interfer-
ence screw fixation exhibits pull-out force and stiffness similar to tita-
nium screws. Am J Sports Med 1998;26:119–126.
29. Stähelin A, Weiler A. All-inside anterior cruciate ligament reconstruc-
tion using semitendinosus tendon and soft threaded biodegradable
interference screw fixation. Arthroscopy 1997;13:773–779.
30. Hunt P, Unterhauser FN, Strobel MJ, et al. Development of a
perforated biodegradable interference screw. Arthroscopy 2005;
21:258–265.
298
31. Brand J, Weiler A, Caborn D, et al. Graft fixation in cruciate ligament
surgery: current concepts. Am J Sports Med 2000;28:761–774.
32. Brand JC Jr, Pienkowski D, Steenlage E, et al. Interference screw
fixation strength of a quadrupled hamstring tendon graft is directly
related to bone mineral density and insertion torque. Am J Sports
Med 2000;28:705–710.
33. Steenlage E, Brand JC Jr, Johnson DL, et al. Correlation of bone tun-
nel diameter with quadrupled hamstring graft fixation strength using a
biodegradable interference screw. Arthroscopy 2002;18:901–907.
34. Weiler A, Hoffmann R, Siepe C, et al. The influence of screw geom-
etry on hamstring tendon interference fit fixation. Am J Sports Med
2000;28:356–359.
35. Gobbi A, Domzalski M, Pascual J, et al. Hamstring anterior cruciate
ligament reconstruction: is it necessary to sacrifice the gracilis? Arthros-
copy 2005;21:275–280.
36. Tashiro T, Kurosawa H, Kawakami A, et al. Influence of medial ham-
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single- and double-tendon harvest. Am J Sports Med 2003;31:522–529.
37. Hefzy M, Grood E, Noyes F. Factors affecting the region of most
isometric femoral attachments. Am J Sports Med 1989;17:208–216.
38. Loh JC, Fukuda Y, Tsuda E, et al. Knee stability and graft function
following anterior cruciate ligament reconstruction: comparison
between 11 o’clock and 10 o’clock femoral tunnel placement.
Arthroscopy 2003;19:297–304.
39. Sapega AA, Moyer RA, Schneck C, et al. Testing for isometry during
reconstruction of the anterior cruciate ligament. Anatomical and bio-
mechanical considerations. J Bone Joint Surg 1990;72A:259–267.
40. Arnold MP, Kooloos J, van Kampen A. Single-incision technique
misses the anatomical femoral anterior cruciate ligament insertion: a
cadaver study. Knee Surg Sports Traumatol Arthrosc 2001;9:194–199.
41. Musgrove TP, Salmon LJ, Burt CF, et al. The influence of reverse-
thread screw femoral fixation on laxity measurements after anterior
cruciate ligament reconstruction with hamstring tendon. Am J Sports
Med 2000;28:695–699.
42. Musahl V, Plakseychuk A, Vanscyoc A, et al. Varying femoral tunnels
between the anatomical footprint and isometric positions. Am J Sports
Med 2005;33:712–718.
43. Tsuda E, Fukuda Y, Loh JC, et al. The effect of soft tissue graft fixa-
tion in anterior cruciate ligament reconstruction on graft-tunnel
motion under anterior tibial loading. Arthroscopy 2002;18:960–967.
44. Arneja S, Froese W, MacDonald P. Augmentation of femoral fixation
in hamstring anterior cruciate ligament reconstruction with a bioab-
sorbable bead: a prospective single-blind randomized clinical trial.
Am J Sports Med 2004;32:159–163.
45. Nagarkatti DG, McKeon BP, Donahue BS, et al. Mechanical evalua-
tion of a soft tissue interference screw in free tendon anterior cruciate
ligament graft fixation. Am J Sports Med 2001;29:67–71.
46. Kousa P, Jarvinen TL, Vihavainen M, et al. The fixation strength of
six hamstring tendon graft fixation devices in anterior cruciate liga-
ment reconstruction. Part II: tibial site. Am J Sports Med
2003;31:182–188.
47. Hill PF, Russell VJ, Salmon LJ, et al. The influence of supplementary
tibial fixation on laxity measurements after anterior cruciate ligament
reconstruction with hamstring tendons in female patients. Am J Sports
Med 2005;33:94–101.
48. Weiler A, Richter M, Schmidmaier G, et al. The EndoPearl device
increases fixation strength and eliminates construct slippage of ham-
string tendon grafts with interference screw fixation. Arthroscopy
2001;17:353–359.
 Anatomical Retroscrew Anterior Cruciate
Ligament Fixation: Single- and Double-
Bundle Anterior Cruciate Ligament
Reconstruction with Retroscrew
Biointerference in a Single Femoral Socket
The concept of anatomic graft positioning for
anterior cruciate ligament reconstruction (ACL)
has been previously described by many authors.1–6
In the past, anatomical graft tunnels were believed
to obtain an optimal ACL reconstruction; the
position of the graft within bone tunnels had to
avoid the intercondylar roof and wall impinge-
ment. Studies have documented the landmarks
for the placement of endoscopic tunnels in anato-
mical reconstructions through a full knee range of
motion that will avoid impingement.7,8
Recently, issues regarding graft fixation
position have become important. Experimental
and clinical trials have shown that anatomical
graft fixation and position at or near the origin
and insertion of the native ACL in contrast to
nonanatomical fixation position will (1) mini-
mize graft tension, (2) minimize graft length
change, (3) produce a more stable reconstruction
through full knee range of motion, and (4) avoid
anteroposterior, sagittal, windshield wiper–type
graft motion.1,2,4,7–10 Five-year follow-up
studies comparing anatomical and nonanatomi-
cal fixation for ACL reconstruction have shown
absence of tunnel expansion up to 5 years with
an anatomically fixed graft at the intraarticular
tibial tunnel orifice (Fig. 40-1)5,6,8,11,12
The Retroscrew (Arthrex, Naples, FL)
(Fig. 40-2) is inserted into the tibial tunnel in an
inside-out position so that the head of the screw
achieves aperture fixation at the intraarticular
tunnel orifice. Standard interference screw
fixation is used on the femoral side. The Retro-
screw is beneficial during tensioning because
40
CHAPTER
unlike an antegrade screw, the Retroscrew will pull Steven Gorin
the graft tighter into the tunnel, especially during
Craig D. Morgan
tensioning.
Morgan et al4 first described an “all-inside” David Caborn
technique for ACL reconstruction that addressed
the issues of anatomical fixation. However, the
procedure was not popular because of its techni-
cally demanding nature3,5,6,13 (Fig. 40-3).
Graft choices for this technique include
quadriceps tendon autograft, quadrupled ham-
string autograft, Achilles allograft, hamstring
allograft, and tibialis tendon allograft.
Once a graft has been selected, prepared,
and sized, the appropriate tunnels are placed:
7 mm anterior to the posterior cruciate ligament
(PCL) between the tibial spines for the tibia
and at the 2-o’clock position for a left knee or
10-o’clock position for a right knee on the lat-
eral intercondylar wall.
OPERATIVE TECHNIQUE: SINGLE
FEMORAL SOCKET, SINGLE-BUNDLE
GRAFT
Once the appropriate anatomical bone tunnels
have been placed, the graft is passed in a routine
fashion. Femoral fixation may be achieved using
an interference screw equal to the diameter of
the tunnel placed through the anteromedial por-
tal with the knee in hyperflexion. Alternatively,
femoral fixation may be accomplished with a
specially designed, cannulated Retroscrew driver
299
 Anterior Cruciate Ligament Reconstruction

FIG. 40-1 A, An all-inside anterior cruciate ligament (ACL) reconstruction with a quadriceps tendon autograft
fixed anatomically at the intraarticular tibial and femoral socket orifices. Retrograde and antegrade headed titanium
interference screws (Arthrex) were used in the tibial and femoral sockets, respectively. B, A lateral radiograph of the
same case illustrating anatomical interference screw positioning.

(Arthrex) passed through the tibial tunnel to achieve parallel

interference screw fixation. This is performed using a pre-
loaded Fiberstick Suture (Arthrex) withdrawn from the tip
of the screw driver and out the anteromedial portal (see
Fig. 40-3).
The #2 suture is then passed through the cannulation
of the Retroscrew, and a 3-mm Mulberry knot is tied to
prevent the screw from disengaging the driver. Intraarticular
passage of the femoral Retroscrew from the anteromedial
portal is facilitated with the aid of a flexible slotted cannula
(shoehorn cannula, Arthrex) at the same time as the suture
exiting the handle portion of the screwdriver is pulled
(Fig. 40-4). The shoehorn cannula avoids hang-up of the
screw in the fat pad. This is used to secure and lead a
femoral Retroscrew (7 to 10 mm  20 mm) onto the driver
tip. Once the screw has been securely placed onto the end of
the driver, the suture may be removed. With the leg in
approximately 90 degrees of flexion, the screw is advanced
into the femoral socket to secure the femoral side of the
graft.
Tibial fixation can next be performed by placing a
tibial Retroscrew equal to the tunnel diameter. As previously
described, the tibial Retroscrew (8 to 10 mm  20 mm) is
placed onto the driver tip over a #2 Fiberwire suture from
the medial portal. It is important that the screwdriver tip
be anterior to the graft and free of all soft tissue. Obscuring
the tip will prevent seating of the screw on the driver.
Once inside the joint, the screw is “flipped” onto the
driver by pulling the suture exiting the driver handle at the
same time as the driver tip is lowered into the aperture
(Fig. 40-5). The screw is then secured to the driver by
FIG. 40-2 The femoral and tibia Retroscrews are shown. The screws are
wrapping the exiting suture around the grommets on the
tethered by a #2 Fiberwire suture. driver handle.
300
 Anatomical Retroscrew Anterior Cruciate Ligament Fixation 40

FIG. 40-4 Tibial Retroscrew insertion via anteromedial portal assisted by

flexible slotted cannula (shoehorn cannula).

FIG. 40-3 A, A 2.5-year follow-up magnetic resonance image (MRI) of an

all-inside quadriceps tendon autograft anterior cruciate ligament (ACL)
reconstruction using bioabsorbable interference screws. Graft and screw
resorption up to the intercondylar floor where biological graft
incorporation appears similar to a native ACL without tunnel widening. B,
Radiograph 6 years after a quadriceps tendon autograft ACL reconstruction
illustrates the absence of tunnel expansion on either the femoral or tibial
side of the joint.

The graft is then tensioned as the screw is advanced

counterclockwise until its head is flush with the intraarticu-
lar aperture of the tibial tunnel. With the arthroscope turned
toward the tibial surface, the knee may be extended to near
full extension as the screw is advanced into the top of the FIG. 40-5 Placement of tibia Retroscrew into the aperture of the tibial
tibial tunnel. If additional tibial fixation is desired, a second tunnel.

301
 Anterior Cruciate Ligament Reconstruction

interference screw may be placed from outside in, antegrade
and posterior to the graft. This will result in an interlocking
screw–graft fixation construct.
OPERATIVE TECHNIQUE: SINGLE FEMORAL
SOCKET, DOUBLE-BUNDLE GRAFT
The simplicity of this technique is what makes it appealing.
Only minor modifications are made to the previously described
single-bundle procedure. Our preferred graft source for the
double-bundle technique is a two-limbed tibialis tendon allo-
graft. During preparation, it is recommended that it be
prepared in the manner described by Charlick and Caborn.14
Specifically, this may be carried out by suturing (#2 Fiberwire)
20 mm to either side of the midline of the folded soft tissue
graft (Fig. 40-6). If a hamstring graft is chosen, the semitendi-
nosus and gracilis tendons should first be sutured together
under tension to create a two-limbed, folded graft. Further
suturing is performed distally after accommodating 30 to
35 mm for the intraarticular portion of the graft. This addi-
tional whipstitch aids in controlling the anteromedial bundle
(AMB) and posterolateral bundle (PLB) as they are oriented
into the femoral and tibial tunnels. Caborn stitching has been
shown to increase pullout to failure by approximately 30%
when using interference screw fixation for soft tissue grafts.14
After standard femoral and tibial socket preparation,
to create the double-bundle socket on the femur, a notching
device is used to create two slots on the femoral socket
intraarticular orifice, for the AMB and PLB of the ACL
graft, respectively. The slots can be further delineated using
a motorized bur or shaver or a curved curette (Fig. 40-7).
With the knee flexed 90 degrees, the AMB slot is made
at the 10- or 2-o’clock position and the PLB slot is made
at the 4- or 8-o’clock position within the circumference of
the tunnel orifice. Each slot is typically 6 to 7 mm in width.
The graft is then passed in routine fashion using a
Beath pin. While the graft is held into the tunnel by an
assistant, the limbs of the graft are rotated into their respec-
tive notches. The AMB is retraced by a probe from the
anteromedial portal. Femoral fixation is then carried out
with a concentrically placed femoral Retroscrew placed cen-
tral between the bundles and secured into position by the
driver, which is passed through the tibial tunnel as described

Midline of graft

20 mm 30 mm 20 mm 20 mm 30 mm 20 mm

Graft passing suture

FIG. 40-6 Demonstration of the two-bundle soft tissue anterior cruciate ligament (ACL) graft with suture
preparation to accommodate femoral and tibia interference screws. Note the suture pattern performed to enhance
thread contact of the interference screw. This preparation also assists in orienting the bundles on the femoral and
tibial attachment sites.

302

FIG. 40-7 Single socket, double-bundle femoral socket preparation
featuring specific notches created for the anteromedial and posterolateral
bundles.
previously (Fig. 40-8). As the screw is advanced in the tun-
nel, the graft strands will seek the two-bundle origin of the
ACL in their respective slots (Fig. 40-9).
The graft strands are then anatomically positioned
directly anterior and posterior to one another within the tib-
ial tunnel (AMB, anterior; PLB, posterior). Tibial fixation
is carried out using a tibial Retroscrew, as previously
described, medial to the strands with the knee flexed
approximately 70 degrees. Both bundles are equally ten-
sioned at 70 degrees of flexion prior to tibial Retroscrew fix-
ation. Secondary backup fixation can be applied with a
FIG. 40-8 Concentric placement of femoral Retroscrew separating the
graft into the anteromedial and posterolateral bundle positions.
Anatomical Retroscrew Anterior Cruciate Ligament Fixation 40
FIG. 40-9 Final inspection of the single-tunnel, double-bundle, soft tissue
anterior cruciate ligament (ACL) reconstruction.
bicortical post and washer or a second interference screw
secured to the distal tibial cortex.
References
1. Barber FA. Flipped patellar tendon autograft anterior cruciate liga-
ment reconstruction. Arthroscopy 2000;16:483–490.
2. Ishibashi Y, Rudy T, Livesay G, et al. The effect of anterior cruciate
ligament graft fixation site at the tibia on knee stability: evaluation
using a robotic testing system. Arthroscopy 1997;13:177–182.
3. Leitman EH, Morgan CD, Grawl DM. Quadriceps tendon anterior
cruciate ligament reconstruction using the all-inside technique. Opera-
tive Tech Sports Med 1999;7:179–188.
4. Morgan CD, Kalman VH, Grawl D. Isometry testing for
anterior cruciate ligament reconstruction revisited. Arthroscopy
1995;11:647–659.
5. Palmeri M, Morgan CD. The all-inside anterior cruciate ligament
reconstruction: a double socket approach. Operative Tech Orthop
1996;6:161–176.
6. Stahelin A, Weiler A. All-inside anterior cruciate ligament reconstruc-
tion using semitendinosus tendon and soft threaded biodegradable
interference screw fixation. Arthroscopy 1997;13:773–779.
7. Howell SM, Clark JA. Tibial tunnel placement in ACL reconstruc-
tions and graft impingement. Clin Orthop 1992;283:187–195.
8. Morgan CD, Kalman VH, Grawl DM. Definitive landmarks for
reproducible tibial tunnel placement in anterior cruciate ligament
reconstruction. Arthroscopy 1995;11:275–288.
9. Howell SM, Clark JA, Farley TE. A rationale for predicting anterior
graft impingement by the intercondylar roof. A magnetic resonance
imaging study. Am J Sports Med 1991;19:276–281.
10. L’Insalata JC, Klatt B, Fu FH, et al. Tunnel expansion following anterior
cruciate ligament reconstruction: a comparison of hamstring and patellar
tendon autografts. Knee Surg Sports Traumatol Arthrosc 1997;5:234–238.
11. Weiler A, Hoffman RFG, Bail HJ, et al. Tendon healing in a bone
tunnel. Part II: histologic analysis after biodegradable interference fit
fixation in a model of anterior cruciate ligament reconstruction in
sheep. Arthroscopy 2002;18:124–135.
303
 Anterior Cruciate Ligament Reconstruction
12. Weiler A, Peine R, Pashmineh-Azar A, et al. Tendon healing in a
bone tunnel. Part I: biomechanical results after biodegradable interfer-
ence fit fixation in a model of anterior cruciate ligament reconstruction
in sheep. Arthroscopy 2002;18:113–123.
13. Morgan CD. Quadriceps tendon autograft for ACL reconstruction. In
Jackson D (ed): Master techniques in orthopaedic surgery, ed 2.
New York, 2002, Lippincott.
14. Charlick DA, Caborn DN. Alternative soft-tissue graft preparation
technique for cruciate ligament reconstruction. Arthroscopy 2000;16:
E20.
304
Suggested Readings
Brand JC Jr, Pienkowski D, Steenlage E, et al. Interference screw fixation:
strength of a quadrupled hamstring tendon graft is directly related to
bone mineral density and insertion torque. Am J Sports Med
2000;28:705–710.
Morgan CD, Caborn D. Anatomic graft fixation using a retrograde biointer-
ference screw for endoscopic anterior cruciate ligament reconstruction: sin-
gle-bundle and 2-bundle techniques. Tech Orthop 2005;20:297–302.
 PART G SOFT-TISSUE GRAFT TIBIAL FIXATION
SUB PART I CORTICAL
Fastlok Device for Tibial Fixation of a
Tripled or Quadrupled Semitendinosus
Autograft for Anterior Cruciate Ligament
Reconstruction
INTRODUCTION
The number of surgeons using hamstring
tendons for anterior cruciate ligament (ACL)
reconstruction has continuously increased in the
past years. As a result, various modifications
associated with graft preparation and fixation
have been introduced. However, despite these
variations in technique, the goal of reconstructing
a strong and viable graft with a dependable fixa-
tion system remains unaltered. The standard
means by which mechanical fixation of hamstring
grafts is achieved can either be through direct
(interference screws) or indirect (Endobutton
[Smith & Nephew, Andover, MA] or screw
and washer) techniques. Direct fixation is
achieved with an interference screw. With this
technique, factors such as divergence, direction
of screw placement, the geometry and material
composition of the screw, and the graft and tun-
nel characteristics should be considered to
increase the likelihood of a successful outcome.1,2
Indirect fixation techniques, on the other
hand, require a linkage material (tape or suture)
that would connect the graft tissue to the fixation
device. Factors to consider with this technique
include: (1) the strength and stiffness of the
linkage material to minimize both the potential
for elongation of the graft-fixation device
construct3–5 and graft-tunnel motion6–8 and (2)
the distance of graft fixation from the joint line,
which can also influence graft-tunnel motion,
especially with early stress on the graft during
aggressive rehabilitation. The farther the fixation
41
CHAPTER
site from the joint line, the greater the creep of Alberto Gobbi
the graft-fixation device construct.2,5
Ramces Francisco
The technique described here incorporates
the use of the Fastlok device (Neoligaments,
Leeds, United Kingdom), which is an indirect graft
tibial fixation system for hamstring tendon grafts.
SCIENTIFIC RATIONALE
A variety of options are available for hamstring
tendon graft tibial fixation during ACL recon-
struction. These include different types of
washers (AO, Washerloc, and Spiked Washer),
staples, suture/post, and bioabsorbable screws.9–12
Ideally, the type of fixation chosen should provide
the strength and stiffness necessary to withstand
failure during cyclical loading, allow the strands
to be equally tensioned and compressed into the
tibial tunnel wall, and also have the provision for
removal when the need arises for revision
reconstruction.
The use of only the semitendinosus ten-
don for ACL reconstruction minimizes the pos-
sibility of having subsequent flexor weakness
from the disruption of the hamstring muscle.
With the quadrupled configuration of this graft
construct, indirect fixation is usually required
because of the total length of the graft
achieved.13,14 In the description of the tech-
nique that follows, the Fastlok device is com-
bined with a tibial tunnel bone plug that
provides additional tunnel compression, which
facilitates tendon to bone healing and at the
305
 Anterior Cruciate Ligament Reconstruction
same time reduces the risk for tunnel widening by limiting
the sagittal motion of the graft.15 The Fastlok, on the other
hand, offers the ease of using a simple threading technique
during application, which helps the graft to retain tension
throughout the fixation procedure. In addition, it also mini-
mizes slippage with the staple and buckle fixation, reducing
the risk of suture and graft loosening while at the same time
maintaining a low profile, which is very important consider-
ing the relatively thin soft tissues that cover the involved
area of the medial aspect of the proximal tibia.
SURGICAL TECHNIQUE
Following the administration of the appropriate anesthesia,
the patient is positioned supine on the operating table. A thigh
support is placed at the level of the tourniquet cuff while a
foot bar is positioned at the end of the table to enable the knee
to be fixed at 90 degrees of flexion during surgery while at the
same time still allowing free range of motion. Standard
prepping and draping of the operative field are performed.
During the graft harvest, the tourniquet is kept inflated.
Anatomical dissection is carried out to identify the semitendi-
nosus tendon (ST) and separate its accessory limb to avoid
premature amputation of the graft. The tendon’s proximal
end is detached with the use of an open tendon stripper while
its distal end is harvested with an attached tibial bone plug
obtained with the aid of an osteotome. Ideally, a graft length
of 28 to 30 cm is desired. In the meantime, diagnostic arthros-
copy and any associated procedures (e.g., meniscectomy) are
performed prior to the preparation of the bone tunnels.
The graft is then prepared at the back table, as
described in Chapter 16, “Hamstring Anterior Cruciate
Ligament Reconstruction with a Quadrupled or Tripled
Semitendinosus Tendon Graft.”
Tunnel Preparations and Graft Fixation
On the tibia, the tunnel is drilled through the same incision
used for tendon harvesting, the length of which depends on
the total length of the graft construct, but 2 cm of the graft
should remain inserted in the tibia. However, the tibial
opening should not be too superior to maintain the desired
low profile of the Fastlok device following fixation.
The desired entry point for the femoral tunnel is at
the 10:30 position for the right knee. The appropriate tun-
nel depth and diameter are then drilled, and the intraarticu-
lar span between the tunnels is measured and recorded.
Based on these measurements, the graft is marked with
a pen at the level coinciding with the opening of the femoral
tunnel. Prior provisions have to be made to consider the
length of the Endobutton (8 mm) attached at the end of the
306
A
B
D
C
FIG. 41-1 The ends of the polyester tape (C) are threaded through the
buckle (A). The buckle is then flipped, followed by the insertion of the two
prongs of the staple (B) attached at the end of the impactor (D).
graft if it is to be effectively used as a reference point that
indicates the graft is entirely seated in the tunnel with enough
space for the Endobutton to be “flipped” into position.
Next, the graft is inserted in the tunnels with the stan-
dard technique. Proximal fixation is achieved by ensuring that
the Endobutton is securely anchored against the posterolat-
eral cortical surface of the femur. At the distal end of the
construct, tension on the polyester tapes is maintained in
preparation for the placement of the Fastlok fixation device.
The polyester tapes are initially passed through the
buckle component, which is subsequently flipped. The two
prongs of the staple are then threaded through the buckle
(Fig. 41-1). Then, with the knee in 30 degrees of flexion,
the surgical assistant holds the buckle with a forceps in a
flipped position while holding the ends of the tape with
the other hand. The Fastlok device is then pressed against
the tibia. Once the Fastlok is in position, an impactor is
used to drive the staple down in a perpendicular manner.
During this step, it is important to maintain the graft’s
tension. The protruding portion of the tape is trimmed,
and the device is further impacted as needed to achieve a
low profile for the device (Fig. 41-2, A–C). Finally, the
bone plug obtained from reaming the tibial tunnel is
impacted back into the tibia (Fig. 41-3, A, B). Arthroscopic
assessment of the graft position during flexion and exten-
sion is carried out to make sure that no graft impingement
exists.
RESULTS
In a biomechanical study conducted to analyze the me-
chanical properties of linkage systems used in hamstring
tendon ACL reconstruction,10 three constructs (5-mm
braided polyester [Mersilene], double-loop; 3-mm woven
polyester [Orthotape], double-loop; and 3-mm Orthotape,
 Fastlok Device for Tibial Fixation of a Tripled or Quadrupled Semitendinosus Autograft for Anterior Cruciate Ligament Reconstruction 41

B C
FIG. 41-2 The staple is positioned perpendicular to the tibial surface with the aid of the impactor (A) while
maintaining tension on the graft by pulling on the ends of the polyester tape. Actual appearance of the device
prior to final impaction to demonstrate the relation of the tape relative to the device: anteroposterior view (B),
lateral view (C).

single-loop—all connected to the Fastlok fixation device in
bovine bone sections) were compared using an Instron tensile
test machine to document their pull tensile strength, residual
tensile strength, and fatigue strength at a loading regimen of
540,000 cycles at 25-Hz frequency.
Findings indicate that the double-loop Mersilene-
Fastlok construct was weaker than either the single-loop
or double-loop Orthotape-Fastlok construct. The mean
failure strength of double-loop Orthotape-Fastlok was
93% higher, and its mean stiffness was 40% greater at failure
than the Mersilene-Fastlok. At a 150N load, Mersilene-
Fastlok was stiffer, whereas at 300N, Orthotape-Fastlok
was stiffer. At 600N, the Mersilene-Fastlok had already
failed, whereas the Orthotape-Faslok maintained a stiffness
of 128.91 N/m. The mode of failure in all constructs was
tape breakage under the Fastlok device.

307
 Anterior Cruciate Ligament Reconstruction
FIG. 41-3 The bone plug obtained from the tibia during tibial tunnel preparation (A) is inserted back into the
tibial tunnel after the Fastlok device is fixed (B).
Protrusion heights of the constructs after cyclical
loading demonstrated no significant increase in height, indi-
cating absence of device pullout or slippage from the bone.
The double-loop Orthotape-Fastlok construct had a mean
protrusion height of 5.19 mm compared with 4.30 mm for
the Mersilene-Fastlok construct.
Clinical results reviewed in 190 cases of hamstring
ACL reconstruction using the Fastlok device for tibial fixa-
tion revealed 17 cases that required subsequent removal of
the device. Thirteen cases were secondary to anterior knee
pain (over the tibial fixation site) experienced during inci-
dental contact, and four cases were secondary to wound
infection (three superficial and one deep). Complaints of
pain over the fixation site eventually subsided with removal
of the device, and the infected cases were managed success-
fully with antibiotic administration, with only one case
(deep streptococcal infection) requiring further treatment
with arthroscopic débridement and lavage.
TROUBLESHOOTING
Achieving a stable and reproducible technique for tibial fixa-
tion is always a challenge for most surgeons. Although good
results have been obtained with the use of conventional sta-
ples, certain aspects of both the device and the technique of
achieving fixation can be improved. One of the main concerns
when using staples for tibial fixation involves the occurrence
of slippage. Because this is not immediately apparent at the
time of surgery, the surgeon can only do so much in averting
this problem. However, in cases in which proper tension is
not achieved or the graft is found to be loose after the staple
has been placed, the surgeon has no choice but to remove
308
the staple and reapply it with proper tension. To minimize
this problem, we recommend the use of a staple device in
combination with a buckle (e.g., Fastlok). The addition of this
simple component facilitates tensioning and locks the graft in
position while the staple is driven down the tibia (see
Figs. 41-1 and 41-2). The device can be easily fixed, assuming
the surgeon maintains a perpendicular position while driving
the Fastlok to the tibia. Concerns regarding the prominence
of the device are addressed by allowing sufficient soft tissue
coverage over the staple prior to skin closure. Moreover, once
the graft has healed, removal of the staple remains an option.
CONCLUSIONS
Indirect fixation in quadrupled semitendinosus tendon ACL
reconstruction with the use of a Fastlok device combined with
a tibial bone plug enable the achievement of good clinical
results with a reliable and secure tibial fixation. The profile
compared with other staples and washers is lower; however,
despite this advantage, we still had an 8% incidence of
hardware removal, especially in thin female patients.
Therefore we do not suggest the use of this device in this
particular group of patients. In contrast, our findings
suggest that Fastlok fixation is better suited for high-demand
male athletes, with the better clinical results including the
degree of knee stability achieved compared with the former
group.
References
1. Bickerstaff D. BASK instructional lecture 4: anterior cruciate ligament
graft fixation. Knee 2001;8:79–81.
 Fastlok Device for Tibial Fixation of a Tripled or Quadrupled Semitendinosus Autograft for Anterior Cruciate Ligament Reconstruction
2. Kurosaka M, Yoshiya S, Andrish JT. A biomechanical comparison of
different surgical techniques of graft fixation in anterior cruciate liga-
ment reconstruction. Am J Sports Med 1987;15:225–229.
3. Brand J Jr, Weiler A, Caborn DNM, et al. Graft fixation in cruciate
ligament reconstruction. Am J Sports Med 2000;28:761–774.
4. Cooley VJ, Deffner KT, Rosenberg TD. Quadrupled semitendinosus
anterior cruciate ligament reconstruction: 5 year results in patients
without meniscus loss. Arthroscopy 2001;17:795–800.
5. Ishibashi, Y, Rudy TW, Kim HS, et al. The effect of anterior cruciate
ligament graft fixation site at the tibia on knee stability: evaluation
using robotic testing system. Arthroscopy 1997;13:177–182.
6. Frank CB, Jackson DW. The science of reconstruction of the anterior
cruciate ligament. J Bone Joint Surg 1997;79A:1556–1576.
7. Gobbi A, Panuncialman I. Quadrupled bone-semitendinosus ACL
reconstruction: a prospective clinical investigation in 100 patients.
J Orthop Traumatol 2003;3:120–125.
8. Hoher J, Livesay GA, Ma CB, et al. Hamstring graft motion in the
femoral bone tunnel when using titanium button/polyester tape fixa-
tion. Knee Surg Sports Traumatol Arthrosc 1999;7:215–219.
9. Brown CH Jr, Sklar JH. Endoscopic anterior cruciate ligament recon-
struction using quadrupled hamstring tendons and Endobutton femo-
ral fixation. Tech Orthop 1998;13:281–298.
10. Gobbi A, Mahajan S, Tuy B, et al. Hamstring graft tibial fixation:
biomechanical properties of different linkage systems. Knee Surg Sports
Traumatol Arthrosc 2002;10:330–334.
11. Magen HE, Howell SM, Hull ML. Structural properties of six tibial
fixation methods for anterior cruciate ligament soft tissue graft. Am
J Sports Med 1999;24:35–43.
41
12. Weiler A, Scheffler S, Gockenjau A, et al. Different hamstring tendon
graft fixation techniques under incremental loading conditions
[abstract]. Arthroscopy 1998;14:425–426.
13. Gobbi A, Domzalski M, Pascual J, et al. Hamstring anterior cruciate
ligament reconstruction: is it necessary to sacrifice the gracilis? Arthros-
copy 2005;21:275–280.
14. Gobbi A, Francisco R. Fastlok tibial fixation for hamstring anterior
cruciate ligament reconstruction. Tech Orthop 2005;20:274–277.
15. Fu FH, Bennett CH, Ma B, et al. Current trends in anterior cruciate
ligament reconstruction. Part II: operative procedures and clinical cor-
relations. Am J Sports Med 2000;28:124–130.
Suggested Readings
Aune AK, Holm I, Risberg MA, et al. Four-strand hamstring tendon
autograft compared with patellar tendon autograft for anterior cruciate
ligament reconstruction: a randomized study with two year follow-up.
Am J Sports Med 2001;29:722–728.
Höher J, Moller HD, Fu FH. Bone tunnel enlargement after anterior cru-
ciate ligament reconstruction: fact or fiction? Knee Surg Sports Traumatol
Arthrosc 1998;6:231–240.
Kousa P, Jarvinen TL, Vihavainen M, et al. The fixation strength of six
hamstring tendon graft fixation devices in anterior cruciate ligament
reconstruction. Part II: tibial site. Am J Sports Med 2003;31:182–188.
309
 42
CHAPTER
Whipstitch-Post Tibial Fixation for Anterior
Cruciate Ligament Reconstruction
Chadwick C. Prodromos Essentially, only three methods are currently in
use for gripping anterior cruciate ligament
Aaron Hecker
(ACL) grafts so that they may be fixated to
bone. These methods are as follows:
1 Friction: Fixation is applied either against
cancellous bone by an intratunnel
interference screw or on the cortex by a
gripping washer such as a WasherLoc, staple,
or similar device.
2 Loop: The graft is looped around a post such
as a cross-pin or through a fabric loop such as
the Endobutton-CL construct. This is
generally, but not always, done at the femoral
end.
3 Whipstitch: A suture is interwoven into the
graft and then tied around a post or loop—the
so-called “whipstitch-post fixation” (WSP).
WSP was one of the first devised methods
of graft fixation, but with the increase
in popularity of bone–patellar tendon–bone
(BPTB) grafts and interference screws in the
1980s, the WSP became less popular. Ham-
strings (HS) were believed to be less stable,
and hamstring surgeons emulated BPTB tech-
niques in an effort to increase stability, includ-
ing the use of interference screws with bone
blocks and other friction fixation techniques.
This ignores the fact that friction fixation is
inherently less suited to the smooth, compress-
ible, viscoelastic soft tissue graft than to the
rough-surfaced, rigid BPTB graft. It also ignores
the fact that many of the highest-stability results
in the literature with soft tissue grafts used WSP
310
tibial fixation. This chapter will present
biomechanical and clinical data supporting
WSP. It also provides detailed technique and
troubleshooting sections.
BIOMECHANICS
Elongation and Stiffness
The purpose of fixation is to hold the graft with-
out allowing elongation from the fixation site
until biological healing has occurred. Elongation
can occur from slippage of the fixation device
relative to the bone or slippage of the graft relative
to the fixation device. Although stiffness has been
much considered as an important attribute of
ACL graft fixation devices, it is less important
than elongation because it only represents the
elasticity of the graft–fixation construct prior to
the healing of the graft in the tunnel. For BPTB
this is roughly 6 weeks. For soft tissue it is 8 to
10 weeks. After this period the stiffness of the
fixation device or the extraarticular portion of
the graft is no longer part of the load-bearing
portion of the structure, which consists only of
the intraarticular portion of the graft. In fact, a
high-stiffness construct will tend to concentrate
mechanical force on the graft–bone interface
before graft incorporation has occurred, whereas
a low-stiffness construct will dissipate graft strain
through elastic deformation of the graft–fixation
construct and potentially offer some protection
to slippage or elongation at the fixation–bone
interface. The WSP method relies on extratunnel

TABLE 42-1 Graft Elongation as a Function of Tibial Fixation Method:
Coleridge and Amis and Prodromos Results
Fixation Method Mean Adjusted Range (mm) Standard
Slip (mm) Deviation (mm)
Intrafix (2) 0.69 0.43–3.72 0.66
WasherLoc (2) 0.88 0.80–3.92 0.86
Delta screw (2) 1.14 0.80–3.92 0.86
Bicortical screw (2) 1.17 0.84–2.44 0.55
RCI screw (2) 1.30 0.76–3.27 0.92
Endobutton (3) 1.13 0.66–1.64 0.32
cortical fixation and would be a lower-stiffness construct
than an aperture-fixated construct because it is longer, if all
else were equal. However, To et al1 have shown that the
increase in stiffness produced by the use of cortical fixation
is much greater than the reduction in stiffness from the
greater length of the construct.
Clinically, grafts usually elongate as a result of cycli-
cal loading, not catastrophic failure. Some of the lowest
elongations yet recorded from cyclical loading were pub-
lished in a recent study of six commonly used devices by
Coleridge and Amis2 and are in the range of 1 mm after
1000 cycles. In a recent study we found elongation using
WSP fixation to be unsurpassed by any of these fixation
devices3,4 (Table 42-1). The standard deviation was also
very low, indicating high consistency of the fixation
results.
Indirect Versus Direct Fixation
Direct fixation holds direct purchase on the graft. Examples
are interference screws and spiked ligament screw washers.
Indirect fixation holds purchase through an intermediary
substance. Tibial WSP fixation is in the indirect category,
as is the fabric loop of Endobutton fixation. Both methods
can be used effectively. However, indirect fixation has the
added advantage of being able to accommodate a shorter
graft. There is evidence that 15 mm5 or less6 is sufficient
graft length in the tunnel to allow satisfactory healing. This
is all that is needed for indirect fixation such as the WSP
described here. Greater length is required for interference
screw fixation to allow sufficient length of graft along the
interference screw. Even more length is required if a spiked
ligament screw washer is used on the tibial cortex because
the graft must be long enough to extend out of the tibial
tunnel.
Whipstitch-Post Tibial Fixation for Anterior Cruciate Ligament Reconstruction 42
CLINICAL RESULTS
A recent meta-analysis of all HS and BPTB clinical series7
subdivided HS grafts into subgroups by fixation type.
The subgroup with the highest stability rates used an
Endobutton on the femur and primarily WSP tibial fixa-
tion. Of the six high-stability series with no graft failures,
four used WSP fixation.8–11 Finally, the study with the
overall highest stability rate also used WSP.8 Recently
presented data from a series of five-strand hamstring
grafts12,13 that used WSP fixation on both the tibia and
femur with mean 8-year follow-up had the highest stability
rates yet reported for a semitendinosus/gracilis (ST/Gr)
graft.8 It should also be pointed out that these stability
rates exceeded those found using BPTB from this same
meta-analysis.
Morbidity, if the screw is carefully placed, is almost
nonexistent. A 0% rate of screw removal due to patient
irritation from the cortical screw post has been
recently reported in a large series with 2- to 8-year
follow-up.11
SURGICAL TECHNIQUE
Principal
The key to the WSP technique is to maximally tighten the
suture weave in the graft before tying the sutures to the post.
In this way no significant post-fixation elongation should
occur.
Sutures
We use the #2 braided nonabsorbable suture. Newer high-
strength #2 sutures, such as Fiberwire (Arthrex, Naples,
FL) or Ultra-braid (Smith & Nephew, Andover, MA),
can also be used. The suture must be colored or striped
so that the surgeon can clearly differentiate it from the
graft during implantation to avoid knicking or cutting
the suture.
Suitable Tibial Screws
Many suitable products are available (Fig. 42-1). We use the
Smith & Nephew 4.5-mm screw, which does not require a
washer. The screw is best inserted with a 2.7-mm drill bit
rather than the 2.4-mm bit supplied by the company. It
should always be tapped. Most screws are 25 to 35 mm in
311
 Anterior Cruciate Ligament Reconstruction

Because the screw is inserted just posterior to the old

insertion of the semitendinosus at the distal end of the pes
anserinus, it is more than far enough from the knee to allow
satisfactory magnetic resonance imaging (MRI) of the knee
without ferromagnetic artifact.

Whipstitch Implantation

Tubularization
Conceptually the suture tubularizes the graft. If the graft
can be thought of as a sheet (Fig. 42-2), the suture sews
the two ends together so that it is essentially folded longitu-
dinally (Fig. 42-3) and then retraces backward, folding it
longitudinally again. It is key that the surgeon understands
and sees where the suture is going so that he or she does
not damage prior placed suture throws with the needle.
As previously mentioned, it is imperative that a dyed or
striped suture be used. A white suture is difficult to distin-
guish from the white tendon.

FIG. 42-1 Tibial screws for “whipstitch-post” fixation. A, Smith & Nephew,
4.5 mm, no washer used; B, Linvatec, 6.5 mm, washer mandatory; C,
Arthrex 4.5 mm, washer optional.

length. Linvatec makes an excellent 6.5-mm screw that we

used for years, which does require a washer. Arthrex makes
a bioabsorbable screw that we would not recommend (see
later discussion). Arthrex also makes a 4.5-mm screw for
use without a washer and a 6.5-mm cancellous screw, which
is used with a washer. This last screw, however, is used with
a small, 2.5-mm, hexagonal screwdriver. In the past we had
problems with screwdriver head breakage due to the smaller
hexagonal size relative to the larger screw.

Bioabsorbable or Radiolucent Tibial Screws FIG. 42-2 The periosteum continuous with the common insertion is held
at full width.
Bioabsorbability
The tibial screws have not needed to be removed, so there is
little benefit to bioabsorbability. Also, recent evidence has
shown that most of the supposedly bioabsorbable screws
are still intact years after implantation. More impor-
tant, any bioabsorbable screw will be made of a softer
material than metal. The tension of the sutures on the screw
is quite high. Any indentation of the screw by the suture,
even if only a few millimeters, would be sufficient to com-
promise stability. Therefore we believe bioabsorbable screws
pose unacceptable risk and no significant benefit. Arthrex
does make such a screw. We have no experience with it.
Radiolucency
We know of no radiolucent tibial post screw except for the
bioabsorbable one described in the previous paragraph. FIG. 42-3 Whipstitches are placed to fold the tendon on itself.

312

FIG. 42-4 With every two throws, the suture is pulled very tightly to
eliminate slack as the tendon tubularizes.
Tensioning
Of equal importance is that the sutures be maximally tight-
ened after roughly every two throws (Fig. 42-4) so that no
further tightening takes place after implantation. This
requires the assistant to wrap the free suture end twice
around his or her finger so that it will not slip while the sur-
geon wraps the other end around his or her own finger.
They are then pulled in opposite directions, maximally
tightening the weave. The force required is great, and if
the suture is not wrapped properly it is possible to cut one’s
finger on the suture (without cutting the glove). This should
not happen in practice if care is taken. When the tightening
of the weave is complete, the surgeon and assistant will have
a sense of transmitting force directly to each other via the
suture because no tightening is occurring within the graft.
Techniques for Specific Grafts
2ST/2Gr
The 2ST/2Gr is our most commonly used graft. The common
insertion of the ST and Gr is double the width of each tendon
individually. This is because at the insertion the ST and Gr
are a single tendon for their terminal 1.5 cm or so. In line with
this distally is another roughly 1.5 cm of periosteum that is dis-
sected free from the tibia, which serves to prolong this terminal
insertion to a length of usually 3 cm. This provides an ideal
whipstitch implant tissue. This common distal insertion and
periosteal extension is longitudinally cut to make two separate
tendons prior to whipstitch insertion. The assistant holds two
Adson forceps on the corners of each of the graft ends while
the surgeon interweaves the suture, tubularizing it as described
previously. The whipstitches from the distal ends and the
proximal ends are eventually each tied 2  2 around the tibial
post with the graft apex held at the femoral end by the
Endobutton-CL loop or a cross-pin. It is helpful to use two
different colored sutures for the semitendinosus and for the
Whipstitch-Post Tibial Fixation for Anterior Cruciate Ligament Reconstruction 42
gracilis. These ends are knotted together before passage. Like
double sutures can then be tied together after tensioning for
each graft.
4ST
Our second most commonly used graft is the 4ST. This is
used if the semitendinosus is 50 cm or more in length. The
graft is cut in half to make two separate graft limbs. The
subsequent whipstitch technique is then identical to that
described above for the four-strand semitendinosus/gracilis
graft. In the 4ST we begin by overlapping the two free ends
of the graft and then whipstitching them together in the
same fashion as described earlier for the ST overlapped above
with the Gr. For example, if the total length were 30 cm, this
would result in a 15-cm double thickness graft. A heavy
suture is then looped under the apex of this graft and strong
tension applied while the just-implanted whipstitch provides
countertension from the other end. The second whipstitch is
then interwoven in this folded end of the graft.
3ST/2Gr
We use this five-strand graft for knees in which extra
strength is required, such as patients with generalized liga-
mentous laxity, large patients with small tendons, or revisions
or chronic ACL tears with stretched-out secondary
restraints. Preparation is the same as for 2ST/2Gr except that
the extra strand of ST has a #2 whipstitch placed in each end.
The wider distal end of the limb has the sutures tied 1  1
around the fabric loop of the Endobutton-CL. The proximal
end sutures are tied 1  1 around the tibial screw post.
Tibialis or Peroneus Allograft
For this wider tendon, only one whipstitch is tied in each
end. For this reason, it is important that either a newer
high-strength #2 braided nonabsorbable suture (as described
above) or alternatively a #5 braided nonabsorbable suture is
used. This is because only half the number of sutures are
available to withstand the tensile stresses of this two-strand
graft compared to the number of suture strands available for
the four-strand hamstring grafts.
Quadriceps Tendon Autograft or Tendo-Achilles
Allograft
The technique is the same for both grafts. In both cases we
would recommend the graft without bone, although if
desired, bone can be left attached at one end and inter-
ference fixation used on that end in the femur. The terminal
3 cm of each end is then longitudinally split, creating four
ends. Whipstitches are then placed in each so that they
can be tied 2  2 around a post placed in the tibia and
another on the femur. Alternatively the femoral sutures
can be tied around the fabric loop of an Endobutton-CL.
313
 Anterior Cruciate Ligament Reconstruction
Trimming Tendon Grafts
Tendon grafts should be cleaned of all nontendinosus tissue
before whipstitch implantation. However, after the whip-
stitches are put in, the surgeon should again trim off loose
pieces of tissue with an Adson forceps from the tendon
ends, thereby further debulking them. It is important to
debulk the tendon ends in this fashion. The whipstitches
add bulk such that the tibial end is usually 8 to 10 mm,
most commonly 9 mm. If the ends are not debulked, the
graft can potentially require an 11-mm tunnel. The sizing
of the graft can also help to streamline the ends and shrink
them by 0.5 mm or so.
Sizing the Grafts
It should be noted that the femoral looped end is almost
always smaller than the tibial end if whipstitches are used
on the tibial end. Typically the femoral end will be 1 mm
smaller, often 8 mm for the femoral tunnel and 9 mm for
the tibial tunnel. The femoral tunnel for the 2ST/2Gr can
be as small as 7 mm. If the graft is sized before whipstitch
implantation, 1 mm should be added to allow for the bulk
of the suture.
Tying the Whipstitches
The 2  2 tying routinely done must be performed under
strong tension. The following procedure is performed first for
one graft limb and then repeated for the second limb. First
the suture ends are pulled down, two on either side of the pre-
viously inserted tibial screw post. The post is inserted so that
the threads are implanted in bone but the short smooth shank
area is exposed. The sutures are then crossed around the
smooth shank and pulled up. Very strong tension is maintained
while the assistant cycles the knee moderately slowly three
times from 0 degrees to full-flexion range of motion. We tie
the sutures with the knee at 30 degrees flexion with the patient’s
foot supported on the surgeon’s anterior thigh closest to the
table. The tension in the graft comes from the surgeon pulling
up on the sutures, crossed below the smooth screw shank, while
the assistant pushes down on the top of the thigh to provide
countertension. The assistant uses the other hand to control
the patient’s ankle. Seven or eight very firm square throws are
tied. Some feel the sutures should not be tied with the
knee at 30 degrees flexion lest the knee become too tight,
“constrained,” or “captured.” However, we have never had a
significant flexion contracture using this technique with a soft
tissue graft and believe it is important not to under-tension
and thus leave residual laxity. Final screw tightening is then
carried out.
314
Screw Insertion
Screw Insertion Location
The screw should be inserted just posterior to the former inser-
tion of the harvested ST along the medial tibial shaft just ante-
rior to the tibial attachment of the medial collateral ligament.
Unicortical Implantation
The screw should be inserted unicortically and not bicorti-
cally for four reasons, as follows:
1 The screw is eventually tightened down nearly flush with the
bone but cannot be tightened enough initially to allow the tip
to engage a hole in the opposite cortex for bicortical use
because enough of the smooth shank must be left out of the
tibial cortex to allow room for suture tying. After tying, the
screw is further tightened. However, the tying of the sutures
is done under such strong tension that the screw will often
toggle slightly in the tunnel before settling. This is not
visually apparent, but the screw can be thereby redirected
enough that the tip will not find the predrilled hole in the far
cortex. In some cases this will prevent final tightening,
resulting in the screw sitting proud where it can be a later
irritant to the patient. If the tibial tunnel is inserted
unicortically the length will only be measured to the opposite
cortex. Then when the screw is tightened, the tip of the screw
will at most meet but not abut or be stopped by the opposite
tibial posterior cortex. This allows the screw to sit nearly flush
against the tibial cortex, where it will not irritate the patient.
2 Neurovascular structures are located near the exit point of
the tibial screw.15,16 Unicortical use avoids neurovascular
risk without loss of satisfactory purchase.
3 These are cancellous screws, which are not meant to be
inserted bicortically. Such a screw is potentially
irremovable if the tip is buried in cortical bone.
4 It is not necessary to insert the screw bicortically. We
have used it unicortically for many years with excellent
stability results.11
Screw Tightening
The low-profile tibial screw post has been previously inserted
so that the threads are interosseous and only the smooth shank
remains exposed to prevent the sutures from being cut on the
threads. After tying, the screw should be further tightened.
A “dead man’s” angle of 10 degrees or so is desirable, with
the screw inserted so that the tip points slightly proximally
and the head will wind up slightly distal. In this way the
sutures cannot ride over the head of the screw. The strong ten-
sion on the sutures also prevents this. Because the screw enters
slightly obliquely and because the sutures and knot have some
bulk, the screw will not sit flush against bone but rather will sit

a few millimeters proud (i.e., the width of the compressed
suture and knot). We have not seen this to be a clinical pro-
blem, although the screw may be palpable if patients feel
for it. We have never had a patient request that a screw be
removed. One should not attempt to flatten the screw
against the tibia by repeated twisting because this can loosen
its purchase. It should not be hit with a mallet to avoid
potential tibia fracture.
TROUBLESHOOTING
1 What if the graft is loose after the WSP procedure is finished?
We have had this happen once in a large patient in whom
adequate tension was not maintained on the sutures during
tying. The screw was positioned too high up in the deep but
short incision to allow room for satisfactory upward tension
on the sutures by the surgeon. This was discovered on final
arthroscopic inspection of the graft after tying. The screw
was unscrewed, using a hemostat (pushing, not gripping)
to keep the sutures held tightly upward on the smooth
shank to avoid trauma on the sharp threads. The screw was
then pulled more distally until strong tension was felt
(a distance of about 5 mm), a new tibial hole was drilled
with a good bone bridge separating it from the prior hole,
and the screw was inserted in this more distal location.
Excellent graft tension and stability resulted.
2 What if the whipstitch is damaged during the suture
interweaving? If there is any question of the suture being
damaged, it must be removed and the process begun again.
We have done this on a few occasions with no ill effects.
The suture must be carefully removed. The graft is strong
enough to tolerate a new whipstitch being put in. It must be
carefully tightened again during implantation.
3 What if the graft is so long that it abuts the screw, not allowing
room to tension the sutures? We have not had this happen.
If it were to happen we would recommend withdrawing
the screw and inserting it more distally. By planning graft
length in advance, this should be easily avoided.
CONCLUSIONS
1 Stability: WSP fixation produces unsurpassed stability.
2 Morbidity: Morbidity is virtually nonexistent. The
incidence of screw irritation and removal of the screw is
very low if it is properly placed (0 in our series).
3 Unicortical screw placement: For several reasons, as cited
previously, the screw should be placed unicortically.
4 Metallic screws: Metallic screws are recommended. They
do not interfere with MRIs because they are remote from
Whipstitch-Post Tibial Fixation for Anterior Cruciate Ligament Reconstruction 42
the knee joint on the metaphysis. Bioabsorbable screws
are not recommended due to their softness.
5 Use with a short graft: Because this is indirect fixation, it
can be used with a shorter graft or 4ST or quadriceps
tendon. The literature supports a minimum of 15 mm of
graft, possibly less in the tunnel for healing. More is
required for interference or other friction fixation.
6 Ease of use: The whipstitches must be meticulously placed
and the weave maximally tightened, but the technique is
straightforward and easy to learn for surgeons not familiar
with it.
References
1. To JT, Howell SM, Hull ML. Contributions of femoral fixation
methods to the stiffness of anterior cruciate ligament replacements at
implantation. Arthroscopy 1999;15:379–387.
2. Coleridge SD, Amis AA. A comparison of five tibial-fixation systems
in hamstring-graft anterior cruciate ligament reconstruction. Knee Surg
Sports Traumatol Arthrosc 2004;12:391–397.
3. Prodromos CC, Hecker A. Unpublished data.
4. Harvey AR, Thomas NP, Amis AA. The effect of screw length and
position on fixation of four-stranded hamstring grafts for anterior cru-
ciate ligament reconstruction. Knee 2003;10:92–102.
5. Zantop T, Brucker P, Bell K, et al. The effect of tunnel-graft length on the
primary and secondary stability in ACL reconstruction: a study in a goat
model. Presented at the 2006 meeting of the European Society of
Sports Traumatology, Knee Surgery, and Arthroscopy, Innsbruck,
Australia, May, 2006.
6. Yamazaki S, Yasuda K, Tomita F, et al. The effect of intraosseous
graft length on tendon-bone healing in anterior cruciate ligament
reconstruction using flexor tendon. Knee Surg Sports Traumatol
Arthrosc 2006;14:1086–1093.
7. Prodromos CC, Joyce BT, Shi K, et al. A meta-analysis of stability after
anterior cruciate ligament reconstruction as a function of hamstring versus
patellar-tendon graft and fixation type. Arthroscopy 2005;21:1202–1208.
8. Cooley VJ, Deffner KT, Rosenberg TD. Quadrupled semitendinosus
anterior cruciate ligament reconstruction: 5-year results in patients
without meniscus loss. Arthroscopy 2001;17:795–800.
9. Feller JA, Webster KE. A randomized comparison of patellar tendon
and hamstring tendon anterior cruciate ligament reconstruction. Am
J Sports Med 2003;31:564–573.
10. Hamada M, Shino K, Horibe S, et al. Preoperative anterior knee laxity
did not influence postoperative stability restored by anterior cruciate
ligament reconstruction. Arthroscopy 2000;16:477–482.
11. Prodromos CC, Han YS, Keller BL, et al. Stability results of ham-
string anterior cruciate ligament reconstruction at two- to eight-year
follow-up. Arthroscopy 2005;21:138–146.
12. Prodromos CC, Joyce BT. Five-strand hamstring ACL reconstruction:
a new technique with better long-term stability than four-strand.
Presented at the 2006 meeting of the Arthroscopy Association of
North America, Hollywood, FL, May, 2006.
13. Prodromos CC, Fu F, Howell S, et al. Controversies in soft tissue anterior
cruciate ligament reconstruction. Presented at symposium at the 2006 of the
American Academy of Orthopaedic Surgeons, Chicago, March, 2006.
14. Prodromos CC. Unpublished data.
15. Post WR, King SS. Neurovascular risk of bicortical tibial drilling for
screw and spiked washer fixation of soft-tissue anterior cruciate liga-
ment graft. Arthroscopy 2001;17:244–247.
16. Curran TA, Sekiya JK, Gibbs AE, et al. Two techniques for anterior
cruciate ligament tibial fixation with a bicortical screw: an in vitro
study of neurovascular risk. Am J Orthop 2006;35:261–264.
315
43
CHAPTER
WasherLoc and Bone Dowel Tibial Fixation
of a Soft-Tissue Graft
Stephen M. Howell INTRODUCTION
The fixation of a soft-tissue anterior cruciate
ligament (ACL) graft is more challenging than
a bone–patellar tendon–bone (BPTB) graft
because the tendon heals slower to a bone tun-
nel and the fixation is stressed earlier and more
vigorously. Slower healing coupled with early
and more vigorous stress at the site of fixation
can cause slippage and loss of stability with a
soft-tissue ACL graft that might otherwise not
occur with a BPTB graft. This chapter focuses
on the use of the WasherLoc and bone dowel
to fix a soft-tissue ACL graft to the tibia. The
WasherLoc and bone dowel is a simple, low-
profile fixation technique that promotes early
tendon tunnel healing, resists slippage under
cyclical load and exercise, and prevents tunnel
widening, which simplifies revision surgery.
WASHERLOC AND BONE DOWEL
SURGICAL TECHNIQUE
The superior clinical and biomechanical
performance of the WasherLoc and bone dowel
during aggressive rehabilitation and testing in
the laboratory has been extensively documented
since the technique was introduced in 1997.1–13
The WasherLoc is a multi-spiked washer with
four long peripheral spikes that engage cortical
bone and multiple shorter spikes that purchase
the soft-tissue graft (Fig. 43-1). The WasherLoc
316
comes in two lengths (long and standard) and
three diameters (14, 16, and 18 mm). The
preferred fixation for a 9- to 10-mm diameter
soft-tissue graft is the 18-mm-long spike
WasherLoc; for a 7- to 8-mm diameter graft,
the 16-mm long spike WasherLoc.
The WasherLoc is seated in a counter-
bore inside the distal end of the tibial tunnel.
The counterbore recesses the WasherLoc
below the cortical surface, which eliminates
hardware irritation of the overlying skin
(Fig. 43-2).9 A self-tapping, cancellous screw
compresses the WasherLoc and soft-tissue graft
against the back wall of the tibial tunnel.
The tip of the screw engages the lateral tibial
cortex, which avoids any damage to the more
posterior neurovascular structures. The portion
of the tunnel anterior to the soft-tissue graft is
dilated, and the bone dowel is compacted into
the tunnel. The following is a detailed descrip-
tion of the surgical technique with pertinent
illustrations.
Harvest a Bone Dowel from the
Tibial Tunnel
Remove the cortex overlying the distal end of
the tibial tunnel. Choose a cannulated reamer
that matches the diameter of the soft-tissue
ACL graft, and ream over the tibial tunnel
guidewire. Slide the calibrated plunger over
the tibial guidewire. Impact an 8-mm bone
dowel harvester over the plunger and guidewire
to the subchondral bone (Fig. 43-3). Rotate
 WasherLoc and Bone Dowel Tibial Fixation of a Soft-Tissue Graft 43
fibula, and impact the awl. Insert the counterbore into
the awl hole, and orient the counterbore so that it is parallel
to the posterior wall of the tibial tunnel and oblique to the
anterior tibial cortex. Remove a small amount of bone from
the anterior tibial cortex until the counterbore is flush with
the back wall of the tibial tunnel (Fig. 43-4).

Impact the WasherLoc

Long spike Standard spike
FIG. 43-1 The WasherLoc is a low-profile washer with four long peripheral
spikes and multiple short central spikes. The long peripheral spikes engage
cortical bone and contain the soft-tissue anterior cruciate ligament (ACL)
graft under the washer. The multiple shorter spikes purchase the soft-tissue
graft.
the bone dowel harvester several times clockwise and coun-
terclockwise to break off the cylindrical bone. Remove the
bone dowel and harvester. If the guidewire is removed with
the bone dowel, then insert an 8-mm reamer into the tibial
tunnel and rethread the guidewire through the cannulation
in the reamer. Finish reaming the tibial tunnel.
Drill the Counter Bore
Use electrocautery and a ronguer to remove a small section
of the superficial layer of the medial collateral ligament
(MCL) that overlies the cortical opening of the tibial tun-
nel. Insert the counterbore guide into the tibial tunnel until
the vertical sleeve abuts against the distal end of the anterior
edge of the tibial tunnel. Point the vertical sleeve at the
Position the knee in full extension. Thread the awl into the
drill sleeve and the drill sleeve into the WasherLoc. Tension
the soft-tissue graft. Rotate the flat edge of the WasherLoc
distal, place half of the soft-tissue ACL graft on each side of
the awl, insert the awl in the hole, and direct the tip of
the awl toward the fibula. Impact the WasherLoc into the
back wall of the tibial tunnel until it is fully seated
(Fig. 43-5).
Insert the Self-Tapping, Cancellous
Compression Screw
Remove the awl, insert a 3.2-mm diameter drill into the
drill sleeve, aim toward the fibula, and drill through the lat-
eral cortex of the tibia. Measure the length of the drill hole,
and insert the self-tapping, cancellous compression screw
until it fully engages the lateral cortex of the tibia.
Dilate the Tibial Tunnel
Confirm that stability has been restored to the knee and the
tension in the ACL graft is correct. Place the tip of the

FIG. 43-2 The correct orientation of the WasherLoc is perpendicular to the back wall of the tibial tunnel. The
correct orientation of the self-tapping, cancellous compression screw is toward the fibula, which avoids damage to
the neurovascular structures that are more posterior. The tip of the screw purchases the lateral tibial cortex. The
bone dowel fills the anterior and medial tibial tunnel, causing the narrowing seen in the distal half of the tibial
tunnel on the anteroposterior and lateral view.

317
 Anterior Cruciate Ligament Reconstruction

FIG. 43-3 An 8-mm diameter bone dowel harvester is driven over a tibial guidewire to the level of the
subchondral bone. The harvester is rotated several times to break the bone dowel away from the subchondral
bone. The typical length of the bone dowel is 20 to 30 mm.

tapered dilator between the anterior surface of the soft-
tissue graft and tibial tunnel (Fig. 43-6). Gently impact
the dilator to the level of the joint line, which is typically
25 mm.
Compact the Bone Dowel
Stuff any loose bone reamings and wallplasty fragments into
the tibial tunnel, and compact the bone with a 7 or 8 impin-
gement rod. Place the plastic cover on the sharp tip of the
bone dowel harvester, and drive the bone dowel into the tib-
ial tunnel (Fig. 43-7).
Promoting Tendon–Tunnel Healing of a
Soft-Tissue Anterior Cruciate Ligament Graft
Healing of a soft-tissue ACL graft14 is a greater concern
than that of a BPTB graft because a tendon graft heals
slower than a bone plug during the first 6 weeks of implan-
tation.15 Healing is more of a problem in the tibia than in

318
 WasherLoc and Bone Dowel Tibial Fixation of a Soft-Tissue Graft 43
the femur because the marrow is filled with more fat16 and
the bone is softer.17 Therefore a soft-tissue graft requires
better fixation technique than a BPTB graft,15 especially
in the tibia.16 The consequence of not addressing the
slow tendon–tunnel healing is slippage during early
rehabilitation.18 Slippage is more likely with a soft tissue
ACL graft than with a BPTB graft because there is less
pain early on.19

Strategies That Promote Tendon–Tunnel Healing

Aim toward
fibula
FIG. 43-4 The counterbore is oriented parallel to the back wall of the tibial
tunnel and is aimed toward the fibula. The purpose of the counterbore is to
recess the WasherLoc inside the tibial tunnel to avoid irritating the
overlying soft tissues.
One strategy for promoting tendon–tunnel healing is the
use of a long, snug tunnel (Fig. 43-8). The healing of a
tendon graft is stronger and stiffer when the tunnel is
lengthened and the fit between the tendon and tunnel wall
is snug.20 Lengthening the tunnel requires placement of
the fixation device at the end of the tunnel and not inside
(intratunnel device).12 Compaction of a bone dowel into
the tibial tunnel along side a soft-tendon graft increases
the snugness of fit by filling gaps between the tendon and
tunnel wall.21,22
A second strategy for promoting healing is to allow
circumferential and avoid one-sided healing between the
tendon and tunnel wall (see Fig. 43-8). The healing of a

FIG. 43-5 The awl (A) is threaded into the drill sleeve (B), which is threaded into the WasherLoc. Half of the graft
is placed on either side of the awl. The WasherLoc is oriented parallel to the back wall of the tibial tunnel and is
aimed toward the fibula.

319
 Anterior Cruciate Ligament Reconstruction
Cone-shaped
dilator
FIG. 43-6 The cone-shaped dilator is inserted anterior to the soft tissue
anterior cruciate ligament (ACL) graft and is impacted 25 mm into the tibial
tunnel. The cone-shaped space prevents the cylindrical-shaped bone
dowel from being driven into the joint.
tendon graft is stronger and stiffer when the tendon heals to
the tunnel circumferentially and is not one-sided. Circum-
ferential healing requires placement of the fixation device
at the end of the tunnel so that the entire surface area of
the tunnel can heal to the graft.12 One-sided healing occurs
with intratunnel devices such as the interference screw.23
The interference screw “interferes” and slows tendon–tunnel
healing because the screw prevents one side of the tendon
from healing to the graft.12
A third strategy is to surround the tendon graft with a
biologically active substance. Healing of a tendon is acceler-
ated and stronger when a biologically active substance is
inserted in the tunnel with the graft. Wrapping periosteum
around the graft accelerates the healing process of a tendon
in a bone tunnel and leads to better biomechanical fixation
in a shorter period of time.24 Adding bone morphogenetic
protein accelerates the healing process when a tendon graft
is transplanted into a bone tunnel.25 The acceleration of
healing by periosteum and bone morphogenetic protein sug-
gests that compaction of autogenous bone into the tunnel
320
might also benefit healing. Autogenous cancellous bone
has viable osteoblasts that may initiate, regulate, and acceler-
ate the ingrowth of bone into the tendon. The use of the
WasherLoc at the end of the tibial tunnel with compaction
of bone dowel fulfills these criteria for promoting tendon–
tunnel healing by providing a long, snug tunnel; circumfer-
ential healing; and the addition of a biologically active
substance.
WASHERLOC RESISTS SLIPPAGE UNDER
CYCLICAL LOAD
Several biomechanical studies have shown that the
WasherLoc has superior resistance to slippage, higher
stiffness, and higher strength than other soft tissue tibial
fixations.2,3,4,6–9,11–13 When studies are performed using
human bone, the WasherLoc slips less, is stiffer, and stron-
ger than interference screw, double staples, soft tissue
washer and screw, and sutures tied to a post.9 Although
there has been no head-to-head comparison of the IntraFix
versus the WasherLoc in human bone, the IntraFix has
been shown to slip more under cyclical load than the
interference screw,26 which indicates that the IntraFix slips
substantially more than the WasherLoc.
Cyclical testing simulating 6 weeks of normal walking
showed that the slippage of a two-strand soft tissue graft
fixed with a WasherLoc was less than 0.6 mm, which is
clinically imperceptible (Fig. 43-9). The fixation site was
loaded 225,000 times from 0N to 170N to simulate the
predicted number of steps in 6 weeks of normal walking
and the load in the ACL during normal gait.13 The slippage
resistance of the WasherLoc is consistent with clinical
results that showed excellent anterior stability with use of
brace-free, aggressive rehabilitation and early return to sport
at 4 to 6 months.1,5
BONE DOWEL LIMITS TUNNEL WIDENING AT 1
TO 2 YEARS
Tunnel expansion in ACL reconstruction is greater with a
hamstring autograft than with a BPTB autograft27–29 and
occurs with a variety of hamstring fixation devices.28–32
The clinical consequences of the common phenomenon of
tunnel expansion are being defined; however, tunnel
expansion can complicate revision surgery.33,34 Therefore
a technique for fixing a hamstring graft to the tibia that
limits tunnel expansion to the cross-sectional area of the
reamer might have a clinical benefit by simplifying revision
surgery.
 WasherLoc and Bone Dowel Tibial Fixation of a Soft-Tissue Graft 43

FIG. 43-7 The plastic sleeve is placed over the sharp tip of the bone dowel harvester and inserted into the dilated
opening. The bone dowel is compacted into the tibial tunnel and anterior to the soft tissue anterior cruciate
ligament (ACL) graft.

FIG. 43-8 Fixation of a soft tissue anterior cruciate ligament (ACL) graft in the tibia is problematic because the
cancellous bone is softer and more filled with fat than the femur. The use of a WasherLoc and bone dowel promotes
tendon–tunnel healing by providing a long, snug tunnel; circumferential healing (arrows); and the addition of a
biologically active substance (A). The use of an intratunnel device such as an interference screw or IntraFix retards
tendon–tunnel healing by allowing only one-sided healing between the tendon and tunnel wall (B).

321
 Anterior Cruciate Ligament Reconstruction

WasherLoc

G1
T1
G4
T3
T
T5
T4

T6
T2

Proximal end
of tibia

G2 G3
Cross-section
R

2.5-mm
post

Aluminum
support
FIG. 43-9 Slippage of a two-strand soft tissue anterior cruciate ligament
(ACL) graft fixed to the tibia with a WasherLoc was measured using
roentgen stereophotogrammetric analysis. The site of fixation was loaded
from 0N to 170N for 225,000 cycles, which simulated the loading of the
ACL in 6 weeks of normal walking. The slippage was less than 0.6 mm,
which is clinically imperceptible and justifies the use of the WasherLoc with
brace-free, aggressive rehabilitation and early return to sport at 4 months.
FIG. 43-10 A computed tomography scan of the bone dowel in the tibial
tunnel alongside a double-looped hamstring graft (blue) is shown
postoperatively and at 2 years. The bone dowel indents the tibial tunnel,
reducing and changing the shape of the space occupied by the anterior
cruciate ligament (ACL) graft from round to a smaller crescent shape.
Although the tunnel widens somewhat after 2 years, the cross-sectional area
of the tunnel at 2 years was no larger than the cross-sectional area of the
reamer used to drill the tunnel. The bone dowel limits tunnel widening to
that of the reamer at 2 years by shrinking the tunnel cross-sectional area on
the day of surgery. (From Matsumoto A, Howell SM. Time related changes in
the cross-sectional area of the tibial tunnel after compaction of an autograft
bone dowel alongside a hamstring graft. Arthroscopy. In Press.)

In an in vivo study, a bone dowel averaging 23 mm in CONCLUSION

length and 7 mm in diameter was harvested from the tibial
tunnel in 10 subjects undergoing hamstring ACL reconstruc-
tion. The cross-sectional area of the tibial tunnel was calculated
on the day of surgery, 4 months, and 1 to 2 years postopera-
tively from computed tomography scans. The bone dowel
reduced the cross-sectional area of the tunnel on the day of
surgery and limited tunnel expansion to that of the cross-
sectional area of the reamer at 4 months and 1 to 2 years
(Fig. 43-10). Ninety percent of the subjects treated with a bone
dowel had little to no tunnel expansion at 1 to 2 years. The lim-
itation of tunnel expansion to that of the cross-sectional area of
the reamer has not been shown with other tibial fixation tech-
niques. Limiting tunnel expansion to that of the cross-sectional
area of the reamer should simplify revision surgery.10
This chapter provides scientific documentation that the
WasherLoc and bone dowel meet all the challenges of fixing
a soft tissue ACL graft to the tibia. Fixation at the end of
the tunnel and the compaction of the bone dowel allow cir-
cumferential tendon–tunnel healing and increase the snug-
ness of fit, which solves the problem of a soft tissue ACL
graft healing slower than a BPTB graft. Mechanical fixation
of the WasherLoc in cortical bone and gripping of the soft
tissue graft with multiple spikes solve the problem of the site
of fixation being more vigorously stressed than with a
BPTB graft. The compaction of the bone dowel prevents
tunnel widening, which simplifies revision surgery. The use
of the WasherLoc and bone dowel is a simple, low-profile

322

fixation technique that promotes early tendon–tunnel heal-
ing, resists slippage under cyclical load and exercise, and is
well suited for brace-free, aggressive rehabilitation of
patients reconstructed with a soft tissue ACL graft.
References
1. Aglietti P, Giron F, Buzzi R, et al. Anterior cruciate ligament recon-
struction: bone-patellar tendon-bone compared with double semiten-
dinosus and gracilis tendon grafts. A prospective, randomized clinical
trial. J Bone Joint Surg 2004;86A:2143–2155.
2. Bailey SB, Grover DM, Howell SM, et al. Foam-reinforced elderly
human tibia approximates young human tibia better than porcine tibia:
A study of the structural properties of three soft-tissue fixation devices.
Am J Sports Med 2004;32:755–764.
3. Coleridge SD, Amis AA. A comparison of five tibial-fixation systems
in hamstring-graft anterior cruciate ligament reconstruction. Knee Surg
Sports Traumatol Arthrosc 2004;12:391–397.
4. Grover DM, Howell SM, Hull ML. Early tension loss in an anterior
cruciate ligament graft. A cadaver study of four tibial fixation devices.
J Bone Joint Surg 2005;87A:381–390.
5. Howell SM, Gittins ME, Gottlieb JE, et al. The relationship between
the angle of the tibial tunnel in the coronal plane and loss of flexion
and anterior laxity after anterior cruciate ligament reconstruction. Am
J Sports Med 2001;29:567–574.
6. Howell SM, Roos P, Hull ML. Compaction of a bone dowel in the
tibial tunnel improves the fixation stiffness of a soft tissue anterior cru-
ciate ligament graft: an in vitro study in calf tibia. Am J Sports Med
2005;33:719–725.
7. Kousa P, Jarvinen TL, Vihavainen M, et al. The fixation strength
of six hamstring tendon graft fixation devices in anterior cruciate
ligament reconstruction. Part II: tibial site. Am J Sports Med
2003;31:182–188.
8. Kudo T, Tohyama H, Minami A, et al. The effect of cyclic loading
on the biomechanical characteristics of the femur-graft-tibia
complex after anterior cruciate ligament reconstruction using Bone
Mulch screw/WasherLoc fixation. Clin Biomech (Bristol, Avon)
2005;20:414–420.
9. Magen HE, Howell SM, Hull ML. Structural properties of six tibial
fixation methods for anterior cruciate ligament soft tissue grafts. Am
J Sports Med 1999;27:35–43.
10. Matsumoto A, Howell SM. Time related changes in the cross-sec-
tional area of the tibial tunnel after compaction of an autograft bone
dowel alongside a hamstring graft. Arthroscopy 2006;22:855–860.
11. Roos PJ, Hull ML, Howell SM. Lengthening of double-looped tendon
graft constructs in three regions after cyclic loading: a study using Roentgen
stereophotogrammetric analysis. J Orthop Res 2004;22:839–846.
12. Singhatat W, Lawhorn KW, Howell SM, et al. How four weeks of
implantation affect the strength and stiffness of a tendon graft in a
bone tunnel: a study of two fixation devices in an extraarticular model
in ovine. Am J Sports Med 2002;30:506–513.
13. Smith CK, Hull ML, Howell SM. Lengthening of a single-loop tibia-
lis tendon graft construct after cyclic loading: a study using roentgen
stereophotogrammetric analysis. J Biomech Eng 2006;128:437–442.
14. Chen CH, Chen WJ, Shih CH, et al. Enveloping the tendon graft with
periosteum to enhance tendon-bone healing in a bone tunnel: a bio-
mechanical and histologic study in rabbits. Arthroscopy 2003;19:290–296.
15. Tomita F, Yasuda K, Mikami S, et al. Comparisons of intraosseous
graft healing between the doubled flexor tendon graft and the bone-
patellar tendon-bone graft in anterior cruciate ligament reconstruction.
Arthroscopy 2001;17:461–476.
16. Grassman SR, McDonald DB, Thornton GM, et al. Early healing
processes of free tendon grafts within bone tunnels is bone-specific:
a morphological study in a rabbit model. Knee 2002;9:21–26.
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17. Corry IS, Webb JM, Clingeleffer AJ, et al. Arthroscopic reconstruc-
tion of the anterior cruciate ligament: a comparison of patellar tendon
autograft and four-strand hamstring tendon autograft. Am J Sports
Med 1999;27:444–454.
18. Giurea M, Zorilla P, Amis AA, et al. Comparative pull-out and
cyclic-loading strength tests of anchorage of hamstring tendon grafts
in anterior cruciate ligament reconstruction. Am J Sports Med
1999;27:621–625.
19. Feller JA, Webster KE, Gavin B. Early post-operative morbidity fol-
lowing anterior cruciate ligament reconstruction: patellar tendon versus
hamstring graft. Knee Surg Sports Traumatol Arthrosc 2001;9:260–266.
20. Greis PE, Burks RT, Bachus K, et al. The influence of tendon length
and fit on the strength of a tendon-bone tunnel complex. A bio-
mechanical and histologic study in the dog. Am J Sports Med
2001;29:493–497.
21. To JT, Howell SM, Hull ML. Contributions of femoral fixation
methods to the stiffness of anterior cruciate ligament replacements at
implantation. Arthroscopy 1999;15:379–387.
22. Wallace MP, Howell SM, Hull ML. In vivo tensile behavior of a
four-bundle hamstring graft as a replacement for the anterior cruciate
ligament. J Orthop Res 1997;15:539–545.
23. Weiler A, Hoffmann RF, Bail HJ, et al. Tendon healing in a bone
tunnel. Part II: histologic analysis after biodegradable interference fit
fixation in a model of anterior cruciate ligament reconstruction in
sheep. Arthroscopy 2002;18:124–135.
24. Kyung HS, Kim SY, Oh CW, et al. Tendon-to-bone tunnel healing in a
rabbit model: the effect of periosteum augmentation at the tendon-to-
bone interface. Knee Surg Sports Traumatol Arthrosc 2003;11:9–15.
25. Rodeo SA, Suzuki K, Deng XH, et al. Use of recombinant human
bone morphogenetic protein-2 to enhance tendon healing in a bone
tunnel. Am J Sports Med 1999;27:476–488.
26. Caborn DN, Brand JC Jr, Nyland J, et al. A biomechanical compari-
son of initial soft tissue tibial fixation devices: the Intrafix versus a
tapered 35-mm bioabsorbable interference screw. Am J Sports Med
2004;32:956–961.
27. Clatworthy MG, Annear P, Bulow JU, et al. Tunnel widening in
anterior cruciate ligament reconstruction: a prospective evaluation of
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Arthrosc 1999;7:138–145.
28. L’Insalata JC, Klatt B, Fu FH, et al. Tunnel expansion following ante-
rior cruciate ligament reconstruction: a comparison of hamstring and
patellar tendon autografts. Knee Surg Sports Traumatol Arthrosc
1997;5:234–238.
29. Webster KE, Feller JA, Hameister KA. Bone tunnel enlargement fol-
lowing anterior cruciate ligament reconstruction: a randomized com-
parison of hamstring and patellar tendon grafts with 2-year follow-
up. Knee Surg Sports Traumatol Arthrosc 2001;9:86–91.
30. Buck DC, Simonian PT, Larson RV, et al. Timeline of tibial tunnel
expansion after single-incision hamstring anterior cruciate ligament
reconstruction. Arthroscopy 2004;20:34–36.
31. Buelow JU, Siebold R, Ellermann A. A prospective evaluation of tun-
nel enlargement in anterior cruciate ligament reconstruction with
hamstrings: extracortical versus anatomical fixation. Knee Surg Sports
Traumatol Arthrosc 2002;10:80–85.
32. Simonian PT, Levine RE, Wright TM, et al. Response of hamstring
and patellar tendon grafts for anterior cruciate ligament reconstruction
during cyclic tensile loading. Am J Knee Surg 2000;13:8–12.
33. Bach BR Jr. Revision anterior cruciate ligament surgery. Arthroscopy
2003;19:14–29.
34. Fink C, Zapp M, Benedetto KP, et al. Tibial tunnel enlargement fol-
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323
44
CHAPTER
Double-Spike Plate: Cortical Fixation
Device Enabling Graft Fixation Under
Optional Tension
Konsei Shino BACKGROUND AND BASIC CONCEPT
The pullout technique by tying sutures around
a screw post or over a button is commonly used
as a stand-alone fixation or as an augmentation
for interference screw fixation into a tibial bone
tunnel in the final stage of anterior cruciate liga-
ment (ACL) or other ligament reconstruction.
As the step of tensioning cannot be separated from
that of fixation in this technique, the following
problems have remained unsolved: loosening or
breakage of the sutures while tying sutures around
a post1 and difficulty in correctly controlling the
tension to the graft.2 In order to solve these pro-
blems, a fixation device, the double-spike plate
(DSP) (Ref. 020A-004, MEIRA Corp., Nagoya,
Aichi, Japan) was developed to separate the step
of tensioning from that of fixation.1 This device
is currently commercially-sold only in Japan by
Smith & Nephew Japan but will be shortly
launched into the world market.
SPECIFICATIONS AND INSTRUMENTS
FOR USE
The DSP is a small plate made of titanium alloy
with three holes and two spikes on the reverse
side (Fig. 44-1). There are two sizes available:
the standard DSP for big knee or single tunnel
reconstruction (11 mm wide  18 mm long 
1.5 mm thick with two spikes of 5.5 mm length)
to be used with a 6.5-mm screw and the small
DSP for a small knee or double-bundle procedure
(8.5 mm wide  13.8 mm long  1.5 mm thick
324
with spikes of 4.2 mm length) to be used with
a 5-mm screw (see Fig. 44-1). The impactor is
available for securely hammering base spikes into
the cortical bone (Fig. 44-2). The centering drill
guide is also available for creating a screw hole.
RATIONALE FOR MAINTAINING THE
TENSION DURING GRAFT FIXATION
TO THE TIBIA
If the top end of the DSP closely keeps in close
contact with the tibial cortex without movement,
the DSP should show hinge motion around its
top in the sagittal plain while its spikes are
hammered into the tibia (Fig. 44-3). Thus the
prehammering tension of the graft suture that
has already been tied to the top hole could be
assumed to be equal to its post-hammering
tension. Although there is an instant increase of
the tension due to minimal distal movement
of the plate when the base spikes are hammered
into the cortex, the tension goes down almost to
the predetermined level after load relaxation for
a minute or two (Fig. 44-4).
IN VITRO BIOMECHANICAL DATA
USING PORCINE TIBIAE AND BOVINE
FLEXOR TENDONS
Ten fresh frozen porcine tibias, in which 8-mm
drill holes had been created from just medial to
the tibial tubercle to the attachment of the
ACL, were rigidly fixed to an Instron tension
 Double-Spike Plate: Cortical Fixation Device Enabling Graft Fixation Under Optional Tension
FIG. 44-1 Double-spike plate (DSP) for graft fixation under an optional
tension. The standard-sized DSP is a 1.5-mm-thick, 18-mm-long,
11-mm-wide, small plate made of titanium alloy with three holes and two
spikes of 5.5 mm length on the reverse side. 1, Top hole for connecting the
double-spike plate (DSP) to the free ends of a graft by tying sutures; 2,
central hole to insert a screw for completing the fixation; 3, bottom hole for
tensioning the suture; 4, spikes for temporal fixation without loss of tension.
FIG. 44-2 The tip of the impactor for securely hammering the base
spikes into the bone.
analyzer. Using bovine tendons, a quadrupled graft consist-
ing of two double-looped tendons of 7 cm in length and
8 mm in diameter were prepared with baseball glove stitch-
ing using #3 braided polyester sutures at the distal end of
the graft. The graft was passed through the drill hole, and
its proximal loop ends were connected to a load cell for
monitoring tension (see Fig. 44-3, A). The graft sutures
were tied to a standard-sized DSP through its top hole, pre-
tensioned at 49N or 98N for 5 minutes, and temporarily
fixed to the tibia by hammering the spikes on its reverse side
to the anterior surface of the tibia (see Fig. 44-3, B). Perma-
nent fixation was achieved by inserting a 6.5-mm cancellous
screw (see Fig. 44-3, C). Although the graft tension
instantly increased to 69N  11N (mean  standard
44
Sutures connecting graft to DSP
Fixed to
a load
Tension
with a suture
Tibial tunnel
A
C
FIG. 44-3 Three steps of graft fixation under tension with double-spike
plate (DSP) after completion of fixing the graft on the other end. A,
A certain amount of tension is applied to the graft with a suture through
the bottom hole after the graft’s distal sutures are tied to the top hole. B,
Temporary fixation is achieved by hammering the spikes into the bone
with the plate’s top end kept closely in touch with the bony surface. C, The
final fixation is accomplished by inserting a screw through the center hole.
deviation) (range 53–80N) or 133N  14N (range 121–
157N) during hammering of the spikes, it settled to 49N
 1N (range 37–63N) or 100N  7N (range 88–107N)
at 5 minutes after completing the fixation.
The same experiment on four porcine tibias was
performed with a small-sized DSP under the initial tension
of 49N, followed by final fixation using a 5.0-mm
325
 Anterior Cruciate Ligament Reconstruction

80 (1)
70 (2)

60
Graft tension (N)

50

40

30

20

10

0
0 50 100 150 200 250 300 350 400
Time (sec) FIG. 44-5 Fixation of two- or three-bundle graft using double-spike
FIG. 44-4 Note that graft tension instantly increased up to 73N and plates (DSP) under tension after femoral fixation. Note the tensioners
gradually settled down to 52N over time. 1, Hammering the spikes; installed to the half-shell tensioning boot, which is bandage-fixed to the
2, inserting a screw. calf.

cancellous screw. Although the graft tension instantly

increased to 53N  6N (range 48–63N) during hammering
of the spikes, it settled to 45N  7N (range 37–53N) after
completing the fixation (see Fig. 44-4).
Considering that porcine tibias are softer than those
of young active candidates for ACL reconstruction, these
results suggest that the graft tension can be adjusted at the
time of its fixation to the tibia with the DSP.

EASY, SECURE, AND CONSISTENT PULLOUT

ANTERIOR CRUCIATE LIGAMENT GRAFT
FIXATION WITH DOUBLE-SPIKE PLATES
First, the periosteum should be removed from the bony
surface where installation of the plates is planned.
After femoral side fixation is completed, the sutures
placed to the graft’s distal end are tied to the top hole of
DSP. The tensioning sutures distally connected to the
DSP are tied to the tensioners mounted to a metal shell
boot that has already been fixed to the tibia with bandage
(Fig. 44-5). It is our current choice to apply a total amount
of 20N as the graft initial tension: 10N for the anterior
two bundles and 10N for the posterior doubled graft in the
triple-bundle ACL reconstruction,2 and 20N for the bone–
patellar tendon–bone graft in the rectangular tunnel ACL
reconstruction.3 After the intended amount of the tension
is applied, the knee undergoes passive flexion-extension FIG. 44-6 A radiograph showing fixation hardware. Note the Endobuttons
movement for several times, and the tensioning sutures are are perpendicularly placed on the femoral cortex, whereas the double-
retightened by repetitive strong manual pull. After the ten- spike plates and screws are installed in the tibia.
sion stops to drop following load relaxation, the knee is
maintained at 15 to 20 degrees under the tension for an plastic hammer of higher mass makes it possible to gently
additional 2 minutes. Finally, the graft is fixed with a DSP strike the base spikes into the tibial cortex and to avoid
and cancellous screw (Fig. 44-6). Use of a metal rather than breakage of the cortex by overstriking.

326
 Double-Spike Plate: Cortical Fixation Device Enabling Graft Fixation Under Optional Tension
At the time of double- or triple-bundle reconstruc-
tion, two tensioners should be used. It is our policy to
accomplish tibial side fixation under the same tension
between the anterior (anteromedial and intermediate) and
posterolateral grafts at 15 to 20 degrees of flexion.
TENSION ACHIEVED IMMEDIATELY AFTER
ANTERIOR CRUCIATE LIGAMENT
RECONSTRUCTION
We have been routinely checking the restored anterior stability
with KT-1000 or KT-2000 under anesthesia immediately
after ACL reconstruction since 1999, when this device was
introduced in our practice. None of the ACL-reconstructed
knees has shown greater KT values than the opposite healthy
knees. This has made our clinical results more consistent.
TROUBLESHOOTING
If some soft tissue remained at the cortex for the DSP place-
ment, the temporary fixation after hammering the base
spikes could be somewhat unstable. In this situation, final
fixation could be completed by inserting a screw while the
DSP is stabilized with a microfracture awl through the
bottom hole for suture tensioning.
44
Even if the tibial cortex is somewhat broken by over-
hammering around the base spikes, the graft may not lose
tension significantly as the top portion is stabilized on the
cortex. In case the graft lost tension significantly, the DSP
should be shifted medially or laterally and the procedure
repeated.
Excessive repetitive hammering by extra-strong man-
ual force with a plastic hammer of lower mass may potentially
break the graft sutures. In this worst-case scenario, the graft
should be removed for replacing the graft sutures and the pro-
cedure repeated. Although use of thinner, higher-strength
suture (e.g., Fiberwire by Arthrex, Naples, FL, and Xiros by
Smith & Nephew, Andover, MA) could decrease the risk of
this scenario, use of a metal hammer with higher mass is the
key to completely avoiding this complication.
References
1. Shino K, Mae T, Maeda A, et al. Graft fixation with predetermined
tension using a new device, the double spike plate. Arthroscopy
2002;18:908–911.
2. Shino K, Nakata K, Nakamura N, et al. Anatomic ACL reconstruction
using two double-looped hamstring tendon grafts via twin femoral and
triple tibial tunnels. Oper Tech Orthop 2005;15:130–134.
3. Shino K, Nakata K, Nakamura N, et al. Anatomically-oriented ACL
reconstruction with a bone-patellar tendon graft via rectangular
socket/tunnels: a snug-fit and impingement-free grafting technique.
Arthroscopy 2005;21:1402.e1–1402.e5.
327
 SUB PART II INTERFERENCE SCREW–BASED
45
CHAPTER
Anterior Cruciate Ligament Hamstring
Graft Fixation with BioScrew XtraLok Tibial
Fixation Device
Don Johnson INTRODUCTION
The fixation of soft tissue grafts and the four-
bundle hamstring grafts have been the weak
point of the anterior cruciate ligament (ACL)
hamstring graft fixation. Kousa et al1 and Brand
et al2 have published laboratory studies to pro-
vide some guidance in selecting the strongest
fixation device. On the femoral side the cross-
pins and closed-loop Endobutton are more than
double the strength needed for activities of daily
living (1000N versus 450N). The tibial side
remains the weak part of the construct. The
IntraFix device (DePuy Mitek, Norwood,
MA) has been reported to be around 1000N,
and the staples on the cortex approximately
500N. Harvey et al3 demonstrated that screws
with cortical fixation were almost twice the
strength of screws that were placed in the
cancellous bone portion of the tunnel. This
presentation will describe the technique of using
a cortical cancellous screw fixation for the four-
bundle hamstring graft.
FIXATION OF THE GRAFT IN THE
TIBIAL TUNNEL
The four-bundle graft is pulled up through the
tibial tunnel with the leader sutures attached to
the Endobutton (Fig. 45-1). The graft is pulled
3 cm into the femoral tunnel. The Endobutton
is flipped on the periosteal surface of the femur.
The graft is pulled distally so that approximately
328
1 cm of graft is protruding out of the tibial
tunnel.
The sutures of the graft are attached to
the tensioner. Approximately 50N of tension is
applied to the semitendinosus graft and 30N of
tension to the gracilis graft. The knee is cycled
for 12 cycles, and the tension usually drops off
in both grafts. This is reapplied and cycled again
until the tension remains static.
The flexible guidewire is inserted into
the middle of the four bundles, and the XtraLok
BioScrew (Conmed/Linvatec, Largo, FL) is
inserted up the middle of the four bundles
(Fig. 45-2). The stability of the knee is measured
at the end of the fixation and compared with
the preoperative manual maximum measure-
ment of the opposite knee.
RESULTS
We have performed a randomized clinical trial
comparing the XtraLok BioScrew and IntraFix
tibial fixation device. The results were given as
a podium presentation at the Arthrosopy Asso-
ciation of North America (AANA) meeting in
Vancouver in May 2005. There were no
significant differences in the functional outcome
or in the mechanical stability as measured by the
KT-1000 arthrometer. The initial results did
show a trend to lower KT values at the 1-year
follow up. The BioScrew cortical fixation
combined with the tensioner has given excellent
and reproducible clinical results in hamstring
soft tissue graft fixation.
 Anterior Cruciate Ligament Hamstring Graft Fixation with BioScrew XtraLok Tibial Fixation Device
FIG. 45-1 The four-bundle hamstring graft.
FIG. 45-2 The tension is applied to each of the grafts, and the screw is
inserted up the middle.
XTRALOK TIPS AND TROUBLESHOOTING
The XtraLok tibial bioabsorbable screw comes in two
lengths: 35 and 40 mm. It is available in 8-, 9-, 10-, and
11-mm sizes.
The theory of the screw design is centered on the bio-
mechanical principles that a centrally placed, longer, and
larger screw with cortical fixation improves the pullout
45
strength of hamstring grafts on the tibial side. The screw
is tapered from 8 mm at the insertion tip to 9 mm at the
cortical end. It is recommended to use one size larger than
the tibial tunnel. For example, if the tunnel is 7 or
7.5 mm, then the author uses an 8-  40-mm screw. The
screw is designed to have the maximum purchase on the
cortex. The screw should only be placed level with the cor-
tex and not beyond. The nitinol guidewire is placed up the
middle of the four bundles of hamstring graft. These are
tensioned and separated by the mechanical SE tensioner
(Conmed/Linvatec). The screw must be started with con-
siderable axial load. Once the screw is inserted about half-
way, the guidewire should be removed. This avoids
pushing the guidewire into the joint or having the screw
bind on the wire and break it. It is important to stop about
one turn short of the screw being flush at the cortex. The
depth of the screw is palpated with a finger, and after the
graft is cut off, the screw can be inserted another turn if nec-
essary. It is important not to insert the screw beyond the
cortex as it loses 50% of its pullout if situated in only cancel-
lous bone. The screw cannot be reversed, and when this
happens, it should be advanced to the internal aperture to
obtain proximal cortical fixation.
References
1. Kousa P, Jarvinen TL, Vihavainen M, et al. The fixation strength of six
hamstring tendon graft fixation devices in anterior cruciate ligament
reconstruction. Part II: tibial site. Am J Sports Med 2003;31:182–188.
2. Brand J Jr, Weiler A, Caborn DN, et al. Graft fixation in cruciate
ligament reconstruction. Am J Sports Med 2000;28:761–774.
3. Harvey AR, Thomas NP, Amis AA. The effect of screw length and
position on fixation of four-stranded hamstring grafts for anterior
cruciate ligament reconstruction. Knee 2003;10:97–102.
329
 46
CHAPTER
Intratunnel Tibial Fixation of Soft-Tissue
Anterior Cruciate Ligament Grafts: Graft
Sleeve and Tapered Screw
Charles H. Brown, Jr. INTRODUCTION
Nader Darwich
Tibial fixation of soft-tissue anterior cruciate
ligament (ACL) grafts remains challenging.1–5
Tibial fixation is challenging because of the
lower bone mineral density of the proximal
tibia, the fact that tibial fixation devices must
resist shear forces applied parallel to the axis of
the tibial bone tunnel, and the longer time
required for soft-tissue grafts to heal within
the bone tunnels.2,6 Tibial fixation of soft-tissue
grafts using screws and ligament washers that
anchor to the tibial cortex can address many of
these issues; however, these implants are often
prominent and often cause local skin irritation
and pain, requiring a second operation for
removal.5 Intratunnel tibial fixation of soft-
tissue grafts using interference screws avoids
the problem of prominent hardware; however,
laboratory biomechanical studies have shown
that the tensile properties of soft-tissue grafts
fixed with interference screws are highly depen-
dent on bone mineral density, and this fixation
technique often results in low initial fixation
strength and slippage under cyclical loading.2,4,5
The Graft Sleeve and Tapered Screw (GTS)
System (Smith & Nephew Endoscopy,
Andover, MA) intratunnel tibial fixation
technique was developed to increase the failure
load and stiffness and to decrease slippage of
four-strand soft-tissue grafts.
The GTS System is an intratunnel
tibial fixation technique that positions a poly-
L-lactic acid (PLLA) tapered, fine-pitch screw
330
concentrically within a four-strand soft-tissue
graft. The tapered screw features shorter thread
distance, which enhances compression of the
soft-tissue graft in cancellous bone. The GTS
System consists of the tapered screw and a
three-lumen, woven, nonabsorbable polypropyl-
ene (PPE) mesh graft sleeve that organizes the
four-graft strands in the tibial tunnel. The graft
sleeve prevents graft twisting during screw
insertion; maximizes bone–tendon contact,
which enhances healing; and provides better
compression of each ligament strand against
the bone tunnel wall while protecting the graft
strands from screw damage (Fig. 46-1).
BASIC SCIENCE
Biomechanical Testing
Biomechanical testing of the graft sleeve and
tapered screw using human doubled gracilis
and semitendinosus tendon (DGST) grafts has
been performed in the proximal tibia of calf
bone (2 years or younger) with bone mineral
density similar to that of the proximal tibia in
young humans.1,7 The tibia–DGST–graft sleeve
complex was subjected to a 50N preload fol-
lowed by cyclical loading between 50N and
250N at 1 Hz for 1000 cycles with the direction
of tensile loading applied parallel to the axis of
the tibial bone tunnel. Graft slippage was
measured using a noncontact, three-camera,
motion analysis system that allowed the position
 Intratunnel Tibial Fixation of Soft-Tissue Anterior Cruciate Ligament Grafts: Graft Sleeve and Tapered Screw
FIG. 46-1 Graft Sleeve and Tapered Screw (GTS) System. The graft sleeve is
a 15-mm-long, three-lumen, nonabsorbable, woven polypropylene mesh.
The two bottom lumens (white threading tubes) are used to house the
gracilis tendons, while the 1.5-mm guidewire and tapered screw is inserted
through the single top lumen (blue threading tube). The outer suture
acts as a cinch to hold the sleeve in place on the gracilis tendon during
insertion into the tibial tunnel. The tapered screw is made of poly-
L-lactic acid (PLLA) and is available in sizes 7 to 9 mm  30 mm and
8 to 10 mm  30 mm.
of retroreflective bone and graft markers to be recorded in
three dimensions during cyclic loading. Mean graft slippage,
in which graft slippage was defined as the change in posi-
tion of the tendon marker relative to the bone marker under
the 50N preload and after cyclical loading, was 1.14

0.83 mm. The mean linear stiffness was 158
31 N/mm,
and the mean failure load was 736
162 N, in which fail-
ure load was defined as the load when the load displacement
curve substantially deviated from linear. The predominant
mode of failure (60%) was pullout of the DGST tendons,
graft sleeve, and tapered screw from the tibia. Comparison
of the GTS System and the IntraFix Tibial Fastener
(DePuy Mitek, Norwood, MA) using the just-mentioned
testing protocol demonstrated no statistically significant
differences in the cyclical and failure properties between
the two devices.
Biocompatibility and Histology of Fixation
Site Healing
Biocompatibility of the PLLA screw and PPE graft sleeve has
been studied in a sheep model.8 Gross histological examina-
tion demonstrated that implantation of the PLLA screw
and polypropylene graft sleeve had no adverse effect on the
articular cartilage. Microscopic analysis of the synovial fluid
using polarized light failed to detect the presence of any
polymeric debris. Signal intensity at the bone–tendon inter-
face evaluated by computed tomography (CT) was used as
46
an indicator of bone–tendon healing. CT slices in the axial
plane demonstrated a progressive increase in healing at the
bone–tendon interface over time. By 12 weeks a neocortex
surrounded the tendon grafts. Based on the appearance of
the signal intensity at the bone–tendon interface, the presence
of the graft sleeve and tapered screw did not interfere with
healing of the tendon to bone. No adverse reactions were
noted related to the PLLA screw and PPE graft sleeve.
Histological examination performed using a hard tissue
technique in polymethylmethacrylate (PMMA) demon-
strated that the PLLA screw compressed the tendons directly
against the bone tunnel wall. These sections showed correct
positioning of the PLLA screw in the PPE sleeve, as well as
organization of the tendons in the PPE sleeve and bone tun-
nel to give a maximum bone–tendon interface (Fig. 46-2).
Healing at the bone–tendon and tendon–screw inter-
face was evaluated on paraffin sections stained with hema-
toxylin and eosin (H&E) and trichrome stains. Bone–
tendon healing progressed over time and was observed in
all specimens. The tendon grafts were compressed against
the adjacent bone as a result of the screw being placed in
the central lumen of the graft sleeve. The bone–tendon
interface was composed of loose connective tissue, fibroblas-
tic cells and local areas of bone–tendon integration. There
was no evidence of macrophage or foreign body reaction at
the bone–tendon interface (Fig. 46-3). Connective tissue
was noted to infiltrate throughout the PPE sleeve, and no
significant difference was seen between areas where the
sleeve and screw were present and areas in the proximal part
of the bone tunnel where only the tendon grafts were
present. The interface between the tendon graft and screw
was composed of a thin layer of loose connective tissue with
FIG. 46-2 Polymethylmethacrylate (PMMA) cross-section perpendicular to
the long axis of the screw. Histology at 3 weeks demonstrates central
placement of the tapered screw and organization and compression of the
four tendon graft strands in the tibial bone tunnel. (From Smith & Nephew
Endoscopy, Andover, MA.)
331
 Anterior Cruciate Ligament Reconstruction

FIG. 46-3 A, Cross-sectional histology at 6 weeks. The tendon graft is seen in the bone tunnel with healing at the
tendon–bone interface. The interface tissue is composed of loose connective tissue, fibroblasts, and local areas of
tendon–bone integration. B, 12-week histology demonstrating the tapered screw and the maturing tendon–bone
interface. The interface between the screw and tendon graft consists of loose connective tissue with cellularity. The
tendon graft is compressed against the adjacent bone as a result of the screw being placed into the central lumen of
the graft sleeve. C, 52-week histology demonstrating tendon–bone healing with a well-defined interface. (From Smith
& Nephew Endoscopy, Andover, MA.)

cellularity. There was no evidence of macrophage or foreign

body reaction at the tendon–screw interface. In conclusion,
histological analysis demonstrated the following:
1 The graft sleeve and tapered screw oriented the graft to
provide the maximum contact area for tendon–bone
healing.
2 Normal tendon–bone healing progressed throughout the
bone tunnel with no differences between areas with and
without the graft sleeve.
3 Tissue infiltrated freely throughout the sleeve and around
the tapered screw.
4 No adverse reactions to the PLLA screw and
polypropylene sleeve were observed.
SURGICAL TECHNIQUE
Tibial fixation with the graft sleeve and tapered screw can be
used with any four-strand soft-tissue ACL graft, provided
the graft is long enough to reach the anterior tibial cortex
after the graft has been fixed in the femur. The device is ide-
ally suited for use with DGST tendon grafts, but it can also
be used with doubled tibialis tendon allografts.
Advantages of the Graft Sleeve and
Tapered Screw
Compared with other intratunnel soft-tissue tibial fixation
techniques, the advantages of the graft sleeve and tapered

332
 Intratunnel Tibial Fixation of Soft-Tissue Anterior Cruciate Ligament Grafts: Graft Sleeve and Tapered Screw
screw include consistent concentric insertion of the tapered
screw, high screw insertion torque, uniform compression of
the four-strand soft-tissue graft into the bone tunnel walls,
and minimal rotation of the graft strands during screw inser-
tion. Laboratory biomechanical testing has shown that these
properties enhance initial graft fixation strength, stiffness,
and resistance to slippage under cyclic loading.7,9 Finally,
optimal surgical technique for implantation of the graft sleeve
and tapered screw incorporates use of a mechanical tensioning
device that equally tensions all four strands of the soft-tissue
graft. Hamner et al10 have demonstrated in a laboratory
biomechanical study that equal tensioning of all four strands
of a four-strand hamstring tendon graft is necessary to maxi-
mize initial tensile strength and stiffness of the DGST graft.
Hamstring Tendon Graft Preparation
Preparation of the hamstring tendon grafts and use of the
GTS System are facilitated by the use of a graft preparation
board (Graft Master II, Smith & Nephew Endoscopy).
Residual muscle fibers on the musculotendinous end of both
tendons are bluntly dissected off the tendons using a metal
ruler, a large curette, or a Cushing-type periosteal elevator.
The two tendon grafts are cut to the same length, and the ends
of each tendon are tubularized with a running, baseball-style
whipstitch using a #2 nonabsorbable suture. The sutures on
each end of the tendon grafts are tensioned with a “cinching”
motion to remove excess slack from the whipstitches. The two
tendon grafts are looped around a #5 nonabsorbable suture,
creating a DGST graft. The diameter of the DGST graft is
measured to the nearest 0.5 mm using a 0.5-mm incremental
sizing block. The diameter of the combined grafts is usually
7 to 8.5 mm in males and 6.5 to 8 mm in females. The ends
of the DGST graft are equalized in length and the axilla of
the DGST graft looped around an Endobutton tensioning
post. The DGST graft is covered with a moist laparotomy
pad and pretensioned to 5 pounds on the graft preparation
board for the remainder of the procedure.
Tibial Tunnel
A tibial tunnel length of 40 to 50 mm is optimal because this
length range will allow the 30-mm-long tapered screw to be
inserted flush with the tibial cortex, with there being no pos-
sibility that the screw will protrude into the intraarticular
aspect of the knee joint. Setting the adjustable tibial aimer
between 50 and 55 degrees will usually allow these tunnel
lengths to be achieved. If the transtibial tunnel technique is
used to drill the femoral tunnel, the starting position of the
tibial guide pin must be located adjacent to the anterior fibers
of the medial collateral ligament (MCL). This is necessary to
46
achieve the correct tunnel angulation so that the femoral
tunnel can be oriented at the 10-o’clock position. Laboratory
biomechanical studies have demonstrated that single-tunnel
ACL grafts placed at the 10-o’clock position provide better
rotational control compared with ACL grafts placed at the
11-o’clock position.11 The starting location of the tibial guide
pin is not critical if the femoral tunnel is drilled using the
anteromedial portal technique.
A tight fit of the soft-tissue ACL graft in the bone
tunnels is desirable to optimize tendon–bone healing.12 To
ensure a tight fit, half-millimeter size drill bits are used to drill
the bone tunnels. To prevent anterior drift of the tibial tunnel,
a cannulated, rear entry–style drill is used to drill the tibial
tunnel. Because attaching the graft sleeve to the DGST graft
increases its diameter, it is necessary to overdrill the first 10 to
15 mm of the tibial tunnel by 1 mm greater than the measured
size of the ACL graft. The remainder of the tibial tunnel is
drilled using a drill size equal to the measured diameter of
the DGST graft. Half-round or angled ACL chamfering
rasps are used to smooth the intraarticular edge of the tibial
tunnel to minimize graft abrasion. To ensure smooth passage
of the graft sleeve into the tibial tunnel, it is important to clear
soft tissue from around the edges of the tibial tunnel using an
electrocautery pencil and a Cobb periosteal elevator.
Femoral Tunnel and Fixation
The graft sleeve and tapered screw can be used with any
femoral fixation technique. However, because of its high
strength, minimal slippage, and ease of use, we prefer femoral
fixation with the Endobutton-CL.13 The femoral tunnel can
be created using the transtibial tunnel or anteromedial portal
techniques. The femoral guide pin is positioned at the
10-o’clock position along the sidewall of the lateral femoral
condyle, and the Endobutton femoral tunnel and closed-
end femoral socket are drilled in the usual fashion.14 An
Endobutton depth gauge with adjustable knob (Smith &
Nephew Endoscopy) is used to measure the femoral tunnel
length and the total tunnel length (distance from the lateral
femoral cortex to the superior margin of the anterior tibial
cortex) (Fig. 46-4). These measurements are used to calculate
the Endobutton-CL length and the location for attaching the
graft sleeve on the gracilis tendon graft. If interference screw
or cross-pin fixation techniques are used, the total tunnel
length is measured from the end of the closed-end femoral
socket to the anterior tibial cortex.
Application of the Graft Sleeve
The appropriate-length Endobutton-CL is inserted into
the Endobutton holder with extender (Smith & Nephew
333
 Anterior Cruciate Ligament Reconstruction

passage, we have found it helpful to position the sleeve

th
ng
10 mm closer to the Endobutton end of the graft. After ver-

le
el
ifying that the blue threading tube lies in the third lumen of

nn
tu
the sleeve, the graft sleeve is attached to the gracilis tendon

al
or
m
by securely tying the preinserted cinching suture. To provide

Fe
additional security and to prevent the leading edge of the
sleeve from puckering and impinging at the entrance of
the tibial tunnel, we have found it helpful to loop and tie
an additional #0 absorbable suture around the leading edge
of the graft sleeve. The semitendinosus strands are equalized
in length and the whipstitches are attached to the superior
th
ng knobs of the tensioner. The semitendinosus strands should
le
l
ne

straddle the right/left sides of the top lumen on the graft

un

sleeve and rest on the top surface of the lower two lumens
lt
ta
To

containing the gracilis tendon (Fig. 46-5).

Graft Passage

A full-length #5 Fiberwire (passing suture) and #2 high-

FIG. 46-4 Measurement of femoral tunnel length and total tunnel length strength nonabsorbable suture (flipping suture) are passed
using the Endobutton depth gauge with adjustable knob. (From Smith & through the end holes of the Endobutton. We recommend
Nephew Endoscopy, Andover, MA.)
against the use of conventional #5 polyester passing suture
because it may break during graft passage as a result of the
Endoscopy) and the DGST graft passed through the contin-
greater force required to advance the graft sleeve into the
uous loop. The DGST graft is marked at the previously
tibial tunnel. The Endobutton sutures are passed across
measured femoral tunnel length. The ends of the doubled
the joint and out the lateral thigh using a 2.7-mm, drill-
semitendinosus tendon graft are equalized in length, the
tipped passing pin.
sutures are clamped together with a small surgical clamp,
Maintaining slight tension on the tibial end of the
and the semitendinosus tendon graft is flipped off the side of
DGST graft using the tensioner handle, the Endobutton
the Endobutton holder with extender. The Graft Tensioning
and the attached hamstring tendon graft are passed across
Device (Smith & Nephew Endoscopy) is inserted into the
the knee joint and into the femoral socket using the #5
tensioner device holder (Smith & Nephew Endoscopy), and
Fiberwire passing suture. The DGST graft must be
the back of the tensioner device holder is positioned on the
advanced until a mark previously placed at the femoral tun-
GraftMaster II board at the 18-cm mark. The Endobutton
nel length is seen to pass up into the femoral socket approx-
depth gauge with adjustable knob is used to mark the doubled
imately 6 mm. This extra distance allows the Endobutton to
gracilis tendon at the previously measured total tunnel length.
pass outside the lateral femoral cortex and flip. Tension is
This mark is used to position the graft sleeve on the gracilis
tendon. If the femoral tunnel was drilled through the antero-
medial portal, the end of the Endobutton depth gauge is posi-
tioned at the previously marked femoral tunnel length and the
gracilis tendon is marked at a distance that equals the intra-
articular length of the ACL plus the tibial tunnel length.
The sutures on the end of the gracilis tendon are
threaded through the white, plastic threading tubes of the
graft sleeve and the gracilis sutures attached to the lower
knobs of the tensioner. It is important that the graft sleeve
be attached to the gracilis tendon such that the cinching
suture is positioned toward the Endobutton-CL. The white,
plastic threading tubes are removed from the graft sleeve,
and the sleeve is positioned on the gracilis at the previously FIG. 46-5 Each end of the gracilis tendon is passed through one of the
two lower lumens of the graft sleeve. The 1.5-mm guidewire for the
marked total tunnel length. Because the graft sleeve has a tapered screw is inserted into the third lumen of the sleeve, and the sleeve
tendency to slide distally on the gracilis tendon during graft is secured to the gracilis tendon by tying the preinserted cinching suture.

334
 Intratunnel Tibial Fixation of Soft-Tissue Anterior Cruciate Ligament Grafts: Graft Sleeve and Tapered Screw
applied to the tibial end of the graft, and the surgical mark
previously placed at femoral tunnel length will be seen to
slide back down the femoral tunnel. If the measurements
are correct, this mark should lie at the entrance of the
femoral tunnel and the graft sleeve should be slightly
recessed or lie flush with the entrance of the tibial tunnel.
Tibial Fixation
The knee is cycled from 0 to 90 degrees for a minimum of
30 cycles with a preload of 80N to 100N applied to the
DGST using the tensioning device. Cycling of the knee
under a preload allows the Endobutton-CL to settle on
the femoral cortex and removes creep from the continuous
loop and DGST graft. At the present time, the optimal
graft tension and knee flexion angle during tibial fixation
are unknown. Depending on the graft excursion pattern
detected while cycling the knee, we fix the graft with the
knee between 0 and 20 degrees of flexion. The usual graft
excursion pattern detected with our bone tunnel placements
results in the DGST graft pulling into the tibial tunnel a
few millimeters during the last 20 degrees of terminal
extension. When minimal graft excursion is detected, we
tend to fix the graft with the knee at 20 degrees of flexion
and near full extension with greater excursions. Because of
the high fixation strength and stiffness and the resistance
to slippage of the graft sleeve and tapered screw, we caution
against applying excessive tension (greater than 80N) to the
graft or fixing the knee at a flexion angle greater than
30 degrees. High graft tension force in combination with
the knee flexed more than 30 degrees can overconstrain or
“capture” the knee.
With the knee held at the desired flexion angle and
80N applied to the DGST graft, a 1.5-mm guidewire is
inserted through the blue threading tube into the knee joint.
The blue threading tube is removed, leaving the guidewire
in place in the third lumen of the graft sleeve. If the diame-
ter of the DGST graft is 6 to 8.5 mm, we recommend use
of the 7- to 9-mm  30-mm tapered screw. For larger graft
sizes, the 8- to 10-mm  30-mm tapered screw is used. The
appropriate-sized tapered screw is inserted onto the BioRCI
screwdriver (Smith & Nephew Endoscopy) and the screw
advanced over the guidewire into the third lumen of the
graft sleeve. While maintaining an 80N load on the DGST
graft, the tapered screw is screwed into the graft sleeve and
up into the tibial tunnel until the end of the screw is flush
with the anterior tibial cortex (Fig. 46-6). Insertion of the
tapered screw is usually accompanied by a “squeaking” feel
and sound. Because the best bone quality is at or next to
the anterior tibial cortex, inserting the tapered screw too
deeply may decrease fixation strength.9
46
The fixation strength of any intratunnel fixation
device is dependent on the local bone mineral density.1,2,5
If the surgeon believes that there was inadequate insertion
torque during the insertion of the tapered screw or if the
patient has soft bone, then we recommend that supplemen-
tal tibial fixation be used.3 Depending on the graft length,
the protruding DGST tendons can be stapled below the tib-
ial tunnel using a small barbed staple (Smith & Nephew
Orthopaedics, Memphis, TN), or the sutures can be tied
around a extra-small, nonbarbed staple or tibial fixation post
(Smith & Nephew Endoscopy) (Fig. 46-7).
The stability and range of motion of the knee are
checked. It is important to verify that the patient has full
range of motion before leaving the operating room. The
arthroscope is inserted into the knee, and graft tension
and impingement are assessed. Our usual graft placement
and tensioning technique results in the four strands of the
DGST being maximally tight between 0 and 20 degrees,
with the graft tension decreasing slightly as the knee is
flexed to 90 degrees (Fig. 46-8). After confirming that the
patient has a full range of motion and normal anterior laxity,
the passing and flipping sutures are pulled out of the lateral
thigh.
POSTOPERATIVE MANAGEMENT
Follow-Up
The patient is seen at 7 to 10 days for suture removal and
postoperative radiographs (Fig. 46-9).
Rehabilitation
Our postoperative rehabilitation protocol is described in
Table 46-1. The weight-bearing schedule is modified if a
meniscus repair, microfracture, or other associated ligamen-
tous surgery has been performed.
USE OF THE GRAFT SLEEVE WITH TIBIALIS
TENDON ALLOGRAFTS
Due to the potential issues of graft–tunnel mismatch and the
lack of availability of bone–patellar tendon–bone (BPTB)
allografts, double-stranded anterior and posterior tibial ten-
don (tibialis tendon) allografts have become an increasingly
popular graft choice for ACL reconstruction. At the present
time, bioabsorbable interference screws are most commonly
used for tibial fixation of tibialis tendon allografts. For
surgeons desiring improved initial fixation properties, it is
335
 Anterior Cruciate Ligament Reconstruction

B
FIG. 46-6 A, The tapered screw is advanced over the 1.5-mm guidewire into the third lumen of the graft sleeve.
B, Tibial fixation is completed by inserting the tapered screw until it is flush with the anterior tibial cortex.
(From Smith & Nephew Endoscopy, Andover, MA.)

336
 Intratunnel Tibial Fixation of Soft-Tissue Anterior Cruciate Ligament Grafts: Graft Sleeve and Tapered Screw
A B
FIG. 46-7 Supplemental tibial fixation. A, The tendons are fixed to the tibia with a barbed ligament staple.
B, The tendon whipstitches are tied around a screw and washer. (From Smith & Nephew Endoscopy, Andover, MA.)
FIG. 46-8 Arthroscopic appearance of the doubled gracilis and
semitendinosus tendon (DGST) graft demonstrating equal tensioning of
the graft strands. Note that the femoral attachment site of the graft is
located along the sidewall of the lateral femoral condyle and the graft
is oriented at a 10-o’clock position in the notch.
possible to modify the ends of the tibialis tendon allograft to
allow use of the graft sleeve and tapered screw. The tibialis
tendon allograft is thawed and looped around a #5 suture, cre-
ating a double-stranded graft. The diameter of the doubled
tibialis allograft is measured to the nearest half-millimeter as
previously described. After drilling the tibial and femoral
bone tunnels, the Endobutton depth gauge with adjustable
46
knob is used to measure the femoral tunnel length, the total
tunnel length, and the length of the tibial tunnel. The appro-
priate-length Endobutton-CL is selected, and the tibialis
allograft is passed through the CL loop, creating a doubled
tibialis tendon allograft. The total tunnel length is marked
on the tibialis allograft as previously described. This mark
serves to locate the position for attaching the graft sleeve.
Using the total tunnel length mark as the starting point, a sec-
ond mark that equals the length of the tibial tunnel is made
toward the Endobutton end of the graft. The free ends of
the tibialis tendon allograft are split in half with a 15 knife
blade up to the tibial tunnel length mark, creating four tendon
graft strands. The four graft strands are whipstitched using a
#2 nonabsorbable suture. The graft sleeve is attached in the
usual fashion to two strands of the doubled tibialis tendon
allograft (Fig. 46-10). The tibialis tendon allograft is passed
and fixed in the femur as previously described. The knee is
cycled 30 times with a preload of 100N applied to the graft
strands. While maintaining an 80N load on the tibialis ten-
don allograft, the tapered screw is screwed into the graft sleeve
and up into the tibial tunnel until the end of the screw is flush
with the anterior tibial cortex.
PEARLS AND PITFALLS OF THE TECHNIQUE
The most common technical problems encountered during
use of the graft sleeve and tapered screw are (1) the difficulty
in getting the sleeve to pass into the tibial tunnel and (2) the
337
 Anterior Cruciate Ligament Reconstruction

FIG. 46-9 Postoperative radiographs. A, The tibial tunnel forms a 65-degree angle with the joint line. Proper tibial
tunnel placement results in placement of the Endobutton at the flair of the distal femur. B, Lateral radiograph in
maximum hyperextension. The tibial tunnel is parallel and posterior to Blumensaat’s line.

sliding of the sleeve on the soft tissue graft, resulting in part  Tying a “purse-string” #0 nonabsorbable suture around
or all of the sleeve coming to lie outside of the tibial tunnel. the leading edge of the graft sleeve to help further secure
These problems can be prevented by the following: the sleeve to the soft tissue graft

 Overdrilling the first 10 mm of the tibial tunnel 1 mm
greater than the measured size of the soft tissue graft
 Removing soft tissue from the entrance of the tibial
tunnel
 Making sure that the graft sleeve is attached to the soft
tissue graft with the cinching suture oriented toward the
Endobutton end of the graft
 Verifying that the blue threading tube for the 1.5-mm
guidewire is inserted into the third lumen of the
graft sleeve before securing the sleeve to the soft
tissue graft
 Avoiding the use of a strong nonabsorbable “purse-string”
suture because it may not break during insertion of the
tapered screw, preventing advancement of the tapered
screw into the third lumen of the graft sleeve
 Using a #5 Fiberwire suture as the Endobutton passing
suture
RESULTS
We have performed more than 30 hamstring ACL recon-
structions using graft sleeve and tapered screw tibial fixation

338
TABLE 46-1 Hamstring Anterior Cruciate Ligament Postoperative Rehabilitation Protocol
Goals Exercises
46
Phase I: Days 0–7
Control pain, inflammation, joint effusion, swelling Knee CryoCuff, thigh-length TED stocking, elevation
Full passive extension equal to the opposite knee Heel props, pull knee into hyperextension using elastic band
Achieve 90 degrees of flexion Wall slides, gravity assisted flexion sitting on the edge of a table
Prevent quadriceps shutdown EMS, quad isometrics, SLR, active-assisted extension 90–0 degrees
Prevent heel cord contracture Ankle pumps, calf stretches with elastic bands
Gait training Weight bearing as tolerated with knee immobilizer and crutches
Meniscus repair, revisions: " 25% BW/week, wean off crutches end of week 4

Phase II: Weeks 1–2

Control inflammation, pain, joint effusion, swelling Continue Phase I exercises
Maintain full symmetrical extension Continue Phase I exercises
Achieve 100–125 degrees of flexion Assisted flexion using opposite leg, wall slides, heel drags, rolling stool
Develop muscular control to safely wean off knee Continue Phase I exercises, mini-squats, toe raises, active extension 90–30 degrees
immobilizer and crutches
Protect hamstring donor site Prevent sudden, forceful hamstring stretching with the knee and hip in extension, such as attempting to
lean forward and put on socks and shoes or leaning forward to pick up an object off the floor

Phase III: Weeks 2–4

Maintain symmetrical extension Heel props, prone heel hangs, lock knee out, “stand at attention”
Wean off knee immobilizer Patients who fail to obtain symmetrical extension should be considered for extension splinting or a
“drop-out” cast; discard immobilizer when able perform SLR without a quad lag
Wean off crutches One crutch when able to bear 75% BW; discard crutches when full weight bearing and able to walk
with normal heel–toe gait
Achieve 125–135 degrees flexion Heel slides, sitting back on heels
Hamstring strengthening Hamstring isometrics 0–90 degrees, pulling, rolling, rolling stool backwards
Quadriceps strengthening Continue Phase II exercises, mini-squats with elastic band for resistance
Hip strengthening Side-lying hip abduction, adjustable-angle hip machine
Proprioceptive training Balance board double-leg stance
Aerobic conditioning Elliptical machine

Phase IV: Weeks 4–6

Obtain full flexion Heel slides, sitting back on heels
Continue quadriceps, hamstring, and hip Mini-squats, leg press 50–0 degrees, front step-ups (control hip valgus), StairMaster backward, PNF,
strengthening toe raises, seated leg curl machine 0–90 degrees
Proprioceptive training Balance board double- and single-leg stance, add ball throws and catches
Aerobic conditioning Stationary bike (adjust to protect PFJ), elliptical machine, pool exercises

Phase V: Weeks 6–12

Increase lower extremity strength and endurance Increase intensity Phase IV exercises, high-speed (300–360 degrees/sec) isokinetics extension (90–30
degrees)/flexion (0–90 degrees), elliptical machine, StairMaster backward and forward, treadmill
walking, pool exercises
Advance proprioceptive and perturbation training Increase intensity of Phase IV exercises

Phase VI: Weeks 12–16

Increase quad and hamstring strength Increase intensity of Phase IV exercises, mid-range (180–240 degrees/sec) isokinetics extension (90–30
degrees)/flexion (0–90 degrees)
Increase hamstring strength at high-flexion angles Prone leg curls with elastic tubing and leg curl machine (90–120 degrees)
Jogging and running Treadmill jogging and running, outdoor running on low-impact surface
Crossover drills Lateral step-over, carioca drills

Phase VII: Weeks 16–24

Hard cutting and sports-specific drills Figure-eight, circle run, plyometrics, hopping, jumping, sprinting
Return to noncontact sports at 4–5 months Golf, tennis, biking, hiking
Return to full sports at 6 months (revisions,
9 months)

BW, Body weight; EMS, electrical muscle stimulation; PFJ, patellofemoral joint; PNF, proprioceptive neuromuscular facilitation; SLR, straight leg raises. 339
 Anterior Cruciate Ligament Reconstruction
FIG. 46-10 A, Preparation of tibialis tendon allograft for tibial fixation with
graft sleeve and tapered screw. The ends of the tibialis tendon allograft are
split and whipstitched with a #2 nonabsorbable suture. B, Two of the split
ends are threaded through the graft sleeve, and the sleeve is secured to
the tibialis tendon allograft by tying the cinching suture.
since the device became clinically available. There have been
no infections, recurrent effusions, or other complications
related to the device. The early objective stability and clini-
cal results are similar to those we reported using the IntraFix
tibial fastener.14 However, due to the higher insertion
torque and the tighter fit in the tibial tunnel, we have used
supplemental tibial fixation less frequently.
FUTURE OF THE TECHNIQUE
An osteoconductive tapered screw (Calaxo Screw, Smith &
Nephew Endoscopy) that will integrate in the tibial tunnel
and be replaced by bone within 1 year is currently under
development. This would preserve bone stock and eliminate
the need for screw removal in revision cases. One of the
major differences between ACL reconstructions performed
using BPTB and hamstring tendon autografts is the faster
fixation site healing of patellar tendon grafts. Ongoing basic
science research is directed at promoting and accelerating
healing of soft tissue grafts to bone. Bone morphogenic pro-
teins and biological growth factors are currently being inves-
tigated as possible methods to promote and accelerate soft
340
tissue–bone healing. Because of the woven, porous nature
of the graft sleeve and the demonstrated ability of the
interface tissue to infiltrate throughout the sleeve, the graft
sleeve should serve as an ideal carrier when the appropriate
biological enhancement factors are identified.
References
1. Brand JC, Pienkowski D, Steenlage E, et al. Interference screw fixa-
tion strength of a quadrupled hamstring tendon graft is directly related
to bone mineral density and insertion torque. Am J Sports Med
2000;28:705–710.
2. Brand JC, Weiler A, Caborn DNM, et al. Graft fixation in cruciate
ligament reconstruction. Am J Sports Med 2000;28:761–774.
3. Hill PF, Russell VJ, Salmon LJ, et al. The influence of supplementary
tibial fixation on anterior laxity measurements after anterior cruciate
ligament reconstruction with hamstring tendons in female patients.
Am J Sports Med 2005;33:94–101.
4. Kousa P, Jarvinen TLN, Vihavainen M, et al. The fixation strength of
six hamstring tendon graft fixation devices in anterior cruciate ligament
reconstruction. Part II: tibial site. Am J Sports Med 2003;31:182––174.
5. Magen HE, Howell SM, Hull ML. Structural properties of six tibial
fixation methods for anterior cruciate ligament soft tissue grafts. Am
J Sports Med 1999;27:35–43.
6. Rodeo SA, Arnoczky SP, Torzilli PA, et al. Tendon healing in a bone
tunnel: a biomechanical and histological study in the dog. J Bone Joint
Surg 1993;75A:1795–1803.
7. Hecker AT, Blough R. GTS Sleeve vs. IntraFix Fastener: a biomechan-
ical comparison of initial fixation properties. Report on file at Smith &
Nephew Endoscopy, Andover, MA.
8. Cotton NJ, Blough RA. Histological evaluation of the GTS Sleeve/GTS
Tapered Screw intratunnel tibial fixation system in an ovine model.
Report on file at Smith & Nephew Endoscopy, Andover, MA.
9. Harvery AR, Thomas NP, Amis AA. The effect of screw length and
position on fixation of four-stranded hamstring grafts for anterior
cruciate ligament reconstruction. Knee 2002;10:97–102.
10. Hamner DL, Brown CH, Steiner ME, et al. Hamstring tendon grafts
for reconstruction of the anterior cruciate ligament: biomechanical
evaluation of the use of multiple strands and tensioning techniques.
J Bone Joint Surg 1999;81A:549–557.
11. Loh JC, Fukuda Y, Tsuda E, et al. Knee stability and graft function
following anterior cruciate ligament reconstruction: comparison
between 11 o’clock and 10 o’clock femoral tunnel positions. Arthros-
copy 2003;19:297–304.
12. Greis PE, Burks RT, Bachus K, et al. The influence of tendon length
and fit on the strength of a tendon-bone tunnel complex: a biomechani-
cal and histologic study in the dog. Am J Sports Med 2001;29:493–497.
13. Brown CH, Wilson DR, Hecker AT, et al. Graft-bone motion and
tensile properties of hamstring and patellar tendon anterior cruciate
ligament femoral graft fixation under cyclic loading. Arthroscopy
2004;20:922–935.
14. Brown CH, Sklar JH, Darwich N. Endoscopic anterior cruciate liga-
ment reconstruction using autogenous doubled gracilis and semitendi-
nosus tendons. Tech Knee Surg 2004;3:215–237.
 Hamstring Anterior Cruciate Ligament
Reconstruction with IntraFix Tibial
Fastener
INTRODUCTION
The optimal initial graft fixation technique for
hamstring tendon anterior cruciate ligament
(ACL) grafts remains controversial.1–6 Bio-
mechanical studies have demonstrated that
cross-pin and Endobutton-CL femoral fixation
techniques provide excellent initial fixation
properties.7,8 However, tibial fixation of ham-
string tendon ACL grafts has been more prob-
lematic. This is primarily due to the lower
bone mineral density of the proximal tibia and
the fact that tibial fixation devices must resist
tension applied parallel to the axis of the tibial
bone tunnel.2,9–11 Extratunnel tibial fixation
techniques that anchor to the tibial cortex can
provide secure initial fixation; however, the
implants are often prominent and cause local
skin irritation and pain, requiring a second
operation for removal.12 Intratunnel tibial
fixation using interference screws eliminates
the problem of prominent hardware, but the
single interference screw technique has been
shown to have somewhat low initial fixation
strength and increased slippage under cyclical
loading.2,4,9,13
The IntraFix tibial fastener was designed
with two goals in mind, one mechanical and
one biological. The first goal was to achieve more
rigid intratunnel fixation of soft tissue grafts and
eliminate or decrease the need for supplemental
tibial fixation. The second goal was to maximize
bony integration of the soft tissue graft strands
into the bone tunnel wall. To achieve these goals,
47
CHAPTER
the device was designed with an expandable, Joseph H. Sklar
four-channel, ridged, 30-mm polyethylene Charles H. Brown, Jr.
sheath and a tapered Delrin expansion screw.
The four channels individually capture and grip
each of the four strands of the hamstring tendon
graft into separate compartments and directly
compress each of the graft strands against cancel-
lous bone. We performed cyclical and single load
to failure (LTF) tests comparing the plastic
IntraFix and bioabsorbable interference screws
in paired young to middle-aged human cadaver
tibiae with human doubled gracilis and semiten-
dinosus grafts (DGSTs) (Table 47-1). The plas-
tic IntraFix demonstrated a mean ultimate failure
load of 800N and stiffness of 200 N/mm, which
was significantly higher than interference screw
fixation. In an independent biomechanical study
comparing commonly used hamstring tendon
graft tibial fixation devices, Kousa et al14 demon-
strated that the IntraFix had the highest LTF
(1309N) and stiffness (267 N/mm) and the least
amount of slippage (1.5 mm) after cyclical loading.
Following the successful clinical introduc-
tion of the nonabsorbable IntraFix tibial fas-
tener, a Bio-IntraFix composed of poly-L-
lactic acid/tricalcium phosphate (PLLA/TCP)
was developed to satisfy the desire of some
surgeons for a bioabsorbable device. Testing of
the Bio-IntraFix using DGST and paired
human cadaveric tibiae (mean age 63  10
years) was performed with the line of force
applied parallel to the axis of the tibial tunnel.
Elongation was measured using a video camera
system to determine displacement of contrast
341
 Anterior Cruciate Ligament Reconstruction

TABLE 47-1 Sizing Scheme for Bio-IntraFix

Graft Diameter Drill Tunnel Screw Size

7 mm 8.5 mm 6–8 mm

8 mm 9.0 mm 6–8 mm

9 mm 10.0 mm 7–9 mm

10 mm 11.0 mm 8–10 mm

markers attached to the graft and bone. The graft–Bio-

IntraFix–bone complex was cyclically loaded between 50N
and 200N at a rate of 0.5 Hz for 1000 cycles (33 min,
20 sec). One thousand cycles approximates 1 week of post- FIG. 47-1 Transaxial magnetic resonance image of the tibia in an anterior
operative intermittent passive motion. The mean ultimate cruciate ligament (ACL) reconstructed patient showing a cannulated screw
failure load and linear stiffness for the Bio-IntraFix were anteriorly and a graft bundle posteriorly. Note the very limited contact of
the graft bundles with the surface of the bone tunnel.
643  152N and 325  111 N/mm, respectively.
Elongation after 1000 cycles was 2.28  1.19 mm. The
failure load of the Bio-IntraFix was found to be superior
to that of the Delta screw (Arthrex, Naples, FL), and the Bone
ingrowth
stiffness was two times that of the Delta Screw. During
cyclical loading, three of six Delta screws failed compared Graft
with only one of six DGST grafts fixed with the tissue
Bio-IntraFix.
The second goal of this design was to maximize the
amount of contact between graft tendons and bone. Fixation
outside tunnels and from suspension devices results in a
loose fibrous attachment between the tunnel wall and the
graft, with little if any bony ingrowth into the graft
(Fig. 47-1). In contrast, direct compression of tendon to
bone by interference screws within the tunnel leads to bony FIG. 47-2 Histology 12 weeks after reconstruction of the anterior cruciate
ingrowth including Sharpey fiber formation.15 However, a ligament (ACL) in a sheep using autogenous extensor tendons and tibial
fixation with IntraFix, seen at the bottom right of slide. Note Sharpey fiber
single interference screw inserted next to a bundled four-
formation (linear strands) and new bone ingrowth (dark blue) into tendon
stranded graft definitely leaves a considerable portion of (light blue).
the tunnel filled by the screw and some of the tendons with-
out bony contact. In contrast, the IntraFix has the potential
for more extensive bone–graft integration because each SURGICAL TECHNIQUE
strand is pressed against bone and the entire tunnel wall is
in contact with graft. A limited histological study performed Graft Preparation
on the IntraFix in sheep demonstrated early bony integra-
tion (Fig. 47-2). Thus extrapolation of the interference Preparation of the tendons is facilitated by the use of a graft
screw data to this device seems justified. Further evidence preparation board. The two tendons are cut to a total length
of extensive bony integration when using the IntraFix and of 20 to 21 cm, and the opposite ends of the tendons are
Bio-IntraFix comes from direct examination of the tibial whipstitched for 4 to 5 cm using a #2 nonabsorbable suture.
tunnel many months after reconstruction. Fig. 47-3 shows This length of tendon graft allows for 25 mm of the DGST
an example of the appearance of the tibial tunnel 1 year after tendon graft to be inserted into the femoral tunnel and
ACL reconstruction; it was obtained during a revision case typically results in a significant length of suture-reinforced
after the sheath had been removed and the arthroscope tendon within the tibial tunnel and a short (1-cm) length of
inserted into the tibial tunnel. It shows a firm surface, the tendons extending outside the tibial tunnel. If more of
apparent integration of the sutured tendons into the bone the DGST tendon graft is inserted into the femoral tunnel,
tunnel wall, capillary ingrowth, and no loose fibrous tissue. or if the tibial tunnel is longer than 40 to 45 mm, then the

342
 Hamstring Anterior Cruciate Ligament Reconstruction with IntraFix Tibial Fastener
total length of the two tendons should be increased accord-
ingly. This is important because suture-reinforced tendon
constructs have been shown to increase pullout strength by
30% to 40% in our laboratory biomechanical tests.
Use with Allografts
If a soft tissue allograft such as a tibialis tendon is used, we
prefer to divide each end of the allograft in two for a dis-
tance of 5 cm and then to whipstitch each strand so that a
four-stranded construct comparable to a DGST is created.
The IntraFix four-chambered sheath accommodates and
provides more uniform compression with a four-strand graft
preparation compared with a two-stranded graft. The graft
construct is then placed on a tensioning board, cinching
the whipstitched sutures and removing creep from the graft
construct. Removing creep from the graft–suture construct
is particularly important if supplemental fixation is required.
Tibial Tunnel
Our preferred method for performing endoscopic ACL
reconstruction is the transtibial tunnel technique. The transti-
bial technique allows a longer femoral tunnel to be drilled com-
pared with drilling the femoral tunnel through the
anteromedial portal and also allows cross-pins to be used for
the femoral fixation. Another advantage of the transtibial
technique is that the femoral tunnel does not have to be drilled
with the knee in hyperflexion, which constricts fluid inflow
and limits visualization in the notch. The disadvantage of the
transtibial tunnel technique is that it provides more limited
access to the sidewall of the lateral femoral condyle compared
FIG. 47-3 Appearance of the tibial tunnel using an arthroscope during
revision surgery following removal of the IntraFix device. Note the apparent
integration of tendons/sutures 360 degrees around the tunnel and imprint
of the sheath’s ridges.
47
with drilling the femoral tunnel through the anteromedial
portal.
The tibial tunnel must be carefully oriented in both the
sagittal and coronal planes for several reasons. Due to the large
cross-sectional area of four-strand hamstring tendon grafts,
sagittal placement of the tibial tunnel is especially critical.16
The tibial tunnel position in the sagittal plane determines
whether the ACL graft impinges against the roof of the inter-
condylar notch in full knee extension.2,16–19 Roof impinge-
ment is associated with effusions, loss of extension, anterior
knee pain, quadriceps weakness, and increased anterior laxity.
Coronal plane orientation is the primary determinant of
placement of the femoral tunnel along the side wall of the
intercondylar notch and, to some degree, of the length of
the femoral tunnel. A more medial starting position on the
tibia allows the femoral tunnel to be drilled closer to the
10- or 2-o’clock position along the sidewall. A femoral tunnel
at the 10-o’clock (right knee) or 2-o’clock position (left knee)
is important because a single-bundle ACL graft positioned at
these locations in the intercondylar notch is more effective at
resisting combined rotatory loads than one placed at the
11-o’clock position. Biomechanical studies have demon-
strated little difference in coupled anterior tibial translation
between this graft and a double-bundle hamstring ACL
reconstruction at low degrees of flexion.20
In our surgical technique, a tibial tunnel length of 35
to 45 mm is optimal because this will accommodate the
entire 30-mm IntraFix or Bio-IntraFix with no chance of
the device protruding into the joint. In general, setting the
variable angle tibial aimer between 45 and 55 degrees will
allow these tibial tunnel lengths to be achieved. The guide-
lines of Jackson and Gasser,21 Howell,15 and Simmons
et al22 are used for intraarticular placement of the tibial
guide pin. If necessary, the tibial guide pin position can be
checked by intraoperative radiographs or fluoroscopy with
the knee in maximum extension.
Tunnel Sizing
When using the plastic IntraFix, the diameter of the tibial
tunnel should equal the diameter of the suture-reinforced end
of the graft. When using the Bio-IntraFix, the tibial tunnel
should be drilled 0.5 to 1.0 mm larger than the diameter of
the suture-reinforced end of the graft because the Bio-IntraFix
sheath does not compress or flow during screw insertion.
Biomechanical testing of this oversized scheme showed no loss
of fixation strength for the Bio-IntraFix compared with tunnels
sized to the same diameter as the graft. Half-millimeter–sized
drill bits can be used to make this sizing more precise. The tibial
tunnel should be drilled with a fluted drill to prevent anterior
drift of the tunnel as the proximal cortex is breeched.
After drilling the tibial tunnel, it is important to clear
soft tissue from around the edges of the tibial tunnel using
343
 Anterior Cruciate Ligament Reconstruction
an electrocautery pencil and a Cobb periosteal elevator for
several reasons. First, a clear view is necessary to ensure that
the tab of the IntraFix sheath is flush with the tibial cortex
and that the sheath is fully inserted. Second, a clear view
helps ensure that the screw is neither over- nor under-
inserted into the tunnel. Finally, clearing of soft tissue also
improves the ability to see and trim excess tendon and
sheath at the end of the case so that there is no prominence
that might later irritate the patient.
Femoral Tunnel and Graft Fixation
Because the IntraFix tibial fastener can be used with any
femoral fixation technique, the choice of the femoral fixa-
tion is based on the surgeon’s preference. However, we pre-
fer cross-pins or the Endobutton-CL because these fixation
techniques have been shown to be strong and stiff and to
have the least amount of elongation under cyclical load-
ing.7,8 More importantly, these two femoral fixation techni-
ques permit equal tensioning of all four graft strands. This is
an important goal because, as shown by Hamner et al,23 it is
necessary to equally tension all four strands of a DGST graft
to maximize initial graft strength and stiffness. An equally
tensioned DGST graft was stronger and stiffer than a 10-
mm, central-third patellar tendon autograft. However, when
no attempt was made to equally tension all four graft
strands, the ultimate failure load and stiffness of the DGST
graft were not statistically different from that of a doubled
semitendinosus tendon graft alone. Thus failure to equally
tension all four graft strands of a DGST graft negated any
contribution from the doubled gracilis tendon graft.
Graft Passage, Graft Tensioning, and Tibial Fixation
For the IntraFix device to function properly, the strands of
the graft need to be parallel and untangled within the tibial
tunnel. This can be accomplished easily if the surgeon
arranges the strands in this way as the graft is drawn into
the knee by the assistant.
After the femoral side of the DGST or tibialis tendon
allograft has been securely fixed in the lateral femoral condyle,
the whipstitches from the gracilis tendon or corresponding
opposite ends of the tibialis tendon allograft are tied together
to create a loop approximately 4.5 to 5 inches from the end of
the tibial tunnel. This step is repeated for the semitendinosus
tendon and the corresponding opposite ends of the tibialis
tendon allograft (Fig. 47-4, A and B).
The two suture loops are placed around the tie tensioner
(DePuy Mitek, Norwood, MA) but can be held by hand.
The tie tensioner frees one hand for the surgeon. Because it
contains a calibrated spring, it allows for quantification of
the tension applied to the graft at the time of fixation. Prior
344
to inserting the IntraFix, the knee is cycled from 0 to 90
degrees approximately 25 to 30 times with a tension of 60N
to 80N maintained on the graft limbs. The tie tensioner will
equally tension and separate each strand of the DGST graft.
Cycling allows stress relaxation of the femoral fixation
device, allows the tendons to compress around the cross-pin
or Endobutton-CL, and removes creep from the DGST
or tibialis tendon allograft and the tendon whipstitches.
At present the optimal graft tension and knee flexion
angle at the time of tibial fixation are unknown. The usual
excursion pattern detected with our bone tunnel placements
results in the DGST graft pulling into the tibial tunnel a
few millimeters during the last 20 degrees of terminal exten-
sion. When minimal graft excursion is detected, we fix the
graft with the knee at 20 degrees of flexion because it is eas-
ier to do so at this position. When a larger excursion is
detected, we fix the tibial side near full extension. Because
of the high fixation strength and stiffness and the resistance
to slippage of the IntraFix and Bio-IntraFix, we caution
against applying excessive tension (greater than 80N) to
the graft and against fixing the knee at a flexion angle
greater than 20 degrees. High graft tension results in the
graft construct being under tension through a greater range
of motion, subjects the graft to higher abrasion forces at the
femoral tunnel edge (killer angle) during knee motion, and
can overconstrain or “capture” the knee.
Device Insertion
Concentric device placement within the tibial tunnel is critical
to the success of the technique. To achieve this, the central
axis of the tibial tunnel is identified by passing a stout guide-
wire or a Trailblazer (Smith & Nephew Endoscopy, Andover,
MA) through the center of the tie tensioner and down the
center of the four graft strands into the knee joint
(Fig. 47-5). Once the central axis of the tibial tunnel is iden-
tified, the tie tensioner should be held in this orientation
during all the subsequent steps to avoid divergent placement
of the IntraFix sheath and screw. The surgeon can improve
his or her ability to maintain this orientation by placing several
fingers or the entire side of the hand holding the tensioner on
the tibia during the next steps. Next, the four-quadrant dilator
is inserted down the center of the four graft strands and ori-
ented so that each graft strand sits in its own channel
(Fig. 47-6). While maintaining the desired tension on the
graft, the four-quadrant dilator is tapped into the tibial tunnel
for a distance of 35 mm. This step compresses and separates
the four tendon strands, and, in the case of smaller tunnels
(7 to 8 mm), notches the bone tunnel wall to accept the
sheath. It is important to keep the dilator oriented along the
axis of the tibial tunnel as it is impacted because the dilator
 Hamstring Anterior Cruciate Ligament Reconstruction with IntraFix Tibial Fastener 47

4.
5
–
5"

B
A
FIG. 47-4 A, The use of differently colored sutures on the gracilis and semitendinosus tendons helps with
identification during graft tensioning and tibial fixation. B, The sutures are marked between 4.5 and 5 inches from
the edge of the tibial tunnel. A hemostat can be used to hold this location during knot tying. The two gracilis
suture limbs and the two semitendinosus suture limbs are tied together, creating a suture loop.

has a tendency to diverge, as do most tunnel dilators. Because
the sheath for the IntraFix and Bio-IntraFix is 9 mm in diam-
eter, the four-quadrant dilator also enlarges the tibial tunnel
in the case of smaller tunnels, providing easier insertion of
the IntraFix sheath and tapered screw. There are now two
sheaths for the Bio-IntraFix and a smaller and larger dilator
appropriate to each. The smaller sheath is used for 7- and
8-mm tunnels and the larger for 9- and 10-mm tunnels.
After dilating the tibial tunnel, the 30-mm Intrafix
sheath is placed on the sheath inserter with the derotational
tab on the sheath oriented to match the tab on the sheath
inserter. The knee is positioned at the chosen flexion angle,
and a final tension of 60N to 80N is applied to the DGST
graft or tibialis tendon allograft using the tie tensioner.
The Intrafix sheath is inserted among the four graft
strands, taking care that each graft strand is positioned into
a separate channel of the IntraFix sheath. The derotational
tab on the sheath is oriented at the 3- or 9-o’clock position
(Fig. 47-7). Orienting the derotational tab at these positions
allows the IntraFix sheath to be inserted more deeply into
the tibia and prevents prominence of the device. The
inserter is tapped into the tunnel until the derotational tab
is flush with the cortex. As stated earlier, clearing the soft
tissue from the bone tunnel opening will allow for better
assessment of the depth of insertion and trimming of any
protruding tendon or sheath after the screw has been
inserted. The sheath inserter is removed, and the 0.042-inch
guidewire for the IntraFix tapered screw is inserted through
the center of the sheath until a loss of resistance is felt as the
tip of the guidewire enters the knee joint.
For the plastic IntraFix, a tapered screw size 1 mm
larger than the tibial tunnel diameter is used. For example,
an 8-mm tapered screw is used for a 7-mm tibial tunnel.
Given the typical size of DGST grafts, the 7- to 9-mm
tapered screw is most commonly used. The IntraFix screw
is inserted into the plastic sheath until its inferior aspect
is flush with or buried just below the tibial cortex
(Fig. 47-8). Because the best bone quality is at or next to
the tibial cortex, overly deep insertion of the screw may
decrease fixation strength.24 The tension on the graft

345
 Anterior Cruciate Ligament Reconstruction

FIG. 47-5 The resulting suture loop from the gracilis and semitendinosus tendons is looped over the arms of the
tie tensioner. The tie tensioner will equally tension and separate each strand of the graft. The central axis of
the tibial tunnel is identified by passing a 1.1-mm guidewire through the center of the tie tensioner and down the
center of the four graft strands into the knee joint.

strands from the tie tensioner should prevent the sheath
from rotating during screw insertion in hard bone, but some
rotation of the outer sheath is acceptable because the sheath
within the tunnel does not move in concert. Protruding or
prominent areas of the polyethylene sheath are trimmed
flush with the tibial cortex using a 15 blade and a small bone
rongeur.
The technique for insertion of the Bio-IntraFix device
is identical, but the sizing scheme differs from that just
described (Table 47-2). Because the PLLA/TCP sheath is
noncompressible and because the insertion torque is higher
than with the plastic version, the tunnel should be drilled
or dilated 1.0 mm larger than the graft diameter. The Bio-
IntraFix sheath adds more than 1 mm to the diameter of
the Bio-IntraFix screw, so in effect the fixation device in
total is oversized to the tunnel diameter, which is the usual
practice with interference screws and with the plastic
IntraFix.

346
 Hamstring Anterior Cruciate Ligament Reconstruction with IntraFix Tibial Fastener 47

FIG. 47-6 Insertion of the four-quadrant trial dilator. The dilator is oriented so that each graft strand is positioned
in its own channel. The dilator will separate and compress the tendons while preparing a bony channel for the
IntraFix sheath.

The stability and range of motion of the knee are Troubleshooting

checked. It is important to verify that the patient has full
range of motion before leaving the operating room. The
arthroscope is inserted into the knee, and graft tension
and impingement are assessed. Our usual graft placement
and tensioning technique results in the four strands of the
DGST being maximally tight between 0 and 20 degrees,
with the graft tension decreasing slightly as the knee is
flexed to 90 degrees.
Sheath Overinsertion
As with any fixation device, potential errors can be made
during the use of the IntraFix device. Overinsertion of the
sheath is one such error. This problem typically occurs when
a sheath smaller than the tunnel size is driven into the tun-
nel and the sheath’s advancement is not controlled. When
this happens, the opening to the sheath cannot be seen

347
 Anterior Cruciate Ligament Reconstruction

FIG. 47-7 Insertion of the 30-mm IntraFix sheath. The knee is positioned at the chosen flexion angle, and the
selected tension is applied to the graft using the tie tensioner. The 30-mm IntraFix sheath is inserted down the
center of the doubled gracilis and semitendinosus graft, parallel to the axis of the tibial tunnel. The derotational tab
on the sheath is positioned at the 3- or 9-o’clock position, with each tendon graft strand positioned in its own
channel.

and central placement of the screw cannot be assured. If the
sheath is far into the tunnel, screw insertion should be aban-
doned until the sheath is pulled back into position or
removed and another sheath is inserted. Because the ridges
on the sheath are slanted to resist slippage of the graft prox-
imally, attempts to grasp the sheath and pull it out of the
tibial tunnel are often unsuccessful. Cutting the sheath or
blindly grabbing it with an instrument such as a pituitary
rongeur can damage the graft strands and the sutures hold-
ing them, risking rupture during tensioning. A better
method involves pushing the sheath further up the tunnel,
together with pulling the graft proximally with a probe
inside the joint until the sheath can be seen entering the
knee joint. At this point, the sheath can be grasped and

348
 Hamstring Anterior Cruciate Ligament Reconstruction with IntraFix Tibial Fastener 47

FIG. 47-8 Insertion of the IntraFix tapered screw. The selected graft tension is maintained on the graft strands
using the tie tensioner, with the knee at the chosen flexion, and the IntraFix tapered screw is inserted along the
guidewire into the IntraFix sheath. The IntraFix tapered screw is advanced until the superior edge of the screw is
just below the anterior tibial cortex.

removed through one of the portals, usually in pieces.
The graft is then retensioned using the tensioner, and the
standard steps noted above are repeated.
Screw Breakage
With the introduction of the PLLA/TCP Bio-IntraFix,
screw breakage has sometimes occurred during insertion.
This problem is partly due to the friction between the screw
and sheath, which was never a concern with the plastic
IntraFix, and in part because the tunnel may not have been
enlarged above the diameter of the graft as recommended.
(At the time of this writing, a newer, more robust screw
and a sheath with improved properties have been produced,
which will make breakage much less likely.) A third
factor that can lead to screw breakage is failure to insert
the screw along the central axis of the sheath and tunnel.
A fourth cause is failure to seat the screwdriver fully within
the screw.

349
 Anterior Cruciate Ligament Reconstruction
TABLE 47-2 Sizing Scheme for IntraFix
Graft Diameter Drill Tunnel Screw Size
7 mm 7 mm 6–8 mm
8 mm 8 mm 7–9 mm
9 mm 9 mm 8–10 mm
10 mm 10 mm 8–10 mm
When screw breakage happens, it is most often early
during insertion, and it is nearly impossible to withdraw
the screw tip with the driver due to a lack of purchase. Fur-
thermore, the screw seems to bind within the sheath. The
surgeon has two basic options at this point. The first
approach is to revise the entire construct. In this case we
use an “easy-out” device, such as those marketed to remove
stripped cannulated interference screws, and core the screw
out from within the sheath. Sometimes a new smaller screw
can be inserted in its place and into the same sheath, but
more commonly the sheath needs to be replaced. If the
smallest of the screws (6 to 8 mm) was used initially,
another screw of the same size is likely to suffer the same
fate. A better strategy is to remove the sheath with a grasper
and then to insert the larger 9-mm dilator more deeply into
the tunnel among the graft strands, enlarging the tunnel
further. After a new sheath is placed, a new screw should
be carefully inserted along the axis of the tunnel. Blood,
fatty tissue, or saline can be used to reduce insertion torque
and should be tried during screw insertion in such instances,
especially if the patient’s bone is hard and if additional tun-
nel dilation efforts did not seem to enlarge the diameter very
much. The second technique, which is less commonly used,
is to take the sutures from the tendon ends and tie them
down onto a staple or screw distal to the tunnel. This
approach can only be recommended if there is a significant
length (greater than 50%) of screw within the sheath so that
the sheath construct will not collapse when the sutures are
tied below and migration of the device will not occur.
Failure to Advance
A related screw insertion problem is failure of the screw to
advance until it is fully seated. This has primarily been a
problem with the Bio-IntraFix. The main cause is a tunnel
diameter too small to accommodate the size of the IntraFix
or Bio-IntraFix that was chosen. This situation, although
quite rare, may be more challenging than screw breakage.
The fact that the screw failed to advance almost certainly
indicates that the screw has gained good purchase, at least
in the distal portion of the tunnel. Therefore if the screw
is no more prominent than an external fixation device such
as a screw-washer, then it can probably be left in place,
350
although it may require later removal after the graft has
healed. If a much longer portion protrudes and it cannot
be withdrawn with the screwdriver, then the protruding
portion must be removed with a saw; the inserted portion
and sheath removed; and a new, more properly sized device
inserted.
Low Bone Density
The fixation strength of any intratunnel fixation device is
dependent on the local bone mineral density. If, during
the insertion of the tapered screw, the surgeon subjectively
feels that there was low insertion torque, or if the patient
has soft bone as assessed during drilling and dilation of
the tunnel, then we recommend that supplemental tibial fix-
ation be used.13 Depending on the graft length, the tendons
can be stapled below the tibial tunnel opening using one or
two small barbed staples (Smith & Nephew Orthopaedics,
Memphis, TN). Another method of backup is to tie the
sutures around a small nonbarbed staple, a screw and
washer, or a tibial fixation post (Smith & Nephew
Endoscopy).
Too Short a Graft
Finally, the surgeon may be faced by a graft that is not long
enough and with ends that are recessed in the tunnel. If the
graft is recessed to the degree that identification of the indi-
vidual strands is not possible, then concentric placement of
the sheath becomes much more difficult. One could try to
separate the strands blindly, but then insertion of the dilator
runs the risk of rupturing the sutures, with loss of ability to
tension. In this case, therefore, it is probably best to tie the
sutures onto a fixation post or use an interference screw as
the sole means of fixation, or to use a hybrid of the two
methods.
Closure and Postoperative Dressings
A Hemovac drain can be inserted under the sartorius fascia
and into the hamstring harvest site to prevent postoperative
hematoma formation and decrease subcutaneous skin ecchy-
mosis along the medial side of the knee.25 This is particu-
larly useful when excessive bleeding is encountered during
the hamstring tendon harvest. The sartorius fascia that was
preserved during the hamstring tendon graft harvest is
closed over the tibial hardware and repaired back to the tibia
with a #0 absorbable suture. The subcutaneous tissue is
closed in layers with fine absorbable sutures. A running
#3–0 Prolene (Ethicon, Sommerville, NJ) subcuticular pull-
out suture or #4–0 Monocryl produces a very cosmetic clo-
sure. A light dressing is applied over the wound, followed by
a thigh-length TED antiembolism stocking (Cryocuff, Air-
cast, Summit, NJ) and knee immobilizer.
 Hamstring Anterior Cruciate Ligament Reconstruction with IntraFix Tibial Fastener
POSTOPERATIVE MANAGEMENT
The procedure is routinely performed as an outpatient pro-
cedure. If a Hemovac drain is used, the drain is removed
when the patient is discharged from the day surgery unit.
We allow unrestricted motion and weight bearing as toler-
ated. Early flexion performed as heel slides is encouraged
because it prevents scarring of the extensor mechanism.
The weight-bearing schedule is modified if a meniscus
repair, microfracture, or other associated ligamentous surgery
has been performed. The patient is weaned from the knee
immobilizer when quadriceps control is regained. Crutches
are continued until the patient has regained a normal gait
pattern. Riding a stationary bike can be started when the
patient has at least 100 degrees of flexion. Closed chain
strengthening exercises using a leg press machine, elliptical
cross-trainer, StairMaster, and step-ups are started around 4
to 6 weeks after surgery. During the first 3 months after
surgery, the hamstring donor site must be protected by avoid-
ing sudden hamstring stretching with the hip and knee in
extension. This position is commonly encountered during
activities of daily living such as bending down to tie shoes or
put on socks or reaching down to pick an object off the floor.
We also recommend that isolated hamstring resistive exer-
cises performed in the prone position be avoided for the first
2 to 3 months. Isolated hamstring strengthening exercises
using a seated leg curl machine can usually be started after 6
to 8 weeks if tenderness is not present or is minimal at the
hamstring donor site. We allow jogging and running at 3 to
4 months, side-to-side cutting at 4 to 5 months, a return to
noncontact sports at 5 to 6 months, and a return to
unrestricted sports at 6 to 7 months. In revision cases, we
recommend that a return to unrestricted sports be delayed
until 9 months.
RESULTS
We report the preliminary results of the first 84 patients
operated on by Dr. Joseph H. Sklar using a DGST graft with
Endobutton-CL femoral fixation and tibial fixation with the
IntraFix tibial fastener. The mean age of the patients was 30
years (range 16–54 years). Of the patients, 46 were male and
38 were female. The mean diameter of the DGST graft for
all patients was 8.3 mm (range 7–9.5 mm) and 7.9 mm for
females. The mean KT-1000 side-to-side difference for all
patients at the 12-month follow-up was 1.8 mm, with 83%
having a side-to-side difference of 0 to 3 mm; 13%, 3 to
5 mm; and 3%, greater than 5 mm. At the 24-month
follow-up, the mean KT-1000 side-to-side difference was
1.78 mm, with 85% having a side-to-side difference of 0 to
47
3 mm; 11%, 3 to 5 mm; and 4%, greater than 5 mm.
For female patients, the mean KT-1000 side-to-side
difference was 2.3 mm, with 80% having a side-to-side differ-
ence of 0 to 3 mm; 20%, 3 to 5 mm; and no patient had a
difference greater than 5 mm. Supplemental tibial fixation
was used in 17% of the male patients and 42% of the
female patients. There were no postoperative infections in
the group, and no patient had a loss of extension. Flexion
averaged 138 degrees at 24 months. Two patients required
an early manipulation under anesthesia to regain flexion.
No patient has required a second operation to remove
prominent hardware.
CONCLUSION
In summary, the IntraFix and Bio-IntraFix devices provide
strong rigid tibial fixation that is superior to the fixation
properties of interference screws and most external fixation
methods. The device grips each of the graft strands in its
own separate compartment and increases the amount of
graft in direct contact with the cancellous bone of tunnel,
potentially increasing the amount of bone–tendon healing.
Successful use of the device depends on proper tunnel
preparation and sizing and the concentric insertion of the
device parallel to the axis of the tunnel. In cases in which
doubt exists about the hardness of the bone, the IntraFix
and Bio-IntraFix can be used in combination with cortical
backup fixation.
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2002;30:523–535.
Romano VM, Graf BK, Keene JS, et al. Anterior cruciate ligament recon-
struction: the effect of tibial tunnel placement on range of motion. Am J
Sports Med 1993;21:415–418.
Soloman CG, Pagnani MJ. Hamstring tendon harvesting. Reviewing ana-
tomic relationships and avoiding pitfalls. Orthop Clin North Am
2003;34:1–8.
 Hamstring Anterior Cruciate Ligament Reconstruction with IntraFix Tibial Fastener 47
Warren LF, Marshal JL. The supporting structures and layers on the lateral and an anatomical femoral tunnel placement. Am J Sports Med
medial side of the knee. J Bone Joint Surg 1979;61A:56–62. 2004;32:1825–1832.
Woo SL-Y, Hollis JM, Adams DJ, et al. Tensile properties of the human Yasuda K, Onkoshi Y, Tanabe Y. Graft site morbidity with autogenous
femur-anterior cruciate ligament-tibia complex. The effect of specimen semitendinosus and gracilis tendons. Am J Sports Med 1994;23:705.
age and orientation. Am J Sports Med 1991;19:217–225.
Yamamoto Y, Hsu W-H, Woo SL-Y, et al. Knee stability and graft func-
tion after anterior cruciate ligament reconstruction. A comparison of a

353
 PART H BONE–PATELLAR TENDON–BONE FIXATION: FEMUR OR TIBIA
48
CHAPTER
Interference Screw Fixation in Bone–
Patellar Tendon–Bone Anterior Cruciate
Ligament Reconstruction
Gene R. Barrett INTRODUCTION
Taylor D. Brown
Interference screw fixation on both the femoral
and tibial sides remains an effective fixation
scheme for bone–patellar tendon–bone (BPTB)
anterior cruciate ligament reconstruction
(ACLR). Interference screws achieve early sta-
bility with aperture fixation and a rigid fixation
of graft to host bone. Interference screw fixation
of BPTB ACLR provides strength greater than
that needed during early rehabilitation.1–3 This
chapter includes our ideas and techniques for
maximizing the potential for early stability with
interference screw fixation of BPTB ACLR.
GRAFT PREPARATION
In order to visualize our fixation strategies, the
reader should have an understanding of the
shape of our graft. Through a slightly medial
parapatellar incision, the peritenon of the patella
tendon is elevated and the tendon is visualized
from its medial to lateral border. We use a ruler
not only to confirm the tendon to be 30 to
33 mm in width, but also to measure the dis-
tance between longitudinal cuts through the full
thickness of the patella tendon 10 to 11 mm
apart. We use a combination of an oscillating
saw and osteotomes to harvest a trapezoidal-
shaped bone block from the tibial tubercle,
which is 25 to 27 mm long, and a triangular-
shaped bone block from the patella, which is
25 mm long (Fig. 48-1). The bone blocks are
trimmed with a rongeur to pass through either
354
a 10- or 11-mm sizing sleeve. The overall
length of the graft is usually 90 to 105 mm.
Two stay sutures are passed through each bone
block and tendon using #1 absorbable monofil-
ament (PDS) for the femoral block and #5 non-
absorbable braided suture for the tibial end of
the graft. The absorbable suture in the femoral
bone block allows us to cut the suture flush with
the skin if it will not pull out. The bone block
with the better bone, which is usually the tibial
tubercle block, is directed toward the femoral
canal with the #1 sutures (PDS). The graft is
stretched on a graft board with 20 pounds of
tension for 10 to 15 minutes while covered by
an antibiotic-soaked gauze (Fig. 48-2).
SCREW SELECTION
A cannulated, round-headed, partially threaded
screw is used for the femoral side to protect
the graft from laceration at the bone plug–
tendon interface. Any number of manufacturers
produce round–headed, partially threaded
screws.4 A fully threaded screw or a screw with
a squared-off head may put the tendinous por-
tion of the graft at risk. We use a fully threaded
screw for fixation in the tibial tunnel. The extra
threads provide additional fixation, and a round
head is not needed distal to the screw and graft.
The literature has shown that the effect of
screw diameter is interrelated to the tunnel
diameter and the gap size between the graft
bone plug and tunnel.5–7 We make our tunnels
the same size as the sizers through which our
 Interference Screw Fixation in Bone–Patellar Tendon–Bone Anterior Cruciate Ligament Reconstruction 48
Tibial bone
Patellar bone

10–11
9–10 mm mm

25–27 mm 45–50 mm 25 mm

FIG. 48-1 Bone–patellar tendon–bone suture configuration (absorbable suture in tibial bone and permanent in
patellar bone).

use a plastic sheath to protect both the ACL graft and

native posterior cruciate ligament (PCL) when inserting
both metal and bioabsorbable screws into the notch and
femoral tunnel (Fig. 48-3, A and B).
Bioabsorbable screws were introduced as a device to
provide secure mechanical fixation in the interval prior to
biological fixation of the graft and then leave the body with

FIG. 48-2 PDS and permanent suture in a graft that is being loaded.

graft bone plugs pass, usually 10 or 11 mm. In both the

femoral and tibial tunnels, our first choice for screw diame-
ter is 1 mm less than the tunnel diameter for metal screws,
usually 9 or 10 mm, and the same as the tunnel diameter
for bioabsorbable screws, usually 10 or 11 mm.
Length of interference screws has not been correlated
to fixation strength with BPTB grafts.8–10 We try to match
the length of the screw to the length of the graft bone plug.
If the surgeon harvests a full 25 mm of bone plug and makes
a tunnel deep enough to accommodate the whole plug, he or
she should fix the full length of the plug within the tunnel.
We frequently use 25-mm-long metal or 28-mm-long
bioabsorbable screws in the femoral tunnel, and we use
25-mm-long metal or 28-mm-long bioabsorbable screws
in the tibial tunnel.
Metal interference screws have a proven track record
for secure fixation of BPTB ACLR and are well tolerated
by the human body. However, complications related to this
hardware option include laceration of the graft on insertion
and interference with postoperative magnetic resonance
imaging (MRI) scans of the knee, as well as potentially
blocking tunnels for revision ACLR. The influence on
MRI has been lessened with the use of titanium screws
compared with the stainless steel screws initially used. Graft FIG. 48-3 A, Graft protector for screw insertion. B, The plastic sheath
laceration by the screw has not been a problem because we protects the graft from laceration.

355
 Anterior Cruciate Ligament Reconstruction

no residual foreign material. They create less interference

with MRI scans of the knee, cause less graft trauma, and
allow easier revision by disappearing or by just drilling
through any remnant. The disadvantages of these implants
were reported to be breakage and soft tissue reaction due
to poor biocompatibility. Poly-L-lactic acid (PLLA) screws
are most commonly used today. Studies have shown screw
breakage on insertion to be uncommon and, when it does
occur, does not cause adverse effects.11,12 A handful of cases
of late screw fragmentation have been reported, and soft
tissue reactions to PLLA are rare.13,14 The low rate of
soft tissue reactions to PLLA is due to the slow rate of
degradation in vivo. Studies show persistence of these
screws years after insertion.15,16
The tensile strength of cancellous and cortical bone is
less than that for titanium or PLLA. For metal and bioab-
sorbable screws of the same size and shape in the same
anatomical and biological scenario, the failure strength will
be the same because the construct will fail at the weaker
cancellous bone first.3 No significant difference was found
when metal and bioabsorbable interference screws in BPTB
ACLR were compared with regard to initial strength of FIG. 48-4 Use of a tibial pin to check impingement.
fixation as tested with single load and cycle load to failure
(LTF).1–3,17,18 Walton showed no difference during a period and repositioned if it does not meet the just-mentioned
of interval healing when examining sheep specimens 4 to 52 criteria. Once the guidewire is positioned appropriately and
weeks after interference screw fixation in BPTB ACLR.19 no impingement is confirmed, the first reamer, which is
McGuire et al and Kaeding et al showed no significant 2 mm smaller than the graft size and final tunnel diameter,
difference of motion, laxity, or instability between metal is passed. Bone reamings are collected to use as autograft for
and bioabsorbable interference screw fixation of BPTB the patella–bone plug defect at the conclusion of the case.
ACLR as much as 2.4 years postoperatively.11,12 The tibial tunnel is then expanded incrementally 2 mm up
to the final diameter.
The femoral tunnel is placed on the medial aspect of
BONE TUNNEL PREPARATION the lateral femoral condyle with just 1 to 2 mm of cortical
bone posterior to the tunnel.20–22 A 5-mm offset femoral
Much has been written to describe proper tunnel placement guide is used transtibially for femoral tunnel placement
in both the tibia and lateral femoral condyle. We use a target- (Fig. 48-5). The knee must be flexed to a position such that
ing guide for the tibial tunnel with the goal of the guidewire the guidewire is not directed posteriorly to exit the posterior
exiting in the posterior portion of the native ACL footprint, portion of the femur. The guidewire is placed using the off-
just medial to the anterior horn of the lateral meniscus, set guide. The position just anterior to the posterior wall is
centered medial to lateral between the tibial spines. The graft confirmed on a true lateral fluoroscopic image of the distal
harvest incision is retracted medially to place the distal entry femur. A small, 7- or 8-mm acorn reamer is passed to
site halfway between the anterior cortical ridge and the medial a depth of 35 to 40 mm after proper guidewire position is
border of the tibia. We use a guide set at 55 degrees to create a confirmed. The guidewire is repositioned in the anterior
tibial tunnel 50 to 55 mm long. After placing the guidewire, portion of the femoral tunnel and gently tapped into the
we use intraoperative fluoroscopy to confirm the position of depth of the tunnel to secure it in a slightly anterior eccen-
the guidewire within the tibia. On the initial flexed lateral tric position within the femoral tunnel. Progressively larger
image, the guidewire penetrates the proximal cortex of the reamers or dilators are used to enlarge the tunnel to its final
tibia with approximately 20% to 40% of the anteroposterior diameter and avoid posterior wall blowout. A motorized
length anterior to the guidewire. A second lateral fluoroscopic shaver is introduced through the anteromedial portal to
image is obtained with the knee fully extended. A line remove all loose bone-reaming debris from the posterior
extended from the guidewire should be just posterior to joint space and notch. A rasp is placed through the tibial
Blumensaat’s line (Fig. 48-4). The guidewire is removed tunnel and up into to the femoral tunnel to confirm

356
 Interference Screw Fixation in Bone–Patellar Tendon–Bone Anterior Cruciate Ligament Reconstruction
FIG. 48-5 Pin placement for femoral tunnel.
posterior wall by palpation and then to rasp smooth the
anterior aperture of the femoral tunnel (Fig. 48-6). The
arthroscope is then removed from the anterolateral portal
and inserted through the tibial tunnel, across the knee joint,
and into the femoral tunnel to visually check continuity of
the posterior wall. The knee is hyperflexed, and a Beath
pin is placed through both tunnels and the femoral cortex
to exit the anterior thigh. The Beath pin then brings a pass-
ing suture loop across the knee, and the passing suture loop
is used to bring the leading graft sutures through the knee to
exit the anterior thigh. The graft is brought into the knee.
FIG. 48-6 Rasp used to smooth the anterior edge of the femoral hole.
48
RELATIVE POSITION OF SCREW AND GRAFT
WITHIN TUNNEL
The femoral tunnel is placed on the medial aspect of the
lateral femoral condyle with just 1 to 2 mm of cortical bone
posterior to the tunnel.20–22 A 5-mm offset femoral guide is
used transtibially for femoral tunnel placement. A small (8-
mm) acorn reamer is used followed by progressively larger
reamers to avoid posterior wall blowout. The tendinous por-
tion of the graft does not fill the aperture of the femoral
tunnel, so its relative position within the tunnel can be
directed. A soft tissue grasper is inserted through the ante-
romedial portal and used to rotate the graft bone plug prior
to its final entry within the femoral tunnel. We place the
cortical side of the bone plug in the posterolateral aspect
of the femoral tunnel, placing the tendinous portion of the
graft at the posterolateral portion of the aperture. The
guidewire and screw are placed opposite the graft in the
anteromedial portion of the tunnel (Fig. 48-7, A and B).
With regard to depth within the tunnel, the graft bone plug
is usually recessed 1 to 2 mm within the femoral tunnel and
the interference screw is placed with the head flush
with the distal end of the graft bone plug, with no hardware
overhanging the graft bone plug to abrade the tendon
(Fig. 48-8, A and B). Prior to inserting the graft within
the knee, we use a rasp to smooth the anterior lip of the
femoral tunnel opening.
The depth that the tibial bone plug comes to rest
within the portion of the tibial tunnel is dictated by the
length of the graft and the position in which the femoral
bone plug was fixed. There are choices with regard to the
rotation of the cortical-cancellous surfaces and the surfaces
for healing versus fixation. We choose to rotate the graft
bone plug so that the cortical surface comes to lie anteriorly
within the tibial tunnel, and we place the tibial interference
screw anterior to the graft bone plug (Fig. 48-9). Rupp et al
tested bone plugs and found no difference in initial fixation
strength when the screw was placed in either the cortical or
the cancellous surfaces of the graft bone plug.23 However,
the bone density of the proximal tibial metaphysis is lower
than that of the distal femur, and we want to place the inter-
ference screw between the harder cortical surface of the graft
and the harder anterior cortex of the anterior tibia, similar to
a wedge.24 Furthermore, this places the cancellous portion
of the graft bone plug next to the cancellous bone of the
tibial tunnel to facilitate bone–bone healing. Yoshiya et al
demonstrated incorporation of the bone plug at the bone–
bone interface at 12 weeks when the cancellous portion of
the bone plug was placed next to the bone tunnel and the
interference screw was placed at the cortical side of the bone
plug.25
357
 Anterior Cruciate Ligament Reconstruction

Guidewire

A
FIG. 48-7 A, Pin position prior to femoral screw insertion. B, X-ray confirmation of pin placement prior to screw
insertion.

A
FIG. 48-8 A, Screw parallel to and the same length as the bone block. B, Parallel screw placement by x-ray.

358
 Interference Screw Fixation in Bone–Patellar Tendon–Bone Anterior Cruciate Ligament Reconstruction
FIG. 48-9 X-ray demonstrating femoral/tibial fixation.
PARALLELISM AND DIVERGENCE
The goal with femoral interference screw insertion is paral-
lelism. This is desired to accomplish one of the stated ben-
efits of this graft choice: early rigid fixation. Initial rigid
fixation allows early weight bearing, early motion, and an
accelerated rehabilitation program.
This goal can be accomplished when both the femoral
tunnel reaming and femoral interference screw insertion occur
through the same path. Three options meet this criterion.
Early anatomical ACLR used a distal lateral thigh exposure
for a two-incision reconstruction. The femoral tunnel was
drilled from outside-in, and the interference screw followed.
With or without a guidewire, the interference screw could
reliably be positioned parallel to the tunnel and bone block.
Lemos et al reported 0 of 25 cases to have divergence with this
technique.26 Cerullo and Puddu described using an arthro-
scope to view directly down the femoral tunnel from the out-
side to confirm parallel position of the femoral screw within
the femoral tunnel, and he stated it could be done as well in
the tibial tunnel.27 We frequently resort to this two-incision
technique if we are doing a revision or have a long graft
(greater than 105 mm) and a graft–tunnel mismatch.
One-incision, arthroscopic-assisted ACLR is more
commonly performed today, and most femoral tunnels
today are guided by wires through tibial tunnels and reamed
through those same tibial tunnels. In a manner similar to
that described by Paulos, Brodie et al inserted the femoral
screw into the joint through an anteromedial portal, but
screw insertion into the femoral canal was carried out with
48
the screwdriver passing anterior to the distal bone plug in
the tibial tunnel, parallel to the path taken by the femoral
canal reamers. No patient had screw/tunnel divergence
greater than 15 degrees in either plane.28 Schroeder showed
only 4% divergence when passing a 7-mm interference
screw and driver through the tibial tunnel, tapping the distal
bone plug as it passed, into the parallel femoral tunnel.29 A
third option involves both reaming and placing the femoral
screw through an anteromedial portal with the knee in a
hyperflexed position.
Despite the fact that at present most femoral tunnels are
reamed through a tibial tunnel, most femoral interference
screws are placed through an anteromedial portal. Although
parallelism is the goal, divergence of the femoral screw and
tunnel results can be made acceptable. Efforts to minimize
this divergence are made, as biomechanical studies have
shown little difference in the pullout strength when diver-
gence is less than 15 degrees as compared with parallel, but
pullout strength is much lower when divergence is greater
than 15 degrees.30–32 In addition to the poor initial fixation,
divergence can also cause intraoperative complications
such as guidewire bending, guidewire breakage with inadver-
tent hardware retention, or graft bone block fracture.33
We use several techniques to minimize our femoral
screw/tunnel divergence. The graft has already been passed,
and the femoral bone block rests within the femoral tunnel.
We establish an accessory anteromedial portal, which is
placed lower than a traditional anteromedial portal and just
medial to the border of the patellar tendon. No additional skin
incision is needed, and the arthrotomy for this portal is carried
out through the already open anterior incision for patella
tendon harvest. At this point the knee is taken to a position
of deeper flexion than that with which the femoral tunnel
was drilled. We have not found our arthroscopic visualization
of the opening of the femoral tunnel to be limited by this
change in position. Initially, a rigid “trailblazer” is passed
through this portal and up into the anterior portion of the
femoral tunnel, just anterior to the graft, in an effort to make
an opening for the first few threads of the interference screw
to be placed later. This accomplishes the same result as pass-
ing a few threads of a tap. Then a guidewire is inserted
through this same portal, across the femoral notch, and into
the femoral tunnel anterior to the graft bone plug. The guide-
wire can be felt to slide effortlessly within the femoral tunnel.
At this point a sterile draped fluoroscopy unit is brought
within the operative field, and the position of the guidewire
within and parallel to the femoral tunnel and bone block is
confirmed on lateral fluoroscopic images. Rodin and Levy
have published a similar technique, with only 3% of the 62
cases having significant divergence greater than 15 degrees.34
Finally, we ensure that the guidewire remains freely mobile
during screw insertion to prevent guidewire bending or
359
 Anterior Cruciate Ligament Reconstruction
breakage, with some similarities to the advancing guidewire
technique as described by Ha et al.33 We remove the guidewire
prior to completing the last few turns of the screw within the
femoral tunnel. If for some reason the screw does not insert
appropriately, or if the wire is bending or the screw is divergent,
the screw can be removed, the guidewire can be repositioned or
replaced if bent, and the same-size screw can be reinserted to
achieve the same fixation pullout strength as a screw inserted
only once.35
GRAFT–TUNNEL MISMATCH
Graft–tunnel mismatch is a problem unique to endoscopic
single-incision BPTB ACLR. This term includes any situa-
tion in which the location of the tibial tunnel bone plug
makes placing the tibial tunnel interference screw difficult or
impossible. This is a well-recognized problem, and numerous
publications have presented alternatives to prevent or deal
with graft–tunnel mismatch.
Shaffer et al and Olszewski et al report techniques to
prevent mismatch using intraoperative measurements and
simple mathematical equations to direct the length of tibial
tunnel required prior to creating that tunnel.36,37 The tibial
guide used in this technique provides a measurement of the
length of the tibial tunnel prior to the tunnel being drilled.
Central to these ideas is that the length of the tibial tunnel
and intraarticular distance must be greater than or equal to
the length of the patella tendon and tibial bone plug in order
for the tibial bone plug to come to rest within the tibial tunnel.
The tibial tunnel length is the only nonanatomical variable.
With a long patella tendon, these formulas would suggest
a long tibial tunnel with a high angle down the tibial shaft.
Angles in excess of 60 degrees are not practical because
they disrupt the pes anserina and make creation of femoral
tunnels difficult to achieve without blowing out the posterior
cortex.37
Others recommend always using a standard tibial
tunnel angle of 55 degrees, creating a tunnel length of 50
to 55 mm, and being satisfied that this will work in the
majority of cases.20,38 Options for dealing with the problem
after the femoral and tibial tunnels have been created have
been described as well, including recessing the femoral bone
plug deeper within the femoral tunnel, rotating the graft
along its long axis to shorten the length of the patella ten-
don, flipping the tibial bone plug back onto the tendinous
portion of the graft, and achieving alternative tibial
fixation.39–41 Staples or suture posts can be used when solid
fixation with interference screws cannot be achieved.
360
Our technique for preventing graft–tunnel mismatch
includes preoperative assessment of the lateral radiograph
for patella alta or baja. We harvest our graft and measure
its total and tendinous lengths prior to creating tunnels.
Our grafts are usually 90 to 105 mm in length, with the
patella tendon usually 40 to 55 mm in length. Reported
mean lengths of patella tendons range from 43 to 48 mm,
with outer limits including tendons of 33 to 63 mm.36–38
Graft–tunnel mismatch is more frequent with patella
tendon length greater than 50 mm.36 When our total graft
is longer than 105 mm, we will frequently plan for a two-
incision technique and create our femoral tunnel using an
outside-in fashion. With a two-incision technique, bitunnel
interference screw fixation is not a problem, as the total tun-
nel length is usually 120 mm.36,42 Otherwise, we proceed
with standard tunnel placement and preparations. We drill
a tibial tunnel with a 55-degree angle, drill the femoral tun-
nel through the tibial tunnel, confirm femoral guidewire
placement with fluoroscopy, and prepare a femoral tunnel
35 to 40 mm deep. The anterior edge of the femoral tunnel
is rasped smooth, and the posterior wall is palpated to ensure
integrity. The graft is passed into the femoral tunnel, with
the femoral bone plug recessed 1 or 2 mm from the
aperture. The graft is fixed at this position if the tibial bone
plug rests within the tibial tunnel. Our first step for mis-
match if the tunnels have already been created is to recess
the graft 5 to 10 mm within the femoral tunnel. As with
all femoral interference screws that we place, we confirm
parallelism with fluoroscopic images of the guidewire prior
to screw insertion to a recessed femoral bone plug.
If the tibial bone plug protrudes from the tibial tunnel
after 10 mm of femoral recession, we have two other
options. If the tibial bone plug is longer than the femoral
bone plug, the graft can be reversed so that with the new
bone–tendon margin recessed 10 mm in the femoral tunnel,
the new tibial bone plug is shorter in length and may be
contained entirely within the tibial tunnel. If all these efforts
have failed, we will deepen the distal posterior aspect of the
tibial tunnel with a rongeur and bur to inlay the tibial bone
plug and capture it with a staple.
Mismatch with too short a graft is uncommon
because intraarticular distance between the tunnel apertures
ranges from 20.4 to 26 mm, whereas the mean lengths of
patella tendons range from 43 to 48 mm.36–38 If the graft
is short and the tibial bone plug comes to rest deep within
the tibial tunnel and near the articular surface, we confirm
placement of the guidewire past the tibial bone plug and
into the joint with arthroscopic visualization. We also con-
firm that the screw is not placed too deep within the joint
 Interference Screw Fixation in Bone–Patellar Tendon–Bone Anterior Cruciate Ligament Reconstruction
with the arthroscope. In this situation, a Hewson Ligament
Button can be used as backup cortical fixation.
EXTREMES OF BONE DENSITY
The easier extreme to accommodate is hard, young bone.
The first reamer we use in both the tibial and femoral tun-
nels is usually 2 mm less than the desired diameter. For nor-
mal or hard bone, we will use standard powered reamers to
increase the tunnel diameter up to the desired size in 1-mm
increments. Prior to placing the screws in hard bone, we will
use a metal tap to tap threads for the incoming screw into
both tunnels. Even with hard bone, the usual screw
diameters will be placed.
Softer bone can be more problematic, and thus more
options are available. As stated, our initial reamer is 2 mm
smaller than our final tunnel diameter. If the bone feels soft
in the work leading up to this point, we will use serial dila-
tors in 0.5-mm increments to increase the size of the tunnel
and compact the bone surrounding the tibial tunnel. A tap
is not used prior to inserting the screws. Decreased bone
mineral density has been shown to be correlated with
decreased insertional torque and failure load.5,24,43 Even
without a torque wrench, the surgeon’s own forearm can
indicate a difference in insertional torque in soft bone. With
soft bone, our choice for screw diameter will be 1 mm
greater than usual with normal bone—the same as the tun-
nel diameter for metal screws, usually 10 or 11 mm—and
1 mm greater than the tunnel diameter for bioabsorbable
screws, usually 11 or 12 mm for a 10- or 11-mm tunnel.
However, patients with soft bones frequently have a smaller
patella tendon and we frequently harvest a 9-mm graft,
making the tunnels 9 mm, and the screws are 9 mm for
metal and 10 mm for bioabsorbable. If the surgeon and his
or her own forearm do not believe that the first screw placed
has enough insertional torque, then the screw should be
removed and replaced with a screw 1 mm larger in diameter.
This can be repeated a second time, but if the fixation is
poor at this point, other fixation strategies must be
considered.
Our backup femoral fixation in cases of poor interfer-
ence screw fixation or posterior wall blowout is Endobutton
fixation (Acufex, Smith & Nephew, Mansfield, MA). The
graft is removed from the knee in the case of poor screw fix-
ation and prepared by connecting the Endobutton to the
graft bone plug with two or three loops of #5 nonabsorbable
braided suture passed through drill holes in the bone plug
and woven through the tendinous portion of the graft.
The femoral tunnel is prepared by passing the last reamer
through the femoral tunnel all the way to but not through
the lateral cortex of the femur. A 2.4-mm guidewire and
48
then a 4.5-mm reamer are passed through the lateral cortex
of the femur. Leading and trailing sutures are placed in the
peripheral holes of the Endobutton. The graft is placed
in the knee. The Endobutton is led out of the 4.5-mm
opening in the lateral cortex and then deployed by tugging
on the trailing suture. The graft is tensioned with sutures
in the opposite end of the graft to confirm deployment of
the Endobutton and secure fixation of the femoral end of
the graft. The position of the Endobutton is further con-
firmed with anteroposterior and lateral fluoroscopic images.
An interference screw can be placed in the femoral canal in
the standard fashion if additional fixation is desired.44
Our preferred backup on the tibial side is a Hewson
ligament button placed over the distal opening of the tibial
tunnel under a periosteal flap. The #5 nonabsorbable
braided sutures attached to the tibial bone plug and distal
graft tendon are led through separate openings in the but-
ton. A posterior drawer moment is placed about the knee
with the knee in approximately 60 degrees of flexion. The
sutures are tensioned as appropriate, and the knee is passed
through 20 rotations of range of motion and then tied over
the button. The periosteal flap is then closed over the
button. The button technique allows good cortical bone
fixation as a backup to soft bone.44 Additionally, a suture
post technique with nonabsorbable sutures tied over a screw
and washer can be used. If this is used as a backup for fem-
oral fixation, a separate second incision centered over the
distal lateral thigh will be necessary to place the screw in
the distal femur. All three of these femoral fixation tech-
niques have been shown to have no difference in ultimate
failure load.45
Another form of “soft” bone occurs with graft bone
block fracture. This can occur intraoperatively during screw
insertion or postoperatively during rehabilitation or repeat
injury.46 When the femoral bone block is fragmented, the
graft can be reversed and the patellar bone block can be
inserted and fixed within the femoral tunnel. The opposite
tendinous portion of the graft can be captured with nonab-
sorbable suture and then tied over a button or post on the
tibia. If the tibial bone plug fractures, a similar scenario
without the graft reversal can be attempted. If these techni-
ques do not achieve a stable knee, the remaining options
include obtaining a new autograft from another source (e.g.,
quadriceps, hamstring) or using an allograft to complete
the ACLR.
CONCLUSION
Although interference screw fixation has definite advan-
tages, allowing early range of motion and more aggressive
earlier rehabilitation, it is a very “unforgiving” construct.
361
 Anterior Cruciate Ligament Reconstruction
Meticulous attention to detail is paramount to a good out-
come. Graft harvest must be carefully carried out without
cracking the patella or the bone plug. Great care must be used
to ensure that tunnel placement is as anatomical as possible.
Attention to graft positioning in the tunnels and care during
screw insertion to avoid graft laceration and bone block
fracture are needed for good results. Fluoroscopic visualiza-
tion can be used at any time to confirm positioning of tunnels
or screws. A satisfactory result depends on attention to detail
and is a matter of millimeters.
References
1. Caborn DN, Urban WP Jr, Johnson DL, et al. Biomechanical com-
parison between BioScrew and titanium alloy interference screws for
bone-patellar tendon-bone graft fixation in anterior cruciate ligament
reconstruction. Arthroscopy 1997;13:229–232.
2. Rupp S, Seil R, Schneider A, et al. Ligament graft initial fixation
strength using biodegradable interference screws. J Biomed Mater Res
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3. Beevers DJ. Metal vs. bioabsorbable interference screws: initial fixa-
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 49
Anterior Cruciate Ligament Reconstruction
Using a Mini-Arthrotomy Technique with
Either an Ipsilateral or a Contralateral
CHAPTER Autogenous Patellar Tendon Graft
K. Donald Shelbourne INTRODUCTION
There are many techniques for anterior cruciate
ligament (ACL) reconstruction that involve
using different surgical instruments, graft
choices, fixation devices, and postoperative care.
Each surgeon needs to become an expert at one
technique, track the patients’ results, and then
make refinements in the surgery and rehabilita-
tion to optimize outcomes. It is important to
note that ACL surgery is not just a surgery
but also involves specific preoperative and post-
operative rehabilitation programs to obtain a
good result. Specific rehabilitation guidelines
will be covered in other chapters in this book.
The purpose of this chapter is to describe a
technique for ACL reconstruction using autog-
enous patellar tendon graft from either the ipsi-
lateral or contralateral knee.
In the past 24 years, I have performed
more than 5000 ACL reconstructions, and I
have always used an autogenous patellar tendon
graft for all the surgeries. I prefer to use the
patellar tendon graft because it allows for quick
and predictable bone-to-bone healing, is viable
throughout the entire postoperative course,1
and can respond to stress during rehabilitation.
Although any biological graft that is properly
placed in the knee can achieve the same stability
after surgery, the patellar tendon graft may
allow for the fastest postoperative rehabilitation
program because bone–bone healing is quicker
than tendon–bone healing. Regardless of graft
364
choice, proper rehabilitation must be done to
give the best result.
PREOPERATIVE PLANNING
Radiographs
Radiographs are obtained preoperatively to
assist with surgery planning.
Plain radiographs, including standing
posteroanterior 45 degrees flexed weight bear-
ing,2 lateral, and Merchant3 views are obtained.
The radiographs allow us to measure the width
of the intercondylar notch, length of the patellar
tendon, tibial slope angle, and width of the
patella, which is usually twice the width of
the patellar tendon. These measurements are
helpful for planning the angle and length of
the femoral tunnel and help determine the
amount of notchplasty that may be needed to
accommodate for the width of the new ACL
graft. A magnetic resonance imaging (MRI)
scan is not necessary for our preoperative
evaluation but is reviewed if it has already been
obtained elsewhere.
Rehabilitation
There is never a reason to do an isolated ACL
reconstruction as an emergency surgery. Previous
studies have shown that acute ACL recons-
truction has a higher rate of postoperative
Anterior Cruciate Ligament Reconstruction Using a Mini-Arthrotomy Technique with Either an Ipsilateral or a Contralateral Autogenous Patellar Tendon Graft 49
arthrofibrosis than delayed ACL reconstruction when the Ioban (3M Healthcare, St. Paul, MN) is placed on the knee
patient has the opportunity to undergo rehabilitation to allow over the openings cut in the stockinette. A bump is placed
the knee to return to a quiescent state.4,5 All patients are under the distal thigh to hold the leg in 25 degrees of flexion.
evaluated by a physical therapist at the time of my initial
evaluation. The physical therapist measures knee range of Exposure
motion and strength before surgery and determines when
the patient is ready to undergo surgery. The patient must have The tourniquet is left inflated to 300 mHg/psi (350 mHg/
full knee range of motion equal to the contralateral normal psi for larger thighs). The Ioban drape is taken off the skin
knee, good leg control, and no knee swelling before he or just over the site where the skin incision is to be made. A
she can undergo surgery. Furthermore, the patient must be 6-cm incision is made down to the deep fascia along the
mentally prepared for surgery. The surgery and rehabi- medial side of the patellar tendon, starting 1 cm above
litation program are fully explained to the patient and his or the inferior pole of the patella and extending 4 cm distal to
her caregiver so that they fully understand what is expected the joint line (Fig. 49-1). The subcutaneous tissue is sepa-
of them after surgery. The surgery date is planned for a time rated from the deep fascia medially where the tibial tunnel
when the patient has at least 1 week off school or work and is to be drilled 4 cm distal to the joint and 1 cm medial to
when a family member or friend can be at home with him or the tibia tubercle. The subcutaneous tissue is separated from
her during the first week postoperatively. the deep fascia with Metzenbaum scissors and finger dissec-
tion approximately 1 to 2 cm medial to the patellar tendon.
TECHNIQUE
Tibial Exposure
Preparation
The deep fascia and periosteum of the proximal tibia are
The patient lies supine on the operating table and is given incised with electrocautery starting from the joint line and
a general endotracheal anesthesia. A knee evaluation for extending distally along the medial edge of the patellar ten-
stability, range of motion, and effusion is performed after don for 4 cm, then cutting at a right angle for another 2 cm
the patient is under anesthesia. The patient’s knees are to outline a flap to the level just proximal to the pes
positioned over the break in the table for flexion later.
A tourniquet is applied to the thigh.
A 30-mg bolus of ketorolac is administered for
preemptive pain management. Then 90 mg of ketorolac is
mixed with 1000 mL of saline and an intravenous drip is
started to run at 40 m/hr until completion of the dose.
Intravenous antibiotics are infused.
The knee is preinjected with 0.25% Marcaine (bupi-
vacaine hydrochloride, Winthrop, New York, NY) with
epinephrine. The operative site is prepped with alcohol,
and then the entire leg is painted with povidone-iodine
(Betadine). An impervious stockinette is applied.

Preparation When Using Graft from Contralateral

Knee
A tourniquet is applied but is not inflated at this time. The
contralateral leg is prepped with alcohol, and the entire leg is
painted with povidone-iodine (Betadine). An impervious
stockinette is applied.

Arthroscopic Evaluation

An arthroscopy is performed to examine the knee joint for

articular cartilage damage and meniscal tears. Meniscal tears
FIG. 49-1 A 6-cm incision is made along the medial side of the patellar
are treated with either repair or removal or are left in situ as tendon starting 1 cm above the inferior pole of the patella and extending
appropriate. After the arthroscopy, the leg is redraped and 4 cm distal to the joint line.

365
 Anterior Cruciate Ligament Reconstruction
anserinus. The periosteum/fascial flap is lifted with a perios-
teal elevator to expose bare bone where the tibial tunnel will
be created, made, and drilled (Fig. 49-2). Exposure at this
level will ensure the tibial tunnel will be at least 40 mm long
for the 25-mm bone plugs. The flap is kept as thick and
continuous as possible to allow for closure of the soft tissue
over the polyethylene button used for fixation, which has
reduced the need for postoperative hardware removal.
Medial Arthrotomy
A finger is used to put tension on the medial capsule just
medial to the patella as electrocautery is used to incise the
capsule into the joint at 5 to 10 mm medial to the patella,
starting at the level of the lower third of the patella, extend-
ing distally to the tibia, and staying medial to the fat pad.
Tension is applied to the synovial layer with forceps on both
sides of the incision. After making an opening in the syno-
vium, a Z retractor is inserted to retract the patellar tendon
laterally. A small fork retractor is inserted inside the syno-
vium to retract the soft tissue medially. The incision is
extended distally along the medial edge of the patellar ten-
don toward the tibial periosteal incision, thus connecting
the two incisions. The incision in the fat pad should stay
just medial to the ligamentum mucosum for better exposure
of the joint. At the tibial plateau, the soft tissue is incised up
to the intermeniscal ligament. Proximally, an incision is
made in the retinaculum up to the distal fibers of the vastus
FIG. 49-2 A periosteum/fascial flap is lifted to expose the bone at the site
where the tibial tunnel is drilled.
366
medialis obliquus, cutting from inside the joint toward the
surface to avoid inadvertent injury to the articular surface.
It is not necessary to dislocate the patella for this exposure.
Femoral Exposure
The patellar tendon length is determined preoperatively from
a 60-degree-flexion lateral plain radiograph. The length of
the tendon varies from 34 to 74 mm (mean 49 mm for men
and 46 mm for women). Longer patellar tendons need longer
femoral tunnels. The intraarticular ACL length varies from
22 to 30 mm, so the extra length of the graft is placed in the
femur. The bone plug in the tibia is placed just distal to the
medial tibial spine because the only hard cancellous bone in
the tibia is at the proximal joint line. The femoral tunnel exit
site is adjusted based on the length of the graft. For longer
patellar tendons, the incision will be made more proximally;
for shorter patellar tendons, the incision is made more distally.
In our experience, an oblique incision has resulted in fewer
wound-healing problems than a longitudinal incision in line
with the iliotibial band.
The table is elevated so that the femur is close to eye
level. The foot of the bed is lowered so that the knee is
flexed to 90 degrees. The bump under the thigh may need
to be adjusted to allow for 90 degrees of flexion. The goal
is to expose the flat surface of the lateral femoral cortex
above the metaphyseal flare. The 3-cm lateral oblique inci-
sion is made about 4 to 5 cm above the superior pole of
the patella along Langer’s lines (Fig. 49-3). Sharp dissection
is made down to the iliotibial band. Metzenbaum scissors
are used to split the iliotibial band along its fibers at a level
one-third of its width from the anterior edge. With the knee
extended to relax the quadriceps muscle, finger dissection is
used to sweep the distal fibers of the vastus lateralis ante-
riorly from the femur. A Slocum retractor is inserted
FIG. 49-3 A 3-cm lateral incision is made at a 45-degree angle. The distal
end is posterior and ends 5 cm above the level of the superior pole of
the patella.
Anterior Cruciate Ligament Reconstruction Using a Mini-Arthrotomy Technique with Either an Ipsilateral or a Contralateral Autogenous Patellar Tendon Graft
beneath the vastus lateralis, lifting it anteriorly to expose the
femur, and a Cushing retractor is used to retract the poste-
rior portion of the iliotibial band. A two-prong retractor
pulls the skin distally so that the electrocautery can be used
to incise the iliotibial band distally. Frequently the lateral
superior geniculate artery, veins, or both are in the distal
aspect of the wound running along the femoral surface.
These vessels should be cauterized as soon as identified to
avoid a postoperative hematoma. Electrocautery is then used
to incise the periosteum, making a distally based T. An ele-
vator is used to elevate the periosteal flaps to expose bone.
Notchplasty
The lateral aspect of the notch is cleared of any ACL rem-
nant and scar tissue, if present. The curette and sponge are
used to push the capsule away from the back of the notch so
that its posterior wall over-the-top position can easily be
seen and palpated. The width of the notch and the space
between the lateral femoral condyle and the posterior cruci-
ate ligament (PCL) are measured with calipers (Fig. 49-4).
The space between the lateral femoral condyle and the
PCL is the space available for the ACL graft; it averages
8 mm in width for men and 6 mm in width for women.
The notchplasty is then performed with a large curette to
create at least an 11-mm space between the border of the
lateral femoral condyle and the PCL so that the new
10-mm patellar tendon graft will fit in the notch in full
extension without impingement.
Tunnel Placement
Tibial Tunnel
The ACL attachment on the tibia has a wider footprint
than the femoral insertion and is more difficult to place
FIG. 49-4 Calipers are used to measure the width of the intercondylar
notch, and the space between the posterior cruciate ligament and the
lateral femoral condyle.
49
predictably. Ideal graft placement will result in the graft
lying flush with the roof of the notch with the knee in full
extension. A postoperative full-extension lateral radiograph
should show the tibial tunnel to be parallel and posterior
to Blumensaat’s line. Too anterior of a position may result
in graft impingement when the knee is fully extended and
may cause difficulty with obtaining extension and possibly
graft failure.
The tibial periosteal/fascial flap is retracted medially
with a Cushing retractor.
A 3/32-inch guide pin is placed on the anteromedial
tibia about 4 cm below the joint line. The guide pin is
directed 5 mm medial to the tibial spine and at least 5 mm
anterior to where the tibial plateau “drops off” in the sagittal
plane. This point can be found by palpation and represents
an ideal placement for the tibial tunnel. We view the visible
portion of the medial tibial plateau as a clock. The 9-o’clock
position serves as the middle of the visible tibial plateau for
the right knee (3-o’clock position for a left knee). The cen-
ter of the ideal tibial tunnel corresponds to the position just
posterior to the 9- or 3-o’clock position (Fig. 49-5). The tip
of the guide pin is 5 mm medial to the tibial spine and 6 to
7 mm anterior to the posterior sloping of the tibial plateau
where the PCL crosses. After an acceptable position is
achieved, the guide pin is over-reamed with a 9-mm, end-
cutting, cannulated reamer (Fig. 49-6). Reamings are saved
for bone grafting of the graft harvest site later in the proce-
dure. Curettes are used to position the medial and posterior
wall of the tunnel in the desired place (Fig. 49-7).
PCL
Medial Lateral
Area of 5mm
posteriorization
FIG. 49-5 Tibial tunnel placement. A clock face is interposed on the
portion of the medial tibial plateau that is visualized through the
mini-arthrotomy. The area of posteriorization is created for refinement of
the position so that the back of the tunnel is just at the front slope
of the tibial spine. PCL, Posterior cruciate ligament.
367
 Anterior Cruciate Ligament Reconstruction

10-mm tunnel just adjacent to the PCL and just off the
back wall. The guide pin is then drilled toward the
cleared-off lateral femoral cortex in the lateral oblique
incision. If the guide pin does not exit in the area of the
cleared-off cortex, it must be redirected using the same
starting point. Once the pin is in an acceptable position, it
is over-reamed with a 10-mm end-cutting reamer to the lat-
eral femoral cortex (Fig. 49-8). Bone reamings are once
again saved for filling in the graft harvest site. The joint is
irrigated thoroughly. The tunnel positions are checked using
a suction tip. With the knee extended, the suction tip
should pass colinearly through the tibial tunnel and femoral
tunnel (Fig. 49-9).
FIG. 49-6 After precise placement of the tibial tunnel is achieved with a
guide pin, the guide pin is over-reamed with a cannulated reamer.

Femoral Tunnel
Femoral tunnel placement is one of the more critical and
technically difficult parts of the procedure. Graft placement
that is too vertical (too anterior on radiograph) is probably
the most common problem seen in nontraumatic failed
ACL surgery. The mini-arthrotomy technique allows for
anatomical placement of the femoral tunnel because it is
drilled independently of the tibial tunnel. The tunnels can
be placed where desired because of the ability to view the
notch and the posterior wall. The extremity is placed in a
figure-four position. The posterior wall must be well visual-
ized just adjacent to the PCL. The guide pin is used to pal- FIG. 49-8 Femoral tunnel. A 10-mm tunnel is drilled just adjacent to the
posterior cruciate ligament and just off the back wall of the femur.
pate the edge of the back wall and the lateral border of the
PCL. From this point, the guide pin is moved forward
6 to 7 mm and laterally 3 to 4 mm. This allows for a

FIG. 49-7 A curette is used to position the medial and posterior wall of the FIG. 49-9 Straight-line placement of the graft is checked using a suction
tibial tunnel in the position shown in Fig. 49-5. tip, which should pass colinearly through the tibial and femoral tunnels.

368
Anterior Cruciate Ligament Reconstruction Using a Mini-Arthrotomy Technique with Either an Ipsilateral or a Contralateral Autogenous Patellar Tendon Graft
Graft Harvest and Preparation
Ipsilateral Graft
We prefer to harvest the graft after placement of the tun-
nels. This allows for harvesting of a graft to fit the tunnels,
rather than vice versa. The knee is bent to 90 degrees, and
the foot of the table is lowered. An incision is made just
medial to the patellar tendon, from the inferior pole of the
patella to the level of the tibial tubercle. The length of the
incision depends on the length of the patellar tendon, which
has been determined by measuring preoperative radio-
graphs. The subcutaneous tissue is undermined sharply,
exposing the patellar tendon. The paratenon is split longitu-
dinally, and adequate flaps are maintained for later closure.
The width of the tendon is measured. A 10-mm-wide graft
is harvested using a #10 scalpel (Fig. 49-10). The bony
blocks are scored with the scalpel so that the bone blocks
will measure approximately 10 mm wide and 25 mm long.
An oscillating saw is used to harvest the bone blocks in a
wedge-shaped fashion (Fig. 49-11). The saw blade should
FIG. 49-10 A 10-mm-wide graft is harvested using a #10 scalpel.
FIG. 49-11 An oscillating saw is used to harvest wedge-shaped bone
blocks.
49
be angled in 45 degrees toward the midline. The bone
blocks are removed with a ¼-inch osteotome and contoured
so that they will fit in their respective tunnels. Excess bone
and soft tissue are removed with a rongeur. Three drill holes
are drilled in each bone plug, and #2 Ethibond sutures are
passed through the holes (Fig. 49-12). At this time, the
graft is taken to the back table and excess fat pad is removed
so that there will be no snagging when it passes through the
tunnels. Measurements are taken of the patellar tendon
length and the thickness and length of the graft. The patel-
lar tendon graft is usually longer than the native ACL, but
this extra length is easily accommodated by the femoral tun-
nel. The overall graft length should be 10 to 20 mm shorter
than the overall tunnel length to allow for easy repositioning
and tensioning while maintaining bone plugs inside the
tunnels.
Contralateral Graft
When a patellar tendon graft is used from the contralateral
knee, the tourniquet on that leg is inflated immediately before
graft harvest. The graft harvest is identical to that used for an
ipsilateral graft, as explained earlier. The harvest site is
injected with bupivacaine (Marcaine), the knee is wrapped
with an elastic bandage, and the tourniquet is deflated.
Passage of the Graft, Fixation,
and Tensioning
A suture passer is passed into the tibial tunnel so that it exits
the notch. The individual Ethibond sutures are passed
through and brought out the tibial tunnel. The bone plug
is guided into the tibial tunnel with the cancellous side ante-
rior while keeping tension on the distal sutures. This places
the graft so that the tendinous portion faces posteriorly,
which helps to avoid impingement. Three suture ends are
FIG. 49-12 Three drill holes are placed in each bone plug, and #2
Ethibond sutures are passed through the holes.
369
 Anterior Cruciate Ligament Reconstruction

each passed through a hole of a ligament fixation button Closure

(Fig. 49-13). These are provisionally tied with two throws.
The sutures in the femoral bone plug are looped into the Ipsilateral Graft
suture passer and passed from the notch, exiting through One-quarter (0.25) Marcaine with epinephrine is injected
the lateral incision. The end of the suture passer is guided into the deep and subcutaneous tissues for analgesia and to
through the femoral tunnel exit, the sutures are removed decrease bleeding. Hemostasis is obtained by packing the
from the passer, and the device is withdrawn from the knee. wound with sponges and a compressive wrap. The tourni-
The sutures are passed through a ligament fixation quet is then released. After 1 to 2 minutes, the dressing is
button and tied down tightly over the lateral femoral removed, the wound is irrigated, and bleeders are cauterized.
cortex. The sutures on the tibial side are pulled firmly to seat
the femoral button. The sutures over the tibial button are
loosened and the patellar plug is advanced in the tibial
tunnel, removing any slack in the graft. The tibial sutures
are then retied.
The knee is moved through a full range of motion
from full hyperextension to full flexion (Fig. 49-14, A and
B). If the graft was too tight before taking the knee
through its full range of motion, the slip knots will
accommodate by loosening just enough to allow for full
motion. The tightness of the button on the tibia is checked
again at 30 degrees of flexion. If it is too loose, the tibial
sutures are retied, the knee is placed through full range of
motion again, and the button is rechecked for proper tight-
ness. If the sutures remain tight, three more throws are tied.
This allows for fine-tuning of graft tension to avoid captur-
ing the knee. The graft is then examined through the mini-
arthrotomy to ensure that notch impingement does not
occur.

FIG. 49-14 After button fixation is completed, the knee is moved

through a full range of motion to include full hyperextension (A) and
FIG. 49-13 Button fixation is used on both the tibial and femoral sides. flexion so that the patient’s heel touches the buttocks (B).

370
Anterior Cruciate Ligament Reconstruction Using a Mini-Arthrotomy Technique with Either an Ipsilateral or a Contralateral Autogenous Patellar Tendon Graft
A medium ConstaVac (Stryker, Kalamazoo, MI) drain is
inserted into the lateral femoral wound.
The graft donor site tendon defect is closed tightly
with running #0 Vicryl (Ethicon, Somerville, NJ) suture
through the paratenon, taken with a 2-mm piece of tendon
on each side. We are able to close the defect tightly because
we flex the knee fully after closure and again the evening
after surgery. If the surgeon does not flex the knee fully on
the day of surgery, he or she should close the defect loosely.
Bone shavings obtained from drilling the femoral and
tibial holes are packed into the patellar defect first. The ten-
don soft tissue over the patella defect is sutured over the
bone graft material to contain it. Restoring the normal
patella contour with the bone graft has been important in
preventing the nuisance discomfort of leaving this defect.
The tibial plug defect is filled with any remaining bone
graft, and the tendon insertion is sewed over it as a contin-
uation of the running stitch of the patellar tendon closure.
The mini-arthrotomy capsule is closed with interrupted
figure-eight stitches of #1 Vicryl. The knee is then taken
through a full range of motion, and the button tightness is
checked again before the fascial periosteum flap is closed over
the button. A medium ConstaVac drain is inserted between
the capsule and subcutaneous tissue. No intraarticular drain is
used because the Cryo Cuff (Aircast, Summit, NJ) prevents a
hemarthrosis and forces this blood subcutaneously where the
drain will work. The iliotibial band is closed with #2–0 Vicryl.
The subcutaneous tissue layer is closed with #3–0 Vicryl, and
a running subcuticular #3–0 Proline suture is used for the skin.
The incisions are covered with steri-strips. Plastizote
squares (5  3  ¼ inches) are applied over the steri-strips
for local skin compression, making for a more cosmetic scar
and prevention of a subcutaneous hematoma. An antiembo-
lism stocking (Kendall, Mansfield, MA) and a cold/com-
pression device (Fig. 49-15) (Cryo Cuff) are applied to
assist in preventing swelling.
FIG. 49-15 A cold/compression device is placed on the knee in the
operating room to prevent the formation of a hemarthrosis.
49
Contralateral Graft
When a contralateral graft is used, the graft donor site is
closed as previously explained.
Postoperative Care
Upon admission to the hospital ward, the leg is kept ele-
vated and moving in a continuous passive motion machine.
Extension and flexion exercises begin as outlined in previous
publications.6 The intravenous drip of ketorolac continues
for approximately 23 hours until the dose is completed.
The ketorolac, supplemented with 1 gm of acetaminophen
every 6 hours, has provided excellent pain management for
patients after the ACL reconstructive procedure.7 The over-
night stay allows for patient and family education for the
first week at home and ensures that the immediate postop-
erative goals are met, which prevents complications from
developing.
COMMENTS
The mini-arthrotomy technique using a patellar tendon
autograft and suture-button fixation allows for reproducible
excellent results and remains our method of choice for ACL
reconstructions. Regardless of surgical technique, graft
choice, or fixation device, the knee must be able to be
moved through full range of motion after fixation to ensure
that the graft placement has not captured the joint. The
range of motion illustrated in Fig. 49-14 shows that the full
knee extension includes hyperextension and the full flexion
involves bringing the patient’s heel to the buttocks. If full
range of motion cannot be obtained in the operating room
after graft fixation, then it cannot be expected that the
patient will be able to achieve full range of motion after sur-
gery. Full normal range of motion is required for the patient
to achieve the optimal result after surgery.
The mini-arthrotomy technique might be considered
“old-fashioned” by many, but it has several advantages over
the arthroscopic technique. The angle of drilling the femoral
tunnel from inside to outside is enhanced when starting
medial to the patellar tendon. The medial approach allows
the guide pin to exit at a desirable lateral position. By not
relying on the patellar tendon defect for exposure, the graft
harvest can be delayed until the tunnels are prepared and
thus the bone plug size can be appropriately modified. Dril-
ling the femoral and tibial hole through an arthrotomy
allows for a complete overall view of the ACL placement.
It also allows for the retrieval of bone shavings for bone
grafting of the donor sites. These bone shavings would be
washed away when using arthroscopic techniques.
371
 Anterior Cruciate Ligament Reconstruction
The only ACL injury in which acute or semi-acute
surgery is indicated is when the patient has a dislocated knee
involving the lateral side. The mini-arthrotomy technique
allows for acute surgery, whereas acute surgery cannot be
done arthroscopically because arthroscopic fluid cannot be
contained in the knee joint due to the lateral capsule injury.
The use of button fixation has advantages as well. The
buttons allow for adjustment of graft tension (multiple
times, if necessary) so that stability is achieved while main-
taining full range of motion. Also, complete circumferential
healing of the plug to the host is allowed because no foreign
material is lodged next to the bone plug. Revision surgery is
simpler with button fixation because no hardware needs to
be removed in order to make new tunnels.
Special Considerations with Contralateral
Graft
The use of a patellar tendon graft from the contralateral
knee can allow patients to have a quicker return of range
of motion in the ACL reconstructed knee and a quicker
return to sports. However, the use of this graft source in
itself does not guarantee patients a quick return to activities.
372
It is important to note that proper and specific rehabilitation
must be done for the graft-donor site to be able to achieve
these goals. Specific rehabilitation guidelines are described
in the rehabilitation chapter in this book.
References
1. Rougraff B, Shelbourne KD, Gerth PK, et al. Arthroscopic and histo-
logic analysis of human patellar tendon autografts used for anterior cru-
ciate ligament reconstruction. Am J Sports Med 1993;21:277–284.
2. Rosenberg TD, Paulos LE, Parker RD, et al. The forty-five-degree
posteroanterior flexion weight-bearing radiograph of the knee. J Bone
Joint Surg 1988;70A:1479–1483.
3. Merchant AC. Patellofemoral malalignment and instabilities. In
Ewing JW (ed). Articular cartilage and knee joint function: basic science
and arthroscopy. New York, 1990, Raven Press, pp 79–91.
4. Mohtadi NG, Bogaert SW, Fowler PJ. Limitation of motion following
anterior cruciate ligament reconstruction. A case control study. Am
J Sports Med 1991;19:620–625.
5. Shelbourne KD, Wilckens JH, Mollabashy A, et al. Arthrofibrosis in
acute anterior cruciate ligament reconstruction. The effect of timing
of reconstruction and rehabilitation. Am J Sports Med 1991;19:332–336.
6. Shelbourne KD, Klootwyk TE, DeCarlo MS. Rehabilitation program
for anterior cruciate ligament reconstruction. Sports Med Arthrosc Rev
1997;5:77–82.
7. Shelbourne KD, Liotta FJ, Goodloe SL. Preemptive pain management
program for anterior cruciate ligament reconstruction. Am J Knee Surg
1998;11:116–119.

Bone–Patellar Tendon–Bone Anterior
Cruciate Ligament Reconstruction Using
the Endobutton Continuous Loop
Bone–Tendon–Bone Fixation System
The Endobutton Continuous Loop (CL) (Smith
& Nephew, Andover, MA) for bone–tendon–
bone (BTB) grafts is a femoral fixation system
for grafts that have a bone block for the femoral
attachment, such as BTB autografts, BTB
allografts, and Achilles tendon allografts. The
Endobutton-CL BTB offers several advantages
compared with other forms of fixation, including
interference fixation. The technique is easy, repro-
ducible, and dependable while at the same time
offering possibly the strongest fixation for BTB
grafts available. Several advantages include a short
learning curve; fewer steps than interference fixa-
tion; no needed calculations, minimizing error;
and complete apposition of the bone block in the
femoral tunnel. Complete apposition of the bone
block allows for circumferential healing of the bone
block within the tunnel. It also means that revision
cases do not run the risk of voids in the bone left
from interference screws. More advantages include
the fact that perforation of the posterior femoral
cortex will not compromise fixation. Another
advantage that I enjoy the greatest is that the
BTB graft can be “automatically” countersunk in
the femoral tunnel, allowing the tibial bone block
to easily end flush with the tibial cortex. This elim-
inates the problem of the graft being “too long” and
thus eliminates the tibial bone block protruding
out the tibial tunnel. In other words, there is no
longer a risk of the graft being too long whether
using autografts or allografts and therefore no need
for tricks to accommodate this, such as steeper
angles on the tibial tunnel. Having the tibial bone
block end flush with the tibial cortex also makes
tibial fixation much easier. Continued advantages
50
CHAPTER
are that this technique avoids complications seen Stuart E. Fromm
from interference fixation such as screw diver-
gence, posterior blowout, laceration of the graft,
screw breakage, and retained hardware or voids
encountered during revision surgery. Finally, as
already alluded to, revision anterior cruciate liga-
ment (ACL) surgery becomes much easier for all
these reasons. Revision ACL surgeries are usually
as simple as primary ACL reconstructions.
The Endobutton-CL is a small metal but-
ton that is attached to a continuous loop of nylon.
The continuous loop means that there is no knot,
thus eliminating the risk of knots loosening or
tightening under a load; both situations lead to a
lengthening of a construct and thus failure. The
continuous loop (CL) comes threaded through
the metal Endobutton. The loop is then threaded
through the graft and back on itself. Thus it is a
closed loop system that eliminates a weak link.
This minimizes creep or failure of the construct.
It is well accepted that the weak link in ACL
reconstruction surgery is fixation of the graft
during the immediate postoperative period.
The Endobutton-CL offers one of the strongest
forms of fixation available, with pullout strengths
averaging 1345N compared with interference
screws that average approximately 700N.*
TECHNIQUE OVERVIEW
To emphasize the simplicity of the technique,
an overview is presented first, followed by a
more detailed description with pearls.
*Data on file at Smith & Nephew, Andover, MA.
373
 Anterior Cruciate Ligament Reconstruction
1 Standard knee arthroscopy is performed.
2 Prepare the BTB graft in the usual manner.
3 Ream the tibial tunnel in the usual manner.
4 Ream the femoral tunnel to a depth of the length of the
BTB graft as measured directly off the reamer at the
opening of the tibial tunnel. Then ream an extra 10 mm
to allow room for the Endobutton to flip when passed.
5 Leave the guide pin in place, and drill over it with the
4.5-mm Endobutton drill bit through the lateral femoral
cortex.
6 Measure the length from the lateral femoral cortex to
the opening of the tibial tunnel, and set the “stop” on
the depth gauge.
7 The length of the needed CL is measured directly off
the depth gauge when the graft is set beside it.
8 Attach the CL to the graft.
9 Pass the graft, flip the Endobutton, and tension the graft.
10 Fix the tibial bone plug.
TECHNIQUE IN DETAIL
The technique has a small learning curve with no needed
calculations, which minimizes error. Standard setup and
knee arthroscopy are performed. The bone–patellar
tendon–bone graft is prepared in the usual manner, regard-
less of whether an autograft or allograft is used. Personally I
leave the bone plugs no longer than 20 mm. Grafts are
usually 9 or 10 mm in diameter.
Tibial and femoral tunnels are likewise drilled in the
usual manner. In fact, the femoral tunnel can be drilled right
off the posterior femoral cortex without fear of breaking
through of the posterior wall, as it will not compromise fixa-
tion. I use a 6-mm offset guide for a 10-mm tunnel, which
places the femoral tunnel immediately against the posterior
femoral cortex. Before reaming the femoral tunnel, check
20
30
40
50
FIG. 50-1 Grafts usually measure approximately 80 to 90 mm in total length.
374
the length of the graft. Grafts usually measure approximately
80 to 90 mm in total length (Fig. 50-1). Ream the femoral
tunnel to a depth of the length of the graft as measured
directly off the reamer at the tibial cortex. For example, if
the graft length is 90 mm, ream to a depth of 90 mm as
measured on the reamer at the opening of the tibial tunnel
(Fig. 50-2). By doing this, the reamer is mimicking the graft
itself and therefore mimicking where the graft will be placed,
thus allowing the tibial bone plug to end flush with the tibial
cortex. It is no longer necessary to measure the femoral tunnel;
however, as a check, the femoral tunnel is usually reamed to a
depth of approximately 30 mm. Then ream an extra 10 mm
deeper to allow room for the Endobutton to flip outside of
the lateral femoral cortex. Try to not perforate the lateral fem-
oral cortex with the reamer. On longer grafts, you can run the
risk of running out of room for the femoral tunnel. One way to
effectively add length to the femoral tunnel is to flex the knee
less than 90 degrees. This lessens the angle of the femoral tun-
nel, placing it more in line with the femur, and therefore adds
length to the femoral tunnel if needed for longer grafts
(Fig. 50-3). However, if there is inadvertent perforation of
the femoral tunnel, it can be dealt with using the Xtendobut-
ton, which is discussed later in this chapter.
Leave the guide pin in place, and drill over it with the
4.5-mm Endobutton drill bit (Fig. 50-4). Remove the guide
pin.
Smith & Nephew makes a depth gauge with a stop on
it (Fig. 50-5). Measure from the lateral femoral cortex to the
opening of the tibial tunnel. Set the stop at the opening of
the tibial tunnel (Fig. 50-6). This will be the length of the
entire construct from the Endobutton to the end of the tib-
ial bone plug on your graft. You do not need to know the
actual number or distance; simply hand the depth gauge
with the stop in place to the associate who is preparing
the graft. The associate will lay the graft next to the depth
gauge with the tibial bone plug at the stop. Measure directly
the length of the needed CL, which is usually 40 to 45 mm
(Fig. 50-7; shown here with a quadriceps tendon graft with
a bone block on only one end).
100
60
70
80
90
 Bone–Patellar Tendon–Bone Anterior Cruciate Ligament Reconstruction Using the Endobutton Continuous Loop Bone–Tendon–Bone Fixation System
90
10
0
FIG. 50-2 If the graft length is 90 mm, then ream to a depth of 90 mm as
measured on the reamer at the opening of the tibial tunnel.
FIG. 50-3 One way to effectively add length to the femoral tunnel is to
flex the knee less than 90 degrees. This lessens the angle of the femoral
tunnel, placing it more in line with the femur, and therefore adds length to
the femoral tunnel if needed for longer grafts.
FIG. 50-4 Leave the guide pin in place, and drill over it with the 4.5-mm
Endobutton drill bit.
50
FIG. 50-5 Measure from the lateral femoral cortex to the opening of the
tibial tunnel. Set the stop at the opening of the tibial tunnel.
th
ng
l le
ta
To
FIG. 50-6 This will be the length of the entire construct from the
Endobutton to the end of the tibial bone plug on the graft.
The distance is measured from the 0 on the depth
gauge to the point of attachment of the CL to the graft,
whether it is at the bone–tendon junction or a small drill
hole in the bone plug itself.
Attach the CL to the graft. The Endobutton-CL can
be divided into three areas: a long loop, a short loop, and the
Endobutton (Fig. 50-8). When passing the CL, it is much
easier to pull it rather than push it. Trying to push the CL only
causes it to fray. Therefore it is advisable to pull the CL
through its path with a small nonbraided suture. Simply loop
375
 Anterior Cruciate Ligament Reconstruction

Total length

FIG. 50-7 Measure directly the length of the needed continuous loop, which is usually 40 to 45 mm, shown here
with a quadriceps tendon graft with bone block on only one end.

this suture around the long loop of the CL. Pull the long loop
of the CL via the suture through either the bone–tendon
junction or through a small 2-mm drill hole in the bone block.
When using a drill hole through the bone block, make sure
that it passed through the cortical side of the block and is more
than half the distance toward the tendon to avoid the CL from
pulling through soft bone. Instron studies while the BTB CL
was under development showed no difference in pullout
strength when passing the CL at the bone–tendon junction
versus through a 2-mm hole in the bone block. Then pull

FIG. 50-8 The Endobutton-CL can be divided into three areas: a long loop, a short loop, and the Endobutton.

376
 Bone–Patellar Tendon–Bone Anterior Cruciate Ligament Reconstruction Using the Endobutton Continuous Loop Bone–Tendon–Bone Fixation System 50
the long loop through the short loop, and slip it over the
REVISION ANTERIOR CRUCIATE LIGAMENT
Endobutton (Fig. 50-9). Pull to tighten. Check the total
length against the depth gauge to ensure accuracy. SURGERY
Pull the graft into place. Attach a #5 suture through
No special tricks are needed when using this technique for
one of the holes in the Endobutton and a #2 suture
revision ACL surgery. The technique is the same as that just
through the other, or place different-colored sutures through
described for a primary ACL reconstruction. When revising
each hole so that you will be able to tell them apart when
an ACL that was previously fixed with an interference
passed (Fig. 50-10). Thread all sutures through a passing
screw, I usually leave the interference screw alone because
pin (the two sutures for the Endobutton and the passing
it is usually not in the way. Interference screws are placed
suture through the bone block). Pull the passing pin out the
at the anterior edge of the femoral tunnel. Therefore I can
lateral thigh with the sutures (Fig. 50-11). Separate the
usually drill the new femoral tunnel just off the posterior
sutures. Pull the graft into position with the #5 suture and
femoral cortex as described earlier without fear of breaking
the passing suture, letting the #2 suture trail (Fig. 50-12).
out the posterior cortex with this system—again, if the pos-
The graft will have a definite stop when it is passed far enough
terior cortex is perforated, this will not compromise fixation
to flip the button. In addition, you will know the graft is far
with the BTB CL. Doing this almost always puts the fem-
enough when the tibial bone plug is within the tibial tunnel.
oral tunnel posterior to a previously placed interference
Flip the Endobutton by rocking the Endobutton back and
screw, and therefore these screws can simply be left alone.
forth using the #5 and #2 sutures. Then hold the Endobutton
perpendicular to the lateral femoral cortex and pull back on
the graft, ensuring fixation (Fig. 50-13). The tibial bone plug
Xtendobutton
should be flush with the tibial cortex.
A newer addition to the family of Endobutton-CL for BTB
Tension the graft, and fix the tibial bone block
is the Xtendobutton (Fig. 50-14), which is being finalized at
accordingly.

FIG. 50-9 Pull the long loop through the short loop, and slip it over the
Endobutton. Pull to tighten. Check the total length against the depth FIG. 50-10 Thread all sutures through a passing pin (the two sutures for
gauge to ensure accuracy. the Endobutton and the passing suture through the bone block).

377
 Anterior Cruciate Ligament Reconstruction
FIG. 50-11 Pull the passing pin out the lateral thigh with the sutures.
the time of publication of this chapter. This is simply a
larger button that fits over the Endobutton, effectively
making the Endobutton a larger button. The Endobutton
slides through a 4.5-mm hole and will not slide back when
flipped. The Xtendobutton slides through a larger hole (e.g.,
a 10-mm hole) and will not slide back when flipped. This
can be used for inadvertent reaming through the lateral
femoral cortex when drilling the femoral tunnel. Some
surgeons in preliminary trials prefer to use this exclusively
for femoral fixation, eliminating yet one more step. In other
words, the surgeon could ream the tibial and femoral
tunnels all the way through both cortices without measuring
off the reamer and eliminating the need to drill with the
4.5-mm drill altogether.
TROUBLESHOOTING
Although the Endobutton-CL BTB System is very user
friendly, surgeons should be aware of a few tips or pearls.
If a surgeon struggles to pull the femoral bone block
into the femoral tunnel, a few things should be checked.
First, as with any ACL reconstruction, an oversized bone
block that gives a very tight fit in the bone tunnel can cause
378
a surgeon to struggle when pulling the graft into place. This
is also true with the Endobutton-CL BTB system. Make
sure that the bone block can slide through the appropriate
sizer with the continuous loop in place. The continuous
loop can add a very slight width to the width of the bone
block. Another issue to be aware of is soft tissue around
the opening of the femoral tunnel. If the opening of the
femoral tunnel is not débrided adequately of soft tissue, then
this tissue is drawn into the femoral tunnel with the bone
block. The soft tissue will then impinge between the bone
block and the wall of the tunnel, making it difficult to pull
the bone block into place. Lastly, if the surgeon passes the
continuous loop at the bone–tendon junction, then the bone
block may “rock” as it enters the femoral tunnel. Therefore I
use a passing suture such as a #2 PDS or Proline passed
through the bone block at the midway point. When pulled
with the other sutures, this guides the bone block straight
up the femoral tunnel. A probe through a working portal
may also be used to help guide the femoral bone block
straight up the femoral tunnel.
Another potential trouble spot may be if the surgeon
routinely countersinks the femoral bone block so that the
tibial bone block will lay flush with the tibial cortex, as I
do. This usually requires a slightly longer femoral tunnel
than the femoral bone block (approximately 10 mm longer).
In other words, the longer the ACL graft, the longer the
femoral tunnel needed so as to not have any of the tibial
bone block or graft protruding out of the tibial tunnel. If
the surgeon flexes the knee greater than 90 degrees, as is
usually taught for interference fixation, then there is the
potential to have a femoral tunnel too short to accommodate
the graft. The surgeon then runs the risk of reaming
through the lateral femoral cortex, which would not allow
the use of the standard Endobutton-CL. There are a couple
of ways around this. First, when using this system, I actually
flex the knee less than 90 degrees. This lessens the angle of
the guide pin and reamer, which in fact lengthens the fem-
oral tunnel (see Fig. 50-3). Obviously one would not want
to lessen the angle too far, as then the guide pin will exit
the thigh near the tourniquet or leg holder if these were
used. I have simply become accustomed to placing the guide
pin so that it will exit the thigh just distal to the tourniquet.
This requires the knee to be flexed slightly less than 90
degrees and usually leaves ample room for a femoral tunnel.
If a surgeon inadvertently reams through the lateral femoral
cortex, then he or she has a couple of options. First, the sur-
geon could fix the femoral bone plug with a standard inter-
ference screw. However, a more appealing option would be
to simply slip an Xtendobutton over the Endobutton and
fix the graft as though using a standard Endobutton, as
described earlier.
 Bone–Patellar Tendon–Bone Anterior Cruciate Ligament Reconstruction Using the Endobutton Continuous Loop Bone–Tendon–Bone Fixation System 50

A B
FIG. 50-12 A, Pull the graft into position with the #5 suture and the passing suture, letting the #2 suture trail. B,
The graft will have a definite stop when it is passed far enough to flip the button.

FIG. 50-13 Hold the Endobutton perpendicular to the lateral femoral cortex and pull back on the graft, ensuring
fixation.

379
 Anterior Cruciate Ligament Reconstruction

SUMMARY
The Endobutton-CL BTB system offers what is designed to
be “the best of both worlds” in femoral fixation of grafts that
have a bone block on the femoral side of attachment, such as
BTB autografts, BTB allografts, and Achilles tendon allo-
grafts. It offers one of the strongest methods of fixation while
avoiding complications seen with interference screws and
other types of femoral fixation. It also has made revision
ACL surgery generally as simple as primary ACL surgery by
eliminating complications left from interference fixation.

FIG. 50-14 A newer addition to the family of Endobutton-CL for the

bone–tendon–bone graft is the Xtendobutton.

RESULTS
The Endobutton-CL BTB has been available for implanta-
tion for nearly 2 years at the time of writing this chapter. To
my knowledge, the results have been impressive. There have
been no known failures or complications to date; however, it
must be stressed that these results are subjective. Objective
laboratory tests prior to release showed the Endobutton-
CL to be possibly the strongest fixation available, both in
terms of ultimate strength and creep.*

*Data on file at Smith & Nephew, Andover, MA.

380
 PART I NEWER INTERFERENCE SCREW MATERIALS
Milagro (Beta-Tricalcium Phosphate,
Polylactide Co-Glycolide Biocomposite)
Interference Screw for Anterior Cruciate
Ligament Reconstruction
INTRODUCTION
The initial interference fixation screws were
made from metal and provided screw fixation for
anterior cruciate ligament (ACL) reconstructions.
Biodegradable interference fixation screws
subsequently gained wide acceptance after their
introduction in the early 1990s.1–5 The benefits
of these biodegradable interference screws include
reduction in the concerns previously associated
with metal implants, including difficulties in
postoperative imaging, reduced graft laceration
during insertion, less chance of screw diver-
gence during insertion, easier revision surgery
(Fig. 51-1), and fewer problems with secondary
arthritic procedures that might require the
complete removal of a metal screw. In addition,
the load to failure (LTF) strength of these screws
is sufficient to allow for an aggressive rehabilitation
program. Potential complications associated with
biodegradable interference screws include the risk
of screw breakage during insertion, decreased
holding strength when compared with a metal
alternative, and inflammatory reactions that
could lead to lytic changes and cyst formation.
Poly-L-lactic acid (PLLA) is the most com-
mon material used in biodegradable interference
screws. These screws offer effective graft fixation
with little evidence of adverse inflammatory reac-
tions, and many years pass before any material
degradation occurs.1–8 Interference screws made
of lactic acid copolymers containing dextro
and levo stereoisomers subsequently became
available, as did copolymers of polylactic acid
51
CHAPTER
and polyglycolide. The polymer degradation is F. Alan Barber
more rapid with poly D, L-lactide (PDLLA)
implants than pure PLLA in animal studies.9–11
The Milagro screw (DePuy Mitek, Nor-
wood, MA) is composed of a composite of
30% osteoconductive beta tricalcium phosphate
and 70% polylactic glycolic acid by weight and
represents a new material for interference fixa-
tion screws. This review presents biomechanical
data, an explanation of the material properties
of the screw composition, and a discussion of
the clinical technique.
BIOMECHANICAL AND BIOCHEMICAL
DATA
Implant degradation proceeds through five
stages: hydration, depolymerization, loss of mass
integrity, absorption, and elimination. How rapi-
dly an implant is degraded is influenced by the
polymer of which the implant is made, the degree
of crystallization of that polymer, the initial mass
of the polymer present (implant size), surface
coverings, whether the polymer is self-reinforced,
the processing technique used (machining or
injection molding and sterilization technique),
and the environment in which the implant is
situated.12 In addition, the degradation mecha-
nics of different polymers may differ considerably
based on the hydrophilic or hydrophobic nature
of the different polymers.
Degradation starts at the amorphous
phase of the implant and leads to fragmentation
381
 Anterior Cruciate Ligament Reconstruction
FIG. 51-1 Biodegradable interference screws avoid some of the problems
during revision surgery that are associated with the prior placement of
metal screws.
of the material to smaller parts, which are then phagocy-
tosed primarily by macrophages and polymorphonuclear
leukocytes.13,14 The lactic acid component is broken down
by hydrolysis. The resultant monomers enter the Krebs cycle
and are further dissimilated into carbon dioxide and water.15
In addition to hydrolytic chain scission, glycolic acid mono-
mers are degraded by the enzymatic activity of esterases and
carboxypeptidases.16
All biodegradable materials cause some inflammatory
response. The longer the degradation course, the less visible
the response will be. Usually there is a mild, nonspecific tissue
response with fibroblast activation and the invasion of macro-
phages, multinucleated foreign body giant cells, and polymor-
phonuclear leukocytes during the final stages of degradation.
Because of the more rapid degradation associated with
polyglycolic acid (PGA), there have been some foreign body
reactions with varying degrees of severity ranging from mild
osteolytic changes to intense granulomatous inflammatory
soft tissue lesions that necessitate surgical intervention.17,18
Concerns about implants composed of pure PGA have
led to the development of PGA copolymers that still have a
more rapid rate of absorption compared with PLLA implants,
but the literature supports their use with excellent clinical
results. Lajtai et al19,20 reported good results with a lactide/
glycolide copolymer screw (85/15, D, L lactide/glycolide).
Using magnetic resonance imaging (MRI scans), the screw
was shown to remain intact for 4 months and then disappear
by 6 months. Five years after implantation, the screw was
completely reabsorbed and evidently replaced with new bone.
Morgan et al21 evaluated a PLLA interference screw removed
382
en bloc from a patient 2.5 years after insertion. The histologi-
cal examination and molecular weight measurements showed
a 75% decrease in the molecular weight of the screw with
implant fragmentation and new bone formation adjacent to
the screw. This dramatically contrasted with the MRI evalua-
tion of the patient, which showed the presence of a clear screw
outline. MRI evaluations of PLLA screw show no evidence of
any progressive absorption 4 years after implantation.22 How-
ever, a recent computed tomography (CT) evaluation of
patients who underwent patellar tendon autograft ACL
reconstruction using PLLA screws at least 7 years earlier
demonstrated complete removal of the PLLA screws with-
out any significant bone ingrowth into the screw site.23
The goal of using biodegradable polymers is to have
an implant mechanically strong enough to perform its task
and then degrade in a manner that is clinically insignificant.
An additional advantage would be that once the degradation
is complete, there would be no evidence of the implant ever
having been in place. At this point, pure PLLA and copo-
lymers of PLLA and PGA have demonstrated adequate
strength as interference fixation screws to function effec-
tively for ACL reconstructions. These PLLA and PLLA/
PGA copolymers have also demonstrated that they will
eventually degrade and disappear, even though it may
require many years for this to occur (longer for PLLA than
for PLLA/PGA copolymer). The next step is to develop an
implant that will result in bone filling the vacated screw site.
BASIC SCIENCE OF BETA-TRICALCIUM
PHOSPHATE COPOLYMERS
Bone replacement technology has been in development for
many years. Calcium phosphate ceramic materials like beta-
tricalcium phosphate (ß-TCP) have been studied as potential
bone replacement materials for decades. The calcium phos-
phates are used as bone void fillers, autograft extenders, and
coatings for various implants including joint replacements.
They are also used in products in which reabsorption of the
device and replacement with native bone are desired, includ-
ing different orthopaedic and maxillofacial applications.
Bone, as with other calcified tissue, is an intimate
composite of organic (collagen and noncollagenous proteins)
and inorganic or mineral phases. Bone has several important
properties including osteoconductivity (the ability to serve as
an interactive template or scaffold for forming new bone)
and osteoinductivity (the ability to create new bone or osteo-
genesis). None of the current manufactured materials has
the ability to form bone (osteoinductive), but the benefit
of a material being osteoconductive and being able to act as
a template into which the adjacent bone may migrate is
clear. A biodegradable interference fixation screw with
 Milagro (Beta-Tricalcium Phosphate, Polylactide Co-Glycolide Biocomposite) Interference Screw for Anterior Cruciate Ligament Reconstruction 51
osteoconductive properties would enhance bone ingrowth
into its location as it biodegrades.
Composites are a blend or intimate mixture of two
different materials. This blending usually imparts different
properties to the composite than those that were possessed
by either of the two separate materials individually. The
compressive strength and stiffness of ß-TCP are very high
and, when blended with PLLA, the resultant composite
includes these properties as well. How well dispersed the
two materials of a composite are with one another is another
important property. Once blended, the more homogenous
the composite, the better. Biocryl is a composite of ß-
TCP and PLLA. Biocryl is a very homogenous composite
with a high degree of dispersion of both materials in the
blend. This dispersion of the materials is achieved through-
out the entire implant by a proprietary manufacturing
process known as micro particle dispersion (MPD). The addi-
tion of polyglycolide to polylactide creates a copolymer that
biodegrades much more rapidly than even a very amorphous
form of pure PLLA. The Milagro screw is made of a mate- FIG. 51-2 The Milagro screw can be used for femoral or tibial fixation for
soft tissue or bone–tendon–bone autografts or allografts.
rial that combines the ß-TCP–PLLA (Biocryl) composite
with PGA. This resultant compound polymer composite
consists of 30% osteoconductive ß-TCP and 70% polylac-
tide co-glycolide (PLGA). The presence of the ß-TCP
encourages bone to fill in once the PLGA has reabsorbed.

CLINICAL INFORMATION
The Milagro screw can be used for femoral or tibial fixation
for soft tissue or bone–tendon–bone (BTB) autografts or
allografts (Fig. 51-2). It is available in various diameters
from 7 to 12 mm and in 23-, 30-, and 35-mm lengths.
The Milagro screw is made from a polymer composite, Bio-
cryl Rapide. As previously mentioned, this material consists
of 30% osteoconductive ß-TCP and 70% PLGA. The poly
(lactide-co-glycolide) copolymer is composed of 15% PGA
and 85% PLLA. This ratio of PGA to PLLA was chosen FIG. 51-3 At 24 months postimplantation, the reabsorption of Biocryl
following animal studies to allow for a faster yet controlled Rapide rods was nearly complete and radiographic bridging was observed.
absorption. This copolymer does not contain any of the
D-isomer of lactic acid. Biocryl Rapide sites but not at the PLLA sites. No evidence
This material was recently evaluated in the lateral of inflammatory reaction or cellular necrosis was observed.
femoral cortex of mature beagle dogs.24 Rods of either Bio- By 24 months, the entire cross-section of the Biocryl Rapide
cryl Rapide or PLLA measuring 3  10 mm were inserted test rods was absorbed and replaced by normal bone or bone
into defects in the cortex and evaluated at intervals up to plus fibrous tissue or adipose tissue. The circular orientation
24 months. Histological evaluation at intervals looked for of the new bone was seen under polarized light.
reabsorption of the material and cracks, cell infiltrations, Clinically, the Milagro screw has been available since its
erosions, and fragmentation of the implants. At 24 months introduction in October 2004. The Milagro screw can be used
postimplantation, clear differences existed between the for both BTB autografts and allografts. In these cases the
PLLA rods and the Biocryl Rapide rods (Fig. 51-3). The technique for insertion is essentially the same as for any other
reabsorption of the Biocryl Rapide was nearly complete at biodegradable BTB interference screw. The preferred length
24 months, and radiographic bridging was observed at the for BTB fixation is 23 mm, with the diameter of the screw

383
 Anterior Cruciate Ligament Reconstruction

reflecting the size of the tunnel drilled and the size of the until comfortable flexion to 90 degrees is attained.
bone plug. I most frequently use the 8-mm-diameter screw Straight-ahead jogging without cutting is started at 6 weeks
for both the femoral and tibial sides; however, on occasion postsurgery and pivoting at 12 weeks postsurgery. Full con-
a 9-mm screw will be required for the tibial fixation. tact is begun with a derotational knee brace between 12 and
Soft tissue grafts (hamstring allografts and autografts 16 weeks after surgery. Allograft and soft tissue graft recon-
and the tendon side of a quadriceps tendon autograft or structions are returned to activity less aggressively.
Achilles tendon allografts) require a longer interference Because of the biocomposite in the Milagro screw, its
interface between the soft tissue and the tunnel, especially position can be evaluated on postoperative radiographs.
in the tibial tunnel. For the hamstring or quadriceps soft tis- Postoperative radiographs are obtained on the first post-
sue grafts, the 35-mm screw length is preferred. operative visit and serve as a baseline for subsequent
Once the tunnels are drilled and the graft is prepared, a evaluations. The ability to visualize the screw helps with
groove is made in the superior area of the bone tunnel with a assessing plug location.
notcher for the subsequent placement of a guidewire. The
graft is then pulled into the tunnels. Once the graft is in place,
a guidewire is placed in this notched groove, which is now PEARLS
adjacent to the bone plug in the femoral tunnel. Using the
guidewire, a tap is inserted and threads cut to the correct The tap associated with the Milagro screw has two types of
depth. If the bone is softer, it is only necessary to cut a few threads. The distal threads are blunt, whereas the proximal
threads, which allows the Milagro screw to engage the bone threads are sharp. If the entire course of the screw is to be
and then cut its own way into the interference position. For tapped, care should be taken that these cutting threads do
denser bone, full tapping for the entire screw length is needed. not damage either the graft or the sutures attached to a bone
The tap for the Milagro screw has distal threads that plug. To reduce the chance of cutting the sutures, make cer-
are blunt, whereas the more proximal threads are sharp. tain that the guidewire is placed on the side of the plug
Care should be taken to avoid cutting the control sutures between the two sets of sutures controlling the graft, and
in the bone plug with these proximal tap threads during this not through the sutures.
tapping procedure. It is fairly easy to avoid cutting the Once the tibial screw is in place, tug on the graft
sutures in the femoral plugs, but a greater awareness of the sutures to demonstrate that there is good tension on the
tibial plug orientation, its sutures, and where the tap is being graft and no movement of the graft in the joint. If graft
inserted relative to both of these is required on the tibial side movement is observed, the graft should be retensioned and
to avoid cutting the control sutures. a second screw stacked beside the first to achieve secure fix-
Once tapping is complete, the Milagro interference ation (Fig. 51-4).
screw is advanced over the guidewire to the appropriate
depth. Resistance during insertion is expected and is felt
to increase as the screw advances. An increasingly loud
squeaking should be heard as the screw nears the fully seated
position. Our experience is with the 8- and 9-mm-diameter
sizes. We have not had the Milagro screw break when the
tapping was successfully done. One case of screw breakage
occurred when the tapping step was skipped. The thread
depth as measured between the minor (or core) diameter
and the outer diameter is better than other biodegradable
screws in our experience, and the thread pitch (number of
threads per length) provides sufficient spacing between the
threads to grip and compress the adjacent cancellous bone.
Postoperatively an aggressive rehabilitation program is
followed. The speed and details of this program are dictated
by the nature of the graft material selected and not by the
presence of a biocomposite screw. The patellar tendon auto-
graft reconstructions begin with maintaining full extension
by prone hangs and a full-extension night brace. The knee
FIG. 51-4 If secure fixation of the tibial graft is not achieved with a single
flexion is encouraged by a constant passive motion machine screw, a second screw may be stacked beside the first to achieve secure
for 6 to 8 hours during the day for as long as 2 weeks or fixation.

384
 Milagro (Beta-Tricalcium Phosphate, Polylactide Co-Glycolide Biocomposite) Interference Screw for Anterior Cruciate Ligament Reconstruction
References
1. Barber FA, Elrod BF, McGuire DA, et al. Preliminary results of an
absorbable interference screw. Arthroscopy 1995;11:537–548.
2. Marti C, Imhoff AB, Bahrs C, et al. Metallic versus bioabsorbable
interference screw for fixation of bone-patellar tendon-bone autograft
in arthroscopic anterior cruciate ligament reconstruction. A prelimi-
nary report. Knee Surg Sports Traumatol Arthrosc 1997;5:217–221.
3. Barber FA. Tripled semitendinosus-cancellous bone anterior cruciate
ligament reconstruction with bioscrew fixation. Arthroscopy
1999;15:360–367.
4. Tuompo P, Partio EK, Jukkala-Partio K, et al. Comparison of polylac-
tide screw and expansion bolt in bioabsorbable fixation with patellar
tendon bone graft for anterior cruciate ligament rupture of the knee.
A preliminary study. Knee Surg Sports Traumatol Arthrosc
1999;7:296–302.
5. McGuire DA, Barber FA, Elrod BF, et al. Bioabsorbable interference
screws for graft fixation in anterior cruciate ligament reconstruction.
Arthroscopy 1999;15:463–473.
6. Warden WH, Friedman R, Teresi LM, et al. Magnetic resonance
imaging of bioabsorbable polylactic acid interference screws during
the first 2 years after anterior cruciate ligament reconstruction. Arthros-
copy 1999;15:474–480.
7. Barber FA, Elrod BF, McGuire DA, et al. Bioscrew fixation of
patellar tendon autografts. Biomaterials 2000;21:2623–2629.
8. Kotani A, Ishii Y. Reconstruction of the anterior cruciate ligament
using poly-L-lactide interference screws or titanium screws: a
comparative study. Knee 2001;8:311–315.
9. Sedel L, Chabot F, Christel P, et al. Biodegradable implants in ortho-
pedic surgery. Rev Chir Orthop Reparatrice Appar Mot 1978;64(Suppl
2):92–96.
10. Chen CC, Chueh JY, Tseng H, et al. Preparation and Characterization of
biodegradable PLA polymeric blends. Biometrials 2003;24:1167–1173.
11. Barber FA. Poly-D, L-lactide interference screws for anterior cruciate
ligament reconstruction. Arthroscopy 2005;21:804–808.
51
12. Daniels AU, Chang MKO, Andriano KP. Mechanical properties of
biodegradable polymers and composites proposed for internal fixation
of bone. J Appl Biomater 1990;1:57–78.
13. Lam KH, Schakenrad JM, Esselbrugge H, et al. The effect of phago-
cytosis of poly (L-lactic acid) fragments on cellular morphology and
viability. J Biomed Mater Res 1993;27:1569–1577.
14. Tabata Y, Ikada Y. Macrophage phagocytosis of biodegradable micro-
spheres composed of L-lactic acid/glycolic acid homo- and copoly-
mers. J Biomed Mater Res 1988;22:837–858.
15. Hollinger JO, Battistone GC. Biodegradable bone repair materials.
Synthetic polymers and ceramics. Clin Orthop 1986;207:290–305.
16. Williams F, Mort E. Enzyme-accelerated hydrolysis of polyglycolic
acid. J Bioengin 1977;1:231–238.
17. Böstman O, Pihlajamäki H, Partio E, et al. Clinical biocompatibility
and degradation of polylevolactide screws in the ankle. Clin Orthop
1995;320:101–109.
18. Böstman O. Osteolytic changes accompanying degradation of absorb-
able fracture fixation implants. J Bone Joint Surg 1991;73B:679–682.
19. Lajtai G, Hummer K, Aitzetmuller G, et al. Serial magnetic resonance
imaging evaluation of a bio-absorbable interference screw and the
adjacent bone. Arthroscopy 1999;15:481–488.
20. Lajtai G, Schmiedhuber G, Unger F, et al. Bone tunnel remodeling at the
site of bio-degradable interference screws used for anterior cruciate liga-
ment reconstruction—five year follow up. Arthroscopy 2001;17:597–602.
21. Morgan CD, Gehrmann RM, Jayo MJ, et al. Histologic findings with
a bio-absorbable anterior cruciate ligament interference screw explant
after 2.5 years in vivo. Arthroscopy 2002;18:E47.
22. Radford MJ, Noakes J, Read J, et al. The natural history of a bioab-
sorbable interference screw used for anterior cruciate ligament recon-
struction with a 4-strand hamstring technique. Arthroscopy
2005;21:707–710.
23. Barber FA, Dockery WD. Long term absorption of poly L-lactic acid
interference screws. Arthroscopy 2006;22:820–826.
24. Poandl T, Trenka-Benthin S, Azri-Meehan S, et al. A new faster
degrading biocomposite material: long-term in-vivo tissue reaction and
absorption. AANA Annual Meeting e-poster (E-09), 2005, Vancouver.
385
52CHAPTER
Improving Biodegradable Interference
Screw Properties by Combining Polymers
Timo Järvelä INTRODUCTION
Janne T. Nurmi
Interference screws are widely used for graft
Antti Paakkala fixation in anterior cruciate ligament (ACL)
Anna-Stina Moisala reconstruction, and good clinical results have
Auvo Kaikkonen been reported by several investigators.1–5 In addi-
Markku Järvinen tion to conventional metal screws, biodegradable
interference screws are commercially available
and have been shown to provide at least as strong
graft fixation as metal screws.6,7 In addition, the
biodegradable screws do not interfere with imag-
ing techniques and do not need to be removed in
revision cases because the implants have either
degraded or can simply be drilled through. How-
ever, although biodegradable materials have been
attractive for many years, they have been linked to
limitations such as breakage during insertion due
to brittleness of the material,8,9 tissue reactions
due to poor material quality or too fast or uncon-
trolled degradation (e.g., polyglycolic acid),10,11
or too slow degradation offering no real advan-
tage over metal implants (e.g., poly-L-lactic acid
implants have been documented to take more
than 4 years to degrade).10,12–15 It is obvious that
as a result of these observations, the material
properties have been identified to play a critical
role, and manufacturers have thus been
challenged to further develop and optimize the
chemical compositions of biodegradable imp-
lants. Whether the biodegradable interference
screws are actually finally replaced by bone or
by some other tissue remains controversial.16–20
As a matter of fact, according to a recent study
by Tecklenburg et al,21 even the recently
386
introduced composite screws containing osteo-
conductive materials such as hydroxyapatite and
tricalcium phosphate do not degrade in 2 years
in vivo and thus cannot be replaced by bone. This
clearly demonstrates the need for more optimal
materials that degrade faster but are still
controlled enough not to cause any clinically sig-
nificant inflammatory or foreign body reactions.
In addition, the material should be strong enough
not to break during screw insertion and should
provide adequate fixation strength during the
healing period.
A number of biodegradable polymers have
been approved for safe internal use and have been
used in surgical applications for the past 30 years,
initially as suture materials. Each polymer has its
material-specific properties, and an implant
created from a single type of polymer is naturally
limited by those properties. This explains some of
the problems observed with the first-generation
biodegradable implants. For example, polyglyco-
lic acid (PGA) is strong but very fast to degrade;
poly-L-lactic acid (PLLA) is strong but brittle
and slow to degrade; whereas trimethylene
carbonate (TMC) is rather weak but elastic
like rubber. Copolymer blending is a novel
manufacturing method developed in an attempt
to combine the desired properties of different
polymers and, by doing so, to overcome the lim-
itations of the previous biodegradable implants.
By blending different copolymers it is possible
to create a library of material recipes from which
to select those of the appropriate strength,
toughness, and degradation to meet specific
 Improving Biodegradable Interference Screw Properties by Combining Polymers
FIG. 52-1 The Inion Hexalon biodegradable interference screw.
clinical requirements. A biodegradable interference screw
made of degradable copolymers composed of L-lactic acid,
D-lactic acid, and TMC (Inion Hexalon, Inion Oy,
Tampere, Finland) (Fig. 52-1) was introduced in 2002
and has since been studied both biomechanically and
clinically. According to a recent preclinical sheep study, this
copolymer blend fully degrades in 2 years in vivo without
causing any clinically significant inflammatory, foreign body,
or other tissue reactions.22
BIOMECHANICAL RESULTS
Fixation Strength
Fixation strength of the ACL graft is commonly considered
to be the weakest link of ACL reconstruction. A three-part
biomechanical study was carried out to study the fixation
strength of the new biodegradable copolymer interference
screw (Inion Hexalon) and to evaluate its suitability for
ACL reconstruction by comparing it with the previously
clinically used interference screws.23 In the first part, the
initial soft tissue graft fixation strength of the copolymer
screw was compared with that of a conventional metal inter-
ference screw (Acufex Softsilk). In the second part of the
study, the initial soft tissue graft fixation strength of
the copolymer screw was compared with that of another
biodegradable interference screw (Bionx SmartScrew). In
the third part of the study, the initial bone–tendon–bone
graft fixation strength of the copolymer screw was
compared with that of another commercially available
biodegradable interference screw (Linvatec Bioscrew).
Tibial bone tunnels were created in fresh skeletally
mature porcine cadaver tibiae. A porcine ACL soft tissue graft
52
model previously described and used by Ishibashi et al24 and
Harding et al25 was used in Parts I and II. Porcine patellar
tendons were cut approximately 8 cm distal from their patellar
insertion and left attached to the patellae. The free end of each
patellar tendon was sutured using the running baseball stitch
and thereafter fixed into tibial bone tunnel with an interfer-
ence screw. In Part III, porcine bone–patellar tendon–bone
grafts were prepared by obtaining a tibial bone block. The
graft end with the tibial bone block was fixed into the tibial
bone tunnel, and the maximum screw insertion torque was
determined with a digital torquemeter connected to the
screwdriver. The patellae were left intact to enable easy and
rigid fixation to the mechanical testing machine (Lloyd LR
5K, J.J. Lloyd Instruments). The biomechanical tests were
performed strictly according to the previously described
single-cycle load-to-failure protocol of Kousa et al.7 The
specimens were first subjected to a 50N preload for 1 minute.
Thereafter, vertical tensile loading parallel to the long axis of
the bone tunnel was performed at a rate of 50 mm/min until
failure and the yield load, maximum failure load, and mode
of failure were determined.
In Part I (N ¼ 13), the average yield loads for the co-
polymer screw and metal screws were 491
154N and 418

77N, respectively (P ¼ 0.15). The average maximum failure
loads were 548
130N and 453
94N, respectively (P ¼
0.04). Although the average maximum failure load for the
biodegradable screw group was significantly higher than that
observed for the metal screw group, no significant difference
was found in the more clinically relevant yield load values.
The mode of failure was almost entirely graft slippage past
the screw in both study groups, although also some graft lac-
eration (partial rupture) and “graft stretching” were observed
in the metal screw group, mainly at the screw–graft interface.
In Part II (N ¼ 8), the average yield load for the copolymer
screw was 501
122N and for the SmartScrew, 386
79N
(P ¼ 0.05). The average maximum failure loads were 563

109N and 536
128N, respectively (P ¼ 0.65). The mode
of failure was graft slippage past the screw in both study
groups. In Part III, the average maximum insertion torque
for the copolymer screw (N ¼ 8) was 1.9
0.7 Nm; for the
Bioscrew (N ¼ 4), 1.5
0.6 Nm (P ¼ 0.32). The average
yield loads for the copolymer screw and Bioscrew were
901
262N and 795
524N, respectively (P ¼ 0.77). The
average maximum failure loads were 926
259N and
800
516N, respectively (P ¼ 0.72). All tested specimens
in Part III failed by bone block pullout. One Bioscrew
broke in Part III during insertion. No copolymer screw
breakage was observed in this study.
Based on these biomechanical results, the new biode-
gradable copolymer screw provides initial fixation strength
similar to the other previously used biodegradable and
conventional metal interference screws.
387
 Anterior Cruciate Ligament Reconstruction
Torsional Strength
Screw breakage due to applied torsional forces during screw
insertion rather than postoperative failure of graft fixation is
the most common failure mode of biodegradable interference
screws. The torsional strength of the interference screw is
largely determined by the design of the screwdriver recess
(socket) and the material of the screw. To test the torsional
strength of the new biodegradable copolymer screw, a tor-
sional strength study was performed according to the testing
protocol of Costi et al.8,26 Six 7-  20-mm copolymer inter-
ference screws (Inion Hexalon) were mounted in a 10-mm
layer of polyurethane resin, leaving the proximal 10 mm of
the screws unembedded. This mounting reproduced the fail-
ure scenario observed in vivo, in which only part of the screw
length has been inserted and becomes jammed in bone.
Torque was applied manually with a digital electronic torque
meter (Torqueleader TSD 350, MHH Engineering)
mounted on the screwdriver. The same person applied torque
in all cases in an attempt to provide a constant rate of applica-
tion as well as compression on the screw. Care was taken to
ensure that the application of torque was performed without
associated bending or excessive compression. The maximum
insertion torque was recorded, and the mode of failure was
visually observed. In addition, to further investigate the failure
of the screw, one screw was fixed into the 7-  20-mm screw
cavity of the injection mold and torque was applied manually
with a presettable torque wrench until failure.
A desirable outcome of screw advancement through
the polyurethane resin, rather than a failure of the screw or
instrument, occurred with all test samples. The mean maxi-
mum insertion torque measured during screw penetration
into the resin was 2.4
0.3 Nm. When the screw was fixed
into the injection mold, no failure was observed at torque
values between 0 and 5 Nm. When clinically irrelevant
torque of more than 5 Nm was applied, the screwdriver
shaft failed by rotational bending approximately 20 mm
from the tip of the driver.
Costi et al8 previously tested 12 different biodegrad-
able interference screws using the same protocol. In their
study, the only screws observed to continue screwing into
the resin with no subsequent failure were the majority of
the 7-mm PLLA Linvatec Bioscrews. In our study, all
tested Inion Hexalon copolymer screws could be advanced
through the resin without failure. In our additional test in
which the screw was fixed into its injection mold to deter-
mine the ultimate failure point, the failure occurred first
after a torque of more than 5 Nm was applied, again not
by screw breakage but by bending of the metallic screw-
driver shaft. Based on the previous observations made by
Costi et al,8 this failure torque is above the clinically relevant
388
insertion torques and the failure torques of most commer-
cially available biodegradable interference screws.
Strength Retention
To investigate the effect of hydrolytic degradation on the
mechanical properties of the Inion Hexalon copolymer
screws over time, screw compression tests were performed
after 24 hours and 4, 8, and 12 weeks of incubation of
6-  20-mm and 7-  20-mm screws in phosphate buffer
solution at 37 C (N ¼ 4/time point).27 In the compression
test, each screw was set flat between the compression plates
and loaded with a constant speed of 5 mm/min until failure
(Zwick Z020, Zwick GmbH, Ulm, Germany). In the com-
pression test, both screws retained more than 80% of their
initial mechanical strength as long as 12 weeks.
CLINICAL RESULTS
Clinical Experience
In our clinical work, we have used these new biodegradable
interference screws made of degradable copolymers
composed of L-lactic acid, D-lactic acid, and TMC (Inion
Hexalon) for ACL reconstruction for more than 4 years.
During this period, more than 400 of these screws have
been inserted to patients, and only one screw breakage has
occurred during screw insertion. In this particular case, the
screwdriver broke first, which was the reason for the screw
breakage. These screws can be used both with single-bundle
and double-bundle technique when performing ACL
reconstruction.28,29
Prospective Randomized Clinical Trial
We have done a prospective randomized clinical trial using
either biodegradable screw or metallic screw in fixation of
the ACL reconstruction with a hamstring autograft.29 In
this study, 55 patients were randomized to either metallic
interference screw (Timoni, Finland) (N ¼ 26) or biode-
gradable screw fixation (Inion Hexalon) (N ¼ 29) in ACL
reconstruction with hamstring tendons. The evaluation
methods were clinical examination, KT-1000 arthrometer
(MEDmetric Corporation, San Diego, CA) measure-
ments,30 radiographic evaluation, MRI, and International
Knee Documentation Committee (IKDC)31 as well as
Lysholm32 knee scores. There were no differences between
the study groups preoperatively. For the minimum of 1-year
follow-up (range 12–19 months), 23 patients of the metallic
interference screw group and 26 patients of the
 Improving Biodegradable Interference Screw Properties by Combining Polymers
biodegradable screw group were available (90%). The evalu-
ation methods disclosed no statistical differences between
the groups at the follow-up examinations. However, the
results were significantly better at the follow-up than pre-
operatively, in both groups. Kaeding et al33 have reported
similar results in their prospective randomized study
comparing biodegradable and titanium interference screw
in fixation of the bone–patellar tendon–bone autograft for
the ACL reconstruction.
During the follow-up of our study, three revision
ACL reconstructions had to be performed (two in the bio-
degradable screw group and one in the metallic screw group)
because of new knee trauma. No other complications were
found with these patients. The revision in the biodegradable
screw group 8 months after the primary operation showed
that the biodegradable screw was already soft. The other
revision performed 18 months after primary surgery showed
that the biodegradable screw was almost totally absorbed.
The revision ACL reconstructions with these patients were
easy to perform because we did not have to remove the
screws at all. In the case in which the screw was soft but
not totally absorbed yet, we simply drilled through it and
created a 1 mm wider tunnel for the new graft. In addition,
with another patient, the second-look arthroscopy showed
that the biodegradable screw was totally absorbed 2 years
after the primary operation (Fig. 52-2).
Magnetic Resonance Imaging
Sixteen patients (10 patients in the biodegradable screw
group and six in the metallic screw group) of our prospective
52
randomized study have been evaluated by MRI examination
at a mean follow-up of 27 months (range 24–31 months).
According to this evaluation, we have found that all the bio-
degradable screws (Inion Hexalon) were absorbed totally at
the follow-up (Fig. 52-3). The MRI images appear to
show that the bone tunnels are filled with fibrous tissue with
signal intensity similar to that of the intraarticular ACL
graft. However, because no histological analysis could be
carried out in these human patients, no final conclusions
regarding the tissue type that finally replaces the screw can
be drawn at this point. The follow-up of these patients
has been planned to continue for a minimum of 5 years
postoperatively.
The fact that the screws used in our study had been
absorbed in 2 years is contradictory to the finding in the
previous studies of Ma et al14 and Radford et al.15 They
found that the biodegradable screws they used did not
absorb in even 2 to 4 years. The explanation for this differ-
ence seems logical: the materials of these screws are differ-
ent. In our study, we used biodegradable screws made of
copolymers composed of L-lactic acid, D-lactic acid, and
TMC, whereas in the studies of Ma et al14 and Radford
et al,15 PLLA interference screws were used.
However, two of our patients in the biodegradable
screw group had some tunnel enlargement or cyst of the
tunnel at the 2-year follow-up. One was in the tibial side,
and another was in the femoral side (see Fig. 52-3, B). In
these cases, the enlargement was only 2 to 3 mm when the
width of the normal tunnel was compared. With all
patients, the mean widths of the femoral and tibial
tunnels were 10 mm (range 7–12 mm) and 10 mm (range

FIG. 52-2 A, The Inion Hexalon biodegradable interference screw at the operation during the screw insertion
into the femoral tunnel. B, The same knee 2 years after the anterior cruciate ligament (ACL) reconstruction. The screw
has totally absorbed, and the ACL graft is intact. However, there is some tunnel enlargement in front of the graft.

389
 Anterior Cruciate Ligament Reconstruction

FIG. 52-3 A, Magnetic resonance imaging (MRI) changes 4 months after anterior cruciate ligament (ACL)
reconstruction with the Inion Hexalon biodegradable interference screw fixation on the femoral side. The screw is
still visible (white circle in front of the hamstring graft). B, MRI changes 24 months after ACL reconstruction with
the Inion Hexalon biodegradable interference screw fixation on the femoral side. The screw has absorbed, but
there is some tunnel enlargement in front of the hamstring graft (the graft is the black circle in the posterior part of
the femoral tunnel).

8–14 mm), respectively. No difference was found between CONCLUSIONS

the biodegradable and metallic screw groups. Previously in
the literature, tunnel enlargement has been reported after
using biodegradable fixation methods, as well as after using
other fixation methods such as metallic screws and especially
Endobutton fixation.14,33–35 However, the clinical impor-
tance of the tunnel enlargement still remains controversial.
Theoretically, if the tunnel enlargement were large, it could
be a problem when performing the revision ACL reconstruc-
tion. However, with our patients, the tunnel enlargement was
so minimal that no problem would be expected later in the
event that revision ACL surgery is needed. In fact, there were
no difficulties in performing the revision ACL reconstruction
with the two patients who underwent a revision ACL surgery
in the biodegradable screw group of our study.
The new copolymer screw provides fixation strength similar
to that of other interference screws but has higher torsional
strength than most of the previous biodegradable screws.
The 1-year clinical results of this biodegradable screw are
equivalent with those of conventional metal interference
screws. In addition, this screw seems to degrade fully in
2 years without causing any clinically significant inflamma-
tory, foreign body, or other adverse tissue reactions. This
is important because the screw cannot be replaced by bone
before it has degraded. However, further studies and longer
clinical follow-up are needed before any final conclusions
can be drawn and to evaluate whether the screw is finally
replaced by bone.

390
 Improving Biodegradable Interference Screw Properties by Combining Polymers
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391
 PART J GRAFT TENSIONING
53
CHAPTER
Graft Tensioning in Anterior Cruciate
Ligament Reconstruction
Kazunori Yasuda INTRODUCTION
The final outcome of anterior cruciate ligament
(ACL) reconstruction depends on various implan-
tation variables. Of these variables, graft tension-
ing is an especially important one because it is
controlled by a surgeon during surgery. Essen-
tially, graft tensioning is a procedure in which a
certain degree of initial tension is applied to the
graft at a selected angle of knee flexion. In order
to maintain the applied tension, however, it is nec-
essary to fix the graft to bones with some artificial
materials immediately after tensioning. Therefore,
clinically, graft tensioning and graft fixation are
regarded as one combined procedure in ACL
reconstruction. In addition, we should distinguish
between the initial tension, which is defined as a
tension applied to the graft at a selected angle of
knee flexion during surgery, and the postoperative
graft tension that exists at each period after sur-
gery. These tensions are extremely different in
the late phase after ACL reconstruction. The
former is important because it strongly affects
the latter, but the latter is more important because
it actually affects graft remodeling and knee
functions after ACL reconstruction.
On the basis of clinical experience, pio-
neers of current ACL reconstruction procedures
preferred to apply relatively high initial tension
to not only the doubled pes tendon autograft
but also the patellar tendon autograft at the time
of fixation.1–4 For example, Clancy et al1 per-
formed ACL reconstruction using the distally
stacked and proximally free central third of the
392
patellar tendon as an autograft and recommended
that the patellar bone block be pulled with three
sutures through the femoral tunnel as far as it
would go within the tunnel. On the other hand,
a number of in vitro and in vivo experimental
studies suggested that a high initial tension had
detrimental effects not only on the graft but also
on the knee after ACL reconstruction. Some
recent studies, however, reported that a high ini-
tial tension was better than a low initial tension in
simulation of a middle- or long-term effect. Thus
there has been considerable disagreement on the
effects of initial graft tension among the previous
studies. It has been necessary therefore to con-
duct randomized clinical trials on the effect of
initial graft tension on the outcome after ACL
reconstruction. At the present time, four articles
on the effect of initial graft tension on the clinical
outcome are available for review. In this chapter,
the author reviews recent experimental and
clinical studies on the effect of graft tensioning
during ACL reconstruction on the graft and the
ACL reconstructed knee and explains what has
and has not been clarified at the present time.
IN VITRO BIOMECHANICAL STUDIES
ON GRAFT TENSIONING
The Effect of the Initial Tension on
the Tension-Flexion Curve
In the normal knee, tension in the normal ACL
decreases with knee flexion from the maximum

value obtained at 0 degrees to the minimum value near 30
degrees and then slightly increases with further flexion.5,6
This relationship between the ACL tension and the knee
flexion angle is well known as a tension-flexion curve. In
ACL reconstruction, the initial tension is defined as a ten-
sion applied to the graft at a selected angle of knee flexion
during surgery. Then we should know the effect of the ini-
tial tension on the tension-flexion curve in ACL reconstruc-
tion. In vitro biomechanical studies5,7 reported that in the
standard single-bundle ACL reconstruction procedures,
increase of the initial tension applied at some angle of knee
flexion increased the graft tension by a constant magnitude
at every flexion angle during knee motion and that conse-
quently the shape of the tension-flexion curve was not
changed (Fig. 53-1). Namely, it means that an increase of
the initial graft tension at 30 degrees of knee flexion results
in an increase of the graft tension at every knee flexion
angle. In 2001, Fleming et al8 measured the laxity in nine
different tensioning conditions: three tension magnitudes
(30, 60, and 90N), each applied with the knee at three
angles (30, 60, and 90 degrees), in a goat ACL reconstruc-
tion model using a bone–tendon–bone (BTB) graft. They
stated that both the graft tension and the knee angle pro-
duced significant changes on anteroposterior laxity values.
These in vitro studies indicated that both the initial
tension value and the knee flexion angle at the time of ten-
sioning and fixation are critical in the ACL reconstruction.
In the standard ACL reconstruction procedures, when a
surgeon applies a certain “initial” tension value at about
30 degrees of knee flexion, a graft tension value obtained at
more extension positions or more flexion positions is greater
than the initial tension value.7 Conversely, when a surgeon
100
80
Tension (N)
60
40
20
0

10 0 10 20 30 40 50 60 70 80 90 100
Flexion angle (deg)
22 N 33 N
FIG. 53-1 In the standard single-bundle anterior cruciate ligament (ACL)
reconstruction procedures, increase of the initial tension applied at some
angle of knee flexion increased the graft tension by a constant magnitude
at every flexion angle during knee motion. (From Fleming B, Beynnon BD,
Johnson RJ, et al. Isometric versus tension measurements. A comparison for
the reconstruction of the anterior cruciate ligament. Am J Sports Med
1993;21:82–88.)
Graft Tensioning in Anterior Cruciate Ligament Reconstruction 53
applies a certain initial tension value at the full extension posi-
tion of the knee, graft tension values at flexion positions are
lower than the initial tension value. Clinically, a number of
surgeons have preferred to fix the graft at approximately 30
degrees of knee flexion in order to avoid an insufficient ten-
sion after surgery, specifically for the hamstring tendon graft.
On the other hand, recently many surgeons who perform
ACL reconstruction with the BTB graft have preferred to
fix the graft at the full extension position to avoid postopera-
tive flexion contracture of the knee due to overtensioning of
the graft.
Relaxation of Graft Tension after Surgery
In vitro biomechanical studies have shown that viscoelastic
creep of the graft causes relaxation of graft tension. Howard
et al9 quantified viscoelastic creep in the BTB graft using
both an in vivo and an in vitro model. In the in vivo model,
10-mm BTB grafts were elongated by 14.0% after 89N was
applied for a minimum of 4 minutes. In the in vitro model,
grafts were elongated by 10.1% after 89N was applied for
15 minutes. This study highlights the importance of the
time for preconditioning the graft before grafting.
The author and his colleagues10–12 reported that more
obvious relaxation of graft tension occurred due to elongation
of a bone–graft–bone complex that is composed of bones, ten-
don grafts, and all artificial materials to be used for graft fixa-
tion. They measured the influence of 5000 cycles of
submaximal cyclical displacement upon the tension of various
types of the bone–graft–bone complex after ACL reconstruc-
tion. For example, Yamanaka et al10 showed that initial ten-
sion of 80N applied to the four-strand flexor tendon graft
tethered to the screw post with a suture was reduced to 0N
after 5000 cycles of 2-mm stretching, while the same initial
tension applied to the BTB graft fixed with interference
screws was reduced to 17N (Fig. 53-2). In addition, the relax-
ation rate in the BTB graft fixed with interference screws was
less than that in the BTB graft fixed with sutures and screw
posts, whereas the relaxation rate in the flexor tendon graft
fixed with sutures and screw posts was greater than that in
the BTB graft fixed with the sutures and screw points (see
Fig. 53-2). Boylan et al13 applied an initial tension of 68N,
45N, and 23N to the hamstring graft at 30 degrees of flexion,
fixed with a suture and post technique. After 1000 cycles of
knee motion between 0 and 90 degrees, the tension in the
graft decreased to 34.5N, 16.8N, and 15.4N, respectively.
Arnold et al14 applied 40N initial tension to the BTB graft
at 20 degrees of flexion in ACL reconstruction with cadavers,
fixed with interference screws. The graft tension at 0 degrees
of flexion dropped from 208N, or by 41% at 500 cycles.
Anterior laxity increased from þ1.4 to þ2.8 mm by 500
cycles.
393
 Anterior Cruciate Ligament Reconstruction

300 showed that an increase of ACL tension decreased the degree

Mean  SD (n5 for each group)
Peak load at each cycle (N) *p0.01 (vs 1st cycle) of anterior translation of the tibia to the femur.7,15–17 Melby
250
et al17 described that an 18N tension applied to the graft at
200 * * 30 degrees of knee flexion restored the laxity and stiffness
* * *
most closely resembling that of the intact knee, without
150
*
inducing significant abnormal laxities, but that tensions
* * *
100 * greater than 54N overconstrained the knee. Several in vitro
* * * * *
50
studies warned that overtensioning might result in restriction
* * * * * in range of motion and graft failure.18–20 For example, Nabors
0 et al19 showed that when a high initial tension was applied to
1 1000 2000 3000 4000 5000
Cycle the BTB graft at 30 degrees of knee flexion, loss of knee
A extension frequently occurred after surgery. Graf et al20 indi-
cated that a high tension induced wear-related graft failure.
60 Group A Eager et al21 reported that a high initial tension induced
Valley load at each cycle (N)

Group B posterior subluxation of the tibia with respect to the femur,

50 Group C specifically when a graft having low stiffness was used. Thus
Group D the just-described in vitro studies recommended a low initial
40
tension be applied to the graft in ACL reconstruction.
30
However, a criticism of these in vitro studies is that
*
20 * * they did not take the graft relaxation into account. Beynnon
* *
* et al15 reported that because the tension applied on a graft at
10 * *
* * the time of fixation was acutely decreased by creep elonga-
0 * * * * * tion of an autograft or transposition of an autograft in the
1 1000 2000 3000 4000 5000
Cycle
bone tunnel, insufficient initial tension applied on the graft
B during surgery might result in slackness of a reconstructed
FIG. 53-2 The peak and valley loads during cyclic stretching. Group A, ligament tissue. In 2002, Numazaki et al12 stretched a few
Bone–tendon–bone (BTB) graft fixed with interference screws. Group B, BTB graft types of the femur–graft–tibia complex by 2 mm for 5000
fixed with the suture-post technique. Group C, Multistrand flexor tendon cycles, after an initial tension of 20N, 80N, and 140N was
graft fixed with the tape-staple technique. Group D, Multistrand flexor tendon
graft fixed with the sutures-tied-over-a-button technique. The initial tension of applied for 2 minutes. In a four-strand flexor tendon graft
80N applied to the BTB graft fixed with interference screws was reduced to 17N. with Endobutton fixation, the peak load values at the
In addition, the relaxation rate in the BTB graft was different, depending on the 5000th cycle were 17N, 40N, and 77N, respectively. The
fixation devices. (From Yamanaka M, Yasuda K, Nakano H, et al. The effect of cyclic
displacement upon the biomechanical characteristics of anterior cruciate
researchers stated that applying an initial graft tension of
ligament reconstructions. Am J Sports Med 1999;27:772–777.) approximately 80N did not appear to be too high for the
hamstring tendon graft with Endobutton fixation after
These studies suggested that the initial tension graft relaxation. In 2003, Boylan et al13 applied an initial
applied at the time of fixation is rapidly relaxed after surgery tension of 68N, 45N, and 23N to the hamstring graft at
by repetitive submaximal loading in all ACL reconstruction 30 degrees of flexion, fixed with a suture and post
procedures. In addition, the relaxation rate depends on a technique. The average laxity showed 6.0 mm, 8.1 mm,
combination of a graft and all artificial materials used for and 8.9 mm, respectively. After 1000 cycles of knee motion
graft fixation. In graft tensioning in each ACL reconstruc- between 0 and 90 degrees, the tension in the graft decreased
tion, therefore, a surgeon should determine an appropriate to 34.5N, 16.8N, and 15.4N, respectively, and the average
initial tension value in each procedure, taking into account laxity increased to 7.8 mm, 10.5 mm, and 10.3 mm, respec-
a specific degree of the postoperative graft relaxation. tively (Fig. 53-3). They concluded that to restore anterior
However, a significant problem is that a degree of the translation to within 3 mm of the native ACL condition
postoperative graft relaxation in each surgery has not been after cyclical loading, a relatively high tension of approxi-
precisely clarified yet. mately 68N was required using this fixation technique.
Thus among previous in vitro studies, there have been
Effects of a High or Low Initial Tension on controversies on the effect of high initial tension on the
the Graft and the Knee graft and the knee. However, these in vitro studies that took
the postoperative graft relaxation into account suggest the
A number of in vitro studies with cadaver knees, which strong possibility that an appropriate degree of high initial
simulated conditions immediately after ACL reconstruction, tension may not provide such detrimental effects to the graft

394

15 Before motion
After motion
Anterior laxity (mm)
10
5 essential effect of tension on the tendon graft. The author
0
23-N group 45-N group 68-N group
FIG. 53-3 An initial tension of 68N, 45N, and 23N was applied to the
hamstring graft at 30 degrees of flexion and fixed with a suture and post
technique. After 1000 cycles of knee motion between 0 and 90 degrees,
the average anterior laxity in the 68N group was significantly less than that
the other two groups. (From Boylan D, Greis PE, West JR, et al. Effects of
initial graft tension on knee stability after anterior cruciate ligament
reconstruction using hamstring tendons: a cadaver study. Arthroscopy
2003;19:700–705.)
and the knee compared with those shown in the studies that
did not take this into account.
Clinical Relevance from the Previous In
Vitro Studies
We should note that there are some agreements in the
previous in vitro studies. First, an increase in graft tension
decreases the degree of anterior translation of the tibia to
the femur. Second, a high initial tension applied to the graft
overconstrains the knee at least immediately after surgery.
Third, relaxation of graft tension commonly occurs in a rel-
atively early phase after surgery, and the degree and velocity
of the graft relaxation depend on a combination of the graft
and all artificial materials used for graft fixation. Fourth,
although behaviors of the ACL reconstructed knee have
been considered to be graft specific,16 we should now recog-
nize that the behavior of the ACL reconstructed knee is
graft fixation device–specific. However, we also should note
that there is considerable disagreement among the clinical
messages from the previous in vitro studies on clinical
ACL reconstruction. The relaxation of the graft tension
after surgery may be an important key to understand the
causes of this disagreement. Also, we have found some seri-
ous limitations in the in vitro studies. Thus, in vivo studies
with animal ACL reconstruction models have been
necessary.
Graft Tensioning in Anterior Cruciate Ligament Reconstruction 53
IN VIVO STUDIES WITH ANIMAL ANTERIOR
CRUCIATE LIGAMENT RECONSTRUCTION MODELS
Essential Effects of Tension on the Graft
Properties
Before discussing the effect of graft tensioning on the out-
come after ACL reconstruction, we should understand the
and his associates have performed a series of in vivo studies
on the effect of stress on the in situ frozen-thawed patellar
tendon and ACL, which are idealized extraarticular and
intraarticular autograft models, respectively.22–26 Regarding
the effect of low stress, Ohno et al22 and Majima et al23
demonstrated that reduction of stress dramatically reduced
the mechanical properties of the in situ frozen-thawed rab-
bit patellar tendon at 3, 6, and 12 weeks after surgery.
Regarding the effect of high stress, Tohyama and Yasuda25
reported that enhancement of stress also reduced the
mechanical properties of the in situ frozen-thawed rabbit
patellar tendon at 6 weeks after surgery. Also, Katsuragi
et al26 applied a high tension to the in situ frozen-thawed
canine ACL in which the applied high tension was proven
to be continuously maintained in the experimental period.
This study demonstrated that an unphysiologically high ten-
sion significantly deteriorated the mechanical properties of
the in situ frozen canine ACL at 12 months after surgery
when compared with physiological tension. These in vivo
studies revealed the essential effects of stress to the tendon
graft. Namely, continuous application of both excessively
high and low initial tensions has detrimental effects on the
graft. We should note that the latter is stronger than the
former. However, we should recognize that the mechanical
conditions surrounding the free tendon graft may be differ-
ent from those in these scientific studies because an initially
applied tension may be reduced to various degrees. Even in
the idealized ACL reconstruction model with the canine in
situ frozen-thawed ACL, the initial graft tension is chroni-
cally relaxed over time due to biological mechanisms.27
Effects of Initial Tension on Anterior
Cruciate Ligament Reconstruction Models
Regarding the effect of initial tension on knee stability,
function, and pathology, Yoshiya et al28 investigated the
effects of 1N and 39N initial loads on a canine ACL recon-
struction model with a free patellar tendon graft. They
observed poor vascularity and focal myxoid degeneration
within the graft pretensioned with a load of 39N, but not
within the graft with 1N of tension applied. Although they
395
 Anterior Cruciate Ligament Reconstruction
detected no significant difference in the values for the ulti-
mate failure load of the graft 3 months after reconstruction,
they suggested that a high degree of tension might be detri-
mental to the patellar tendon autograft during surgical
reconstruction of the ACL.
Using the in situ frozen-thawed canine ACL model in
which the applied high tension was proven to be continuously
maintained in the experimental period, Katsuragi et al26
applied a high tension of 20N to the graft model. They
demonstrated not only that an unphysiologically high tension
significantly deteriorated the mechanical properties of the in
situ frozen canine ACL at 12 months after surgery when
compared with physiological tension, but also that it provided
histological changes in the graft and mild cartilage degenera-
tion at the same period. Namely, in the highly tensioned knee,
ovoid and focal degenerative changes with a number of
vacuoles were occasionally found in the matrix, and a small
part of the articular cartilage surface showed mild softening
and fibrillation in each knee, although neither meniscal tears
nor tibiofemoral osteophyte formation was found.
On the other hand, Labs et al29 determined the effect of
initial graft tension (1N, 7.5N, 17.5N) on the biomechanical
and histological behavior of the ACL graft using a rabbit
model at 2, 8, and 32 weeks. The load at failure was 40.5%
of the normal ACL at 1N, 45.1% at 7.5N, and 50.8% at
17.5N at 32 weeks postoperatively. They stated that higher
initial graft tension resulted in improved histological and
biomechanical parameters. In addition, pathological changes
in the graft or cartilage damage due to overconstraining of
the knee were not observed at the selected initial tensions.
In 2003, Abramowitch et al30 performed a goat model
study. They investigated whether the differences in knee
stability, which were present immediately after ACL recon-
struction with grafts fixed at low (5N) and high (35N) ini-
tial tension, remained after 6 weeks and whether the
tensile properties of an ACL replacement graft were influ-
enced by initial graft tension. Although the high initial graft
tension could better replicate the normal knee kinematics at
time-zero, these effects diminished during the early graft
healing process. Further, the stiffness and ultimate load at
failure of the graft were not significantly different between
both reconstruction groups.
Thus, concerning the effect of initial tension on the
graft and the knee functions, we have found considerable
disagreement among the in vivo studies with the animal
models. The reasons may include the fact that postoperative
biomechanical conditions surrounding the ACL graft are
extremely different among the animal models. In vivo studies
with animal models are valuable because we can receive an
important message from each study concerning a specific
focus related with the clinical field. However, we must say that
the postoperative conditions in these in vivo experimental
396
studies differ from those in human ACL reconstruction.
Therefore it has been urgently necessary to conduct rando-
mized clinical trials to determine the effect of initial tension
in each type of ACL reconstruction.
RANDOMIZED CLINICAL TRIALS ON THE EFFECT
OF INITIAL GRAFT TENSION ON THE OUTCOME
AFTER ANTERIOR CRUCIATE LIGAMENT
RECONSTRUCTION
Only four randomized clinical trials have been reported to
evaluate the effect of initial graft tension on the outcome after
ACL reconstruction. In 1997, Yasuda et al31 reported the first
randomized clinical trial using 72 patients. They applied
initial tension of 20N, 40N, and 80N to the doubled
hamstring tendon graft at 30 degrees of knee flexion and
examined clinical outcome at 2 years after ACL reconstruc-
tion. The average side-to-side anterior laxity was 2.1, 1.4,
and 0.6 mm in the 20N, 40N, and 80N groups, respectively
(Fig. 53-4). The postoperative laxity in the 80N group was
significantly less than that in the 20N group. All the patients
restored full range of knee motion. There were no significant
differences in subjective clinical results and muscle strength
among the groups. Based on this study, Kim et al32 recently
investigated whether initial tension of more than 80N
provided any detrimental effects on the knee with hamstring
ACL reconstruction, using 48 patients. They applied three
different initial tensions of 8, 12, and 15 kg to the hamstring
graft at 30 degrees of knee flexion. The patients were observed
10 20N group
40N group
80N group
Side-to-side anterior laxity (mm)
8
6
4
*
2
0
Preoperation Postoperation
FIG. 53-4 When an initial tension of 20N, 40N, or 80N was applied to
the doubled hamstring tendon graft at 30 degrees of knee flexion, the
average side-to-side anterior laxity in the 80N group was significantly less
than that in the 20N group. (From Yasuda K, Tsujino J, Tanabe Y, et al.
Effects of initial graft tension on clinical outcome after anterior cruciate
ligament reconstruction. Am J Sports Med 1997;25:99–106.)

for 1 year or more after surgery. Postoperatively, the average
side-to-side difference in anterior laxity was 1.3 mm in
the 8-kg group, 2.1 mm in the 12-kg group, and 2.4 mm
in the 15-kg group. The authors stated that there were no sig-
nificant differences not only in the anterior laxity but also in
subjective clinical results and knee extensor strength between
the groups. However, we should note that the average laxity
value in the 15-kg group was approximately twice as much
as that in the 8-kg group. These two studies suggested that
relatively high initial tension of approximately 80N reduces
the postoperative anterior laxity of the knee joint after ACL
reconstruction using the hamstring tendons. Any obvious
detrimental effects were noted in these two trials, although
long-term results were not known.
Regarding ACL reconstruction with the BTB graft,
van Kampen et al33 reported a randomized trial with 38
patients in 1998. They applied 20N or 40N tension to the
BTB graft at 20 degrees of knee flexion and examined clin-
ical outcome at 1 year after surgery. The side-to-side ante-
rior laxity averaged 2.6 mm in the 20N group and 2.5 mm
in the 40N group. They found no significant differences.
On the other hand, in 2004 Nicholas et al34 reported a ran-
domized trial using 49 patients. They fixed the graft at 45N
or 90N at the knee extension position and examined the
clinical outcome at an average of 20 months after surgery.
The side-to-side anterior laxity difference was significantly
greater in the patients in the low-tension group (average
3.0 mm) than in the high-tension group (average 2.2 mm)
(Fig. 53-5). The five patients with abnormal anterior tibial
displacement (greater than 5 mm side-to-side difference)
Low tension
10 High tension
Side-to-side difference (mm)
8
6 explain why high tensions decreased the anterior laxity of
4 ination may be increased depending on the degree of initial
2 may result in slackness of a reconstructed ligament tissue,
0
Before surgery 1 week 20 months
FIG. 53-5 When the graft was fixed at 45N or 90N at the knee extension
position, the side-to-side anterior laxity difference was significantly greater
in the patients in the low-tension group than in the high-tension group at
an average of 20 months after surgery. (From Nicholas SJ, D’Amato MJ,
Mullaney MJ, et al. A prospectively randomized double-blind study on the
effect of initial graft tension on knee stability after anterior cruciate
ligament reconstruction. Am J Sports Med 2004;32:1881–1886.)
Graft Tensioning in Anterior Cruciate Ligament Reconstruction 53
were only in the low-tension group. The patients regained
full range of knee motion. Knee outcome scores and hop
test deficits were not different between groups. There is dis-
agreement on the effect of initial graft tension on the knee
stability between these two studies on ACL reconstruction
with the BTB graft. Nicholas et al34 pointed out that the
forces in van Kampen’s study33 were lower than the tensions
routinely applied to the BTB graft by experienced surgeons
during graft tensioning, that initial graft tension affects the
restoration of knee stability, and that a graft tension of
45N was not sufficient for restoring knee stability.
Thus at the present time, no consensus has been
reached regarding the amount of graft tension needed to
re-create normal knee mechanics after ACL reconstruction
using each graft-device combination. However, we have
found the following facts on the effect of initial tension in
the four clinical studies. Namely, no studies reported that
a low tension of less than 40N applied at 0 to 30 degrees
of knee flexion was more beneficial to restore the nearly nor-
mal stability of the knee in the 1- to 2-year outcome after
ACL reconstruction compared with a high tension of
greater than 40 N. Also, no studies reported that a relatively
high initial tension of approximately 80N, which overcon-
strained the knee immediately after surgery, provided detri-
mental effects to the knee function in the 1- to 2-year
outcome. For example, the fact that postoperative range of
knee motion was clearly not different between the high-ten-
sion and low-tension groups in each study demonstrated
that the knee is not overconstrained at the follow-up period.
It is of note that in the two studies with the hamstring or
BTB graft, a relatively high initial tension of 80N or 90N
was more beneficial than a relatively low tension of 20N
or 45N in restoring the nearly normal stability of the knee
in the 1- to 2-year outcome.31,34 This result may support
the fact that current ACL reconstruction specialists prefer
such degrees of high initial tension.35 According to Nicho-
las et al,34 two potential mechanisms are considered to
the knee. The first potential mechanism is that tension of
a ligament tissue reconstructed at the final follow-up exam-
graft tension due to the fact that insufficient initial tension
as the initial graft tension is acutely decreased by various
causes.10–12,15 The second potential mechanism is that the
stiffness and the strength of a reconstructed ligament tissue
may be increased depending on the degree of initial graft
tension because a low tension significantly reduces the
mechanical properties of tendon autograft models.22,23 In
the near future, we should be able to determine which
mechanism is correct. In addition, further randomized clin-
ical studies are required to reach consensus on this issue.
397
 Anterior Cruciate Ligament Reconstruction
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12. Nakano H, Yasuda K, Tohyama H, et al. Interference screw fixation
of doubled flexor tendon graft in anterior cruciate ligament reconstruc-
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2000;15:188–195.
13. Boylan D, Greis PE, West JR, et al. Effects of initial graft tension on
knee stability after anterior cruciate ligament reconstruction using
hamstring tendons: a cadaver study. Arthroscopy 2003;19:700–705.
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cruciate ligament graft tension after cyclic knee motion. Am J Sports
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15. Beynnon BD, Johnson RJ, Fleming BC, et al. The measurement of
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16. Burks RT, Leland R. Determination of graft tension before fixation in
anterior cruciate ligament reconstruction. Arthroscopy 1988;4:260–266.
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reconstructed knee. Arthroscopy 1991;7:257–266.
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18. Gertel TH, Lew WD, Lewis JL, et al. Effect of anterior cruciate liga-
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21. Eagar P, Hull ML, Howell SM. How the fixation method stiffness
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cally high initial tension on the mechanical properties of in situ frozen
anterior cruciate ligament in a canine model. Am J Sports Med
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in the in situ frozen anterior cruciate ligament. Clin Orthop Relat Res
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29. Labs K, Perka C, Schneider F. The biological and biomechanical effect
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replacement graft: a study in goats. J Orthop Res 2003;21:708–715.
31. Yasuda K, Tsujino J, Tanabe Y, et al. Effects of initial graft tension on
clinical outcome after anterior cruciate ligament reconstruction. Am J
Sports Med 1997;25:99–106.
32. Kim SG, Kurosawa H, Sakuraba K, et al. The effect of initial graft
tension on postoperative clinical outcome in anterior cruciate ligament
reconstruction with semitendinosus tendon. Arch Orthop Trauma Surg
2005;28:1–5.
33. van Kampen A, Wymenga AB, van der Heide HJ, et al. The effect of
different graft tensioning in anterior cruciate ligament reconstruction:
a prospective randomized study. Arthroscopy 1998;14:845–850.
34. Nicholas SJ, D’Amato MJ, Mullaney MJ, et al. A prospectively rando-
mized double-blind study on the effect of initial graft tension on knee
stability after anterior cruciate ligament reconstruction. Am J Sports
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35. Cunningham R, West JR, Greis PE, et al. A survey of the tension
applied to a doubled hamstring tendon graft for reconstruction of
the anterior cruciate ligament. Arthroscopy 2002;18:983–988.
 Tensioning Anterior Cruciate Ligament
Grafts
INTRODUCTION
Graft selection, graft position, fixation, and post-
operative rehabilitation are clearly implicated in
the success and failure of anterior cruciate ligament
(ACL) reconstruction. Tensioning of the ACL is
another important factor in providing immediate
and long-term stability in the reconstructed
patient. Jones1 stated that tension applied to the
ACL graft at the time of surgery should be enough
to eliminate an anterior drawer sign but still allow a
full range of motion. Excessive initial tension can
lead to graft failure, fixation failure, loss of knee
motion, excessively reduced anterior laxity, and
cartilage degeneration.2–6 Lewis et al6 introduced
the term overcorrected to describe the phenomenon
in which the tibia was positioned posterior and
externally rotated relative to the femur. Andersen
and Jorgensen7 used a prosthetic ligament to study
the consequence of overcorrected ACL recon-
structions. These kinematic alterations result in
increased graft forces at all flexion angles,
increased forces in the posterior cruciate ligament
(PCL), and alteration of the normal roll–glide
mechanism during knee motion. Melby et al2
found that graft tension–related posterior tibial
subluxation resulted in an increase in quadriceps
force needed to achieve full knee extension and
may lead to an extensor lag if quadriceps atrophy
is present.
As more sophisticated models of ACL ten-
sioning have developed, efforts have focused on
the effect of tension on the graft itself. The termi-
nology can be confusing; terms such as preloading,
54
CHAPTER
pretensioning, preconditioning, and initial tension Lonnie E. Paulos
have been used. For this text, pretensioning refers
to any loading of the graft that is performed before
the graft is pulled into the femoral and tibial bone
tunnels. Preconditioning refers to the loading of the
graft that is performed once the graft has been
fixed within one of the tunnels (usually the femoral
tunnel). The term initial tension refers to the ten-
sion in the graft after fixation within both tunnels.
Initial tension affects the biology of the
graft and is a time-dependent interplay of host
incorporation and biomechanical forces. A num-
ber of factors affect graft tension, including initial
tension (pretensioning and preconditioning), lig-
ament length, graft isometry, tissue type, and fix-
ation type (Fig. 54-1). For the purposes of this
chapter, we will review the consequences of over-
tensioning the ACL graft both histologically and
functionally, explore the factors in low-tension
(bone–tendon–bone [BTB]) and high-tension
(soft tissue) grafts, identify the ideal knee fixation
angle, and provide suggestions for identifying
tensioning problems and possible solutions. His-
torically, much debate has existed in the literature
regarding these issues, with relatively few clinical
studies focusing on graft tension; however, some
consensus has been identified in recent years to
lend clarity to this confusing topic.
NATIVE ANTERIOR CRUCIATE
LIGAMENT TENSION
The goal of ACL reconstruction is to restore
normal knee kinematics. Success requires a basic
399
 Anterior Cruciate Ligament Reconstruction
Ligament Fixation
Tension Isometry Tissue type
length type
Ultimate ligament tension
FIG. 54-1 Factors affecting ultimate graft tension.
understanding of the forces affecting the normal ACL.
Markolf et al8 and Wascher et al9 studied a series of loading
experiments on cadaver specimens by isolating the bone plug
that contained the ligament’s tibial insertion and attaching a
load transducer. Passive extension of the knee generated
forces in the ligament only during the last 10 degrees of exten-
sion, reaching 50 to 240N with hyperextension. Internal tibial
torque generated greater forces in the ligament than did exter-
nal tibial torque and increased as the knee was extended. The
greatest forces (133–370N) were generated when 10 N/m of
internal tibial torque was applied in hyperextension. A varus
moment of 15 N/m generated forces of 94 to 177N at full
extension, and a similar valgus moment generated a mean
force of 56N independent of knee flexion.
Active knee motion near extension substantially
increases forces across the ACL. Paulos et al10 reported that
lengthening of the ACL was observed during active extension
from 40 degrees of knee flexion. Active quadriceps contrac-
tion imparts significant strain on the ACL. Arms et al11
showed that over the first 45 degrees of flexion, the quadriceps
increased strain, whereas it decreased strain at flexion angles
greater than 60 degrees. Beynnon et al12 studied the forces
on the anteromedial bundle of various exercises. Isometric
quadriceps contraction at 15 degrees of knee flexion elicited
the highest peak strain (4.4%), followed by open chain
flexion-extension with a 45N weight (3.8%) and a Lachman
test (3.7%). Isometric quadriceps contraction at 30 degrees
contributed significantly less strain (2.7%) to the ACL.
More recent investigation has focused on the impor-
tance of both the anteromedial and posterolateral bundles
in ACL function. Sakane et al13 examined in situ forces in
nine human ACLs in response to applied anterior tibial
loads at knee flexion angles of 0 to 90 degrees. Their results
showed the magnitude of ACL force to be maximal with
anterior tibial loads applied at 15 degrees of knee flexion,
which differs slightly from Markolf’s earlier conclusions.
The magnitude of force in the posterolateral bundle was
larger than that in the anteromedial bundle at knee flexion
angles between 0 and 45 degrees, reaching a maximum of
75N at 15 degrees of knee flexion under an anterior tibial
load of 110N. The magnitude of force on the anteromedial
bundle, in contrast, remained constant independently of
flexion angle. They concluded that the magnitude of force
400
in the posterolateral bundle was significantly affected by
knee flexion angle and anterior tibial load and was the major
restraint to anteroposterior (AP) instability in early flexion.
No graft currently in use matches the complex anat-
omy of the normal ACL. Woo et al14 compared anterome-
dial ACL reconstructions using hamstring and patellar
tendon reconstructions versus the native ACL and found
significant laxity to a combined rotational load involving
internal rotation and valgus tibial torque at 15 and 30
degrees of flexion. This highlights the importance of the
posterolateral bundle to knee stability in early knee flexion
and has led some to question the anteromedial reconstruc-
tions and revisit the idea of anatomical double-bundle
reconstructions.
BASIC SCIENCE AND GRAFT HISTOLOGY
Evidence from animal experiments lends credence to a
“window” of acceptable ACL graft tension. Graft tension
that is too high can eventually lead to greater laxity and
poorer results than knees fixed under low graft tension.
Conversely, other animal studies demonstrate that deliber-
ately de-tensioned grafts lose strength to a greater extent
than the normally tensioned ACL. Although a stimulus is
essential for the orientation of newly formed collagen during
the remodeling phase,15 basic research studying the effect of
graft tension cautions that high initial tension may be detri-
mental to the remodeling process. Yoshiya et al16 found that
patellar tendon reconstructions in dogs exposed to high ini-
tial graft tension of 39N showed focal degeneration within
the graft and replacement of the normal parallel arrange-
ment of collagen fibrils by a myxoid, extracellular matrix.
Microangiography demonstrated improved vascularity when
the initial tension was 1N rather than 39N. Laxity measure-
ments of the two different preloads showed increased stabil-
ity of the highly tensioned graft at time zero. However, at
3 months, laxity between the two groups was similar.
The use of allograft tissue is gaining popularity in lig-
ament reconstruction. The substantial decrease in graft
strength during initial phases of healing in frozen allograft
tissue relates to the inflammatory stages associated with
revascularization, not the effects of freezing itself.17 Jackson
et al18 studied the biomechanical outcomes of devitalized
ACL at 0, 6, and 26 weeks after treatment with a freeze
probe. At 6 weeks a significant reduction in maximum load
to failure was observed. However, at 26 weeks, no differ-
ences were noted between frozen and contralateral controls
relative to laxity, load to failure, stiffness, or modulus of
elasticity.
Katsuragi et al19 and Mikami et al20 studied non-
physiologically high initial tension after freezing ACL

ligaments in dogs. After applying a freeze-thaw treatment
to both ACLs, they applied initial tension of 20N to the
test group and compared it with the physiologically
tensioned contralateral extremity. The tensile strength in
the highly tensioned knee decreased significantly at 6 and
12 weeks. Histologically, the collagen fibers in the
highly tensioned knees were coarser and disoriented. In
the midsubstance of the ACL, the physiological speci-
mens had a spindle-shaped nucleus; however, the
highly tensioned ACL had signs of degenerative changes
(Fig. 54-2). Overtensioning causes significant degenerative
changes in native, autologous BTB, and freeze-thaw–treated
ACL. Over time, the mechanical properties of the overten-
sioned ACL graft deteriorate compared with physiological
tension.
Tensioning Anterior Cruciate Ligament Grafts 54
GRAFT-SPECIFIC TENSIONING
Stiffness and elasticity vary among autograft tissues. Burks and
Leland4 determined that the graft tension needed to restore
normal anterior laxity is tissue specific. The material (stiffness)
and geometrical (size and length) properties of the graft influ-
ence the amount of tension that needs to be applied. In cadav-
eric knees, they reconstructed the ACL using bone–patellar
tendon–bone (BPTB), doubled semitendinosus, or iliotibial
band grafts. They tensioned each graft to match translation
of an applied 20-pound load (89N) using the KT-1000.
The BPTB graft returned the knee to its preoperative condi-
tion with a mean of 3.6 pounds (16.2N); doubled semitendi-
nosus graft, 8.5 pounds (38.3N), and iliotibial band graft,
13.6 pounds (61.2N). Due to the characteristics of BTB graft

FIG. 54-2 A, Physiologically tensioned anterior cruciate ligament (ACL) at 6 weeks (magnification
20). B, Highly
tensioned ACL at 6 weeks (
20). C, Core sample from a physiologically tensioned ACL at 12 weeks (
100).
D, Core sample from a highly tensioned ACL at 12 weeks (
100). E, Midsubstance sample from a physiologically
tensioned ACL at 12 weeks (
100). F, Midsubstance sample from a highly tensioned ACL at 12 weeks (
100).
(From Katsuragi R, Yasuda K, Tsujino J, et al. The effect of nonphysiologically high initial tension on the mechanical
properties of in situ frozen anterior cruciate ligament in a canine model. Am J Sports Med 2000;28:47–56.)

401
 Anterior Cruciate Ligament Reconstruction
superstructure and fixation, they have been generalized as low-
tension grafts, whereas the mechanical properties of soft tissue
grafts have necessitated high tension for graft fixation. We will
review some of the clinical evidence supporting this.
Low-Tension Grafts
Fleming et al21 studied the relationship between graft ten-
sioning and AP laxity of the reconstructed goat knee. The
AP laxity values of the intact knee were measured with the
knee at various flexion angles. The ACL was then severed
and the laxity measurements were repeated for nine different
tensioning conditions: 30N, 60N, and 90N, each applied
with the knee at 30, 60, and 90 degrees of flexion. They con-
cluded that a 60N load applied at 30 degrees was the best
combination for restoring normal AP laxity values. Pena
et al22 developed a three-dimensional finite element model
of the human knee joint. Under an anterior load of 134N,
the closest anterior tibial translation to that of the intact knee
was obtained with a pretension of 60N. However, they noted
that because this load was likely to cause problems in revascu-
larization and remodeling during postoperative healing, an
initial tension of 40N was recommended.
There is no consensus for the ideal initial tension in
BTB graft in clinical studies. Van Kampen et al23 prospectively
randomized patients into 20N and 40N load groups and fixed
them at 20 degrees of flexion. They found no significant
difference in objective or subjective outcomes at 1 year after
ACL reconstruction. However, they did note a slight
tendency toward progressive instability in the 40N group.
Yoshiya et al24 compared initial graft tension in two groups
using 25N and 50N fixed at extension. In the immediate
postoperative period, the reconstructed knee was similarly
overconstrained in both groups. By 3 months, laxity of the
surgically treated knee had increased significantly, was
similar to the contralateral normal knee, and showed a slight
increase between 3 and 6 months. No significant difference
in the clinical outcome was observed between the groups at
any time during follow-up.
Amis and Jakob25 surveyed a number of surgeons in an
effort to establish a consensus on graft tensioning. Of those
surveyed, the average graft tensioning protocols for BPTB
reconstructions were 47N at 11 degrees of knee flexion. As
previously mentioned, histological evidence of graft degener-
ation has been noted in animal models where the native ACL
or BTB grafts were tensioned in a range of 20 to 40N.
Although there were no direct consequences to knee stability,
it reemphasizes the goal of “least amount of tension necessary
to restore knee stability.” Applying a 20N load to a low-ten-
sion graft should provide adequate stability and reduce the
risk of overconstraining the knee and degenerating the graft.
402
High-Tension Grafts
Multiple outcome studies have indicated that hamstring ten-
don autografts are associated with higher postoperative laxity
measurements than patellar tendon autografts, with clinical
instability rates ranging from 10% to 30%.26,27 Instability is
defined as a 3-mm side-to-side difference in anterior tibial
translation compared with the contralateral intact knee during
manual maximum translation. Clinical instability rates rang-
ing from 10% to 30% have been reported following recon-
struction with hamstring tendon autografts. Soft tissue
grafts present unique challenges. Namely, the length of the
tendons are longer, more friction exists within the tunnels,
and bone–bone healing is lacking. Considering the properties
of soft tissue grafts, most surgeons reconstruct using higher
tensions compared with BTB grafts.25 Burks and Leland4
suggested tension two to three times that required in BTB
reconstructions to restore normal laxity patterns. Boylan
et al28 applied three different loads in a cadaveric model:
68N, 45N, and 23N at 30 degrees of flexion. KT-1000
measurements of anterior translation demonstrated that the
68N load restored stability, whereas the knees loaded with
45N and 23N had significantly more laxity.
The clinical evidence offers some clarity to the issue. In
a prospective randomized study, Yasuda et al29 followed the
clinical results at 2 years in patients who received doubled
semitendinosus/gracilis (2xST/Gr) grafts tensioned at 80N,
40N, or 20N. The average side-to-side difference in anterior
laxity in the 80N group was significantly less than that in
the 20N or 40N group. There were no complications, all
patients regained maximum extension, and no difference in
subjective outcomes were noted. Kim et al30 randomly
allocated 48 patients to three groups in which three different
tensions—8 kg (78N), 12 kg (117N), or 15 kg (147N)—were
applied to a penta-semitendinosus graft. Postoperatively, the
average side-to-side differences in anterior laxity were 1.3,
2.1, and 2.4 mm, respectively, at a minimum of 1 year. There
were no significant differences among the groups in subjective
clinical results, anterior laxity, or knee extensor strength.
As outlined earlier, overcorrecting the joint can lead to
deleterious effects on kinematics of the graft and loss of
motion. Furthermore, the increase in cartilage compression
that occurs with overconstraint and loss of knee motion
may lead to a greater degree of degeneration over time.
Vachtsevanos et al31 looked at the relationship of soft tissue
tensioning and return of postoperative range of motion.
They conducted a prospective randomized study using 61
patients reconstructed with autogenous 2xST/Gr. Patients
were divided into two groups (15 pounds [68N] and
20 pounds [88N]) and followed in the postoperative period
for an average of 15 months. The average side-to-side
 Tensioning Anterior Cruciate Ligament Grafts 54
difference in anterior laxity was 1.7  1.5 mm (68N) and
STRESS RELAXATION, PRECONDITIONING, AND
2.8  2.0 mm (88N), which was significant (Fig. 54-3).
Additionally, they found a significant delay in regaining PRETENSIONING
extension in the 88N group (Fig. 54-4). Based on the evi-
Due to the viscoelastic characteristic of graft tissue, the ini-
dence presented, it is reasonable to assume that an initial
tial tension of ACL grafts is finite in nature. Beynnon
tension of 70N in soft tissue grafts provides consistent
et al32 reported that initial tension applied to the BTB graft
return of motion and clinical stability and that substantially
at the time of fixation immediately decreased by creep elon-
greater tension does not improve results.
gation. Additionally, the percentage of stress relaxation is
independent of the peak load applied to the graft.33 The
data are similar for soft tissue grafts. Höher et al34 demon-
strated a loss of 45% of graft tension in quadrupled ham-
string grafts within 30 minutes due to stress relaxation.
FINAL KT-1000 SIDE-TO-SIDE DIFFERENCE
In vitro studies have been performed to determine the influ-
7 ence of cyclical loading on graft tension following ACL
6 reconstruction. For studies performed with hamstring ten-
Side-to-side difference (mm)

5 don grafts, bovine extensor tendon grafts, and patellar ten-

4 don grafts, cyclical loading reduced graft tension by 50%
3 or more.28,35,36 Numazaki et al37 in a porcine ex vivo study
2 fixed patellar tendon grafts with initial tensions of 20N,
1 80N, and 140N. A cyclical force–relaxation test was per-
0
formed for 5000 cycles until the graft was stretched by
5 10 15 20 25 2 mm. The average peak load values after cycling were
–1
105N, 157N, and 205N, respectively. Considering the in
–2
situ force of the ACL at full extension (16–87N),8 the
–3
authors concluded there was no benefit in tensioning
Patients
the patellar tendon graft greater than 20N. For soft tissue
15 lb. tension grafts under the same initial loads, the average peak load
20 lb. tension values after cycling were 27N, 41N, and 39N. Increasing
FIG. 54-3 Side-to-side difference in 15 and 20 pounds of initial tension initial tension from 20 to 80N presented a significant
measured in millimeters with KT-1000 at 20-pound anterior drawer at an increase in peak load after cycling; however, tensioning to
average of 15 months’ follow-up. Average side-to-side difference in the
140N did not confer any benefit.
15-pound group was 1.7  1.5 mm; in the 20-pound group, 2.8  2.0 mm
(P ¼ 0.047). Attempts have been made to minimize graft viscoelas-
ticity after reconstruction; pretensioning and preconditioning
of the soft tissue grafts before final fixation have been recom-
mended. To review, pretensioning refers to any loading of the
graft that is performed before the graft is pulled into the knee
12
(graft preparation board) (Fig. 54-5). Preconditioning refers to
10
Time in weeks

0
90 120
Range of motion (degrees)

15 lbs. tension
20 lbs. tension

FIG. 54-4 Time to achieve 90 and 120 degrees of flexion for 15- and FIG. 54-5 Example of pretensioning doubled semitendinosus/gracilis
20-pound groups (P ¼ 0.018). graft using Acufex Graftmaster board.

403
 Anterior Cruciate Ligament Reconstruction
loading of the graft that is performed once the graft has been
fixed in one of the tunnels (usually the femoral tunnel). Pre-
conditioning may be further divided into cyclical and isomet-
ric preconditioning. The former denotes a load applied in
multiple consecutive bouts (cycles), and the latter denotes a
constant load applied on the graft before the final fixation of
the graft.
Despite the common use of pretensioning in graft
preparation, there is little clinical evidence to support its
effectiveness. Howard et al38 noted a 10% increase in length
of patellar tendon grafts after applying an 89N load for
15 minutes. They concluded that without pretensioning,
significant postimplantation graft creep will occur. Several
pretensioning techniques have been developed for soft tissue
grafts. Tension of 15 to 20 pounds (44–88N) for 10 to 20
minutes has been suggested for pretensioning hamstring
tendon grafts. The initially set tension gradually decreases
over time as the graft is stretched and the sutures are tight-
ened around the tendon bundle. Accordingly, it would be
misleading to claim that the graft was tensioned with a con-
stant load during the entire time. However, it is reasonable
to assume that pretensioning does eliminate some creep
within the suture–graft interface and allow the surgeon to
provide a more consistent initial tension, and it certainly
improves the ease of graft preparation. There is no obvious
utility in pretensioning BTB grafts.
More sophisticated studies looking at the effectiveness
of preconditioning over time are inconclusive. Nurmi et al39
tested the effectiveness of preconditioning by assigning
anterior tibialis grafts to three groups: control, cyclical pre-
conditioned, and isometric preconditioned. The residual
graft tension was then recorded immediately after the appli-
cation of an initial graft tension of 80N and fixation into
tibia with an interference screw. Immediately after screw
insertion, the residual (AT) graft tensions were 79N 
19N, 100N  17N, and 102N  15N, respectively. How-
ever, after 1 hour, a 60% decrease occurred in the initially
set tension. Ejerhed et al40 prospectively randomized 53
patients undergoing patellar tendon autograft into two
groups. One group of patients underwent isometric precon-
ditioning by passive stretching at a constant load of 39N for
10 minutes immediately prior to implantation. The other
group underwent no preconditioning before the implanta-
tion of the graft. At an average of 25 months, no significant
objective or subjective differences were noted. To date,
there is no clinical evidence proving that pretensioning or
preconditioning of grafts will overcome the viscoelastic
nature of graft tissue and improve clinical outcomes.
However, cyclical preconditioning does allow the surgeon
to identify the force–flexion curve of a specific graft before
final fixation.
404
KNEE FIXATION ANGLE
When considering the ideal knee flexion angle at fixation,
certain assumptions must be made. Namely, the femoral and
tibial tunnels are placed near the native ACL origin and inser-
tion. Excessively anterior placement of the femoral tunnel
causes significant increases in ACL tension in flexion and
laxity near extension. We know from kinematic studies that
the forces generated in the graft as well as in the intact ACL
are greatest at full extension and minimal between 30 and 60
degrees of knee flexion.41 Cadaveric studies by Bylski-Austrow
et al5 concluded that a greater increase in force (50–115N) and
greater posterior shifts in tibial position were produced by
changing the flexion angle at tensioning from 0 to 30 degrees,
rather than doubling the initial tension from 20 to 40N
(15–35N). Gertel et al42 measured ACL graft force using
BTB in cadaveric knees and concluded that graft forces are
greater when the initial tension was applied at 30 degrees of
flexion rather than at 0 degrees. This has led most surgeons
to fix their grafts between 10 and 30 degrees of flexion.25
Asahina et al43 conducted one of the few clinical stud-
ies examining the importance of knee flexion angle at graft
fixation. Using the modified Macintosh technique, 19
patients were fixed with the knees at full extension, whereas
25 patients were fixed at 30 degrees of flexion. A 70N force
measured with a spring balance was used for both groups.
At an average of 38 months, the range of motion in the
extension group was significantly better. However, the sta-
bility of the knees and arthroscopic appearance of the grafts
were significantly worse. This led the authors to suggest that
graft fixation at 30 degrees of flexion is more effective in
restoring stability and sustaining graft viability.
Ultimately, there is no set number for the ideal knee
flexion angle at graft fixation that can be effective in every
reconstruction. Clearly, fixation in the arc of 10 to 30
degrees imparts a significant force to the ACL graft, and
fixation at greater than 60 degrees can create difficulty in
regaining maximal extension postoperatively. The surgeon
must look at the behavior of the graft during cyclical pre-
conditioning to determine the ideal knee flexion angle for
fixation, which will be discussed in the following section.
TENSIONING DEVICES AND STRATEGIES
As mentioned previously, every graft produces its own indi-
vidual force–flexion curve based primarily on the position of
tunnel placement. After the graft is fixed in the femoral
tunnel, the knee should be taken through a range of motion
with tension on the tibial end of the graft (cyclical precondi-
tioning). Based on graft length changes, which are assessed

by motion of the graft within the tunnel, the point where the
graft will be slack and where graft tension increases should be
identified. Ideally, an isometric placed graft will show no sig-
nificant motion and could be tensioned at any point in the
flexion arc.44 Clinically, 2 to 3 mm of elongation is
acceptable as long as the pattern of deviation throughout the
range of motion reproduces that of the native ACL. Namely,
in well-placed tunnels, this inflexion point occurs near
extension as the graft begins to shorten in the tunnel.
Cunningham et al45 studied the results of 13 orthopae-
dic sports medicine physicians who were asked to tension a
soft tissue graft as they would in surgery and then maximally.
They found that graft tensioning was highly variable and
questioned whether tension should be more accurately
measured and controlled intraoperatively. Commercially
available ACL tensioning devices can be applied to the
tibial end of the graft (Figs. 54-6 and 54-7). These allow
FIG. 54-6 Example of a preconditioning device (prototype).
FIG. 54-7 Example of another preconditioning device: the Tie Tensioner
(DePuy-Mitek, Johnson & Johnson Gateway).
Tensioning Anterior Cruciate Ligament Grafts 54
the surgeon to dial in the set amount of tension, eliminating
the need for an assistant. To date, no clinical studies have
identified more consistent or improved outcomes using
these devices.
Although an obvious controversy exists concerning
the ideal pretensioning, preconditioning, and initial tension-
ing of ACL grafts, consensus does prevail. In low-tension
grafts (BTB), pretensioning imparts little benefit and the
graft should be fixed in the range of 20N. For high-tension
grafts (semitendinosus), pretensioning may improve the
immediate viscoelastic behavior of the graft and the graft
should be fixed at no greater than 80N. Preconditioning
of both graft types is advised to characterize the inflexion
point of the individual graft before final fixation. With
well-placed tunnels, this point should be near full extension
(10–30 degrees), at which time the desired initial tension
can be set.
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of a prosthetic anterior cruciate ligament on the anteroposterior laxity
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5. Bylski-Austrow DI, Grood ES, Hefzy MS, et al. Anterior cruciate
ligament replacements: a mechanical study of femoral attachment
location, flexion angle at tensioning, and initial tension. J Orthop Res
1990;8:522–531.
6. Lewis JL, Lew WD, Hill JA, et al. Knee joint motion and ligament
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1989;111:97–106.
7. Andersen HN, Jorgensen U. The immediate postoperative kinematic
state after anterior cruciate ligament reconstruction with increasing
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S62–S69.
8. Markolf KL, Gorek JF, Kabo JM, et al. Direct measurement of resul-
tant forces in the anterior cruciate ligament. An in vitro study per-
formed with a new experimental technique. J Bone Joint Surg
1990;72A:557–567.
9. Wascher DC, Markolf KL, Shapiro MS, et al. Direct in vitro mea-
surement of forces in the cruciate ligaments. Part I: the effect of multi-
plane loading in the intact knee. J Bone Joint Surg 1993;75A:377–386.
10. Paulos L, Noyes FR, Grood E, et al. Knee rehabilitation after anterior
cruciate ligament reconstruction and repair. Am J Sports Med
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11. Arms SW, Pope MH, Johnson RJ, et al. The biomechanics of anterior
cruciate ligament rehabilitation and reconstruction. Am J Sports Med
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the anterior cruciate ligament during squatting and active flexion-
extension. A comparison of an open and a closed kinetic chain
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13. Sakane M, Fox RJ, Woo SL, et al. In situ forces in the anterior cruci-
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14. Woo SL, Kanamori A, Zeminski J, et al. The effectiveness of recon-
struction of the anterior cruciate ligament with hamstrings and patellar
tendon. A cadaveric study comparing anterior tibial and rotational
loads. J Bone Joint Surg 2002;84A:907–914.
15. Frank C, Amiel D, Akeson WH. Healing of the medial collateral lig-
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16. Yoshiya S, Andrish JT, Manley MT, et al. Graft tension in anterior
cruciate ligament reconstruction. An in vivo study in dogs. Am J Sports
Med 1987;15:464–470.
17. Jackson DW, Grood ES, Wilcox P, et al. The effects of processing
techniques on the mechanical properties of bone-anterior cruciate lig-
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18. Jackson DW, Grood ES, Cohn BT, et al. The effects of in situ freez-
ing on the anterior cruciate ligament. An experimental study in goats.
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19. Katsuragi R, Yasuda K, Tsujino J, et al. The effect of nonphysiologically
high initial tension on the mechanical properties of in situ frozen anterior
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20. Mikami S, Yasuda K, Katsuragi R, et al. Reduction of initial tension
in the in situ frozen anterior cruciate ligament. Clin Orthop Relat Res
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21. Fleming BC, Abate JA, Peura GD, et al. The relationship between
graft tensioning and the anterior-posterior laxity in the anterior cruci-
ate ligament reconstructed goat knee. J Orthop Res 2001;19:841–844.
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the effect of graft stiffness and graft tensioning in ACL reconstruction.
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23. van Kampen A, Wymenga AB, van der Heide HJ, et al. The effect of
different graft tensioning in anterior cruciate ligament reconstruction:
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24. Yoshiya S, Kurosaka M, Ouchi K, et al. Graft tension and knee stabil-
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Res 2002;394:154–160.
25. Amis AA, Jakob RP. Anterior cruciate ligament graft positioning,
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6:S2–S12.
26. Feller JA, Webster KE. A randomized comparison of patellar tendon
and hamstring tendon anterior cruciate ligament reconstruction.
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27. Freedman KB, D’Amato MJ, Nedeff DD, et al. Arthroscopic anterior
cruciate ligament reconstruction: a metaanalysis comparing patellar ten-
don and hamstring tendon autografts. Am J Sports Med 2003;31:2–11.
28. Boylan D, Greis PE, West JR, et al. Effects of initial graft tension on
knee stability after anterior cruciate ligament reconstruction using
hamstring tendons: a cadaver study. Arthroscopy 2003;19:700–705.
29. Yasuda K, Tsujino J, Tanabe Y, et al. Effects of initial graft tension on
clinical outcome after anterior cruciate ligament reconstruction.
Autogenous doubled hamstring tendons connected in series with
polyester tapes. Am J Sports Med 1997;25:99–106.
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30. Kim SG, Kurosawa H, Sakuraba K, et al. The effect of initial graft
tension on postoperative clinical outcome in anterior cruciate ligament
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2006;126:260–264.
31. Vachtsevanos JG, Lamberson KA, Paulos LE. Anterior cruciate graft
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33. Johnson GA, Tramaglini DM, Levine RE, et al. Tensile and viscoelastic
properties of human patellar tendon. J Orthop Res 1994;12:796–803.
34. Höher J, Scheffler SU, Withrow JD, et al. Mechanical behavior of two
hamstring graft constructs for reconstruction of the anterior cruciate
ligament. J Orthop Res 2000;18:456–461.
35. Arnold MP, Lie DT, Verdonschot N, et al. The remains of anterior
cruciate ligament graft tension after cyclic knee motion. Am J Sports
Med 2005;33:536–542.
36. Grover DM, Howell SM, Hull ML. Early tension loss in an anterior
cruciate ligament graft. A cadaver study of four tibial fixation devices.
J Bone Joint Surg 2005;87A:381–390.
37. Numazaki H, Tohyama H, Nakano H, et al. The effect of initial graft
tension in anterior cruciate ligament reconstruction on the mechanical
behaviors of the femur-graft-tibia complex during cyclic loading.
Am J Sports Med 2002;30:800–805.
38. Howard ME, Cawley PW, Losse GM, et al. Bone-patellar tendon-
bone grafts for anterior cruciate ligament reconstruction: the effects
of graft pretensioning. Arthroscopy 1996;12:287–292.
39. Nurmi JT, Kannus P, Sievanen H, et al. Interference screw fixation of
soft tissue grafts in anterior cruciate ligament reconstruction: part 2:
effect of preconditioning on graft tension during and after screw inser-
tion. Am J Sports Med 2004;32:418–424.
40. Ejerhed L, Kartus J, Kohler K, et al. Preconditioning patellar tendon
autografts in arthroscopic anterior cruciate ligament reconstruction:
a prospective randomized study. Knee Surg Sports Traumatol Arthrosc
2001;9:6–11.
41. Fleming B, Beynnon BD, Johnson RJ, et al. Isometric versus tension
measurements. A comparison for the reconstruction of the anterior
cruciate ligament. Am J Sports Med 1993;21:82–88.
42. Gertel TH, Lew WD, Lewis JL, et al. Effect of anterior cruciate liga-
ment graft tensioning direction, magnitude, and flexion angle on knee
biomechanics. Am J Sports Med 1993;21:572–581.
43. Asahina S, Muneta T, Ishibashi T, et al. Effects of knee flexion angle
at graft fixation on the outcome of anterior cruciate ligament recon-
struction. Arthroscopy 1996;12:70–75.
44. Arnold MP, Verdonschot N, van Kampen A. The normal anterior
cruciate ligament as a model for tensioning strategies in anterior cruci-
ate ligament grafts. Am J Sports Med 2005;33:277–283.
45. Cunningham R, West JR, Greis PE, et al. A survey of the tension
applied to a doubled hamstring tendon graft for reconstruction of
the anterior cruciate ligament. Arthroscopy 2002;18:983–988.
 PART K LIGAMENTIZATION AND GRAFT-TUNNEL HEALING
Graft Remodeling and Ligamentization
After Anterior Cruciate Ligament
Reconstruction
The successful reconstruction of ligamentous
structures in the knee joint, such as the anterior
cruciate ligament (ACL), requires understand-
ing several factors. These are the mechanical
properties of the selected graft tissue as well as
the mechanical behavior and fixation strength
of its fixation materials. However, it is more
important to understand the biological processes
that occur during graft remodeling, maturation,
and incorporation because they affect the
mechanical properties of the ACL reconstructed
knee joint and therefore determine the rehabili-
tation and time course until normal function of
the knee joint can be expected.
Several studies have analyzed the various
changes that occur during graft healing.1–24
Two main sites of healing exist, which should
be separately assessed because their biological
processes vary substantially: the intraarticular
graft remodeling, often referred to as ligamen-
tization, and the intratunnel graft incorporation,
which develops either by bone–bone or tendon–
bone healing.
In the beginning of the 20th century,
Wilhelm Roux described the “law of functional
adaptation,” elucidating on the fact that “an
organ will adapt itself structurally to an alteration,
quantitative or qualitative in function,”25 laying
groundwork for later research on ligamentiza-
tion. He observed that soft tissue structures such
as ligaments and tendons undergo specific
changes in their mechanical and biological prop-
erties when they are exposed to a different
mechanical loading and biological environment.
Amiel et al were among the first authors1,26 to
55
CHAPTER
analyze the specific functional adaptation of an Sven Ulrich Scheffler
ACL replacement graft and postulate the term
Frank Norman Unterhauser
ligamentization. They found a continuous devel-
opment of a patellar tendon graft with biological Andreas Weiler
and mechanical properties different from the
ACL into a structure that closely resembled these
properties of the intact ACL. They showed that
the patellar tendon underwent several phases of
remodeling: an early phase with central graft
necrosis and hypocellularity and no detectable
revascularization of the graft tissue. This was
followed by a phase of proliferation—the time
of most intensive remodeling and revasculariza-
tion—and finally a ligamentization phase that
provided characteristic restructuring of the graft
toward the properties of the intact ACL. Amiel
described this process as a transformation, not a
restoration, of the native ACL because character-
istic differences remained compared with its
replacement grafts. This study laid the founda-
tion for increased research efforts to improve the
understanding of the basic science of intraarticu-
lar ACL graft healing or ligamentization. With
the evolution of ACL reconstruction techniques
to graft fixation in bone tunnels, it was not until
the beginning of the past decade that the first
studies were published on the biological processes
during osseous graft incorporation.* It was recog-
nized that the combined healing of the intraarti-
cular remodeling and the intraosseous graft
incorporation was dictating the mechanical func-
tion of the joint after ACL reconstruction.
*References 4, 12, 15, 21, 27–29.
407
 Anterior Cruciate Ligament Reconstruction
This chapter will summarize the current knowledge of
the temporal and spatial changes of the intraarticular graft
healing and relate them to the mechanical properties of the
ACL graft tissue. Differences between basic science in vitro
and in vivo animal studies and human biopsy studies will be
explained, and the importance of adequate postoperative care
following ACL reconstruction will be highlighted.
EARLY GRAFT-HEALING PHASE
The early graft healing phase extends from the time of ACL
reconstruction until around the fourth postoperative week.
In comparison to studies of the subsequent proli-
feration and ligamentization phases, significantly less
studies exist with analyses of the biological events of this early
graft healing phase. Most authors agree, using different
in vivo animal models,1,2,18,30,31 that this time period is
marked by increasing graft necrosis, mainly in its center,
and hypocellularity. Ultrastructural cell changes such as
mitochondrial swelling, dilatation of the endoplasmatic
retinaculum, and intracytoplasmatic deposition of lipids, as
well as macroscopic swelling and increased cross-sectional
area, illustrate the increasing graft necrosis and degrada-
tion.30 During this time, no graft revascularization can be
observed.2,9,32,33 The graft necrosis leads to a release of
a number of cytokines, such as tumor necrosis factor
(TNF)–a, interleukin (IL)–1ß, and IL-6, in addition to
chemokines that trigger a cascade of growth factors expres-
sion, which in turn result in cell migration and proliferation
as well as extracellular matrix synthesis and revasculari-
zation.11,34 This remodeling activity becomes more pro-
nounced during the latter proliferative phase. However,
already between the first and second weeks, an influx of
cells can be seen into the graft’s periphery.30,31 Kleiner
et al9 and later Yoshikawa et al33 were able to demonstrate
that these cells were originating from tissue other than the
graft itself and that all original graft cells were completely
replaced by 2 to 4 weeks. They hypothesized that the source
of cells was either the synovial fluid, cells from the stump
of the native ACL, or bone marrow elements originating
from drilling maneuvers. Therefore Arnoczky2 suggested
that preservation of the ACL stump and the Hoffa fat
pad might be beneficial, especially for the early healing
period.
During the first postoperative weeks, the graft’s overall
collagen structure and its crimp pattern are still maintained,1
even though the beginning disintegration of the collagen
fibrils and their orientation can be observed as early as 3 weeks
after reconstruction.30,35 This explains the slow decrease in
the mechanical properties of the graft at this early healing
phase.4,15,20
408
Very little is known about the healing processes in the
osseous tunnels, which will be described in more detail in
the following chapter of this book. In summary, only little
graft incorporation can be seen during this early stage of
healing, such that the mechanical properties of the freshly
ACL reconstructed knee joint are primarily relying on the
mechanical fixation of the graft. Biomechanical testing of
intraarticular ACL reconstructions between 2 and 4
weeks4,5,13,20 shows consistent failure by graft pullout from
the tunnel, indicating insufficient anchorage of the graft to
the tunnel wall. The mechanical strength of the ACL
reconstruction at this time is significantly lower than that
at the time of implantation. However, it continues to
decrease until around 6 weeks, when a further increase in
graft remodeling activity can be found and the failure site
shifts to the intraarticular graft region.4,15,20
The decrease in mechanical strength might lead to the
conclusion that early graft loading (i.e., immediate loading
of the freshly reconstructed knee joint) should be avoided.
However, several studies have pointed out the importance
of adequate mechanical loading for the healing graft. Ohno
et al36 stress-deprived the patellar tendon in vivo and found
a significant loss of tensile strength as early as 1 week with
further deterioration until 6 weeks of healing. This loss in
tensile strength was accompanied by splitting and defrag-
mentation of collagen bundles as early as 2 weeks. Similar
findings were reported by Majima et al,37 who examined
differences in complete and partial stress-shielding of a soft
tissue graft, detecting a significantly higher loss in tensile
strength from the first to third week of healing for the com-
plete stress-shielded group. In another study38 the authors
explained this observation with ultrastructural changes in
the collagen composition that shifted to small-diameter
fibrils, which were shown to provide less mechanical
strength than the large-diameter fibrils found in the intact
ACL.39,40 However, overloading of the graft can also lead
to impaired graft healing. Tohyama and Yasuda showed in
their model using an in situ frozen patellar tendon that a
reduction of the cross-sectional area of the tendon by
half (thereby doubling the tendon stress during loading)
resulted in substantially reduced tensile strength as early as
3 weeks, contrary to only a slight increase in tendon stress
(when the cross-sectional area was reduced by only one-
third), which did not significantly impair the mechanical
strength.41
All these studies show that ACL graft healing can
only progress if mechanical loading occurs; however, the
adequate magnitude must be determined. At this early time
of healing, anterior knee stability mainly depends on good
graft fixation because graft incorporation by tendon–bone
healing has not yet occurred. Adequate fixation strength also
allows for mechanical loading of the healing graft, which is
 Graft Remodeling and Ligamentization After Anterior Cruciate Ligament Reconstruction
required for good graft maturation, as previously discussed.
However, excessive loading must be also avoided because
of the decreasing mechanical strength of the intraarticular
graft structure during the first postoperative month.
No human biopsy studies exist for the initial early
healing period. Therefore the current knowledge is solely
based on in vitro cell analyses (human and animal) and
in vivo animal models. All animal models have certain limita-
tions, such as the difficulty to precisely control postoperative
weight bearing. Also, limitations exist in the replication of
today’s refined techniques with optimized graft placement
and strong fixation, which might have an important impact
on the mechanical forces that are transmitted to the graft
and its ensuing early remodeling and healing.
PROLIFERATION PHASE OF GRAFT HEALING
The proliferation phase is characterized by a maximum of
cellular activity and changes of the extracellular matrix, which
are paralleled by the lowest mechanical properties of the ACL
reconstruction during healing. Because cellular proliferation
has already begun during the early healing period, there is a
continuous transition between these two phases. However,
with the most characteristic changes occurring between the
fourth and twelfth postoperative week, this phase is referred
to as the proliferation phase of ACL graft healing.
During this phase, cellularity constantly increases and
substantially surpasses that of the intact ACL, as was observed
in various in vivo animal models.3,8,18,20,42 Cell clusters are
found at the perimeter of the graft around 6 weeks, with large
acellular areas remaining in the graft’s center (Fig. 55-1).
These hypercellular regions were shown to consist of mesen-
chymal stem cells18 and activated fibroblasts11 that are actively
secreting several growth factors such as basic fibroblast
growth factor (bFGF), TGF-ß1, and isoforms of platelet-
derived growth factor (PDGF) to initiate and maintain graft
remodeling. Kuroda et al11 found that the release of these
growth factors peaks between the third and sixth week and
almost completely ceases at 12 weeks of healing, which lends
further explanation for the maximum remodeling activity
during this proliferation phase. A more even distribution of
cells throughout the graft slowly develops thereafter. Cell
numbers are still increased but recede toward the intact
ACL cellularity at the end of the proliferation phase.17,20
An increased number of specific fibroblasts, so-called myofi-
broblasts, are also found during this healing phase.43,44 These
fibroblasts have the ability to exert isometric tension on the
surrounding cellular and extracellular matrix. In the intact
ACL they seem to be responsible for the crimping structure
of the collagen fibers.45 These contractile fibroblasts are pro-
gressively expressed during the first three postoperative
55
months17,44 in the healing ACL graft, when they seem to be
responsible for the restoration of the in situ tension that is
required for the later ligamentization process.
At the same time of increased cellular proliferation and
intense revascularization of the graft tissue, Yoshikawa et al24
found upregulated expression of vascular endothelial growth
factor (VEGF), a potent stimulator of angiogenesis, already
at 2 to 3 weeks postreconstruction, which is triggered by hyp-
oxia during the avascular necrosis of the early healing phase
(Fig. 55-2).47 However, they did not find a significant
increase in vascular outgrowth before the fourth and eighth
week, confirming the descriptive findings of other previously
published studies. Petersen et al14 and Unterhauser et al42
independently showed that revascularization progresses from
the periphery of the graft toward the entire graft diameter at
the end of the proliferation phase around 12 weeks of healing
(see Fig. 55-2). Vascular density then returns to values of the
intact ACL during the phase of ligamentization by 6
months.14,42 It is assumed that this intense revascularization
triggers and retains the maximal remodeling activity. It has
been a matter of debate whether such increased revasculariza-
tion is beneficial to the healing of the graft. Recent studies
found that upregulation of revascularization (e.g., by exoge-
nous application of VEGF) enhanced cellular infiltration
and fibroblast expression during the proliferation phase of
healing, but this also included a significant deterioration of
the graft’s mechanical properties.33 Weiler et al were able to
relate the vascularity of the healing ACL graft in sheep to
its mechanical properties using gadolinium-enhanced mag-
netic resonance imaging (MRI).23 They found that the time
of maximal revascularization coincides with the lowest
mechanical properties of the healing graft tissue, which was
seen around 6 weeks. Tohyama and Yasuda were able to show
that increased remodeling activity in terms of extracellular
infiltration and revascularization was directly related to the
decline in the graft’s mechanical properties.19 These findings
support the reports of numerous other studies that all found
the mechanical properties to be at their minimum around
the proliferation phase of healing at 6 to 8 weeks.* Graft fail-
ure at this time point occurs either by midsubstance tear20 or
graft pullout due to stripping of the graft tissue out of its bone
tunnels.3,13 This illustrates that the graft tissue has become
the weak link in the reconstruction compared with the
graft–bone interface (due to the lack of graft incorporation)
during the early healing phase. Another factor that has been
identified to play a role in the reduced mechanical properties
is the loss of regular collagen orientation and crimp pattern,
which has progressed since the early healing phase. It is not
until the ligamentization phase that a slow restoration of
the collagen orientation and crimp pattern progresses1,8,17,20
*References 3–5, 8, 13, 15, 17, 18, 20, 22, 27, 29.
409
 Anterior Cruciate Ligament Reconstruction

FIG. 55-1 Anterior cruciate ligament (ACL) graft at 6 weeks of healing (Masson-Goldner trichrome staining).
A, Graft hypercellularity (400) with (B) cellular invasion into the periphery and remaining acellular areas of the
graft (100) and (C) hypervascularity at the areas of increased cellular density (100, immunohistochemistry,
Faktor VIII).

FIG. 55-2 Revascularization during graft healing.17 A, Intact anterior cruciate ligament (ACL); B, 6 weeks;
C, 12 weeks. D, 52 weeks.

410
 Graft Remodeling and Ligamentization After Anterior Cruciate Ligament Reconstruction
(Fig. 55-3). At the beginning of the proliferation phase, a
significant decrease in collagen fibril density is demon-
strated, which is followed by increased collagen synthesis48
and a subsequent return to values of the intact ACL at 12
weeks, as shown in an electron microscopy study by Wei-
ler et al.20 During this time of new collagen formation, a
shift can be observed from large-diameter collagen fibrils,
which are dominant in the intact ACL or patellar or ham-
string tendon graft, to small-diameter fibrils.9,20,49,50 It has
been hypothesized that this shift in collagen diameter and
the increased expression of collagen type III in the healing
graft51 might explain why a full restoration of the mechan-
ical strength of the intact ACL has not been observed
even after 2 years of healing.
Although a substantial deterioration of the mechanical
properties of the healing graft during the proliferation phase
55
has been reported in animal models, clinical outcomes after
ACL reconstruction with immediate aggressive rehabi-
litation have been more successful. Several human biopsy
studies found significant differences between the remodeling
activity of human ACL grafts during the first 3 months and
the healing graft in animal models. Although the previously
described healing phases of animal models (graft necrosis,
recellularization, revascularization) are also found in human
ACL graft biopsies,16,52 the remodeling activity of human
ACL grafts seems to be reduced. The complete replacement
of all intrinsic graft cells by extrinsic cells, as in animal mod-
els, has not been shown in the human healing ACL
graft.16,52 Rougraff and Shelbourne16 found viable intrinsic
graft cells in human biopsy specimens at all time points
between 3 and 8 weeks after ACL reconstruction. Also, the
excessive graft necrosis observed in animal studies could not

FIG. 55-3 Change in collagen crimp during graft healing (polarized light microscopy 200; sheep model17,44).
A, Intact anterior cruciate ligament (ACL); B, flexor tendon graft; C, 6 weeks; D, 12 weeks; E, 24 weeks; F, 52 weeks.

411
 Anterior Cruciate Ligament Reconstruction
be found in humans, in whom necrosis or degeneration never
involved more than 30% of the graft’s biopsies. Large areas of
the human ACL graft seem to stay unchanged, displaying
tendinous structure with normal collagen alignment and
crimp pattern.52 These areas were histologically identical to
the native patellar tendon, suggesting survival of portions of
the original graft. Neovascularization was also found but
did not seem to be as excessive as in the animal model.52 Loss
of collagen organization was only detected in areas of neovas-
cularization in human biopsies, which corresponds with the
findings in animal models. These findings might explain
why early loading and aggressive rehabilitation during the
first 3 postoperative months after human ACL reconstruc-
tion did not result in a significant increase in failure rates.
However, human biopsy studies confirm the remodeling
cascade of (limited) graft necrosis, recellularization, revascu-
larization, and changes in collagen crimp and composition
during the early healing and proliferation phases, also sug-
gesting that the human ACL graft might have its lowest
mechanical strength around 6 to 8 weeks postoperatively.
The most appropriate loading for optimization of this phase
of graft healing will have to be determined. It must be high
enough to stimulate graft cells to produce cellular and extra-
cellular components for preservation of graft stability without
compromising graft integrity, which might result in early
stretch-out of the ACL reconstruction.
LIGAMENTIZATION PHASE OF GRAFT HEALING
The ligamentization phase follows directly after the prolifer-
ation phase and involves the ongoing process of continuous
remodeling of the ACL graft toward the morphology and
mechanical strength of the intact ACL. A clear endpoint
of this phase cannot be defined because certain changes still
occur even years after ACL reconstruction. It is still a matter
of debate whether a full restoration of the biological and
mechanical properties of the intact ACL is possible or
whether it is more of a transformation of graft tissue that
resembles but not does not fully replicate the properties of
the intact ACL.
It has been shown in animal studies that cellularity slowly
returns to values of the intact ACL between 3 and 6 months
after reconstruction.17,23,42,46 The typical ovoid shape of meta-
bolically active fibroblasts with its increased cytoplasm/nucleus
ratio of the proliferation phase slowly changes into the less
metabolically active shape of linear, spindle-like fusiform cells
that are normally seen in the intact ACL. Vascularity through-
out the graft decreases and returns to values of the intact ACL,
and vessels become evenly distributed throughout the entire
graft between 6 and 12 months2,17,23,24,42,46 (see Fig. 55-3).
It has also been shown in rabbit, dog, and sheep models1,21,23,53
412
for certain extracellular matrix proteins such as glycosaminogly-
cans and collagen cross-links that the healing graft undergoes a
transformation from its initial tissue properties (e.g., a patellar
tendon of free soft tissue tendon graft) to properties of the
intact ACL during this ligamentization phase1,53 as early as
6 months. Although certain biological features of the healing
graft have been reported to return to the morphology of the
intact ACL, several differences remain, especially regarding
the extracellular matrix. Collagen fibers regain their organiza-
tion into fascicles after complete loss of alignment and initial
dense packaging during the ligamentization phase, which
microscopically resembles the appearance of the intact ACL
around 6 to 12 months after reconstruction.17,44 However,
their initial loss in collagen crimp and strict parallel alignment
during the proliferation phase is only partially restored. A regu-
lar crimp of the collagen fibers can be seen as early as 6 months,
but even after 2 years its frequency stays increased compared
with the intact ACL, as shown in sheep.17,44 The change from
a bimodal distribution of small and dominating large collagen
fibers of the patellar or hamstring tendon graft to a unimodal
pattern of only small collagen fibers of the healing graft does
not change during the phase of ligamentization8,20,28
(Fig. 55-4). The heterogenous composition of collagen fibers
of varying diameter of the intact ACL is never restored.54
The increased synthesis of collagen type III of the proliferation
phase decreases during the ligamentization phase but continues
to be sustained in significantly higher concentrations than in
the intact ACL even at 2 years.30,55 Ng et al found in a dog
model of ACL reconstruction that type III collagen also
remained increased in the remodeling graft at 1 year but
returned to values of the intact ACL by 3 years, suggesting that
the ligamentization process might continue longer than previ-
ously expected.53 Type III collagen is normally found in scar
or early ligamentous repair tissue and has a lower mechanical
strength than type I collagen. The findings of persistent
small-diameter collagen fibrils and increased type III collagen
content are therefore especially important to understand why
all animal models demonstrated significantly lower mechanical
properties of the healing graft than that of the intact ACL even
after long-term healing of up to 2 years.* It has been shown
that the mechanical properties of ACL reconstructed knee
joints improve substantially during the phase of ligamentiza-
tion and reach their final maximal properties at around 1 year.
But until now there has not been a single animal study demon-
strating that the structural properties (e.g., failure load, stiff-
ness) of the healing graft could surpass 50% to 60% of the
intact ACL.{ Some studies were able to show that these
compromised mechanical properties would still allow for
restoration of anteroposterior (AP) laxity to the laxity of the
contralateral intact ACL,22 but others observed significant
*References 4, 8, 17, 22, 23, 30, 53.
{References 3, 4, 8, 13, 17, 22, 23, 27, 46, 53, 56.
 Graft Remodeling and Ligamentization After Anterior Cruciate Ligament Reconstruction 55

FIG. 55-4 Collagen remodeling of a sheep anterior cruciate ligament (ACL) graft. Continuous shift from the
bimodal collagen diameter distribution of the initial soft tissue graft (sheep long flexor tendon) to a unimodal,
small-diameter collagen fibril distribution at 52 weeks and comparison with the heterogenous collagen fibril
diameter of the intact ACL. A, Intact ACL; B, flexor tendon graft; C, 12 weeks; D, 52 weeks.

lower AP laxity even 3 years after reconstruction.56 In sum-
mary, in animal models overall restoration of graft integrity
and histological appearance is completed between 6 and 12
months of healing, acquiring morphology similar to that of
the intact ACL. This is also substantiated by the mechanical
properties that reach their maximal strength around 12 months
without any further significant changes thereafter. However,
characteristic differences, especially in extracellular matrix com-
position, remain, and the initial mechanical strength of the
intact ACL is not restored.
Although human biopsy studies showed substantial
differences from animal models for the proliferation phase,
the ligamentization phase seems to be rather similar in both
models in terms of biological progression. However, the
timeline of these biological changes appears to be different
in human versus animal models. Rougraff et al57 analyzed
23 biopsies of human patellar tendon ACL reconstruction
between 3 weeks and 6.5 years postoperatively. They found
that necrosis took place in much smaller areas of the graft at
3- and 6-week biopsies than was shown in animal models.
However, they found overall degeneration (albeit limited
compared with animal models) to increase until 6 to 10
months and only slowly disappear between 1 and 3 years
postoperatively. Neovascularity and hypercellularity only
slowly appeared and carried on until 10 months, which dif-
fers from observations in animal models. Some nonbiopsy
studies that evaluated graft revascularization using gadolin-
ium-enhanced MRI during the course of healing for 2 years6
could not detect any revascularization except from the peri-
ligamentous ACL graft tissue, which is in contrast to the
findings of Weiler et al,23 who analyzed sheep ACL recon-
struction (also using gadolinium-enhanced MRI) and could
detect significantly upregulated neovascularization during
the first 3 postoperative months. This underlines the differ-
ences in remodeling activity between humans and animal
models, even though all human biopsy studies have shown
that neovascularization does occur but that the extent of vas-
cularity might be below the threshold detectable with gado-
linium-enhanced MRI. Overall, Rougraff et al57 concluded
that the proliferation phase seemed to be delayed compared
with animal models, with the highest remodeling activity
occurring between 3 and 10 months. Identical findings were
made by Falconiero et al58 using patellar tendon and ham-
string tendon ACL reconstruction. They found that hyper-
cellularity and hypervascularity had not returned to control
intact ACL values before 6 to 12 months, with fiber align-
ment being restored around 6 months. No details are given
on ultrastructural differences between the healing graft and
the intact ACL in this study. Full histological maturity
was not found prior to 12 months of healing. Other stud-
ies54,57 even found increased cell counts and differing fiber
alignment beyond 3 years, with graft being indistinguishable

413
 Anterior Cruciate Ligament Reconstruction
from the intact ACL as late as 3-year biopsies. Human
biopsy studies that analyzed changes of the extracellular
matrix observed changes that are in line with the findings
of animal models. Marumo et al59 found that the collagen
cross-links (dihydroxylysinonorleucine/hydroxylysinonorleu-
cine ratios) of patellar tendon and hamstring tendon auto-
grafts had changed from time zero, when they were
significantly different from the intact ACL, to 1 year post-
operatively, when both grafts had acquired cross-link ratios
that were identical to the intact ACL, confirming the liga-
mentization process found in animal models. Interestingly,
biopsy specimens taken at 6 months still showed signifi-
cantly different cross-link ratios of the healing grafts com-
pared with the intact ACL, which is different from the
earlier cross-link restoration found in animal models. This
also confirms the differing timeline of the remodeling of
human ACL grafts. Regarding collagen remodeling, Cho
et al60 and Abe et al54 confirmed the findings of Weiler
et al20 and others8,28 that patellar tendon54 and hamstring
tendon60 ACL grafts showed a replacement of large-
diameter fibrils by small-diameter fibrils, which did not
change even after more than 2 years after reconstruction,
confirming the observations made in animal models.
It is important to understand that the results of graft
healing studies in animal models cannot be directly applied
to the human ACL patient. The biological processes are
similar, but the intensity of graft remodeling in humans is
significantly lower than in animal models. Graft integrity
is much less compromised during the early healing and pro-
liferation phase in human ACL grafts, which might allow
for the assumption that the mechanical properties are also
substantially higher than in animal models during the first
3 postoperative months. Regardless of any model, whether
human or animal, an adaptation of the healing graft toward
the intact ACL occurs. However, a full restoration of either
the biological or the mechanical properties of the intact
ACL does not seem to be achieved. Still, clinical outcome
studies have clearly shown that patients can return to even
the most strenuous activities after primary ACL reconstruc-
tion at 6 months. This is confirmed by human biopsy stud-
ies that revealed an intact, fully viable graft at this time.
However, no final conclusions can be made regarding the
mechanical strength of healing ACL grafts in humans
because techniques are not available for in vivo measurement
of their mechanical properties.
Even though the exact mechanisms that guide the liga-
mentization process are not fully understood, it seems to be
most important that knee joint mechanics are restored by
ACL reconstruction so that the loading conditions of the
intact ACL are precisely replicated. Only if the reconstruction
can restore the anatomy of the intact ACL will knee joint
motion provide the same mechanical stimulus to the healing
414
ACL graft as to the intact ACL. Only then will adequate
moderate remodeling occur that will maintain initial graft
integrity and (partial) cell viability while initiating cellular
and extracellular proliferation and differentiation to adapt
the graft to its new biological and mechanical environment.
The loading that is adequate for the graft at its different
phases of healing will have to be determined so that it can
continue to function as a “real” ACL in obtaining the exact
loading environment as the intact ACL and thus eventually
becoming a fully restored and not an adapted ACL. Future
research will have to be directed toward (1) optimizing
ACL reconstructions to fully restore ACL anatomy and func-
tion while providing the mechanical strength of the intact
ACL; (2) developing biological treatment options that affect
graft healing, especially during the early and proliferation
phase, to optimize extracellular matrix remodeling; and
(3) better differentiating the “good” from the “bad” remodel-
ing changes so that the time to return to full activity without
any restrictions can be reduced.
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50. Tsuchida T, Yasuda K, Kaneda K, et al. Effects of in situ freezing and
stress-shielding on the ultrastructure of rabbit patellar tendons.
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51. Bosch U, Kasperczyk WJ, Oestern HJ, et al. The patellar tendon graft
for PCL reconstruction. Morphological aspects in a sheep model. Acta
Orthop Belg 1994;60:57–61.
52. Johnson LL. The outcome of a free autogenous semitendinosus
tendon graft in human anterior cruciate reconstructive surgery: a histo-
logical study. Arthroscopy 1993;9:131–142.
53. Ng GY, Oakes BW, Deacon OW, et al. Long-term study of the
biochemistry and biomechanics of anterior cruciate ligament-patellar
tendon autografts in goats. J Orthop Res 1996;14:851–856.
54. Abe S, Kurosaka M, Iguchi T, et al. Light and electron microscopic
study of remodeling and maturation process in autogenous graft for
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55. Petersen W, Laprell H. Insertion of autologous tendon grafts to the
bone: a histological and immunohistochemical study of hamstring
and patellar tendon grafts. Knee Surg Sports Traumatol Arthrosc
2000;8:26–31.
56. Ng GY, Oakes BW, Deacon OW, et al. Biomechanics of patellar ten-
don autograft for reconstruction of the anterior cruciate ligament in
the goat: three-year study. J Orthop Res 1995;13:602–608.
57. Rougraff B, Shelbourne KD, Gerth PK, et al. Arthroscopic and histo-
logic analysis of human patellar tendon autografts used for anterior
cruciate ligament reconstruction. Am J Sports Med 1993;21:277–284.
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58. Falconiero RP, DiStefano VJ, Cook TM. Revascularization and liga-
mentization of autogenous anterior cruciate ligament grafts in humans.
Arthroscopy 1998;14:197–205.
59. Marumo K, Saito M, Yamagishi T, et al. The “ligamentization”
process in human anterior cruciate ligament reconstruction with
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60. Cho S, Muneta T, Ito S, et al. Electron microscopic evaluation of
two-bundle anatomically reconstructed anterior cruciate ligament
graft. J Orthop Sci 2004;9:296–301.

Tendon graft healing within the bone tunnel is
one of the most important factors affecting “liga-
mentization” of the anterior cruciate ligament
(ACL) graft, as it contributes to determine the
mechanical behavior of the femur–ACL graft–
tibia complex. The normal ACL attaches to the
bone through a direct-type insertion, which has
a highly differentiated morphology. In fact,
within 1 mm, four different layers can be recog-
nized: fibrous tissue, fibrocartilage, mineralized
fibrocartilage, and bone (Fig. 56-1). This region
plays an important mechanical role, as it allows
a progressive distribution of the tensile load from
a soft tissue (ligament) to a hard tissue (bone).
Several clinical and experimental studies
have shown that after ACL reconstruction,
tendon graft heals within the bone tunnel by the
formation of a bone–graft junction. Biological,
histological, and biomechanical features of this
healing process can vary depending on many
variables.
HUMAN STUDIES
Despite the large amount of animal studies on
bone–tendon graft healing in ACL reconstruc-
tion, very few investigations in humans have been
reported on this issue. Pinczewski et al1 reported
on two biopsies at the bone–graft interface on
patients who underwent revision ACL surgery
for a traumatic graft failure at 6 and 10 weeks after
initial reconstruction with doubled hamstring
tendon (HT) graft and fixation with metal inter-
ference screws. They described graft integration
Graft-Tunnel Healing
56
CHAPTER
by way of collagen fibers resembling Sharpey Giuseppe Milano
fibers between tendon and bone. Petersen and
Laura Deriu
Laprell2 compared bone–tendon graft healing
after ACL reconstruction between the patellar Carlo Fabbriciani
tendon (PT) and HT on biopsy specimens
obtained at ACL revision surgery from 14
patients. They observed that the PT graft healed
within bone tunnel by bone plug incorporation,
maintaining a direct-type insertion at the native
bone plug–tendon junction. Tendon–bone heal-
ing occurred by formation of a fibrous insertion
with no evidence of fibrocartilage. Ishibashi
et al3 examined the histological changes in PT
autografts at the tibial tunnel in biopsy specimens
retrieved during revision surgery after ACL
reconstruction in 10 patients. They observed that
in the early revisions (less than 1 year from prior
reconstruction), the bone–tendon junction was
still immature, with presence of granulation tis-
sue between the tendon and the tunnel wall; in
the late revisions (more than 1 year), the original
bone–tendon junction was not seen, and the ten-
don continued completely to the tunnel wall with
Sharpey-like fibers. Nebelung et al4 obtained
biopsies from the femoral tunnel in five patients
at 6 to 14 months after ACL reconstruction with
HT. Fixation was performed in four patients
with a suspension device (Endobutton or Trans-
Fix) and in one patient with an interference
screw. At histology of the four reconstructions
with a suspension device, biopsies resembled
granulation tissue without continuity of collagen
fibers between the graft and the bony wall. In
contrast, in the graft fixed with interference
screws, a metaplastic fibrous cartilage between
417
 Anterior Cruciate Ligament Reconstruction
FIG. 56-1 Histological section of a direct-type bone-ligament insertion.
Between bone (B) and tendon (T) a transitional fibrocartilaginous layer
(FC) can be seen (Gomori-Halmi staining, 20).
the tendon graft and the lamellar bone was noted. The
authors hypothesized that suspensory fixation can produce
micromotion at the tendon–bone interface, which can impair
graft healing within the bone tunnel. Robert et al5 performed
12 biopsies on patients undergoing an arthroscopy between 3
and 20 months after ACL reconstruction with HT and fem-
oral fixation with a suspension device (TransFix). Histologi-
cal analysis at 3 months showed a fibrovascular interface and
an uncalcified osteoid with very few collagen fibers between
the tendon and the bone. At 5 and 6 months, some Shar-
pey-like fibers and less immature woven bone were seen.
Maturity of insertion with numerous Sharpey fibers at the
tendon–bone interface was seen by 10 months. After 1 year,
the tendon–bone interface was composed of a continuous
layer of Sharpey-like fibers. In three cases, no contact was seen
at biopsy despite good clinical stability at 1 year. The authors
concluded that suspensory femoral fixation of HT graft pro-
duces an indirect fixation that reaches maturity 10 to 12
months after reconstruction.
All the previously mentioned studies are based on his-
tological examination of biopsy specimens retrieved from
418
patients with an ACL graft failure who underwent revision
surgery. Because failed graft incorporation can be advocated
as a cause of reinjury after ACL reconstruction, even in the
presence of a traumatic event, we cannot exclude the theory
that some findings observed in bioptic specimens were
affected by a disturbance of the healing process of the graft
within the bone tunnel. Therefore the clinical relevance of
the information reported in these studies is somewhat
debatable.
ANIMAL STUDIES
Several animal studies have been performed to evaluate the
healing of a tendon graft within a bone tunnel. Although
the findings reported in experimental studies have a certain
clinical relevance, they cannot be entirely applied to the clin-
ical environment because animals have a different knee
kinematics in comparison with humans and are usually trea-
ted without a controlled postoperative regimen. Moreover,
animal studies on bone–tendon healing frequently differ in
some methodological aspects, which merit discussion.
First, experimental studies on bone–tendon healing are
based on two different models: an extraarticular model and an
intraarticular model. The extraarticular model consists of a
tendon graft that is detached from one of its insertions and
fixed within a drilled tunnel of an adjacent bone (i.e., the
digital extensor tendon detached proximally and fixed within
a bone tunnel in the proximal tibia). In the intraarticular
model, an ACL reconstruction is performed using a free
tendon graft (i.e., the semitendinosus tendon) or the central
third of the PT. This model better reproduces the ACL
reconstruction in humans. In fact, the extraarticular model
does not consider the biological stimuli of the intraarticular
environment that may influence graft healing within the
tunnel.
Second, experimental settings can vary according to
the animal model selected, as knee kinematics of an animal
model can be more or less similar to that of the human
knee; furthermore, the material properties of the tendon
graft selected for reconstruction in comparison with those
of native ACL can influence the results of the study.
Third, studies on tendon–bone healing differ in the
methods of investigation of the results. Several authors
performed a histological examination of the bone–tendon
graft interface,6–13 whereas others focused on the mechanical
properties of the bone–tendon graft complex.14–19 It has to be
considered that most of the biomechanical studies were based
on a load-to-failure (LTF) testing of the femur–graft–tibia
complex and did not consider the effect of primary fixation
on the structural properties of the complex. For this reason,
some authors have performed mechanical testing after

removal of the fixation devices in order to quantify the
mechanical role of bone–tendon graft interface.14,15,17–19
Moreover, almost all the experimental studies performed
histological and/or biomechanical evaluations at different
time intervals, and although some authors evaluated the
long-term fate of tendon graft healing within a bone
tunnel,8,10,11,13,16,20 most authors focused on the first 12
weeks after surgery because of the clinical relevance of this
period for planning postoperative rehabilitation and return
to physical activity.
Finally, the number and type of variables correlated to
the outcome greatly differ among the various studies, so it
is necessary to consider in detail the results reported in the
literature in order to better understand which factors can
affect the healing process of a tendon graft within a bone
tunnel.
Type of Graft
Several experiment studies focused their attention on histo-
logical and biomechanical findings of bone–tendon graft
healing according to the type of tendon graft. The first reports
on tendon graft healing within a bone tunnel showed that it
happens through bone apposition at the tunnel wall and for-
mation of fibrous tissue at the bone–graft interface, which
matures with time and anchors the graft to the bone.21–23
More recent studies on extraarticular animal models6,9
demonstrated that tendon graft heals within a bone tunnel
by formation of an indirect-type junction composed of a
fibrous tissue containing perpendicular collagen fibers
resembling Sharpey-like fibers that penetrate into the bone,
without a transitional fibrocartilaginous layer between
tendon and bone (Fig. 56-2). In a biomechanical analysis,
Rodeo et al6 showed that until 8 weeks after surgery, the
FIG. 56-2 Histological section of an indirect-type bone-ligament insertion.
The fibrous tissue (T) attaches to the bone (B) without a transitional
fibrocartilaginous layer (Gomori-Halmi staining, 20).
Graft-Tunnel Healing 56
healing tissue at the bone–graft interface was not mechani-
cally competent and the graft failed due to pullout from
the tunnel.
Experimental studies performed on intraarticular
models of ACL reconstruction with single or doubled semi-
tendinosus tendon graft confirmed that even an autologous
ACL graft heals within the bone tunnel by formation of
an indirect-type junction at the bone–graft interface, with
Sharpey-like fibers perpendicular to the tunnel wall.7,8,11
The newly formed insertion was evident 8 weeks after sur-
gery and completed after 24 weeks. However, biomechanical
testing showed that the graft remains weak within 1 year
after surgery, with a mean failure load ranging from 25%
to 50% of the normal ACL. Regarding the tensile strength
of the bone–tendon graft junction, Grana et al,7 using a sin-
gle-strand semitendinosus tendon graft in a rabbit model,
observed that during the first 3 weeks after surgery the graft
suffered a rapid and dramatic loss of its mechanical proper-
ties and failed mostly at its midsubstance rather than due to
pullout from the tunnel. On the contrary, Goradia et al,11
using a doubled semitendinosus tendon graft in a sheep
model, observed that up to 12 weeks, graft failure occurred
by pullout from the bone tunnel. Therefore they stated that
for as long as 3 months after surgery, the graft has not
completely healed within the bone tunnel.
Other authors10,12,15 focused their attention on the
healing process of grafts with bone plugs, such as the patellar
tendon, within a bone tunnel (bone–bone healing). They
observed that graft healing occurs differently for the bone plug
and the intraosseous tendinous portion of the graft. In fact,
bone plug incorporation at the tunnel wall occurs through a
progression of necrosis, resorption, and remodeling, and after
3 months it is no longer distinguishable from the surrounding
bone. The intraosseous tendinous portion of the graft heals to
the bone tunnel by formation of an indirect-type insertion
with penetrating collagen fibers that appear well organized
by 3 months after surgery, similarly to the healing process
observed for free tendon grafts. The native bone–tendon
junction of the graft shows degeneration of the fibrocarti-
laginous layer by 6 weeks, which is during the phase of
bone plug remodeling. However, by 6 months it appears to
be redifferentiated with four distinct zones.
Comparative studies between tendon–bone and
bone–bone healing on intraarticular models of ACL recon-
struction confirmed similar histological findings.14,15,24
However, biomechanical testing demonstrated that bone–
bone healing occurs more rapidly than tendon–bone healing.
In fact, up to 3 weeks, both soft tissue and bone plug tendon
grafts fail due to pullout from the bone tunnel. Between 6
and 8 weeks after surgery, the bone–bone interface appears
mechanically stronger than the tendon–bone interface, but
this difference is no more significant by 12 weeks. These
419
 Anterior Cruciate Ligament Reconstruction
observations led the authors to conclude that soft tissue
grafts such as hamstring tendons heal more slowly than
PT within the bone tunnel after ACL reconstruction; there-
fore the fixation device for soft tissue tendon grafts is more
important than comparing it to PT graft during the first
weeks after surgery.
Regarding the tendon allograft, experimental studies
showed that the bone–graft healing process is similar to that
observed for autografts.20,25,26 However, it occurs more
slowly and the newly formed bone–tendon junction is evi-
dent only after a period varying from 18 weeks to 6 months
after surgery. This delayed healing process should be related
to the inflammatory response to the allogenic material,
which persists for a long time around the graft20 and prob-
ably leads to the tunnel-widening phenomenon that mainly
occurs during the first weeks after surgery.26
Bone Quality
Another variable that can influence tendon graft healing is the
quality of bone where the graft is fixed. It is well known that
bone density is different between the distal femur and the
proximal tibia; this could affect the quality and rate of incor-
poration of tendon graft at the cancellous bone surface of
the tunnel wall. Some authors11,27 investigated this feature
of bone–tendon graft healing on experimental intraarticular
and extraarticular models; however, the role of bone quality
on bone–tendon graft healing remains unclear. Goradia
et al11 performed an ACL reconstruction with doubled semi-
tendinosus tendon graft and did not observe histological dif-
ferences in tendon–bone healing between the femoral and
tibial tunnel at each interval (from 2 to 52 weeks). On the con-
trary, Grassman et al,27 using the semitendinosus tendon
graft for extraarticular reconstruction of the medial collateral
ligament in a rabbit model, observed that incorporation and
remodeling of the graft within the bone tunnels were much
more extensive at the cancellous-filled femoral bone–graft
interface than within the marrow-dominated tibial tunnel,
thus suggesting that tendon graft healing may depend on
the cancellous bone architecture at the bone–graft interface.
Fixation Technique
Most studies performed to evaluate tendon–bone healing did
not consider graft fixation technique as a factor affecting
the healing process. Particularly, many authors reported
the use of periosteal or transosseous sutures for graft
fixation.6–9,28 This fixation technique cannot guarantee high
structural properties of the bone–tendon graft complex before
biological fixation has occurred. Recently, some authors
investigated the role of primary fixation on bone–tendon
420
healing, reproducing in animal models some fixation
techniques currently used in humans for ACL tendon grafts.
Weiler et al13,16 performed a histological and biomechanical
evaluation of healing of a tendon graft fixed within the tibial
tunnel with an interference fit screw (1 mm larger than the
tunnel) after an ACL reconstruction with autologous
Achilles tendon split graft in a sheep model. They observed
that bone–tendon healing, under the compressive effect of
the interference screw, progressed partially by direct contact
without development of a fibrous transition interface, whereas
at the articular tunnel aperture site a well-differentiated,
direct-type junction was evident by 24 weeks.13 Biomechani-
cal testing16 showed that at 6 and 9 weeks, all grafts failed
at the screw insertion site. By 24 weeks, grafts failed by
osteocartilaginous avulsion from the tibial attachment site.
These findings indicate that interference fit fixation may
compromise the mechanical properties of the graft in the early
healing phase at the screw insertion site, but the compressive
effect of the screw supplies a biological stimulus toward the
formation of a physiological, direct–type bone–graft inser-
tion. Singhatat et al17 used an extraarticular reconstruction
model in ovine tibiae to evaluate the effect of the fixation tech-
nique on the mechanical properties of a bone–tendon graft
complex, comparing two different fixation devices: an absorb-
able interference screw and a spiked screw and washer
(WasherLoc). They observed that the strength of biological
fixation of tendon to bone increased slower with the interfer-
ence screw than with the screw and washer. In fact, tensile
testing on tendon graft–bone tunnel interface (after removing
the fixation device) after 4 weeks of implantation showed that
with interference fixation, mean strength and stiffness were
respectively 31% and 36% of that observed for the complex
at implantation (time zero). With WasherLoc fixation,
strength and stiffness were respectively 50% and 143% of
the complex at implantation. The authors supposed that
interference fixation might impair tendon healing within the
bone tunnel as it decreased the contact area between the
tendon and the surrounding bone. Furthermore, the com-
pressive effect of the interference screw on the tendon graft
may prevent the ingrowth of blood vessels along the entire
length of the tendon graft. However, this hypothesis was
not confirmed in this study by a histological examination.
Gap Size
Another important factor related to bone–tendon healing is
the gap between the tendon graft and the walls of the
bone tunnel. This is important especially in ACL reconstruc-
tion with doubled HT graft and suspensory femoral
fixation devices, such as Endobutton or TransFix, as these fix-
ation devices do not produce any compressive effect on the

intraosseous portion of the graft, and therefore the thickness
of the healing tissue at the bone–tendon interface depends
on the size of the gap between the graft and the bone at the
time of reconstruction. Tien et al29 evaluated the effect of
gap size on the tendon-to-bone healing on ACL reconstruc-
tion with autologous semitendinosus tendon graft in a rabbit
model and observed that healing tissue at the bone–tendon
interface appeared denser and more organized in the speci-
mens with a smaller gap. Tensile testing at 2 weeks confirmed
a significantly greater maximal tensile strength for specimens
in which the tunnel had the same diameter of the graft than
for specimens with a tunnel 25% to 33% larger than the graft.
Greis et al,28 using an extraarticular bone–tendon healing
model in dogs, reported similar data. They observed that the
failure load of tendon–bone complex was significantly greater
when the bone tunnel approximated the diameter of the
tendon graft (4.2 mm) in comparison with specimens with a
6-mm tunnel. On the contrary, Yamazaki et al30 in an experi-
mental study in dogs observed that a free tendon graft used for
ACL reconstruction healed in a bone tunnel that was 2 mm
larger than the graft by formation of a connective transitional
fibrous layer that was denser and better organized than that
observed in specimens with a bone tunnel having the same
diameter as the graft. Moreover, mechanical analysis showed
that at 3 and 6 weeks, the differences in ultimate failure load
and failure mode between the two groups of specimens were
not significant.
Mechanical Stresses
Indeed, mechanical stresses influence healing of a tendon
graft within a bone tunnel. As previously reported, fixation
technique and gap size can influence graft healing because
they can modify the loads applied to the intraosseous por-
tion of the graft. However, it is unclear how magnitude
and direction of loads applied to the graft can affect the
quality and rate of the healing process.
Regarding load magnitude, it is important to distin-
guish between loads applied during healing time and initial
tensile load due to graft tensioning at the time of surgery.
Sakai et al31 investigated the effect of immobilization on
the biological fixation of a tendon graft within the bone tun-
nel after ACL reconstruction in a rabbit model and showed
that no immobilization delays the bone–tendon healing and
impairs the mechanical strength of the newly formed bone–
graft junction. Abramowitch et al32 evaluated the effect of
initial graft tension on the tensile properties of an ACL
graft in a goat model and observed that high initial tension
of the ACL graft better replicated a normal knee kinematics
immediately after reconstruction in comparison with a low
graft tension; however, this effect diminished during the
early graft healing process.
Graft-Tunnel Healing 56
Some interesting findings regarding the effect of
direction of loads applied to the graft on bone–tendon graft
healing are reported by Yamakado et al,33 who showed that
tendon–bone healing responds to mechanical stress applied
to the tendon graft. In an extraarticular tendon graft recon-
struction in a rabbit model, they observed that tensile stress
enhances the healing process of the bone–tendon junction,
compressive stress promotes chondroid formation, and shear
load has little or no effect on regeneration of the bone–
tendon junction. These forces are differently distributed
along the bone–tendon graft interface and according to the
direction of tunnel in relation to the axis of the intraarticular
portion of the tendon graft.
Authors’ Experience
We analyzed in a sheep model the mechanical behavior of
the tendon graft–bone interface on ACL reconstruction,
comparing patellar tendon (Group 1) and a free tendon graft
(Group 2) using the doubled lateral extensor of toes
(DLET).18 Femoral fixation was achieved in all specimens
with a transverse fixation: a metal setscrew for the PT graft,
and a modified TransFix for the DLET graft. On the tibia,
the graft was fixed with an absorbable interference screw in
both groups. Animals were sacrificed after 1, 2, 3, and 6
months postsurgery, and an LTF mechanical testing on the
femur–graft–tibia complex (FGTC) was performed after
removing (Subgroup A) or maintaining (Subgroup B) the
femoral fixation device in order to evaluate the mechanical
properties of the proximal tendon graft–bone tunnel interface
and the contribution of the fixation device over time.
Specimens were compared with control groups that consisted
of normal ACL, normal grafts, and reconstructions at
time zero.
Results of the mechanical testing performed on the
control (Table 56-1) and treated groups (Table 56-2) showed
a similar trend in the variation of the structural properties of
the two groups in comparison with the controls. At 1 month,
mean failure load dramatically decreased. After this period,
we observed a significant increase, although the variation
between the second and the third month was not significant.
Mean stiffness showed a dramatic decrease at 1 and 2 months,
whereas in the 3-month samples a significant increase
occurred. However, at 2 and 3 months, the structural proper-
ties of the treated groups remained significantly lower than
the control groups. At 6 months, we observed a significant
improvement of the structural properties in both groups,
much greater than that reported in previous studies.8,11,16 In
fact, 6 months after surgery, the PT graft showed a good
recovery of its original structural properties and also approxi-
mated the strength (about 83%) and stiffness (about 107%
to 109%) of a normal ACL. The DLET graft at 6 months
421
 Anterior Cruciate Ligament Reconstruction

TABLE 56-1 Results of Load-to-Failure Tests on the Control Groups
(Mean  SD)
Failure Load (N) Stiffness (N/mm)
Normal ACL 723.0  12.1 156.6  6.1
Normal PT 830.1  16.6 176.8  9.3
Time zero: PT 607.8  14.4 89.8  5.9
Normal DLET 1139.8  44.5 285.7  22.6
Time zero: DLET 1032.8  43.7 210.1  15.5
ACL, Anterior cruciate ligament; DLET, doubled lateral extensor of toes; PT, patellar
tendon; SD, standard deviation.
showed a severe impairment of its original structural proper-
ties. However, strength and stiffness were about 80% and
110% of a normal ACL, respectively. When comparing the
structural properties of the femur–PT graft–tibia complex
with and without a femoral fixation device, we did not observe
significant differences for all the variables considered at every
time interval. This would imply that the presence of the fixa-
tion device did not influence the mechanical behavior of the
FGTC. On the contrary, comparison between the two
DLET subgroups, with and without the fixation device,
showed a significant difference for mean failure load and stiff-
ness in the 1-month samples. Furthermore, on comparison of
the specimens of the two groups in which the femoral fixation
devices had been removed before the mechanical test (Sub-
group A), we observed that at 1 month the structural proper-
ties of the PT group were significantly greater than the
DLET group. For the following time intervals, the structural
properties of the two types of graft did not significantly differ.
Analysis of the failure mode in specimens without the fixation
device showed that at 1 month, PT graft failure always
occurred at its intraarticular part, whereas the DLET grafts
failed by means of pullout from the femoral tunnel. In the
following time intervals, the grafts always ruptured at their
midsubstance in both groups. This would demonstrate that
the bone plug of the PT graft incorporated in the femoral
tunnel in an early phase after ACL reconstruction, making
the bone–graft junction mechanically competent after 1
month, probably due to the compression effect of transverse
fixation that accelerated bone–bone healing. On the contrary,
the DLET graft was not yet incorporated in the femoral
tunnel 1 month after surgery; therefore, in absence of the
fixation device, it slipped out of the tunnel when submitted
to traction.
Although our study was based on an animal model,
we believe that some observations have some clinical
relevance. First, 6 months after ACL reconstruction, both
PT and doubled free tendon grafts are less strong (about
80%) but stiffer (about 110%) than normal ACL, and thus
they may be considered as valid substitutes of the ACL.
Second, although the bone plug of the PT graft allows a
faster incorporation of the graft within the bone tunnel, it
does not improve the mechanical properties of the FGTC.
Third, doubled free tendon grafts need high fixation
strength and stiffness because they require more than 4
weeks to heal into the bone tunnel. Finally, the use of
fixation devices that guarantee a high fixation strength and
stiffness does not allow acceleration of the postoperative
rehabilitation, as primary fixation has a determinant
mechanical role only during the first weeks after surgery.
FUTURE DIRECTIONS
In recent years, numerous experimental studies have been
carried out to evaluate the effects of exogenous factors on
healing of a tendon graft within a bone tunnel, using both
extraarticular and intraarticular experimental models. These
studies focused on two different goals: (1) to accelerate
tendon–bone healing by increasing bone apposition around
the tendon graft and new formation of collagen fibers at the
bone–graft interface, with the aim of allowing early postop-
erative return to normal daily activities as well as sports and
reducing the risk of graft failure due to pullout from the
bone tunnel, and (2) to promote differentiation of the newly

TABLE 56-2 Results of Load-to-Failure Tests on the Treated Subgroups (Mean  SD)
Failure Load (N) Stiffness (N/mm)

Subgroup 1A 1B 2A 2B 1A 1B 2A 2B

1 month 41.8  2.4 43.2  3.0 25.6  4.0 39.7  8.9 30.7  3.3 31.0  3.1 18.2  2.9 29.5  4.1

2 months 165.1  14.4 163.5  10.5 168.6  18.1 171.2  14.0 31.5  2.0 31.2  2.1 30.2  3.0 31.5  2.5

3 months 185.3  17.5 184.9  11.8 179.9  14.3 187.8  16.7 48.6  6.2 49.0  4.5 50.5  4.8 53.0  6.0

6 months 602.9  29.0 600.7  11.0 578.0  15.7 583.7  28.2 167.9  8.4 171.3  10.0 172.3  13.5 170.7  11.3

SD, Standard deviation.

422

formed bone–tendon junction into a direct-type insertion as
similar as possible to that of normal ACL in order to obtain
a more physiological distribution of tensile forces between
the intraarticular part of the graft and its insertion to the
bone. Although these exogenous factors showed promising
results, they cannot yet be widely applied to ACL surgery
because they require further investigation to optimize deliv-
ery techniques, therapeutic concentrations, and maintenance
of therapeutic effects with time and to reduce the risk of
undesirable effects.
Bone Proteins and Growth Factors
Several studies have shown the effect of some polypeptides
including bone morphogenetic proteins (BMPs) and growth
factors (GFs), such as transforming growth factors (TGFs),
fibroblast growth factor (FGF), platelet-derived growth
factor (PDGF), and epidermal growth factor (EGF), on the
activation and regulation of proliferation and differentiation
of bone and fibrous and cartilaginous tissues.34–36 Based on
these experiences, some authors investigated the role of
BMPs and GFs in promoting tendon–bone healing through
the activation and acceleration of bone ingrowth, collagen
fiber synthesis, and fibrocartilaginous differentiation at the
bone–tendon graft interface, with the aim of obtaining early
formation of bone–tendon insertion similar to that of normal
ACL. Rodeo et al37 reported the effect of locally applied
BMP-2 on tendon healing in bone tunnel in dogs. They
showed that animals treated with recombinant human
BMP-2 had radiographic evidence of more extensive forma-
tion and closer apposition of new bone around the tendon
graft in comparison with controls. Biomechanical analysis
confirmed higher pullout strength in BMP-treated speci-
mens. Anderson et al38 reported an experimental study on
ACL reconstruction with autologous semitendinosus tendon
graft in a rabbit model, using a collagen sponge wrapped
around the portion of the graft inside the bone tunnel as a car-
rier vehicle to release a bone-derived extract that contained
several bone morphogenetic proteins (BMP-2, BMP-3,
BMP-4, BMP-5, BMP-6, and BMP-7) and growth factors
with known osteoinductive activity or that can modulate bone
formation, such as TGF-ß1, TGF-ß2, TGF-ß3, and FGF.
Although this mixture of bone-derived proteins did not allow
the effects of each protein on tendon–bone healing to be dis-
criminated, the authors observed that animals treated with
bone-derived proteins had a histological appearance of a more
consistent, dense interface tissue and closer apposition of new
bone to the graft, with occasional formation of a fibrocartila-
ginous interface, when compared with control specimens at 2,
4, and 8 weeks after surgery. Biomechanical analysis demon-
strated a significant increase in ultimate tensile strength of the
Graft-Tunnel Healing 56
treated grafts (from 47% more than controls at 2 weeks to 80%
at 8 weeks). Mihelic et al39 reported a study on ACL recon-
struction with autologous peroneus tertius tendon graft in a
sheep model. They applied a carrier sponge with recombinant
human BMP-7 to the bone–tendon graft interface and
observed that bone formation and remodeling around the
graft at 3 and 6 weeks after surgery were more extensive in
knees treated with BMP-7 compared with control knees.
Mechanical testing showed a significantly greater tensile
strength in grafts treated with BMP-7 than in control speci-
mens. Yamazaki et al19 performed an experimental study in
dogs to detect the effect of TGF-ß1 on healing of the flexor
tendon autograft in ACL reconstruction. TGF-ß1 was mixed
with fibrin sealant and applied in the graft–bone gap of the
tibial tunnel. At 3 weeks, histological examination showed
that perpendicular collagen fibers connecting the tendon to
the bone (resembling Sharpey fibers) were richly generated
in knees treated with TGF-ß1 compared with control knees.
In mechanical pullout testing after removing tibial graft fixa-
tion, the ultimate failure load and stiffness of the graft–tibia
complex of knees treated with TGF-ß1 were significantly
higher than those of controls.
Gene Therapy
Some limits in the intraarticular use of bone proteins and
growth factors are represented by their short half-life and
removal by synovial fluid that can affect the maintenance
of therapeutic local concentrations. For this reason, some
researchers have attempted to develop techniques of gene
transfer, consisting of the injection of transduced cells that
express genes for synthesis of desired proteins (i.e., growth
factors) at high local concentration for prolonged time
periods. These techniques have been applied to enhance
tendon–bone healing. Martinek et al40 reported a study on
genetically engineered semitendinosus tendon grafts used
for ACL reconstruction in rabbits to evaluate the capacity
of BMP-2 gene transfer to improve healing of a tendon
graft in the bone tunnel. They observed that at 6 weeks,
grafts infected with adenovirus-BMP-2 (AdBMP-2) had
broad zones of a newly formed transition layer at the
bone–graft interface, resembling a direct-type insertion.
Mechanical testing showed that ultimate failure load and
stiffness of grafts infected with AdBMP-2 were significantly
greater than controls. This study was highly remarkable, as
it showed that sustained and prolonged local BMP-2 deliv-
ery using gene transfer modality created a bone–tendon graft
insertion similar to that of a normal ACL. However, many
questions need to be answered regarding safety and
regulatory issues before gene transfer is suggested as a ther-
apeutic method in orthopaedics.41
423
 Anterior Cruciate Ligament Reconstruction
Inhibitors of Matrix Metalloproteinases
Matrix metalloproteinases (MMPs) such as collagenases
and stromelysins are zinc-dependent enzymes that have a
catalytic effect on connective tissues by degrading different
types of collagen. These enzymes are increased in the intra-
articular environment in the acute phase following ACL
rupture and are presumably increased following ACL recon-
struction. Therefore it seems likely that MMPs have an adverse
effect on tendon–bone healing that occurs by formation of col-
lagen fibers at the bone–graft interface. For these reasons, some
authors42,43 have hypothesized that tissue inhibitors of metal-
loproteinases (TIMPs) could have a potential positive effect
on the healing process of a tendon graft within a bone tunnel.
Demirag et al43 tested the potential enhancement effect of
a-2 macroglobuline on bone–tendon healing of ACL graft by
blockage of synovial MMP activity in a rabbit model. They
injected a-2 macroglobuline into the knee joint after ACL
reconstruction with semitendinosus tendon autograft to block
the MMPs in the synovial fluid and observed after 2 and 5
weeks a significantly decreased concentration of type I collage-
nase (MMP-8) in the synovial fluid compared with the control
group. Histological examination showed that the bone–tendon
interface within the tunnel in the treated specimens had more
areas of denser connective tissue ingrowth compared with the
controls. Mechanical testing showed that the mean ultimate
failure load of treated specimens was significantly greater than
control specimens at both 2 and 5 weeks.
Cell Therapy
Some authors have investigated the effects of mesenchymal
stem cells (MSCs) on the quality and rate of a tendon graft
osteointegration.44,45 MSCs are pluripotent cells that can be
harvested from bone marrow of the iliac crest, isolated and
cultured in vitro, included in a fibrin gel as carrier, and
applied along the bone–tendon graft interface. Ouyang
et al,44 in an extraarticular rabbit model, showed the pres-
ence of discontinuous areas of fibrocartilage-like tissue con-
taining type II collagen at the bone–graft interface by 4
weeks after surgery. Lim et al45 reported similar results on
an experimental model of ACL reconstruction. By 2 weeks,
they observed large areas of cartilage at the newly formed
bone–graft junction with histological features similar to
those of the normal ACL by 8 weeks. Mechanical testing
showed that the tensile strength of the grafts treated with
stem cells was significantly greater than controls by 8 weeks.
Biological Scaffolds
Some authors have focused their attention on the use of
periosteal grafts to enhance tendon graft healing within a
424
bone tunnel.46–49 Periosteum is an osteogenic tissue that
modulates bone formation and remodeling at the cortical
bone surface. Therefore it was hypothesized that periosteum
should behave as a biological scaffold to promote and acce-
lerate bone–tendon graft healing. Experimental studies on
extraarticular models in rabbits evaluated histological and
biomechanical features of tendon grafts wrapped in perios-
teum in the intraosseous part. They showed that periosteum
promotes a more extensive and closer apposition of new bone
around the tendon graft.48 Moreover, a bone–tendon fibro-
cartilaginous insertion has been observed by 4 to 12 weeks
after surgery.46,47 It was reported that a biological effect of
periosteum on bone–tendon graft healing is more evident
when the cambial layer of the scaffold faced the tunnel wall49
and that fresh periosteal graft is more effective than fresh-
frozen graft.46 Biomechanical testing showed controversial
results regarding the mechanical strength of biological fixa-
tion in the early phase after surgery. In fact, Kyung et al48
reported that the mean pullout strength of periosteum-treated
grafts was significantly greater than controls at 3 and 6 weeks.
On the contrary, Chen et al47 observed that at 4 weeks the
difference in tensile strength between periosteum-treated
grafts and controls was not significant and graft failure at
that period always occurred due to pullout from the bone
tunnel. The difference in mechanical properties between
treated specimens and controls was significant by 8 weeks
after surgery.
Another technique of biological scaffolding to promote
tendon graft healing within a bone tunnel consists of filling
the gap between the tendon and the bone with a bone substi-
tute. Tien et al50 performed an ACL reconstruction with
semitendinosus tendon graft in a rabbit model and filled the
gap between the tendon graft and the femoral bone tunnel
with a paste of calcium-phosphate cement (CPC) obtained
from mixing tetracalcium phosphate (TTCP) and dicalcium
phosphate anhydrous (DCPA) powders. Histological exami-
nation showed that CPC produced early, diffuse, and massive
bone ingrowth within the tunnel in comparison with
control specimens. Mechanical testing showed that the mean
maximal tensile strength for treated grafts was significantly
greater than controls at 1 and 2 weeks after reconstruction.
CONCLUSIONS
Several experimental studies have shown that bone–tendon
graft healing in ACL reconstruction occurs in a period vary-
ing from 3 to 12 weeks. The quality and rate of healing
depend on many variables, predominantly the type of
graft. Soft tissue grafts such as hamstring tendon grafts
heal within a bone tunnel by formation of a fibrous transi-
tional layer between the tendon and bone, which contains

penetrating Sharpey-like fibers. This newly formed bone–
tendon interface matures with time and resembles the
indirect-type insertion observed in tendons and ligaments.
Bone plug tendon grafts, such as patellar tendon, heal
within bone tunnel by incorporation of the bone plug to
the surrounding bone and formation of an indirect-type
insertion at the interface between bone and the intraosseous
fibrous portion of the graft. Bone–bone healing occurs more
rapidly than tendon—bone healing. Resistance to pullout
force appears to be similar between the two types of grafts
by 8 to 12 weeks after surgery. Therefore soft tissue grafts
need high primary fixation strength and stiffness because
of the consistent risk of failure due to pullout from the tun-
nel during the first 2 months. Mechanical stresses can affect
maturation and differentiation of the bone–tendon graft
junction depending on many factors such as bone density,
fixation, placement and tensioning of the graft, gap size,
and postoperative immobilization. Compression of the graft
within the tunnel can enhance healing for both the bone
plug and soft tissue. However, during the first 3 months
after an ACL reconstruction, regardless of the type of graft
used, the strength of the bone–tendon graft junction does
not influence the mechanical behavior of the femur–ACL
graft–tibia complex because the weak link of the ligament
replacement rapidly shifts from the fixation site to the mid-
substance of the graft. Therefore the application of excessive
loads during this period, such as a too-aggressive rehabi-
litation and early return to sport activities, may cause a per-
manent elongation of the graft, thus compromising the
result of the reconstruction. Many efforts have been
made to improve the quality and rate of bone–tendon
healing. Tissue engineering and gene transfer techniques
have been applied to obtain a direct-type fibrocartilaginous
insertion of the ACL graft, similar to that of the native
ligament, and to accelerate the healing process of tendon
grafts within bone tunnel. However, more investigations
will be necessary in the near future to evaluate the possible
employment of these biological techniques in the clinical
practice.
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 PART L REVISION ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION
Revision Anterior Cruciate Ligament
Reconstruction Using Autologous
Hamstring Tendons
INTRODUCTION
Due to the high incidence of anterior cruciate
ligament (ACL) ruptures and the tremendous
socioeconomic importance of this injury, there
continues to be intensive research into basic
science, pathology, and reconstruction techni-
ques of the ACL. Thus a wide range of tech-
niques for ACL reconstruction and numerous
different fixation devices are available. Never-
theless, the perfect technique for ACL recon-
struction still seems to be elusive, demonstrated
by the fact that primary ACL reconstruction is
not successful in restoring normal knee kine-
matics in all cases. According to the current liter-
ature, revision surgery after primary ACL
reconstruction is performed in 3% to 25% of cases
due to long-term graft failure as well as unsatis-
factory outcome (loss of range of motion, locking,
effusion, pain, etc.).1–3
It is generally believed that revision ACL
reconstruction is a challenging procedure requir-
ing experience in a variety of different surgical
techniques and graft fixation techniques. Revision
ACL reconstruction might be even more deman-
ding if surgical mistakes have been made during
primary reconstruction, if a double-bundle recon-
struction was performed, or if a severe tunnel
enlargement has developed. Whether revision
ACL reconstruction can be performed as a
single- or two-staged procedure mainly depends
on tunnel and hardware management.2,4,5
It has to be emphasized that the tech-
nique and the fixation devices selected for
57
CHAPTER
ACL reconstruction should always easily allow Andreas Weiler
for eventual later revision. However, unfor-
Michael Wagner
tunately some techniques do not allow for an
easy revision reconstruction, as demonstrated
later.
The goals of revision ACL reconstruction
are similar to primary ACL reconstruction and
include stabilization of the knee, prevention of
further injury to articular cartilage and menisci,
and recovery of knee function.
It is generally believed that the overall
clinical outcome after revision ACL reconstruc-
tion is inferior compared with primary proce-
dures.2,5–13 Thus the importance of counseling
the patient preoperatively about less satisfactory
results than in primary ACL reconstruction
must be emphasized. However, taking an
inferior result into account, as described in the
current literature, one might be quickly less
optimistic about producing an optimal result
after revision reconstruction. Therefore it should
be our primary goal to be as perfect as possible
with diagnostics and decision making as well
as surgery in order to offer the patient a success-
ful outcome, as in primary reconstruction. Thus
we strongly recommend the use of a clearly
defined diagnostic and treatment algorithm in
order to fulfill that goal.
FAILURE ANALYSIS
Because of different surgical techniques, differ-
ent graft types (including all kinds of autografts
427
 Anterior Cruciate Ligament Reconstruction

and allografts as well as synthetic ligament substitutes), and

different concomitant pathologies, the lack of homogeneity
among patients is obvious. Real ACL rerupture caused by
an adequate trauma can occur at any time after primary
ACL reconstruction, even if perfect knee stability had been
achieved. However, in our experience this is a quite rare
situation. With careful analysis, in most cases specific issues
can be found to be responsible for graft failure, such as the
following:
1 Technical failures (e.g., tunnel malplacement [see later
discussion])
2 Inadequately addressed or unrecognized concomitant
ligament pathology (see later discussion)
3 Graft selection (synthetics, allograft)
4 Biological issues (graft incorporation)
5 Inadequate rehabilitation
The technique used for primary ACL reconstruction
and the reasons that led to graft failure strongly influence
the strategy and complexity of revision ACL reconstruction
(e.g., hardware removal, choice of graft, fixation technique,
additional surgery). Thus careful failure analysis and a thor-
ough evaluation of actual boundary conditions have to be
performed. This includes detailed history taking, especially
regarding retrauma, instability, pain, swelling, and locking.
The thorough clinical examination should address effusion, FIG. 57-1 Lateral radiograph in maximal extension (orange line represents
range of motion, menisci, knee stability (Lachman and Blumensaat line) demonstrating an excessively anterior placement of the
pivot-shift test), and concomitant ligament pathologies tibial tunnel. Sagittal hardware localization is easy to identify.
(see later discussion).

Radiographic Evaluation
Specific radiological assessments have to be performed to
address tunnel placement, tunnel enlargement, type and
location of hardware, degenerative changes, and posterior
cruciate ligament (PCL) insufficiency.
The performed radiographs should routinely include
the following:
1 Lateral view in maximal extension or hyperextension
(Fig. 57-1)
a Localization of hardware and evaluation of
tunnel placement in the sagittal plane (anterior
placement of the tibial tunnel in relation to the
Blumensaat line might result in anterior graft
impingement14)
b Evaluation of hyperextension (Fig. 57-2)
2 45-degree posterior anterior weight-bearing radiograph
according to Rosenberg15 (Fig. 57-3)
a Localization of hardware and evaluation of tunnel
placement in the coronal plane
b Evaluation of degenerative changes
c Evaluation of notch configuration (Fig. 57-4)
3 Posterior stress radiographs of both knees16 (Fig. 57-5)
a Exclusion of additional PCL insufficiency
In cases with clinically apparent varus or valgus
malalignment or posterolateral insufficiency, long standing
radiographs should be made to assess the need for additional
axis correction. In case of tunnel enlargement, a computed
tomography (CT) scan is indicated to clearly analyze its
dimensions (Fig. 57-6).

428
 Revision Anterior Cruciate Ligament Reconstruction Using Autologous Hamstring Tendons 57

FIG. 57-2 Clinical and radiological view of extensive hyperextension of a right knee. The orange line is the
Blumensaat line demonstrating anterior impingement of the graft although the tibial tunnel (white line) is placed
correctly, due to the hyperextension of the knee. Thus, in case of hyperextension, the need for a more posterior
placement of the tibial tunnel as normally recommended has to be evaluated carefully.

FIG. 57-3 A 45-degree posteroanterior weight-bearing radiograph according to Rosenberg, indicating

degenerative medial joint narrowing compared with the contralateral knee (arrow).

Concomitant Pathology pathology, even in perfect ACL reconstructed knees. In fact,

all the knee restraints work as a unit and normal knee stability
The stabilizing functions of the single knee ligaments are not can only be achieved if all ligaments are intact. In cases of
strictly separated. Secondary graft failure can often be found ACL insufficiency, secondary restraints such as the posterior
in combination with unrecognized concomitant ligament oblique ligament (POL) and the posterior horn of the medial

429
 Anterior Cruciate Ligament Reconstruction

FIG. 57-4 A 45-degree posteroanterior weight-bearing radiograph according to Rosenberg, showing narrow
notch configuration (so-called “gothic notch”).

FIG. 57-5 Posterior stress radiographs of both knees after anterior cruciate ligament (ACL) reconstruction of the
right knee demonstrating unrecognized posterior cruciate ligament insufficiency of the right knee.

meniscus might compensate for the instability. However, if
there is medial collateral ligament (MCL) insufficiency (espe-
cially POL) and/or a subtotal medial meniscus loss, the
freshly reconstructed ACL might not be able to absorb the
particular forces and might stretch out. In principle this can
be applied to any other combination of ligamentous knee
injuries. Thus all directions of knee instability, especially rota-
tory instabilities, have to be assessed carefully during clinical
(and radiological) examination. In detail these instabilities
include the PCL (see Fig. 57-5), lateral or posterolateral

430
 Revision Anterior Cruciate Ligament Reconstruction Using Autologous Hamstring Tendons 57

FIG. 57-6 A and B, Conventional radiographs demonstrating tibial tunnel enlargement. C, Computed tomography
(CT) scan performed to exactly assess the dimension of the tunnel enlargement.

FIG. 57-7 Posterolateral rotatory instability. A, Clinical view demonstrating increased external rotation of the right
knee. B, Radiograph after posterolateral reconstruction, which in this case was not successful. C, Intraoperative
view demonstrating severe posterolateral opening.

rotatory instability (PLRI; Fig. 57-7), anteromedial rotatory
instability (AMRI), anterolateral rotatory instabilities
(ALRI), and MCL or posteromedial rotatory instabilities
(PMRI; Fig. 57-8).
Now we have to question which of these concomitant
pathologies needs to be addressed surgically in revision
procedures. If an AMRI or PMRI is present, a certain grade
of instability might be left untreated in a revision case, as the
influence of these instabilities is still not clearly defined
and the outcome of surgery (MCL, POL, PMRI) often is
unsatisfactory. If there is severe valgus opening, a poste-
romedial reefing (e.g., that according to Hughston) or

431
 Anterior Cruciate Ligament Reconstruction
A
FIG. 57-8 Posteromedial rotatory instability. A, Schematic illustration demonstrating increased stress on the
anterior cruciate ligament (ACL) in a case of medial instability. B, Intraoperative view demonstrating severe medial
opening.
a ligament grafting could be done.17,18 Whether a microper-
foration of the medial structures according to Rosenberg is
successful in these conditions needs further clinical research.
In cases of lateral instabilities including PLRI and ALRI,
the situation is different. In former years a grossly positive
pivot shift was often treated by an additional anterolateral
stabilization such as according to Lemaire19–21 (Fig. 57-9).
At present, an additional extraarticular procedure is not rou-
tinely recommended; however, in revision reconstructions
one might make an exception. In cases with only a slight
anterior translation combined with a gross pivot shift, one
might consider an additional anterolateral stabilization in
selected cases if the femoral ACL graft position is lateral
(10-o’clock position). If, for example, a revision reconstruc-
tion with lateral femoral tunnel placement does not restore
the pivot shift during revision surgery, one might consider
an additional Lemaire procedure in these rare cases. How-
ever, only one peripheral concomitant pathology should
always be addressed during ACL revision reconstruction,
the PLRI (see Fig. 57-7), because the high failure rate of
ACL reconstruction in combination with a PLRI is well
known.22–24
In principle, single-staged repair of any of these combi-
nations is possible if boundary conditions allow for the
planned surgical procedure. One major exception has to be
assessed carefully, which is clinically apparent as the “fixed
posterior subluxation.” Normally this phenomenon is dis-
cussed in the context of PCL insufficiency and repair.
432
However, it has been demonstrated that approximately 15%
of all patients with PCL insufficiency underwent previous
isolated ACL reconstruction.25 The reason for this failure
often is a wrongly interpreted positive Lachman test, which
in the case of PCL insufficiency and an intact ACL might
demonstrate an increased way with a firm endpoint. Thus it
is of great importance to always evaluate the PCL in ACL
deficient knees. Additionally, the PCL deficient knee easily
subluxates to posterior during ACL graft fixation, which
might lead to a fixed posterior subluxation.26 This results in
changed femorotibial biomechanics and high patellofemoral
reaction forces. Patients who demonstrate a fixed posterior
subluxation often suffer from very early and severe degenera-
tive lesions. If a fixed posterior subluxation is diagnosed, the
initial treatment includes the wear of a special brace (PTS
Brace, Medi GmbH, Bayreuth, Germany), which pushes
the tibia to anterior.25,26 Depending on boundary conditions
and ligamentous instability, revision ACL reconstruction as
well as PCL reconstruction might be indicated.26
HARDWARE MANAGEMENT
Older fixation devices might compromise new tunnel creation
and graft fixation. Therefore the type and localization of exis-
ting hardware have to be identified preoperatively. If metallic
hardware was used, localization can be easily performed
with plain radiographs in two planes. Even if biodegradable
 Revision Anterior Cruciate Ligament Reconstruction Using Autologous Hamstring Tendons
FIG. 57-9 Lateral extraarticular tenodesis using a strip of the iliotibial band in a case of anterolateral rotatory
instability (Lemaire procedure).
fixation devices have been used, their localization can be
approximated by conventional radiographs because in most
cases old tunnels or sclerotic bone surrounding the old
fixation devices can be seen even years after surgery.
Hardware Removal
Hardware removal might result in distinct postoperative
morbidity or large bone defects (e.g., transfixation devices or
deeply countersunk metal interference screws) (Fig. 57-10).
Thus older fixation devices need to be removed only if they
compromise new tunnel placement or graft fixation. If metal
fixation devices do not completely affect new tunnel place-
ment, they often can be pushed into the cancellous bone by
serial tunnel dilation (Fig. 57-11). Biodegradable interference
screws, even if they are not degraded during revision surgery,
do not need to be removed because they can easily be over-
drilled. Only a careful washout of particles from the joint cav-
ity is needed to prevent later chondral lesions and/or
inflammatory response. Hardware removal also should be
performed if older fixation devices clearly are responsible for
local pain or discomfort (Fig. 57-12).
Due to the variability of fixation devices available on
the market, hardware removal can be extremely frustrating.
Attempts to remove hardware using instruments that do
not fit exactly to the fixation devices might result in large
57
bone defects and iatrogenic lesions. Thus in our experience
a set of specially designed revision screwdrivers can be very
helpful. These instruments fit to most of the fixation devices
available (Fig. 57-13).
Most of the standard metallic interference screws can
be removed nicely in a single-staged procedure. However,
if metal screws have been deeply countersunk (tibial site,
femoral outside-in) and need to be removed for revision
reconstruction, one might consider a two-staged procedure
because the removal in these circumstances could be very
time consuming. Moreover, if the removal of metal implants
and ACL revision reconstruction are planned in the same
procedure, the patient should be informed that it might be
possible to end in a two-staged procedure if problems occur
during implant removal. Sometimes problems occur during
surgery; for example, if there is an incompletely incorrect
tunnel (see later discussion) and the metal screw is large
(9  25 mm), the additional removal of that screw might
lead to a large bone defect, communicating with the old
and desired new tunnel. In these cases, bone grafting in a
two-staged procedure might be necessary. Sometimes the
removal of metallic cross-pin devices, especially the Arthrex
TransFix might be tricky, because the manufacturer recom-
mends the countersinking of the implant (see Fig. 57-10).
Based on our own experience, we always schedule patients
with a metallic TransFix for a two-staged procedure.
433
 Anterior Cruciate Ligament Reconstruction
FIG. 57-10 Completely countersunk femoral transfixation device. Its removal necessitated an additional lateral
approach and opening of the lateral femoral cortex.
FIG. 57-11 Tibial metal screw that is pushed into the cancellous bone by
serial tunnel dilation.
434
TUNNEL MANAGEMENT
Tunnel Malplacement
One of the major keys to successful ACL reconstruction is a
correct tunnel placement. Tunnel malplacement can lead to
graft impingement, elongation, and failure; loss of range of
motion; and high tibiofemoral contact forces.
According to the current literature the femoral tunnel
should be drilled in the 10-o’clock position for right
knees or in the 2-o’clock position for left knees.27–29 This
means that a lateral femoral tunnel position should be
achieved in order to control rotation as well as anterior
displacement of the knee. A femoral tunnel drilled at the
12-o’clock position (“high-noon” or central cruciate) might
be appropriate to control anterior translation but does not
allow for rotational stabilization.30,31 Often in these cases a
normal Lachman test with firm endpoint combined with
a positive pivot-shift test can be found in the clinical
examination.
 Revision Anterior Cruciate Ligament Reconstruction Using Autologous Hamstring Tendons
FIG. 57-12 Hardware that needs to be removed due to local irritation or pain.
FIG. 57-13 A set of specially designed revision screwdrivers. (By permission
of KarlStorz, Tuttlingen, Germany.)
Radiographically the tibial tunnel should be placed
directly posterior to the intersection point of the Blumensaat
line and the tibial joint line (lateral view in full knee exten-
sion) in order to avoid anterior impingement of the graft.
Placement of the tibial tunnel too anteriorly might lead to
an extension deficit due to notch impingement, which pos-
sibly results in long-term graft failure.14
Excessively anterior placed tibial tunnels can cause
high-tension forces to the graft in knee flexion (“nutcracker
knee”). In addition to graft elongation and secondary failure,
this may lead to a flexion deficit and increased tibiofemoral
pressure in flexion. These forces might result in early and
massive chondral defects, even in young patients.
57
In addition to early chondral changes or graft failure,
tunnel malplacement also leads to painful knees (femoral
anterior placement) in many of these cases. If loss of range
of motion and an intact (sometimes very tight) ACL are
found in combination with tunnel malplacement, arthro-
scopic graft resection and arthrolysis have to be evaluated.
If performed, these should be followed by intensive physio-
therapy to regain full range of motion prior to ACL revision
reconstruction.
Classification of Existing Tunnel Positions
At our institution we established a classification of the posi-
tion of formerly placed tunnels to aid in the specific
planning of the revision procedure. Tunnel positions are
diagnosed using conventional radiographs (lateral view
in maximal extension, 45-degree posteroanterior weight-
bearing radiograph) and are graded as follows:
1 Correct (Fig. 57-14, A): The existing femoral or tibial
tunnels are placed completely correctly and can be
used again.
2 Completely incorrect (Fig. 57-14, B): The existing
femoral or tibial tunnels are placed completely
incorrectly, and a new tunnel can be created in the correct
position without touching the old tunnel.
3 Incompletely incorrect (see Fig. 57-14, B): The existing
femoral or tibial tunnels communicate with the new
correctly placed tunnels, which might lead to large
bone defects.
435
 Anterior Cruciate Ligament Reconstruction
FIG. 57-14 A, Completely correct femoral and tibial tunnels. B, Completely incorrect femoral and incompletely
incorrect tibial tunnel. (White line represents the Blumensaat line.)
Surgical Management
In general, the type of graft used during the index surgery
should be known. If a bone–patellar tendon–bone (BPTB)
graft was used, an incompletely incorrect tunnel at the fem-
oral site might not create problems if the bone plug was not
countersunk because a certain osseous fill-up of the defects
is present. If a soft tissue graft was used during index sur-
gery, an incompletely incorrect tunnel might offer the most
challenging problem.
Correctly positioned tunnels measuring less than
approximately 8 mm in diameter can be reused if primary
reconstruction was performed with a soft tissue graft,
depending on the desired type of fixation (isolated versus
hybrid). In these cases, tunnel preparation includes removal
of intratunnel soft tissue using a drill or a shaver followed by
drilling or dilation of the re-created tunnel to the desired
diameter. The important effect of this procedure is a
débridement of the tunnel wall by removing sclerotic bone
so that graft incorporation can proceed (Fig. 57-15).
In cases of complete incorrect tunnel placement or
complete bony replacement of the previous graft (e.g.,
BPTB), new tunnel preparation can be done as in primary
ACL reconstruction. If an old and completely incorrect tun-
nel shows excessive enlargement, it should be filled with a
cancellous bone plug or, as an alternative, with a biodegrad-
able interference screw prior to graft fixation to prevent col-
lapse between the old and new tunnels (Fig. 57-16).
436
Surgically the most demanding cases are those with
incompletely incorrectly placed tunnels. Drilling a correctly
positioned tunnel in these cases might lead to huge bone
defects. To achieve stable tunnel conditions, we suggest
initially drilling a correctly placed tunnel with a diameter of
only 4 to 5 mm and then using the serial dilation technique
to the desired diameter. This procedure leads to a compaction
of cancellous bone from the newly created tunnel into the old
tunnel. In critical cases with very large bone defects or low
bone density, a biodegradable interference screw or a
cancellous bone plug can be placed into the old tunnel prior
to dilation (Fig. 57-17). However, if there is any uncertainty,
a two-staged procedure should be performed.
Tunnel direction must be verified in the coronal plane
in addition to the tunnel entry position. Because many sur-
geons use a transtibial technique for femoral tunnel creation,
the direction of a new tunnel drilled via the anteromedial
portal diverges from the old tunnel, which finally improves
graft fixation even if the tunnel entry site is enlarged
(Fig. 57-18). Thus the anteromedial portal technique should
be recommended routinely in all ACL revision procedures.
The importance of an intraoperative impingement test
to evaluate tibial tunnel position must be emphasized. This
test can be performed by placing the dilatator into the tibial
tunnel. In full knee extension, the likelihood that anterior
graft impingement will occur can be easily assessed. If exces-
sive hyperextension was found in the clinical and radiologi-
cal examination, the tibial tunnel should be placed more
 Revision Anterior Cruciate Ligament Reconstruction Using Autologous Hamstring Tendons 57

FIG. 57-15 Reuse of a completely correct femoral tunnel. Tunnel is cleaned by shaver and drill bit (A, B) followed
by serial dilation (C, D).

FIG. 57-16 Completely incorrect femoral tunnel (shown with tunnel enlargement) is filled with a biodegradable
interference screw prior to graft fixation to prevent collapse between the old (o) and new (n) tunnels.

437
 Anterior Cruciate Ligament Reconstruction

FIG. 57-17 Filling of an

incompletely incorrect tunnel with a
biodegradable interference screw
prior to drilling and serial dilation of
the new tunnel.

FIG. 57-18 Intraoperative and

radiological views of femoral tunnel
divergence. o, Old tunnel; n, new
tunnel.

438
 Revision Anterior Cruciate Ligament Reconstruction Using Autologous Hamstring Tendons
posterior than normally recommended to avoid notch
impingement. In this situation the intraoperative impinge-
ment test should be performed very attentively.
Tunnel Enlargement
Bone tunnel enlargement commonly occurs following an
extracortical (nonanatomical) fixation technique combined
with soft tissue grafts due to intratunnel graft motions or
with BPTB grafts on the tibial site16,32 (windshield-wiper
and bungee-cord effect) (Fig. 57-19). An additional
biological factor that might lead to tunnel enlargement is
inflow of synovial fluid between the tunnel wall and the
graft during cyclical loading, which leads to high intratunnel
pressures and the activation of osteoclasts by synovial cyto-
kines. In these cases, radiographically the tunnel enlarge-
ment often appears pear–shaped below the joint line (see
Fig. 57-19). The inflow of synovial fluid into the tunnel
depends on the type of graft and its fixation.
Factors that inhibit synovial inflow are as follows:
1 The use of grafts with bone blocks
2 Direct and anatomical fixation of any graft type
57
3 Incomplete resection of the tibial ACL stump and
graft placement in the center of the tibial stump (i.e., the
old ACL stump covers the tunnel entry site)
In contrast, the inflow of synovial fluid is advanced
by the following:
1 Nonanatomical (extracortical) or semi-anatomical
fixation of any graft
2 Imprecise graft–tunnel matching (loose grafts)
3 Complete resection of the tibial ACL stump
If excessive tunnel enlargement can be seen on regular
radiographs, a computed tomography (CT) scan is indicated
to identify its exact dimensions. Based on CT findings of
tunnel enlargement, the question of whether a two-staged
procedure is necessary directly depends on the desired type
of graft and fixation technique.
If a two-staged procedure is indicated, the first step
includes autologous or allogenic cancellous bone or bone substi-
tute filling followed by revision ACL reconstruction. On the
femoral site, the impaction of a cylindrical iliac crest graft or a
cylindrical synthetic filler (b-tricalcium phosphate [TCP]) can
be nicely performed arthroscopically (Fig. 57-20). The use of

FIG. 57-19 A, Lateral radiograph demonstrating femoral tunnel enlargement with semi-anatomical fixation
device. B, Lateral radiograph demonstrating tibial pear-shaped tunnel enlargement, which might be due to inflow
of synovial fluid.

439
 Anterior Cruciate Ligament Reconstruction
FIG. 57-20 Arthroscopic filling of an enlarged femoral tunnel with a cylindrical synthetic bone substitute (b-TCP).
bone chips on the femur might require special instruments if
performed arthroscopically.16 On the tibial site one might
use a single or two cylindrical plugs, which should be
impacted. However, in most cases a tight filling with this
technique is difficult. Thus we recommend using autologous
bone chips, which are eventually mixed with synthetic mate-
rials (b-TCP) to tightly fill the old tunnel. In this case one
should be careful not to compact bone chips into the joint
cavity. We therefore recommend not to débride soft tissue
from the tibial tunnel aperture site, which can later prevent
bone chip access to the joint.
A new CT scan before revision ACL reconstruction
should be done to evaluate the exact bony recovery. If filling
of the defects was successful, revision ACL reconstruction
can be performed using the same methods as for primary
reconstruction. The minimum time between bone grafting
and revision reconstruction should be 3 months; 6 months is
optimal.
GRAFT SELECTION AND FIXATION
Graft Selection
Similarly to primary ACL reconstruction, we have to differ-
entiate grafts with bone blocks from soft tissue grafts and
autografts from allografts. At present, the use of synthetic
ligament substitutes is obsolete because of high failure rates
and a high incidence of chronic knee inflammation.
Due to a rising number of revision ACL reconstruc-
tions performed, the use of allografts is becoming more
popular, especially in the United States. Advantages of allo-
grafts include reduced operative trauma (no donor site
morbidity), decreased operation time, smaller incisions,
and the available choices of graft sizes in multiple liga-
ment reconstructions. One disadvantage is longer graft
incorporation time compared with autografts. Thus, the
440
post-treatment needs to be adapted. The use of allografts
with huge bone blocks might be helpful if huge tunnel
enlargement is present. However, the risk of disease trans-
mission must be considered and discussed with the patient.
Hamstring tendons have become increasingly popular
in ACL surgery due to decreased donor site morbidity,
improved cosmesis, and at least identical clinical outcome
compared with autologous BPTB grafts if modern fixation
techniques are used.33
At our institution we routinely use hamstring tendon
autografts (four-stranded semitendinosus tendon) for primary
and revision ACL reconstruction if local boundary conditions
(tunnel enlargement) allow for their use (see Fig. 39-3). In
revision ACL reconstruction it might happen that the favored
graft already has been harvested for primary ACL reconstruc-
tion. Thus if the use of an autograft is desired, it has to be
decided whether another graft from the ipsilateral knee will
be used or whether the graft will be harvested from the unin-
jured contralateral knee. If ipsilateral hamstrings were already
taken for previous surgery, we routinely harvest the contralat-
eral semitendinosus tendon. In cases when no hamstring ten-
dons are left, we prefer autologous quadriceps tendon grafts
rather than BPTB autografts or different allografts (e.g.,
hamstring tendon, BPTB, tibialis anterior tendon, Achilles
tendon).
Graft Fixation
The standard procedure in our institution for ACL revision
reconstruction is a direct fixation technique by the use of
biodegradable interference screws and hybrid fixation
(Table 57-1) at both sites. General surgical principles of this
technique, as well as possible intraoperative problems and their
solution strategies, are described elsewhere in this text (see
Chapter 46). The use of interference screws allows for an ana-
tomical fixation at the level of the joint line, which has been
shown to increase graft isometry34 and knee stability by
 Revision Anterior Cruciate Ligament Reconstruction Using Autologous Hamstring Tendons 57
TABLE 57-1 Graft Fixation Technique
Femoral Hybrid Fixation

 Interference screw and EndoPearl suture button and interference

screw

 Suture button and cancellous bone plug

 Transfixation and interference screw

 Transfixation and cancellous bone plug
Tibial Hybrid Fixation

 Interference screw and suture to bony bridge

 Interference screw and suture button

 Interference screw and staples

 Cancellous bone plug and suture button

 Cancellous bone plug and suture to bony bridge

 Cancellous bone plug and tying of sutures over screw

reducing the graft length to its intraarticular portion, thus

increasing construct stiffness.35,36 The use of interference fit
fixation additionally reduces intratunnel graft motion, which
is a common side effect of nonanatomical (extracortical) graft
fixation.
At present it is generally recommended to perform
hybrid fixation at the tibial site, not only in revision but also
in primary ACL reconstruction, for the following reasons: FIG. 57-21 Metallic and biodegradable interference screws are available
in different sizes and diameters. Thus a precise matching of graft and
1 The bone density of the proximal tibia is lower than tunnel diameter and screw size can be performed.
that of the distal femur.
2 The direction of the tibial channel equals the direction
of the forces that are applied to the ACL. In contrast,
the direction of the femoral tunnel is angled to the
intraarticular direction of the ACL. Thus graft slippage
is more probable at the tibial site.
An easy and secure method for tibial backup fixation is
a suture of the linkage material over a bony bridge. To do so,
a monocortical drill hole is created 2 cm distally of the tibial
tunnel exit site. Then one strand of each attached suture is
passed through the hole and tied over the created bony bridge37
(see Chapter 46).
For femoral hybrid fixation with interference screw
fixation, we prefer the use of a biodegradable spherical device
(EndoPearl, Linvatec, Largo, FL). The EndoPearl is sutured
to the femoral end of the graft and achieves an internal
locking between the graft and the tip of the interference
screw. Thus it increases fixation strength, especially in cases
of tunnel enlargement and low bone density (see Chapter 39).
Technical problems of graft fixation in revision ACL FIG. 57-22 The use of two screws for tibial fixation in a case of tibial
reconstruction often appear due to graft–tunnel mismatch, tunnel enlargement.

441
 Anterior Cruciate Ligament Reconstruction
especially in cases with completely correct or incompletely
incorrect tunnel positions. The principles of tunnel place-
ment depending on previously drilled tunnel positions were
previously explained. If, after appropriate tunnel creation,
the diameter of the femoral tunnel still is 1 to 3 mm larger
than the graft diameter, femoral hybrid fixation with a bio-
degradable interference screw plus the EndoPearl device
prevents graft slippage and allows for secure graft fixation
(e.g., for a 9-mm tunnel and 7-mm graft, use a 9-mm
EndoPearl and 8-mm interference screw).
In cases with rather insecure tibial interference screw
fixation, we favor the use of a suture button instead of the
suture over a bony bridge. Manual rotation of the button
tightens the linkage material, thus preventing graft slippage
(see Chapter 46). Furthermore, in cases with impaired
tibial bone quality, we suggest the use of oversized screws
(diameter of 11–12 mm; Fig. 57-21) or the use of two screws
(sandwich technique; Fig. 57-22) for tibial graft fixation.
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 Revision Anterior Cruciate Ligament
Reconstruction*
INTRODUCTION
Reconstruction of the anterior cruciate ligament
(ACL) has become an increasingly common
orthopaedic procedure. In the United Kingdom,
approximately 5000 ACL reconstructions are
performed per year1; in the United States, more
than 100,000 procedures are currently per-
formed annually.2 This trend is likely to con-
tinue with the general population’s increasing
pursuit of an active lifestyle. Although long-
term functional stability and symptom relief
after primary ACL reconstruction exceed 90%
in some studies,3,4 overall clinical failure rates
of 10% to 25% have been documented.1 It is
currently estimated that between 3000 and
10,000 U.S. patients and approximately 1000
U.K. patients are candidates for revision ACL
surgery annually.1
Revision ACL surgery is recommended
for patients who have instability or reduced
activity with pathological laxity after a failed pri-
mary ACL reconstruction. The important
stages in assessing a patient with a failed ACL
reconstruction include a detailed history, patient
selection, physical examination and appropriate
investigations, choice of graft, surgical tech-
nique, and rehabilitation.5 Eliciting important
relevant history from a patient who is usually
apprehensive and has some knowledge of the
* The authors acknowledge the contributions and assistance of
Dr. J. Ashken (ACL database design), Mrs. F. Wandless (Senior
Physiotherapist), Mr. Niall Flynn (Consultant Orthopaedic Surgeon,
Queen Alexandra Hospital, Portsmouth), and Mr. Raghu Kankate
(Orthopaedic Surgeon).
58
CHAPTER
problem (from general practitioners, phy- Neil P. Thomas
siotherapists, and the Internet) can be difficult.
Hemant G. Pandit
One should spend enough time trying to find
out the details of the original injury (e.g.,
high-velocity trauma may suggest multiligament
laxity) and also the patient’s experience of pre-
vious treatment as well as his or her knowledge
of the problem. A full history of occupational
and future recreational activities is mandatory.
Often the patient’s expectations are not realistic,
and therefore despite achieving knee stability,
the revision surgery will not result in a contented
patient. Instability and/or pain top the list of
patient symptoms. It should be clarified with
the patient preoperatively that a reduced activity
level and/or excellent natural proprioception
may result in a reduction or even an abolition
in symptoms of instability without the need
for surgery. Revision reconstruction should be
offered to patients with symptoms of instability
or those who wish to increase their activity level
to include manoeuvres involving twisting or a
sudden change in direction. In such cases symp-
toms of instability, if left untreated, will contrib-
ute to repeated meniscal and chondral damage,
leading to an earlier progression of osteoarthritis
(OA). At the same time, the patient should be
made aware of the risk of a gradual progression
of OA, irrespective of the method of treatment
but especially if symptoms of instability are
ignored. It should be carefully explained that
symptoms of pain are likely to be caused by
degenerative disease or a torn meniscus and that
a revision ACL reconstruction alone is unlikely
to be the answer to this problem. One should
443
 Anterior Cruciate Ligament Reconstruction
FIG. 58-1 Failed anterior cruciate ligament (ACL) reconstruction.
Anteroposterior (A) and lateral (B) views.
also alert the patient to the potential need for bone grafting
and thus a staged reconstruction.
The most useful investigations are the plain x-ray
series of an anteroposterior (AP) standing radiograph and
a lateral x-ray in full extension, together with skyline and
Rosenberg views (Fig. 58-1).1 These will show the original
tunnel placement and usually the fixation methods used,
tunnel widening,6,7 osteolysis, and the presence and extent
of joint space narrowing. If possible, comparison with pre-
vious radiographs will help quantify bone loss (tunnel wid-
ening). It is our practice to obtain a magnetic resonance
imaging (MRI) scan preoperatively, but only rarely has this
provided additional information that has changed the
course of management. If no reason for the primary failure
can be elicited, vigilance for a missed or complex laxity
should be exercised. Careful clinical examination and an
examination under anesthesia, which may include
fluoroscopic stress views, are useful in finding an
additional laxity.
CAUSES OF FAILURE OF PRIMARY PROCEDURE
The causes of recurrent patholaxity after primary ACL
reconstruction6–26 can be broadly divided into four groups:
technical errors, failure due to biological factors, failure
due to significant trauma, and failure owing to laxity in
the secondary restraints.17 By far the most common cause
444
is error in the surgical technique, with 77% to 95% of all
cases of ACL failure attributed to technical error.27 This
category includes poor graft selection or harvest, improper
tensioning or fixation, and especially incorrect tunnel place-
ment.9,17,18 More than 70% of technical failures, and thus
more than 50% of all ACL failures, can be attributed to
malpositioned tunnels.8,17 Inappropriate positioning of
either the tibial or the femoral tunnel results in excessive
length changes in the graft as the knee moves through a
range of motion, resulting in either a limited range of
motion or excessive graft laxity.8,18 Anterior placement of
the femoral tunnel, a common mistake, will result in limited
flexion and potential graft failure if full flexion is achieved.
Tibial tunnel placement may be somewhat more forgiving,
but anterior placement leads to impingement in extension
and excessive tension in flexion, whereas posterior place-
ment may cause laxity in flexion.17 Perhaps the most com-
mon error in surgical technique involves the anterior
placement of femoral and/or tibial tunnels.16 Carson et al
recently published their review of 90 failed ACL reconstruc-
tions and quoted 52% of the failures as being due to surgical
technical errors.28 Several studies have shown that a poste-
rior and proximal placement of the intraarticular exit of
the femoral tunnel is advisable and involves minimal length-
ening of the ACL substitute toward extension.
TREATMENT OPTIONS
Revision ACL surgery is often considered a salvage proce-
dure with very limited goals, distinctly different from those
of primary ACL reconstruction.5,29 Many reports in the lit-
erature quote inferior results for revision cases compared
with primary reconstruction. However, with many cate-
gories of failure, the population of failed ACLs is a diverse
group and a difficult subset to study.30
We ask the following questions before deciding on a
definitive treatment plan:

Do we know why the primary graft has failed?

Have we obtained a full diagnosis?

Has the patient been fully counseled?

Will the patient cope with a change in plan brought
about by unexpected findings during the examination
under anesthesia (EUA) and arthroscopy, which might
alter the time spent in rehabilitation?

Can the new graft be fully incorporated biologically
within the widened bone tunnels?
Unless the answers to all these questions are positive,
we tend to favor a cautious two-stage approach. If revision
ACL surgery is staged, then the first stage gives the surgeon

an added opportunity to assess the chondral and meniscal
pathology and then give the patient a more realistic
prognosis.
It is also important to ascertain whether the tibial tun-
nel of primary surgery will interfere with the correctly placed
revision tibial tunnel and the extent of loss of bone stock
due to tunnel widening. In addition, one needs to determine
whether the hardware needs to be removed and, if so,
whether that will further contribute to the loss of bone
stock. For the revision graft to function optimally, one needs
to ensure that the tunnels are placed in an optimal position
in a good-quality bone so that the fixation achieved will be
as robust as the primary surgery.
Management of previous tunnel malposition is
technically demanding, and different surgeons have used
various approaches for dealing with bony defects resulting
from incorrectly positioned prior tunnels. In some cases of
gross tunnel malposition, a new tunnel may simply be
drilled without violating the original tunnel or removing
any tunnel hardware. Alternatively, tunnels can be oriented
in a divergent pathway that maintains the appropriate
articular surface attachment. In many cases, however, new
tunnels cannot be drilled without overlapping or breaking
into a previous tunnel. Two or more screws can be used to
supplement fixation and fill the cavity of an enlarged tunnel.
Although this might be useful in limited cases, the fixation
achieved tends to be inferior and postoperative rehabilitation
may be compromised. Graduated tunnel dilators may allow
controlled expansion of a previous tunnel, compacting rather
than removing additional bone.17 In such instances, options
include the use of an allograft tendon with an enlarged bony
portion, an oversized interference screw, or stacked interfer-
ence screws.31 If the original tunnel is correctly positioned
and only slightly larger (3–5 mm) than the new graft,
stacking two interference screws may be sufficient to fill
the tunnel and secure the graft.32,33 Battaglia and Miller34
have described use of freeze-dried allograft bone dowels to
address bony defects during revision ACL reconstruction.
These allografts are readily available and can be easily used
to fill deficiencies resulting from previous tunnels or osteo-
lysis. The grafts provide sufficient structural support to
allow redrilling of new tunnels through or next to the
bone plug. Unfortunately this option implies slower graft
incorporation35 and has implications for the rehabilitation
regimen.
Some authors have tried to stratify the treatment
options by the extent of bony defect. For defects larger than
10 mm, they advocate the use of bone graft and a staged
procedure. Although this stratification is useful, it has cer-
tain limitations. Accurate preoperative assessment of the
tunnel size is difficult and unreliable with plain x-rays.
CT is the most accurate method.
Revision Anterior Cruciate Ligament Reconstruction 58
After clearing the debris from the earlier drilled tun-
nel, the resultant defect is almost always larger than
10 mm. Therefore we usually favor a staged reconstruction
as a default technique. The first stage involves an EUA,
an assessment of chondral and meniscal pathology, the
removal of old graft, tunnel curettage, drilling, and bone
grafting. The second stage is revision ACL reconstruction
after incorporation of bone graft, 3 to 6 months after the
first stage, when a CT scan has shown adequate incorpora-
tion of the bone graft.
DEFINITION OF KNEE INSTABILITY
The IKDC classifies knees that are within 2 mm of the nor-
mal contralateral knee by means of KT-1000 or similar test-
ing as “normal.”36 Knees that have greater than 5 mm of
difference are classified as “abnormal.” The KT-1000
applies a force of 134N to assess knee laxity.
For the past 15 years, we have used the Westminster
cruciometer (University College, London) for laxity measure-
ments. It is a validated tool that applies an 89N force during
the laxity measurement. Similar to the KT-1000, this cruci-
ometer has been shown to give a reproducible quantitative
evaluation of the Lachman test, and a previous study has
shown average displacement of normal knee to be 3.2 mm
as compared with 8.4 mm in the ACL deficient knee.37
A further validation of the Westminster cruciometer was
done recently by comparing the laxity measurements in
normal, ACL deficient, and ACL reconstructed knees.
The correlation between the Westminster cruciometer and
KT-2000 was found to be excellent (Pearson’s coefficient:
97%). The KT-2000 reading can be obtained using the
following equation:
KT  2000 value ¼ 0:845  Westminster reading  0:5904ð61Þ
Since the original recommendations by the IKDC,
various published results have used slightly different cri-
teria in defining knee stability. In addition to instrumented
laxity measurements, the clinically relevant pivot-shift test
is widely used. The pivot-shift test has various grades,
and one needs to be clear in reporting the grade (1þ,
glide; 2þ, clunk; 3þ, subluxation) that is being considered
as abnormal. In our practice using the Westminster cruci-
ometer (applying a force of 89N rather than 134N) to
assess the knees, we use the following criteria to define
normal laxity: The side-to-side difference (SSD) in ante-
rior tibial translation is considered normal if within
2 mm and nearly normal if between 3 and 4 mm. Values
of 5 mm and greater are considered unsatisfactory. Overall
anterior laxity is considered satisfactory if the SSD is less
than 5 mm and the pivot shift is absent or 1þ (glide).
445
 Anterior Cruciate Ligament Reconstruction
In the presence of an SSD greater than 4 mm and/or a
pivot shift of 2þ (clunk) or 3þ (subluxation), the anterior
laxity is considered unsatisfactory.
SURGICAL PROCEDURE
Stage I
Stage I includes an EUA and arthroscopy, assessment and
appropriate treatment of meniscal and chondral pathology,
removal of the previous graft, notch assessment, and notch-
plasty when necessary. Although we have not encountered
infection in this series, a high index of suspicion should
always be maintained, and we routinely send multiple syno-
vial biopsies in each case. Interfering metal work is removed,
and the tibial tunnel is bone grafted with bone graft taken
from the patient’s ipsilateral iliac crest.
The meniscal and chondral structures are assessed and
carefully documented. The menisci commonly show evi-
dence of degeneration, and their tears are complex. These
tears are usually in the white-white zone, necessitating par-
tial meniscectomy rather than meniscal suture. Articular
cartilage assessment invariably reveals more changes than
were previously suggested on a plain weight-bearing radio-
graph and the MRI scan. The changes in the articular carti-
lage are documented with regard to depth, size, and
position. The appearance of the articular cartilage is
recorded as abnormal if the lesion is 15 mm or more in
diameter with fissuring and fragmentation of more than half
its depth or if any subchondral bone was exposed. Loose
chondral flaps are removed, and their edges are débrided
back to stability. The finding of exposed bone is not a con-
traindication to revision ACL surgery. Such lesions are dealt
with using a marrow stimulating technique, namely drilling
and/or microfracture. If a patient has persistent pain after a
failed microfracture, then leg alignment views are requested
and treatment such as osteotomy combined with autologous
chondrocyte implantation should be considered.
The intercondylar notch is usually full of scar tissue,
which includes the previously reconstructed incompetent
ACL. Removing the previous ACL autograft using a com-
bination of hand and powered tools is relatively straightfor-
ward. However, clearance of prosthetic graft can be time
consuming due to the tougher nature of the material. In
cases in which an over-the-top position was used for the
femoral tunnel placement at the time of primary reconstruc-
tion, a large “wadge” of lax, swollen graft can be seen exiting
the joint superolaterally. In all cases, one needs to exercise
extreme care to identify the margin and then the entire pos-
terior cruciate ligament (PCL) so that the safe removal of all
other structures in the notch can be safely performed.
446
If the new tunnel placement is possible without inter-
ference from previous hardware, the hardware can be left in
place. However, if the desired position of the new tunnel(s)
intersects or overlaps (either partially or fully) the previous
tunnels, the metalwork should be removed carefully after
ensuring that the screw head is free of all soft tissue and that
the screwdriver is fully seated.
If the tibial tunnel is interfering with the placement of
the new tibial tunnel (in the correct anatomical position),
then following the initial procedure, the tunnel is viewed
with the arthroscope in air medium (osteoscopy). The
sclerotic walls of the tunnel are drilled with a fine 2-mm
drill, and the tunnel is curetted and rasped until the tunnel
walls are taken back to clean bone. Bone in the form of
dowel grafts is harvested from the iliac crest, placed into
the tibial tunnel, and then impacted. If there is insufficient
autologous bone, then this can be supplemented with
human bone (either from a bone bank or a proprietary
human bone). It is important to impact the bone. Care is
taken not the breach the exit point of the tibial tunnel
within the joint. This is achieved by viewing the relevant
articular surface of the tibial plateau with the arthroscope
as the bone graft is being impacted up the tunnel. We have
chosen not to graft the femoral tunnel but merely alter the
technique. However, if the surgeon finds that he or she will
not be able to make a satisfactory new tunnel, then the exist-
ing femoral tunnel can be bone grafted (similar to tibial tun-
nel) so as to ensure good bone quality for the second-stage
surgery. A CT scan obtained after 4 to 6 months is useful
to assess healing of the bone graft (or its dissolution) in
the tibial tunnel. Blurring of the tunnel margins, reactive
sclerosis, and presence of bone within the tunnel are used
as signs of adequate healing.
Stage II
The second stage includes a further EUA, arthroscopy, rel-
evant meniscal and chondral surgery, graft harvest, and revi-
sion ACL reconstruction. Our choice of graft is described in
Table 58-1.
TABLE 58-1 Choice of Graft for Revision Surgery
Primary Graft Revision Graft
Bone–patellar tendon–bone Four-strand hamstring
(BPTB)
Four-strand hamstring BPTB
Prosthetic Ipsilateral BPTB graft or four-strand
hamstring

The revision procedure itself is similar to any primary
procedure, and attention is given to achieve the correct anato-
mical placement of the tunnels. Because the landmarks are
often less distinct than in a primary case, the tibial tunnel
should be referenced off the PCL on the medial side of the
mid-intercondylar point and the femoral tunnel referenced
from the over-the-top position. We have favored the use of
proprietary jigs (femoral Puddu guide, Acufex). Perioperative
imaging using an image intensifier may occasionally be
necessary to ensure optimal tunnel placement (Fig. 58-2).
The correctly placed revision tibial tunnel is drilled.
For the femoral tunnel, the technique used at the time of
revision surgery is different than that used at the time of pri-
mary surgery. If an inside-out technique was used during
the primary reconstruction, the femoral tunnel is drilled
from outside-in (and vice versa) to ensure the new revision
tunnel placement in virgin bone.
FIG. 58-2 Radiographs after second-stage revision. Anteroposterior (A) and lateral (B) views.
Revision Anterior Cruciate Ligament Reconstruction 58
GRAFT CHOICE: AUTOGRAFT VERSUS ALLOGRAFT
For a long time it has been debated whether an autograft or an
allograft should be used for revision ACL reconstruction.38–41
Allografts have certain advantages. The donor site morbidity
is eliminated, which may help during the rehabilitation.
When weighed against the total costs of a two-staged ACL
reconstruction, their use could be financially justified.
However, they do have specific risks. Viral transmission of
hepatitis, human immunodeficiency (HIV) virus, or other
infection is a concern.42 Allografts tend to integrate more
slowly than autografts and can cause immunological reac-
tions, which may interfere with the healing process; hence
the recommendation of a slower rehabilitation protocol.41
Furthermore, the sterilization process used may decrease the
mechanical properties of the allograft. In addition, this
increases the cost. As of March 11, 2002, the Centers for
447
 Anterior Cruciate Ligament Reconstruction
Disease Control and Prevention (CDC) had received 26
reports of bacterial infections from musculoskeletal allo-
grafts.43 Because the notification of infection secondary to
use of allografts is voluntary, it is likely that its true incidence
is underestimated. We agree with the concept that every effort
should be made to ensure killing of bacteria and bacterial
spores with the help of available technologies. These added
risks of using an allograft have led us to refrain from their
routine use. An allograft should only be considered when host
material is scarce. This is sometimes the case in patients with
multi-ligament laxity. One can use ipsilateral and contralat-
eral bone–patellar tendon–bone (BPTB) as well as hamstring
tendons but may still have to use allografts for a multi-
directional laxity involving the ACL, PCL, posterolateral
corner (PLC), and/or medial collateral ligament (MCL).44–46
We have always favored the use of autograft rather than
allograft. It is not our practice routinely to use the contralateral
limb for harvesting the graft, although some surgeons prefer
the contralateral limb in the primary or revision setting.46
We do not have any experience of using reharvested BPTB
or four-strand hamstring (4-SH) graft; reports in the litera-
ture of their use and satisfactory clinical outcome are few.47
GRAFT FIXATION: CORTICAL OR APERTURAL
The techniques for graft fixation during the revision proce-
dure are similar to those used in the primary procedure.
When dealing with bone–bone fixation, the interference
screw,48 is our traditional method of fixation, although if
the femoral tunnel is a tight fit, Rigidfix (Mitek Products,
Ethicon, Edinburgh) is satisfactory. For hamstring fixation,
we use IntraFix (Mitek) on the tibial side; for a cortical fixa-
tion on the femoral side, a Corin anchor (Corin Group, The
Corinium Centre, Cirencester, United Kingdom) is used.
The types of fixation method used on both the femo-
ral and tibial sides play a crucial role in the stability achieved
after ACL reconstruction. The fixation devices must be able
to withstand early postoperative forces until graft–tunnel
healing has occurred. The fixation should facilitate graft
tunnel healing, producing a normal histological transition
zone between the host bone and the new ligament.45,49
The fixation methods can be broadly classified as cor-
tical (suspensory) or apertural (intratunnel).50 There is a
belief that cortical fixation may not perform as well as aper-
ture fixation and that there may be a “bungee effect” causing
reduced stability because fixation is farther from the joint,
resulting in a longer graft with reduced stiffness. Cyclical
elastic stretching under loading can be expected to increase
with lengthening of the graft between the points of fixation.
Anchoring the graft distant to the joint line may also allow
AP movement, described as a “windshield wiper” effect after
448
widening of the tunnel. However, this is debatable. Graft
fixation relies on the friction between the graft and the fixa-
tion device until the graft integrates with the surrounding
host tissues.50 Older methods such as in-line staples (tibial
side) or simple buttons (femoral side) have a high chance
of graft slippage due to their dependence on “simple fric-
tion” between the fixation device and a smooth, compress-
ible soft tissue graft. This prevents the grafts being
satisfactorily tightened and held. On the other hand, techni-
ques such as Endobutton (Smith & Nephew, Andover,
MA), Corin Anchor, and newer tibial devices rely on
“complex friction” and thereby ensure better stability.51–56
Prodromos et al,50 in a recent meta-analysis of ACL recon-
struction, considered stability after ACL reconstruction as
a function of hamstring versus patellar tendon graft and fix-
ation type. The authors concluded that four-strand ham-
strings had overall higher stability than BPTB and the
graft stability was fixation dependent. Four-strand ham-
string grafts with Endobutton femoral fixation and sec-
ond-generation tibial cortical fixation (belt-buckle staple
configuration or interference screws augmented with sta-
ples) resulted in higher stability than all other graft/fixation
combinations. Therefore either the bungee effect does not
exist or, if it does exist, it seems inconsequential. Also, it
is likely that the bungee effect is only likely during the early
postoperative period before the bone tunnels have healed
around the graft, converting cortical to apertural fixation.50
Different authors have assessed34,49,57–60 the fixation
strengths of various femoral and tibial fixation devices used
for ACL reconstruction. Harvey et al in their succinct
review article considered the different types of fixations used
along with results of laboratory testing.49 These are sum-
marized in Tables 58–2, 58–3, and 58–4.49
Tibial fixation is commonly considered more prob-
lematic than femoral fixation because forces on the ACL
substitute are parallel to the tibial drill hole,60,61 the bone
quality of the tibial metaphysis is inferior to that of the
femur,61,62 and the four-tailed end of the hamstring tendon
graft that is fixed to the tibia is more difficult to secure.
The WasherLoc secures the graft at the external tibial aper-
ture, and the tandem spiked washers have an even longer
working length because they are placed completely outside
the tibial tunnel. The IntraFix may be considered a semi-
aperture fixation because the 30-mm plastic sheath extrudes
distally from the entrance of the tibial drill hole and thus, in
a normal tibial tunnel of 35 to 45 mm in length, leaves 5 to
15 mm of free graft within the proximal opening (aperture)
of the drill hole. Finally, interference screws can be consid-
ered truly anatomical (apertural) fixations because they can
be advanced to the internal tibial tunnel orifice.
When interference screws are used in the tibia, they
are inserted from the outside-in, producing forces that are
 Revision Anterior Cruciate Ligament Reconstruction 58
TABLE 58-2 Bone–Patellar Tendon–Bone (BPTB) Fixation Options
Authors BPTB Fixation Specimen Test ULF Stiffness Cyclical Mode of Failure
(N) (N/mm) Testing

Johnson Stainless steel interference Human Femoral bone cortext 436 — N/A Tendon and cortical bone graft
and van screw (9 mm) removed. Force in line of pulled out of femur
Dyk tunnel

Biodegradable interference Human Femoral bone cortex 565 — N/A Failure between cortical and
screw (9 mm) removed. Force in line of cancellous bone of the graft
tunnel

Steiner Interference screw (9  Human Femur–tibia complex 423 45 N/A Bone plug slippage past
et al 25 mm, outside-in interference screws, usually on
technique) tibial side

Interference screw (7  Human Femur–tibia complex 588 33 N/A

25 mm, endoscopic
technique)

Caborn Interference screw: Bioscrew Human Femur 552.5 — N/A Femoral fixation–ligament bone
et al (7  25 mm) separation

Titanium alloy interference Human Tensile load 20 mm/min 558 — N/A Fracture tibial bone block–
screw (7  25 mm) ligament bone separation

Yamanaka Suture post Porcine Femur–tibia complex 851 23.5 5000 cycles Bone plug breakage or thread
et al ULF: 754N rupture

Kurosaka Suture tied over buttons Human Tibia/femur not specified 248.2 12.8 N/A Avulsion fracture at tendon
et al insertion

Staple Human Tibia/femur not specified 128.5 10.8 N/A

AO 6.5-mm screw Human Tibia/femur not specified 214.8 23.5 N/A

Ruop et al Titanium interference screw Porcine Tibia: vertical tensile load 785 — N/A Bone block pulled out in most
(7  25 mm) cases

Biodegradable interference Porcine Tibia: vertical tensile load 555 — N/A Bone block pulled out in most
screw (PGA 7  25 mm) cases

Biodegradable interference Porcine Tibia: vertical tensile load 592 — N/A Bone block pulled out in most
screw (PLA 7  23 mm) cases

Ruop et al Press-fit fixation Porcine Tibia: vertical tensile load 462.5 — N/A Pullout of complete bone plug in
most cases

Titanium interference screw Porcine Tibia: vertical tensile load 768.6 — N/A
(9  25 mm)

Biodegradable screw (7  Porcine Tibia: vertical tensile load 805.2 — N/A Pullout of complete bone plug in
23 mm) most cases

Gerich 2 staples with bone block in Human Tibia: force in line with 588 86 N/A Slippage of bone block in tibial
et al tibial groove tibial axis groove

Novak Krackow suture #5 Ticron Bovine Tibia 374 24 N/A

et al over screw and post

Screw and free bone block Bovine Tibia 669 90 N/A —

(9  20 mm)

(continued)

449
 Anterior Cruciate Ligament Reconstruction

TABLE 58-2 Bone–Patellar Tendon–Bone (BPTB) Fixation Options—Cont’d

Authors BPTB Fixation Specimen Test ULF Stiffness Cyclical Mode of Failure
(N) (N/mm) Testing

Matthews Interference screw Porcine Tibia 435 — N/A —

et al
#2 nonabsorbable sutures Porcine Tibia 454.2 — N/A
tied over screw and washer

#5 nonabsorbable suture Porcine Tibia 415.8 — N/A

ULF, Ultimate load to failure.

Caborn et al. Arthroscopy 1997(13):229–232; Gerich et al. Knee Surg Sports Traumatol Arthrosc 1997(5):84–88; Johnson et al. Arthroscopy 1996(12):452–456; Kurosaka et al. Am J Sports
Med 1987(15):225–229; Matthews et al. Arthroscopy 1993(9):76–81; Novak et al. Arthroscopy 1996(12):160–164; Rupp et al. Arthroscopy 1997(13):61–65; Rupp et al. J Biomed Mater Res
1999(48):70–74; Steiner et al. Am J Sports Med 1994(22):240–246. Yamanaka et al. Am J Sports Med 1999(27):772–777.

TABLE 58-3 Hamstring Femoral Graft Fixation Options

Authors Hamstring Femoral Fixation Specimen Test Protocol ULF (N) Stiffness Cyclical Testing Mode of Failure
(N/mm)

Ciurea Clawed washer and screw Bovine Femur: pull in line 502 — 1500N: 300 cycles 5.7 mm Tendon
et al of bone tunnel– elongation 450N: failure shredded by
bovine exts tendons teeth of washer

Interference screws (soft) Bovine Femur: pull in line 591 (8  — 150N: 1 to 3 mm slippage Slippage of
(titanium) 7, 8, 9 mm  25 mm of bone tunnel 25 mm by 1100 cycles 450N: tendon past
screws Tunnel 7, 8, 9 8, 9, 10 mm screw) specimen failed 1100 cycles screws

Interference screw (round Bovine Femur: pull in line 445 (8  — 150N: 6.8 mm slippage by Cutting and
headed) 25 mm  8 mm screw of bone tunnel 25 mm 1100 cycles 450N: slippage of
9 mm tunnel screw) specimen failed tendon past
screw

Caborn Interference screws RCI screw Human Femur 242 — — Graft pulled out
et al (7 mm) around screw 13/
16 specimens

Bioabsorbable (7 mm) Bioscrew Human Femur 341 — — Graft and screw

pulled out from
femoral tunnel
3/16

Kousa Endobutton-CL Porcine Femur: force along 1086781 — 1500 load cycles (50–200N)
et al axis drill hole after
cyclical
loading

Bone mulch screw 1112925 —

after
cyclical
loading

Bioscrew 589565 —
after
(continued)

450
 Revision Anterior Cruciate Ligament Reconstruction 58
TABLE 58-3 Hamstring Femoral Graft Fixation Options—Cont’d
Authors Hamstring Femoral Fixation Specimen Test Protocol ULF (N) Stiffness Cyclical Testing Mode of Failure
(N/mm)

cyclical
loading

RCL screw 546534 —

after
cyclical
loading

Rigidfix 868768 —
after
cyclical
loading

Clark Cross-pin (2.5 mm diameter) Porcine Femora 2.5 mm/sec 1003 — N/A Graft rupture of
et al 35 mm to failure slippage from
grip

70 mm 1604 — N/A

To et al Endobutton Human Femora 430 23 N/A Failure of suture

loop knot

Mitek anchor Human Pull in line of tunnel 312 25 N/A Distal migration
of the anchor in
the bone tunnel

Cross-pin (post–bone graft) Human 1126 225 N/A Bending or

fracture of the
pin

ULF, Ultimate load to failure.

Caborn et al. Arthroscopy 1998(14):241–245; Clark et al. Arthroscopy 1998(14):258–267; Giurea et al. Am J Sports Med 1999(27):621–625; Kousa et al. Am J Sports Med 2003
(31):174–181; To et al. Arthroscopy 1999(15):379–387.

counter to the direction of the tension on the graft, as POSTOPERATIVE REHABILITATION

opposed to the femoral side, where the screw is placed from
the inside-out, thus wedging the graft during screw inser-
tion. The strength of fixation of interference screws is influ-
enced by several variables, such as the density of the bone,61
the insertion torque,63 the geometry55,64,65 and material of
the screw,66 and the length and diameter of the screw.67
Different considerations may be important in the fixation
of hamstring and BPTB grafts. Increasing the diameter of
the screw increases the fixation of the hamstring by a
press-fit mechanism that crushes the surrounding cancellous
bone. However, poor engagement of the thread into the
tendon may make this less important and length of the
screw more so. Engagement of the thread into a corticocan-
cellous BPTB block gives good fixation, which is influenced
more by the changes in the diameter of the screw and less so
by changes in the length (Fig. 58–3).49
All patients start knee flexion on the first day after surgery,
and resting with the heel supported is encouraged to achieve
full hyperextension. Patients are encouraged to perform
static quadriceps exercises to prevent a quadriceps lag, and
ice therapy is used regularly to ensure an early reduction in
swelling. The patients are mobilized on the first or second
day after surgery with elbow crutches, which are used until
a good gait pattern has been achieved. The regimen is
continued at home with emphasis in the first 2 weeks on
achieving full hyperextension, flexion past 90 degrees, a
reduction in swelling using ice elevation, rest, non–weight-
bearing exercises, and minimal walking. The rehabilitation
program is continued as an outpatient with a series of
graduated mobilizing, strengthening (isometric, closed
chain, and [later] some open chain), and dynamic stability

451
 Anterior Cruciate Ligament Reconstruction

TABLE 58-4 Hamstring Tibia Graft Fixation Options

Authors Hamstring Tibia Specimen Test Protocol ULF (N) Stiffness Cyclical Testing (mm) Mode of Failure
(N/mm)

Magno Animal/human Pull in line of tibial 50N increments slippage

et al not specified tunnel (mm) at 250N(a), 500N(b)

WasherLoc 821* 200 (a) 0.23(b) 0.81 —

Tandem washers 1375 248 (a) 0.49(b) 1.23 —

Sutures/posts (#5 830 259 (a) 1.67(b) 4.87 —

Ethibond)

Staples 705 60 (a) 1.01(b) 3.31 —

Interference 776 118 (a) 0.25(b) 0.72 —

screw (9 
25 mm)

Spiked 20-mm 930 225126 (a) 1.12(b) 3.52 —

washer

Giurea Stirrup Bovine Tibia: pull in line of 898 — 150N elongation 2.1 mm —
et al tunnel 450N intact

Nagarkuiti Bioabsorbable Porcine Tibia 408 69 0–150N 5000 cycles 2 of 5 failures

et al screw Anatomical graft 1.3 mm displacement before 5000
placement: vertical cycles
load

Kousa et al WasherLoc Porcine Tibia: load applied 9751917 after 1500 cycles 50–200N
along drillhole axis cyclical loading

Spiked washers 759675

IntraFix 13321309

Bioscrew 512567

Coleridge Bovine 1000 cycles 70–22N

and Amis slippage (mm)

RCL Tibia: pull in line of 491 1.3

tunnel

Delta screw 641 1.15

IntraFix 543 0.69

Bicortical screws 770 1.17

WasherLoc 945 0.88

ULF, Ultimate load to failure.

Coleridge et al. Knee Surg Sports Traumatol Arthrosc 2004(12):391–397; Giurea et al. Am J Sports Med 1999(27):621–625; Kousa et al. Am J Sports Med 2003(31):182–188; Magen et al.
Am J Sports Med 1999(27):35–43; Nagarkatti et al. Am J Sports Med 2001(29):67–71.
*Yield loads.

exercises. Running is started from 10 weeks or when a
“quiet” knee (i.e., minimal pain and swelling) has been
achieved. Rehabilitation programs are individually tailored
to include sports-specific training, and patients can return
to contact sports from 6 months. Patients with meniscal or
chondral deficiency may be advised to avoid high-impact
training and activities.
Brown and Carson2 suggested that an accelerated
rehabilitation program68 for revision ACL reconstruction
is not appropriate due to weaker initial graft fixation. We

452

FIG. 58-3 Scan of a failed anterior cruciate ligament (ACL) reconstruction
demonstrating a huge tibial defect.
have found that this is not necessary, as using a two-stage
technique ensures that there is good quality bone around
the tunnels and initial graft fixation is as secure as in the pri-
mary reconstruction. We have followed the same rehabilita-
tion program for both primary and revision ACL patients
and have not found any significant difference between the
objective and subjective laxity assessment at follow-up
between the primary and revision ACL reconstruction.
OUR EXPERIENCE WITH A TWO-STAGE
REVISION ANTERIOR CRUCIATE LIGAMENT
RECONSTRUCTION
From 1991 to 2003 the senior author performed 75 revision
ACL reconstructions. Of these, nine were performed as a
single-stage revision, and 11 were performed in patients with
multi-ligamentous laxity needing attention. The remaining
55 patients underwent revision ACL reconstruction using a
two-stage technique with bone grafting of the tibial tunnel
(Fig. 58-4). Of these 55 patients, 49 had a minimum fol-
low-up of 3 years or more, and we compared this group of
patients with a matched cohort of 49 patients with primary
ACL reconstruction. These results were recently published
in the American Journal of Sports Medicine.1 The salient find-
ings of this study are summarized here.
The average age of the patients at the time of revision
ACL reconstruction was 35.4 years (range 26–42 years).
None of the patients was lost to follow-up in this study.
The mean follow-up was 6 years (range 3–11 years). Preop-
eratively, all knees had positive Lachman and pivot-shift
tests. The pivot shift was graded 1þ (glide) in four knees,
Revision Anterior Cruciate Ligament Reconstruction 58
FIG. 58-4 Scan of the proximal tibia 6 months after bone grafting the tibial
tunnel.
2þ (clunk) in 34 knees, and 3þ (subluxation) in 11 knees.
This improved to pivot-shift grades of 0 in 43 knees, 1þ
in five knees, and 2þ (clunk) in one knee. The mean laxity
measurement (SSD) using Westminster cruciometer was
1.36 mm (standard deviation [SD]: 1.11), and this was not
significantly different from the primary reconstructions
(mean 1.2 mm; SD: 1.5). In one patient from the revision
ACL group, the graft stretched out (the patient suffers from
generalized ligamentous laxity) 4 years after the revision sur-
gery, and the patient is awaiting rerevision surgery.
Technical error was the most common reason for graft
failure (femoral, 28 cases; tibial, 20 cases; both femoral and
tibial, four cases). Tunnel enlargement was seen in all the
cases. The mean tibial tunnel measurements were
13.7 mm (SD: 2.5 mm) on AP and 13.9 mm (SD:
2.3 mm) on lateral radiographs.
The mean IKDC subjective and objective scores were
lower for the revision group compared with the primary
group. On analysis of the subjective scores, the main differ-
ences noticed between the two groups were in the pain level
and the activity level. On analysis of the objective IKDC
scores, main differences were noticed in passive motion deficit
and finding of crepitus in various compartments.
None of the revision ACL group patients in our study
returned to original level of activity (pre–ACL injury). This
can be explained by the presence of associated meniscal and
chondral pathology and should form an important part of
the counseling offered to revision ACL surgery patients
prior to their operation.
Patients who have a prosthetic ligament as the
primary graft and are undergoing subsequent revision sur-
gery merit separate discussion. In all cases, the first-stage
453
 Anterior Cruciate Ligament Reconstruction
revision surgery was more demanding and time consuming,
as the synthetic graft evoked a lot of synovitis and scarring
within the knee. Extra care was needed to identify the
PCL before clearing the intercondylar notch. The extent
of tunnel enlargement was also more pronounced in these
cases.
REVIEW OF LITERATURE
Noyes and Barber-Westin reported on 55 patients who had
a revision ACL reconstruction with a BPTB autograft.33
The failure rate, which was determined in a fashion similar
to that in their revision allograft report, was 24%. Of these
13 patients, six had a reharvested patellar tendon autograft.
This was a heterogenous group, and the authors stratified
the group of 55 knees into those who had an ACL recon-
struction only, those who required a staged high tibial
osteotomy, and those who required a concurrent ligament
reconstructive procedure. The group requiring only ACL
reconstruction had a failure rate of 16% (5/32 knees). Ear-
lier, the same research group had also published their results
of revision ACL surgery with the use of a BPTB allograft.39
They noted an incidence of 33% failure at a mean of 42
months. In this series, the allografts were obtained from tis-
sue banks certified by the American Association of Tissue
Banks (AATB) and were fresh-frozen at the time of pro-
curement. The grafts had been sterilized with 25,000 gray
of gamma irradiation. This amount of low-dose irradiation
probably does not alter the mechanical properties of the
graft. In fact, AATB has advocated use of low-dose irradia-
tion for many years and several authors have used it for
ACL allografts to improve the protection against bacterial
contamination.42,43 Noyes et al advocate that allograft
should not be considered as the first choice of graft for revi-
sion surgery. If no autograft is available for revision surgery,
they advise augmentation of the allograft with the lateral
extraarticular iliotibial band procedure to reduce the high
failure rate associated with the use of allograft.33
Fox et al recently published their results of revision
ACL reconstruction using nonirradiated patellar tendon
allograft.69 Thirty-two of 38 patients (84%) were available
for follow-up. The mean patient age was 28 years with a
mean follow-up of 4.8 years (range 2.1–12.1). This is a good
homogenous group of patients with critical evaluation of
results. None of the patients in the series had meniscal allo-
graft surgery, posterolateral reconstructions, high tibial
osteotomies, or contralateral ACL deficiency or reconstruc-
tion. Of this patient group, 87% were subjectively satisfied,
87% had 0/1þ pivot shift, and 84% had a KT-1000 SSD
of less than 3 mm. The authors quote a failure rate of 28%
using stringent criteria, namely the presence of a positive
454
pivot-shift test (grade 1/2/3) and/or a KT-1000 result of
more than 5 mm SSD. If the criteria used for definition
are changed to SSD greater than 5 mm and pivot-shift
grade 2 or more, then the failure rate is just 6%. The authors
very correctly point out that the criteria used for defining
failure after revision surgery are variable, which further com-
plicates the comparison.
The Pittsburgh series of Johnson et al20,21,48 used irra-
diated, fresh-frozen allografts. Nine of the 25 patients had a
KT-1000 maximum manual difference of greater than
5.5 mm. Eighty percent had grade 0 or 1 Lachman result,
and 20% had grade 2 Lachman result; 76% of patients were
satisfied with the results.21
Uribe et al reported on 54 patients with revision ACL
reconstruction using a variety of grafts including ipsilateral
patellar tendon autograft, contralateral patellar tendon
autograft, allograft patellar tendon, and hamstring autograft.
All the patients had an improvement in their objective
stability; however, only 54% of the patients returned to their
pre–ACL injury activity level.70
Battaglia et al34 recently published their experience of
revision ACL reconstruction using freeze-dried allograft
bone dowels. The advantages of these grafts are their ready
availability, the elimination of donor site (iliac crest)
morbidity, and their ability to provide sufficient structural
support for the new tunnels. Although all these proposed
benefits are true, with passage of time the allograft may
become resorbed, compromising the stability of the ACL
reconstruction.
Our results compare favorably to those published in
the literature28,33,34,39,69–71 with regard to laxity measure-
ments, and our failure rate is significantly lower. In only
one case the graft had failed at 52 months and the patient
complained of instability requiring revision, giving a failure
rate of 2.04%. In another patient, the cruciometer reading was
5 mm, suggestive of increased laxity. However, this patient is
coping well at present and has not had any further surgical inter-
vention. These results have been achieved despite an uncompro-
mised rehabilitation regimen, and we believe that this can be
attributed at least partly to the two-stage technique we used,
which allows for the consolidation of the bone graft in the tibial
tunnel. These figures also represent the “worst-case” scenario, as
no patient was lost to follow-up.
This study has certain limitations. In an ideal world,
we would have set up a randomized controlled trial compar-
ing the results of a two-stage revision surgery with a one-
stage revision surgery to highlight the differences (if any).
Although a two-stage surgery provides good bone for place-
ment of the tibial tunnel, it exposes the patient to another
surgical intervention. This may indeed have negative effects
on the patient’s range of motion and pain after surgery and
also may prolong the rehabilitation period. In the period of

the past 10 years, the senior surgeon has performed nine
revision ACL reconstructions using a single-stage tech-
nique. As this is quite a small number, we did not compare
the results with one-stage revisions. In our opinion, a single-
stage technique should only be used if the placement of the
primary tibial tunnel is so incorrect that it will not overlap at
all with the correctly placed revision tunnel. This was rarely
the case in our series with both tunnels.
In this study, we decided to graft the tibial tunnel, as
there was no other way of bypassing the defect in the bone
created during the primary surgery. Bone grafting the primary
tibial tunnel and ensuring its adequate healing prior to
proceeding to the second stage of revision reconstruction
ensured that the new tunnel could be drilled through an area
with adequate bone stock, which in turn would not com-
promise the fixation achieved or the postoperative rehabilita-
tion. In cases of femoral tunnels in this series, it was always
possible to alter the technique of drilling the femoral tunnel
(outside-in versus inside-out), thereby ensuring that the bony
defect created during the primary procedure was avoided.
Revision ACL surgery is both a challenging and a
rewarding enterprise for the surgeon. It is challenging in
that it uses all the surgeon’s experience and communication
skills in dealing with these complex cases and patients. It
also tests the surgeon’s surgical expertise and knowledge of
fixation techniques and biological healing and thus the best
predictable outcome for each patient. The treatment process
benefits from a mature organizational setup and a compe-
tent team. The rewards are self-evident.
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 PART M ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION FOR
SKELETALLY IMMATURE PATIENTS OR PARTIAL TEARS
Anterior Cruciate Ligament Reconstruction
in Skeletally Immature Patients
Intrasubstance tears of the anterior cruciate lig-
ament (ACL), a common injury in adults, are
relatively rare in children and adolescents.1 Pre-
sumably, this difference in prevalence of ACL
tears is due to anatomical and biomechanical
differences that predispose skeletally immature
knees to physeal and bone injury rather than
ACL tears. Despite being an uncommon occur-
rence, ACL tears in children and adolescents
have recently been reported with increasing fre-
quency.2–20 The increased recognition of this
injury may be attributed to an increase in sports
participation combined with improved exami-
nation and diagnostic methods. When a skele-
tally immature patient presents with a torn
ACL, the physician is confronted with a diffi-
cult decision because nonoperative treatment
may result in instability with subsequent menis-
cal tears and early degenerative changes,2,6,9–11
and surgery may cause iatrogenic leg length dis-
crepancy or angular deformities.5–7,12–15
Management of ACL tears in skeletally
immature patients remains controversial because
of a deficiency in the basic science literature on
physeal growth and response to injury. Clinical
studies published on the treatment of this con-
dition have contributed to the confusion by hav-
ing poor methodology with low levels of
evidence and combining patients with different
levels of maturation and methods of treatment.*
Although a fundamental lack of knowl-
edge is the cause of the controversy surrounding
treatment of ACL injuries in children and
*References 4, 7, 11, 12, 14–19
59
CHAPTER
adolescents, a rational approach to management Allen F. Anderson
of this problem can still be developed based on
Christian N. Anderson
current understanding of the natural history of
this injury, normal growth and development,
response of the physis to injury, and treatment
options. This approach enables the surgeon to
estimate whether the patient is at high, interme-
diate, or low risk of iatrogenic growth distur-
bance and to choose the method of treatment
depending on the level of risk.
NATURAL HISTORY
The natural history of ACL tears in children
and adolescents has not been clearly documen-
ted, but it can be extrapolated from the results
of studies published on nonoperative treatment.
The unique challenge of treating intrasubstance
ACL tears in skeletally immature patients com-
bined with the absence of an efficacious surgical
procedure resulted in a historical approach
of nonoperative treatment, consisting of brac-
ing, quadriceps and hamstring strengthening,
counseling, and activity modification. A grow-
ing body of evidence from studies of nonopera-
tive treatment proves that the natural history of
ACL tears in children and adolescents is gener-
ally poor for behavioral or other reasons. ACL
deficient patients in this age group are noncom-
pliant with activity modification, and conse-
quently they often experience recurrent
instability, meniscal damage, and sports-related
disability. Kannus and Jarvinen10 treated 25
patients with grade II partial ACL tears and
457
 Anterior Cruciate Ligament Reconstruction
seven patients with grade III complete ACL tears. Eight
years after the initial injury, the results were excellent or
good for the patients with Grade II ACL tears. The long-
term results of grade III ACL injuries were poor because
these patients developed chronic instability and posttrau-
matic arthritis. Kannus and Jarvinen reported that the
results of nonoperative treatment for complete ACL tears
in this age group were not acceptable. Angel and Hall3 eval-
uated 27 children and adolescents who had a torn ACL. At
the time of follow-up, the majority had pain and limitations
of activity. Eleven of 12 patients in their series of children
younger than age 14 were disabled with knee function. Graf
et al9 found that seven of eight children treated conserva-
tively sustained new meniscal tears within 15 months.
McCarroll et al11 found that 37 of 38 adolescent patients
had episodes of instability, and 27 of 38 had symptomatic
meniscal tears. Eleven of 18 patients in the series of Mizuta
et al20 developed degenerative changes within 51 months,
and the researchers stated the results were “poor and unac-
ceptable.” Millet et al21 also found that the incidence of
meniscal injuries increased significantly in chronic cases.
Ideally, operative treatment of ACL injuries in skele-
tally immature patients could be postponed until physeal
closure. The results of these studies, however, indicate that
nonoperative treatment may actually result in a greater risk
to the knee than surgery.
ASSESSING SKELETAL MATURITY
The central issue in treatment of ACL tears in the pediatric
age group is the patient’s skeletal age, which determines the
relative risk and potential consequences of iatrogenic physeal
injury. Some skeletally immature patients will have a great
deal of growth remaining, whereas others will have minimal
growth of the distal femur and proximal tibial physes. The
consequences of growth disturbance may be severe in the
former patients and insignificant in the latter patients. The
lack of specific documentation of skeletal maturity in clinical
studies (i.e., wide-open physis) published on the treatment
of ACL tears in skeletally immature patients is a source of
the controversy surrounding the treatment of the condition.
A rational approach to management of this problem can be
based on estimation of the relative risk (high, intermediate,
or low) by determining the patient’s chronological age, skel-
etal age, and physiological age.
For large populations, chronological age is an excel-
lent predictor of skeletal maturity; however, patients may
show a significant variance from the average. Consequently,
it is important to determine the skeletal age with radio-
graphs. The most common method of estimating skeletal
age is by comparing an anteroposterior radiograph of the
458
patient’s left hand and wrist with the age-specific radio-
graphs in the Greulich and Pyle atlas.22
Physiological age can be determined with Tanner
staging of sexual maturation.23 Patients are preliminarily
staged prior to surgery by questioning them about the onset
of menarche or growth of axillary hair. After induction
of anesthesia and prior to surgery, Tanner staging is deter-
mined by examining the patient’s secondary sexual deve-
lopment, including the growth of pubic and axillary hair,
breasts, and genitalia. Prepubescent patients are categorized
in Tanner stage I and II of development, pubescent patients
are in stage III, and postpubescent patients are in Tanner
stage V (Table 59-1).
NORMAL GROWTH AND DEVELOPMENT
The physes of the distal femur and proximal tibia are the
most rapidly growing in the body. Anderson et al24 esti-
mated that the distal femoral physis contributes 40% and
the proximal tibia physis contributes 27% of the overall
lower extremity length. More recently, Pritchett25 reported
that the distal femur grows at 1.3 cm per year until the last
2 years of maturity, when the growth rate drops to 0.65 cm
per year. The rates of the proximal tibial growth are 0.9 cm
per year and 0.5 cm per year in the last 2 years. The peak
height velocity for males is 13 to 15 years of age (average
13.5 years), and it rarely occurs before Tanner stage IV.
Twenty percent of males do not hit peak height velocity
until Tanner stage V. For females, the peak height velocity
occurs in Tanner stage III between 11 and 13 years of age
(average 11.5 years). Peak height velocity in females pre-
cedes menarche by approximately 1 year.
The severity of iatrogenic growth deformity is deter-
mined in part by the patient’s skeletal maturity at the time of
injury. It has been estimated that complete closure of the
proximal tibial physis in the average 12-year-old boy, complete
closure of the distal femoral in a 13-year-old boy, or com-
plete closure of the femoral and tibial physes of a 14-year-old
boy will result in a 3-cm leg length discrepancy. A leg length
discrepancy of 1.2 cm is considered within normal variance.
The greatest concern, however, is not leg length discrep-
ancy but angular deformity. An over-the-top femoral groove
may result in a valgus/flexion deformity of the distal femur by
damaging the perichondral ring of LaCroix. Damage to the
anterior tibial physis may result in recurvatum. In the worst-
case scenario, Wester et al26 estimated that a 14-year-old boy
with 2 cm of remaining distal femoral growth could develop a
14-degree valgus deformity with a lateral femoral epiphysiod-
esis or 11-degree recurvatum with partial tibial physeal arrest.
The results of these studies may be used to rank the
potential consequences of an iatrogenic physeal injury.
 Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients 59
TABLE 59-1 Tanner Staging Classification of Secondary Sexual performed an ACL reconstruction with the semitendinosus
Characteristics tendon using 2-mm transphyseal femoral and tibial holes in
Tanner Stage Male Sexual Female Sexual immature rabbits. The femoral holes damaged 11% of the
Characteristics Characteristics transverse diameter and 3% of the cross-sectional area of
the physis, and the tibial holes damaged 12% of the trans-
Stage I Testes <4 mL or <2.5 cm No breast development verse diameter and 4% of the cross-sectional area of the
(prepubescent) No pubic hair No pubic hair physis. Two of the 21 tibiae developed a valgus deformity,
Stage II Testes 4 mL or 2.5–3.2 cm Breast buds and one was shorter. The researchers recommended careful
Minimal pubic hair at base Minimal pubic hair on evaluation of the percentage of damage to the area of the
of penis labia physis before performing intraarticular methods of recon-
struction of the ACL in adolescents.
Stage III Testes 12 mL or 3.6 cm Elevation of breast;
Houle et al29 performed a transphyseal ACL recon-
(pubescent) Pubic hair over pubis areolae enlarge
struction in a rabbit model using four tunnel diameters
Voice changes Pubic hair of mons
ranging from 1.95 to 3.97 mm. They found that the larger
Muscle mass increases pubis
drill holes caused more marked deformity and the soft tissue
Axillary hair
graft did not offer protection to physeal arrest. They recom-
Acne
mended that tunnels involve 1% or less of the area of the
Stage IV Testes 4.1–4.5 cm Areolae enlarge physis when reconstructing the ACL in children.
Pubic hair as adult Pubic hair as adult Janarv et al30 drilled 1.7-, 2.5-, and 3.4-mm holes in
Axillary hair rabbit femurs. The hole in one femur was left empty, and
Acne the hole in the contralateral femur was filled with a soft tissue
Stage V No growth No growth
autograft. They found that growth retardation occurred when
(postpubescent) Testes as adult Adult breast contour
the drill injury destroyed 7% to 9% of the distal femoral
Pubic hair as adult
physis, but no retardation was seen in injuries of 4% to 5%
Pubic hair as adult
Facial hair as adult
of the cross-sectional area of the physis. The soft tissue grafts
prevented solid bone bridging, but a bone cylinder formed
Mature physique
around the grafts. They also measured the tibial and femoral
Other Peak height velocity: 13.5 Peak height velocity:
physis of a 12-year-old girl and estimated that an 8-mm drill
years 11.5 years
hole would destroy 3% to 4% of the physis. In contrast to the
Menarche: 12.7 years
results of Houle et al29 and Guzzanti et al,28 Stadelmaier
et al31 found that a soft tissue graft placed in transphyseal drill
holes of a canine model prevented formation of a bony bridge
High-risk patients are prepubescent and in Tanner stages I and subsequent growth disturbance.
and II of sexual maturation. Intermediate-risk patients are The effect of tensioning a graft across open physes has
pubescent and in Tanner stage III. Low-risk patients with also been evaluated. Edwards et al32 found that tensioning a
closing physes are in Tanner stage IV of sexual maturation. fascia lata autograft at 80N in a canine model caused valgus
femoral and varus tibial deformities without radiographic or
histological evidence of physeal bar formation, indicating
BASIC SCIENCE RESEARCH ON PHYSEAL INJURY the physes were responding to the Hueter-Volkmann prin-
ciple, which states that application of compressive force per-
Although a deficiency exists in the age-specific basic science pendicular to the physes will inhibit longitudinal growth.
on physeal injuries, research has demonstrated the effects of This study illustrates the potential risks for ACL reconstruc-
drill hole damage to the physis and the results of placing tion in this age group, even with physeal-sparing procedures.
a soft tissue graft through a transphyseal hole in animal
models. Makela et al27 in 1988 drilled 2- and 3.2-mm trans-
physeal femoral holes in a rabbit model. The 2-mm holes RISK FACTORS FOR IATROGENIC GROWTH
destroyed 3% of the cross-sectional area of the physis, and DISTURBANCE
the 3.2-mm holes destroyed 7% of the cross-sectional area.
The destruction of 7% of the cross-sectional area of the The potential consequences of growth disturbance after
growth plate caused permanent growth disturbance. ACL reconstruction in the skeletally immature knee have
Other researchers have evaluated the effect of placing a major influence on decisions about surgical technique.
a soft tissue graft across the physis. Guzzanti et al28 Although the results of basic science studies on physeal

459
 Anterior Cruciate Ligament Reconstruction
injury in animals may not be entirely applicable to humans,
several important risk factors for growth disturbance after
physeal injury have been identified. The studies of Guzzanti
et al28 and Houle et al29 demonstrated that the proximal
tibial physis seems to be more vulnerable than the femoral
physis to growth arrest.
In general, the risk of growth disturbance is related to
the extent of damage relative to the cross-sectional area of
the physis. However, uncertainty still exists, even in animal
models, regarding the size and orientation of the drill holes
that can be made without causing growth disturbance. The
drill hole size threshold for growth disturbance in animal
models has been between 1% and 7% of the cross-sectional
area of the physis.27,28–30 The holes should be drilled per-
pendicularly, rather than obliquely, to limit the area of dam-
age to the physis. Although results have been mixed, placing
a soft tissue graft across the physis appears to offer protec-
tion from bone bridging and growth arrest. Research also
demonstrates that the physes are sensitive to compressive
forces,32 and consequently ACL grafts, including those used
in physeal sparing procedures, should not be overtensioned.
Significant leg length discrepancy or angular defor-
mity, although rare, has been reported after ACL reconstruction
in skeletally immature patients.5,6,14 Kocher et al5 surveyed Her-
odicus and the ACL study group. One hundred and forty
respondents reported 15 cases of growth disturbance. We have
also seen two cases of valgus knee deformity after ACL recon-
struction in adolescents. One of these patients had a staple placed
across the lateral femoral physis.6 The other patient was a 12-
year-old boy who was recently seen 6 months after a transphyseal
ACL reconstruction with an Achilles tendon allograft. The graft
had failed, and the patient had a 3-degree valgus alignment of
the normal knee and a 7-degree valgus alignment of the ACL
deficient knee, without physeal arrest.
TREATMENT OPTIONS
Case reports and animal studies showing iatrogenic growth
disturbance after intraarticular transphyseal replacement have
prevented clinicians from routinely applying proven methods
of ACL reconstruction for adults to skeletally immature
patients. Nonoperative management of ACL tears in children
and adolescents is an especially seductive approach. The
advantages of delaying surgery include additional psychologi-
cal maturation of the patient, which facilitates compliance
with postoperative rehabilitation, and greater skeletal matu-
rity, which allows for less risky and more familiar traditional
procedures. For these reasons, some surgeons still advocate a
nonoperative approach despite the poor results.7,12,14
Other surgeons have performed primary repair33,34 or
extraarticular replacement in this age group.9,11 Unfortunately,
460
these procedures have been found to be no more successful in
children than they are in adults.
Modified physeal-sparing intraarticular replacements
have also been advocated to minimize the risk of physeal
injury.19 Parker et al35 reconstructed the ACL by passing
the hamstring tendons through a groove in the anterior aspect
of the tibia and over the top of the lateral femoral condyle.
Kocher et al13,18 reported the results of 44 Tanner stage I or
II patients who were treated with a combined intraarticular
and extraarticular reconstruction of the ACL. The iliotibial
band was placed extraarticularly around the outside of the lat-
eral femoral condyle and through the intercondylar notch and
then sutured to the periosteum of the proximal tibia. Two
patients in their series required reconstruction for graft
failure. The mean IKDC subjective score for the remaining
42 patients was 96.7, and the mean growth from surgery to
follow-up was 21 cm. The Lachman examination revealed
that 23 patients were normal, 18 were nearly normal, and
one was abnormal. The results of the pivot-shift test were
normal in 31 patients. The researchers concluded that this
procedure provided an excellent functional outcome with
minimal risk of growth disturbance. Some surgeons have used
transphyseal tibial holes and the over-the-top femoral posi-
tion with autografts16,17 and allografts.12 Recently, Guzzanti
et al36 recommended ACL reconstruction with single-
stranded semitendinosus and gracilis tendon graft in Tanner
stage I patients with a transepiphyseal tibial hole and a femo-
ral over-the-top femoral position. Although these over-the-
top procedures have not caused growth disturbances, they
do not provide isometry of the graft. Odensten and Gill-
quist37 demonstrated that the femoral over-the-top position
resulted in an average of 10 mm of graft elongation as the
knee approached extension. If the over-the-top femoral posi-
tion is used, the clinician should avoid rasping, which
may damage the perichondral ring.
ACL replacement procedures with intraarticular
transphyseal placement of the graft remain controversial
because of the potential for physeal injuries. Clinical studies
documenting the safety of transphyseal replacement have pri-
marily involved postmenarchal adolescent females or postpu-
bescent adolescent males with physes that were near
closure.11,12,38–40 Pressman et al15 performed an intraarticular
replacement in 18 patients, only seven of whom had open
physis and 11 of whom had closed or closing physis. Andrews
et al12 and McCarroll et al7 also performed intraarticular
replacements, but postoperatively their patients grew only
4.5 cm and 2.3 cm of height, respectively. The average age
of the patients at the time of ACL reconstruction was greater
than 14 years in other case series.38,40,41 The potential for
leg length discrepancy or angular deformity is relatively low
in these cohorts. Surgical treatment of patients who are in
Tanner stage I or II of maturation presents greater

FIG. 59-1 Anteroposterior and lateral radiographs made 4 months after transepiphyseal anterior cruciate ligament
(ACL) reconstruction in a 10-year, 8-month-old Tanner stage I male.
consequences if growth disturbance occurs, potentially resulting
in significant limb length discrepancy or angular deformity. Only
a few patients who were that immature were included in the pre-
vious clinical reports on transphyseal replacement. Conse-
quently, the safety of transphyseal procedures for preadolescent
children has not been substantiated in the clinical literature,
and basic science studies have also failed to clearly demonstrate
the safety of transphyseal drilling or placement of a soft tissue
graft across the physis.
Guzzanti et al42 recommended transphyseal recon-
struction in Tanner stage II and III patients with semitendi-
nosus gracilis grafts. They emphasized that the holes should
not be larger than 6 mm.
Anderson43 reported the preliminary results of a
transepiphyseal replacement that followed the generally
accepted principles of ACL reconstruction in adults but
theoretically minimized the risk of physeal injury by not
transgressing either the tibial or femoral physes (Figs. 59-1
and 59-2). Twelve patients, including three who were in Tan-
ner stage I, four in Tanner stage II, and five in Tanner stage
III, were evaluated at a mean of 4.1 years after surgery. The
mean growth from the time of surgery to follow-up was
16.5 cm. The difference in lengths of the lower limbs, as
measured on long leg radiographs, was not clinically relevant.
The mean score on the IKDC Subjective Knee Form was
96.5. Ligament laxity testing with a KT-1000 arthrometer
Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients 59
revealed a mean side-to-side difference of 1.5 mm. The
rating, according to the criteria of the Objective 2001 IKDC
Knee Form,44 was normal for seven patients and nearly nor-
mal for five patients.
Subsequently, eight additional patients (three in Tanner
stage I, two in Tanner stage II, and three in Tanner stage III)
had transepiphyseal replacement of the ACL with this tech-
nique, and the mean interval from surgery for the original series
is now more than 6 years. One patient in the original study pop-
ulation, who rated 100 on the IKDC Subjective Score at 2 years,
reruptured his ACL graft 4 years after surgery while playing
sports. Another patient, who had an ACL replacement more
recently, fell from a motorcycle 8 weeks after his ACL recon-
struction and sustained a grade III injury to his medial collateral
ligament and the ACL graft. This patient’s lack of compliance
illustrates why it is difficult to treat patients in this age group.
The Endobutton Continuous Loop broke in another patient 1
year after surgery. The washer was removed, and the patient’s
knee was rated as excellent with no residual pathological laxity.
TREATMENT AND RECOMMENDATIONS
Our approach to treatment of ACL tears in the pediatric
age group is based on the patient’s skeletal age and sexual
maturation, which determine the relative risk and potential
461
 Anterior Cruciate Ligament Reconstruction
FIG. 59-2 This arthroscopic view shows the position of the quadruple
hamstring graft after transepiphyseal anterior cruciate ligament (ACL)
reconstruction.
consequences of iatrogenic physeal injury. Prepubescent
patients in Tanner stages I or II of development, including
males less than 12 years of age and females less than 11
years of age, are at high risk.
FIG. 59-3 Anteroposterior and lateral radiographs demonstrating the position of the drill holes 6 months
after transphyseal anterior cruciate ligament (ACL) reconstruction in a 14-year, 2-month-old Tanner stage IV male.
462
Transepiphyseal ACL reconstruction is recommended
for high-risk patients because this procedure adheres to the
generally accepted principles of ACL replacement in adults
but theoretically minimizes the risk of physeal injury by
not transgressing either the tibial or the femoral physis.
For surgeons who are worried about the technical difficulty
of a transepiphyseal ACL replacement, the physeal-sparing
reconstruction described by Kocher et al13 may be an alter-
native. Although the iliotibial band is a relatively weak graft
and is not placed isometrically on either the tibia or femur,
the functional results appear to be good.
Pubescent Tanner stage III patients, including males
13 to 16 years of age and females 12 to 14 years of age,
are at intermediate risk. Transepiphyseal replacement is also
recommended for this group because the threshold of safety
of transphyseal drilling is currently unknown.
More mature, low-risk, pubescent Tanner stage IV
patients are treated with a transphyseal replacement using
quadruple hamstring grafts fixed with an Endobutton proxi-
mally and screw and post distally (Fig. 59-3). Postpubescent
patients in Tanner stage V of development, including males
older than 16 years and females older than 14 years, may be
treated safely with a standard adult ACL replacement.

TRANSEPIPHYSEAL ANTERIOR CRUCIATE
LIGAMENT RECONSTRUCTION
Surgical Technique
The injured lower limb is placed in an arthroscopic leg holder
with the hip flexed to 20 degrees to facilitate C-arm fluoro-
scopic visualization of the knee in the lateral plane. The
C-arm is positioned on the side of the table opposite the
injured knee, and the monitor is placed at the head of the
table. The tibial and femoral growth plates are visualized in
both the anteroposterior and lateral planes before the limb is
prepared and draped. When the distal part of the femur is
viewed, the C-arm is adjusted so that the medial and lateral
femoral condyles line up perfectly in the lateral plane. The
C-arm is then rotated to visualize the extension of the tibial
physis into the tibial tubercle on the lateral view of the tibia.
An oblique 4-cm incision is made over the semitendi-
nosus and gracilis tendons, which are dissected free, trans-
ected at the musculotendinous junction with use of a
standard tendon stripper, and detached distally. The ten-
dons are then doubled, and a #2 Fiberwire suture (Arthrex,
Naples, FL) is placed in the ends of the tendons with a
whipstitch. The doubled tendons are then placed under
4.5 kg (10 pounds) of tension on the back table with use
of the Graftmaster device (Acufex-Smith & Nephew, And-
over, MA). The arthroscope is inserted into the anterolat-
eral portal, and a probe is inserted through the
anteromedial portal. Intraarticular examination is systemati-
cally performed in the usual manner. Debris in the intercon-
dylar notch is removed, and a minimal notchplasty is
performed to visualize the anatomical footprint of the
ACL on the femur. If a substantial meniscal tear is found,
it is repaired.
With the C-arm in the lateral position, the limb is
adjusted to show a perfect lateral view (Fig. 59-4, B). The
point of the guidewire is placed on the skin over the lateral
femoral condyle, corresponding with the location of the
footprint of the ACL on the femur. This point is approxi-
mately one-fourth of the distance from posterior to anterior
along the Blumensaat line and one fourth of the distance
down from the Blumensaat line (see Fig. 59-4, B). A 2-
cm lateral incision is made at this point, the iliotibial tract
is incised longitudinally, and the periosteum is stripped
from a small area of the lateral femoral condyle. The C-
arm is used to visualize the entry point of the guidewire in
both the anteroposterior and the lateral planes. With the
C-arm in the lateral planes and using a freehand technique,
the point of the guidewire is introduced 2 to 3 mm into the
femoral epiphysis. The pin is not angulated anteriorly or
posteriorly but is kept perpendicular to the femur in the
Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients 59
coronal plane. The C-arm is then rotated to the anteropos-
terior plane to make sure that the guidewire is not angulated
superiorly or inferiorly. The guidewire is then driven across
the femoral epiphysis, perpendicular to the femur and distal
to the physis (see Fig. 59-4, A and B). Entrance of the guide-
wire into the intercondylar notch is subsequently visualized
arthroscopically. The guidewire should enter at the center of
the anatomical footprint of the ACL on the femur. This fem-
oral guidewire is left in place, and a second guidewire is then
inserted into the anteromedial aspect of the tibia through
the epiphysis with the aid of a tibial drill guide. From the
direct lateral position, the C-arm is rotated externally approx-
imately 30 degrees to clearly demonstrate the physis extend-
ing into the tibial tubercle. The guidewire is then drilled
into the tibial epiphysis under real-time fluoroscopic imaging
(see Fig. 59-4, C). The handle of the drill guide must be lifted
for the pin to clear the anterior part of the tibial physis. The
pin should enter the joint at the level of the free edge of the
lateral meniscus and in the posterior footprint of the ACL
on the tibia. The appropriate position of both guidewires
should be confirmed arthroscopically at this point. Tendon
sizers are used to measure the diameter of the quadruple ten-
don graft (which typically ranges from 6 to 8 mm). A tight fit
is important; consequently, the smallest appropriate drill is
used to ream over both guidewires. The edge of the femoral
hole is chamfered intraarticularly, and the width of the lateral
femoral condyle is measured. The appropriate Endobutton-
CL (2–3 cm) is chosen so that approximately 2 cm of the qua-
druple hamstring tendon graft will remain within the lateral
femoral condyle. The Endobutton-CL is then passed around
the middle of the double tendons and is looped inside of itself
to secure the tendons proximally (Fig. 59-5). Alternatively,
the tendons can be placed through the continuous loop
before the tendon ends are sutured together. However, this
requires drilling and measuring the length of the femoral
hole before graft preparation. Otherwise, it is difficult to
determine the appropriate length of the Endobutton-CL
necessary to leave 2 cm of the tendon graft within the lat-
eral femoral condyle.
A #5 Fiberwire suture is placed in one end of the
Endobutton, and a suture passer is used to pass it from
anterior to posterior through the tibia and out the lateral
femoral condyle (see Fig. 59-5). The Endobutton and
tendons are then pulled up through the tibia and out of
the femoral hole with use of the #5 suture. An Endobutton
washer (Smith & Nephew, Memphis, TN), 3 to 4 mm
larger than the femoral hole, is placed over the Endobutton.
Tension is then applied to the tendons distally, pulling the
Endobutton and washer to the surface of the lateral femoral
condyle (Fig. 59-6). The washer is necessary to anchor the
graft proximally because the hole in the lateral femoral
463
 Anterior Cruciate Ligament Reconstruction

A B

C
FIG. 59-4 Anteroposterior (A) and lateral (B) views demonstrating the position of the guidewire in the femoral
epiphysis. C, Lateral view of the tibia, demonstrating the position of the tibial guidewire. Although the guidewire
appears to enter the tibial tubercle in this view, it actually enters the epiphysis medial to the tibial tubercle.

condyle is larger than the Endobutton. The graft is placed
under tension, and the knee is then extended to determine
arthroscopically whether there is impingement of the graft
on the intercondylar notch. Although an anterior notch-
plasty is usually unnecessary when this technique is used, if
the anterior outlet of the intercondylar notch touches or
indents the graft in terminal extension, a small portion of
the anterior outlet may be removed. With the knee in 10
degrees of flexion, the quadruple hamstring graft is secured
distally by tying the #5 Fiberwire sutures over a tibial screw
and post that is placed medial to the tibial tubercle apophy-
sis and distal to the proximal tibial physis. If the tendon
graft extends through the tibial drill hole, it is also secured
to the periosteum of the anterior tibia with multiple #1
Ethibond sutures with use of figure-eight stitches (see
Fig. 59-6). The subcutaneous tissue and skin are closed in
a routine fashion, and a hinged brace is applied.
Postoperative Rehabilitation
The patient’s knee is placed in a hinged brace postopera-
tively. Phase I of rehabilitation is started as soon as the
patient awakes after surgery. The patient is encouraged to
perform quadriceps muscle contraction and straight-leg
raises. Cryotherapy is used for 5 to 10 minutes every hour.
Range-of-motion exercises and hamstring muscle stretches
while the patient is prone are started the day after surgery.
The patients who did not have a meniscal repair are allowed
to walk with crutches with weight bearing as tolerated. The
patients who underwent a meniscal repair are allowed only
toe-touch weight bearing for 6 weeks.
At 1 week after surgery, the goal is a range of motion
from 0 degrees of extension to 90 degrees of flexion. Phase
II of rehabilitation, the strengthening phase, lasts from
2 to 11 weeks postoperatively. Active range-of-motion exer-
cises along with patella mobilization and electrical muscle
stimulation are begun. Patients progress through the exer-
cises at their own pace. They are fitted with a functional
knee brace 2 weeks after surgery, and full weight bearing is
encouraged. Exercises, which are introduced into the reha-
bilitation program in order of increasing difficulty, include
hamstring and quadriceps muscle stretching and strength-
ening, proprioception exercises, functional strengthening,
and aquatic strengthening exercises. The goal is a

464

FIG. 59-5 The semitendinosus and gracilis tendons are pulled up through
the tibia and out of the lateral femoral condyle with use of the #5 suture
in the Endobutton. (Courtesy Deliah Cohn.)
full range of motion equal to that of the contralateral normal
knee at 6 weeks after surgery.
Phase III of rehabilitation lasts from 12 to 20 weeks
postoperatively. This phase included functional strengthen-
ing, straight-line jogging, plyometric exercises, sport cord
exercises for jogging, lateral movement, and foot agility
exercises. At 16 to 20 weeks postoperatively, patients are
permitted to perform functional activities, including full-
speed running, while wearing the brace. They are allowed to
advance to full activity, including competitive sports, 28
weeks after surgery.
PHYSEAL-SPARING ACL RECONSTRUCTION WITH
THE ILIOTIBIAL BAND
The following is the technique described by Kocher
et al.13,18 Although it is not an isometric ACL replacement,
the functional results may be good. If this technique is
Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients 59
FIG. 59-6 The Endobutton washer is placed over the Endobutton, and the
washer is pulled back to the surface of the lateral femoral condyle. The
quadruple hamstring grafts are secured distally by tying the #5 Fiberwire
sutures over a tibial screw and post. (Courtesy Deliah Cohn.)
chosen, the defect in the iliotibial band over the vastus later-
alis muscle should be closed. Failure to do so may result in a
cosmetic problem caused by herniation of the vastus lateralis
muscle.
This procedure, a modification of the McIntosh and
Darby13 intraarticular and extraarticular ACL reconstruc-
tion, is performed with the patient supine and a tourniquet
on the proximal thigh. A 6- to 10-cm incision is made from
the lateral joint line along the superior border of the ilioti-
bial band. The iliotibial band is exposed, and incisions are
made along its superior and inferior margins from Gerdy’s
tubercle for a distance of 15 and 20 cm proximal to the joint
line, depending on the patient’s size. The iliotibial band is
detached proximally, dissected free from the lateral capsule,
and tubularized with a whipstitch using a #5 Ethibond
suture. Arthroscopy is then performed through anterome-
dial and anterolateral portals. Remnants of the torn ACL
and fat pad are resected, and a small notchplasty is per-
formed. Soft tissue is removed from the over-the-top posi-
tion of the lateral femoral condyle, but care is taken to
avoid injury to the perichondral ring, which is close to the
465
 Anterior Cruciate Ligament Reconstruction

over-the-top position. Another incision is made parallel to
the medial border of the patellar tendon, extending from
the joint line for a distance of 4 cm distally. Dissection is
carried down to the periosteum. The physis is identified
with the use of a Keith needle. A curved clamp is placed
under the intermeniscus ligament, and a groove is made in
the proximal tibial epiphysis with the use of a small curved
rasp. Care is taken to avoid damage to the anterior tibial
physis. The iliotibial band graft is then pulled into the knee
with a full-length clamp or tendon passer that is passed
through the anteromedial portal, over the top of the lateral
femoral condyle, and out the lateral capsule. The clamp is
then passed under the intermeniscal ligament, and the graft
is regrasped and pulled into the medial incision. The graft is
seated into the groove in the tibial epiphyses, placed under
tension, and sutured to the lateral femoral condyle at the
insertion of the lateral intermuscular septum with the knee
in 90 degrees of flexion and 15 degrees of external rotation
(Fig. 59-7). The periosteum is incised distal to the physis,
and a trough is made in the metaphysis. The graft is placed
under tension and sutured to the periosteum at this location
with the knee in 20 degrees of flexion. The defect created by
harvesting the iliotibial band is closed over the vastus later-
alis muscle. The lateral patella reticulum is left open to avoid
excessive pressure on the lateral facet of the patella. The
wounds are closed in a routine fashion.
Postoperative Rehabilitation
The patient’s knee is placed in a hinged knee brace for 6
weeks postoperatively. A continuous passive motion (CPM)
machine set for range of motion of 0 to 90 degrees is used
for the first 2 weeks after surgery. The patient is maintained
on partial weight bearing for 6 weeks. Thereafter, the

FIG. 59-7 The iliotibial band graft is passed over the top of the lateral femoral condyle, through the knee, under
the intermeniscal ligament, and into the groove in the proximal tibia. The graft is sutured to the lateral femoral
condyle with the knee in 90 degrees of flexion and 15 degrees of external rotation. It is then sutured to the
periosteum of the proximal tibia with the knee in 20 degrees of flexion. (Courtesy Deliah Cohn.)

466
 Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients 59
protocol for rehabilitation is similar to that used for in the left knee and the 1:30 position in the right knee. The
transepiphyseal ACL reconstruction. depth of the femoral hole should be 10 mm greater than the
desired graft insertion into the lateral femoral condyle so as
to allow for rotation of the Endobutton. The Endobutton
TRANSPHYSEAL ANTERIOR CRUCIATE LIGAMENT 4.5-mm reamer is then drilled over the guidewire and out
RECONSTRUCTION the lateral femoral cortex. The femoral hole is chamfered to
minimize graft fraying. The Endobutton depth gauge is used
Surgical Technique to measure the length of the femoral tunnel from the antero-
lateral femoral cortex to the opening in the intercondylar
The injured lower limb is placed in an arthroscopic leg holder notch. The Endobutton-CL that leaves 20 to 25 mm of graft
and scrubbed, prepped, and draped in a standard fashion. With within the femoral tunnel is chosen. A #5 Ethibond suture is
the knee in 60 degrees of flexion, an oblique 4-cm incision is passed through one of the outside holes of the Endobutton.
made over the semitendinous and gracilis tendons, which are This suture is used to pass the Endobutton through the tibia
dissected free, transected at the musculotendinous junction and femur. A #2 Ethibond suture is passed through the
with use of a standard tendon stripper, and detached distally. other outside hole of the Endobutton, and it is used to rotate
A #2 Fiberwire suture is placed in each end of each tendon with the Endobutton after it exits the anterolateral femoral cortex
an interlocking whipstitch. Tendon sizers are used to measure (Fig. 59-8). The hamstring grafts are then passed through
the diameter of the quadruple hamstring grafts, which typically the Endobutton-CL, creating a quadruple graft. Both strands
range from 6 to 8 mm. The doubled tendons are then placed of the #5 and #2 sutures in the Endobutton are passed
under 4.5 kg (10 pounds) of tension on the back table with through the eyelet of the passing 2.7-mm pin. The passing
use of the Graftmaster device (Acufex-Smith Nephew, And- pin is inserted up through the tibial and femoral holes,
over, MA). The arthroscope is inserted into the anterolateral piercing the quadriceps and skin proximal to the knee (see
portal, and a probe is inserted through the anteromedial portal.
Intraarticular examination is systematically performed in the
usual manner. Debris in the intercondylar notch is removed,
and a minimal notchplasty is performed to visualize the anato-
mical footprint of the ACL on the femur. Care is taken not to
enlarge the posterior arch of the intercondylar notch because
the femoral physis is in close proximity. If a substantial menis-
cal tear is found, it is repaired.
The point of the tibial drill guide is inserted through
the anteromedial portal. The guide is set at a 55-degree
angle and oriented so that the guide pin enters the antero-
medial aspect of the tibia at a 65- to 70-degree angle in
the coronal plane. The pin should enter the joint at the level
of the free edge of the lateral meniscus and in the posterior
footprint of the ACL on the tibia. The tibial hole is reamed
over the guidewire using a standard cannulated drill bit.
A tight fit of the graft within the tibial tunnel is important;
consequently, the smallest appropriate drill bit is used to
ream the tibial hole. After drilling the tibial tunnel, the
debris around the hole is removed with a shaver.
The knee is flexed to at least 90 degrees prior to inser-
tion of the femoral guidewire. An over-the-top femoral guide
is used that leaves 2 mm of bone between the drill hole and the
posterior cortex of the lateral femoral condyle. The 2.7-mm
passing pin is advanced through the offset guide and through
the lateral femoral condyle until it penetrates the lateral fem-
oral cortex. The pin may be palpated under the skin distal to FIG. 59-8 The #2 and #5 Ethibond sutures are threaded through the eyelet
the tourniquet. An acorn reamer that matches the diameter of the 2.7-mm passing pin. The passing pin is inserted up through the tibial
and femoral holes, piercing the quadriceps muscle and skin. The pin is then
of the graft is used to create the femoral tunnel. The femoral pulled out of the femur proximally to pass the sutures. (Courtesy Deliah
hole is drilled to a depth of 30 to 35 mm at the 10:30 position Cohn.)

467
 Anterior Cruciate Ligament Reconstruction
FIG. 59-9 The #5 suture is pulled first, advancing the Endobutton and
graft. The #2 suture is then pulled to rotate the Endobutton external to the
femur. (Courtesy Deliah Cohn.)
Fig. 59-8). The pin is then pulled out of the femur proximally
to pass the sutures. The #5 suture is pulled first, advancing the
Endobutton and graft into the femoral hole (Fig. 59-9). The
#2 suture is pulled next, rotating the Endobutton external to
the femur. The graft is then pulled distally, locking the Endo-
button on the outside of the femoral cortex. Secure fixation
should be felt. Then the #2 and #5 sutures in the Endobutton
are removed. The knee is cycled through a range of motion
several times to pretension the graft. The graft is placed under
tension, and the knee is then extended to determine arthro-
scopically whether there is impingement of the graft on the
intercondylar notch. If the anterior outlet of the intercondylar
notch touches or indents the graft in terminal extension, a
small portion of the anterior outlet may be removed. With
the knee in 20 degrees of flexion, the quadruple hamstring
graft is secured distally by tying the #5 Fiberwire sutures over
a tibial Bioscrew and post that is placed medial to the tibial
tubercle apophysis and distal to the proximal tibial physis
(Fig. 59-10). If the tendon graft extends through the tibial
drill hole, it is also secured to the periosteum of the anterior
tibia with multiple #1 Ethibond sutures with use of figure-
eight stitches. The subcutaneous tissue and skin are closed
in a routine fashion, and a hinged brace is applied.
Postoperative Rehabilitation
The postoperative rehabilitation is the same as that
described for the transepiphyseal ACL reconstruction
technique.
468
FIG. 59-10 The graft is pulled distally, locking the Endobutton on the
outside of the femoral cortex. The quadruple hamstring graft is secured
distally by tying the #5 Fiberwire sutures over a tibial Bioscrew and post.
(Courtesy Deliah Cohn.)
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469
 60
CHAPTER
Anterior Cruciate Ligament Reconstruction
of Partial Tears: Reconstructing
One Bundle
Fotios Paul Tjoumakaris INTRODUCTION
Anthony Buoncristiani
It has been estimated that approximately 60,000
James S. Starman to 75,000 anterior cruciate ligament (ACL)
Freddie H. Fu reconstructions are performed annually in the
United States.1 This number is likely higher, as
larger segments of the population have become
active and participate in year-round sporting
activities within the past several years. Outcomes
of ACL reconstructions have been exhaustively
studied, with many reports demonstrating suc-
cessful return to sport and returning stability to
the previously injured knee, particularly when
compared with conservative management.2,3
Despite tremendous advances within the field of
ACL reconstruction, success rates of primary
reconstruction continue to hover between 70%
to 95% within the best centers.4–6 With the
increasing numbers of ACL being performed
come the requisite number of cases that fail due
to any variety of mechanisms: arthrofibrosis,
extensor mechanism failure, recurrent patholax-
ity, and traumatic arthrosis.7 Several studies have
demonstrated inferior results of revision surgery
when compared with primary reconstruction,
with many of these studies citing recurrent laxity
as the primary mechanism of failure.8–12
The concept of recurrent laxity following
a partial ACL injury or of a failed ACL recon-
struction (with an intact, well-placed graft) can
be treated within the same context. Both sce-
narios represent the same underlying anatomical
defect: an isolated injury or absence of one of
the bundles of the ACL that compromises the
470
ability of the knee to achieve stability and nor-
mal kinematics. Most ACL injuries are cur-
rently treated with reconstruction of the
anteromedial (AM) bundle of the ACL. Recur-
rent laxity within this situation can be classified
as recurrent tear of the graft, continued instabil-
ity despite graft incorporation and healing with
proper graft placement, and improper place-
ment of the graft leading to continued laxity.
Recurrent laxity after isolated partial ACL tears
can be from isolated injury to the posterolateral
(PL) or AM bundles that results in the inability
of the knee to resist either rotatory or transla-
tional forces.13 Our technique of isolated PL
or AM augmentation surgery has evolved from
this foundation of applying anatomical princi-
ples of the ACL with the anatomical injury or
failure pattern. This chapter outlines our tech-
nique for isolated PL bundle augmentation sur-
gery within the setting of recurrent patholaxity
after prior ACL reconstruction (and a healed,
well-placed ACL graft) as well as after partial
ACL disruption (isolated PL bundle injury).
Please see Chapter 25 for a more detailed
description of the ACL anatomy and double-
bundle reconstruction technique.
PREOPERATIVE CONSIDERATIONS
History
ACL injuries typically occur in patients who
participate in activities that require running,
 Anterior Cruciate Ligament Reconstruction of Partial Tears: Reconstructing One Bundle
jumping, or cutting. The classic scenario is often a young
female athlete who sustains an injury while her foot is planted
and slightly flexed, with a pivot moment applied to the knee.
The ensuing injury is often characterized as a “pop” or other
traumatic event, and swelling from a hemarthrosis is often
present within minutes to hours after this insult. The patient
history from a partial disruption of the ACL or from a patient
who continues to have laxity despite having undergone prior
reconstruction can be more vague. In some instances of partial
ACL disruption, a traumatic event may occur, as is the case
with a complete tear; however, in many cases patients may
report a minor event in which the knee may have felt as
though it shifted or rolled. Patients may have even gone back
to competitive play the same day or within a week of the
initial injury. In rare cases, there may be the minor complaint
of pain with certain activity, with no specific injury reported.
Within the setting of prior ACL reconstruction, patients are
usually good historians with regard to their symptoms due
to their prior experience. The patient in this setting may state
that the knee continues to feel unstable or has no strength, or
the patient may be observed by coaches and the training staff
to lack this confidence on the knee due to subtle differences
from the noninjured leg. Determining the exact amount of
morbidity from these symptoms can be challenging but is very
important in deciding whether surgical intervention is
warranted.
Physical Examination
The physical examination is very similar to that for most
knee injuries. The knee is first inspected for any bruising
or contusion that may indicate a more serious injury. The
knee is checked for an effusion; if one is present and causing
significant discomfort that impedes the physical examina-
tion, we will aspirate it from a superolateral portal. The
range of motion is assessed; if limited, it may indicate con-
comitant meniscal pathology, although this is rarely seen
with partial tears of the ACL. The knee is then examined
for any tenderness along the joint line or joint line swelling,
which also could represent the presence of meniscus pathol-
ogy. The ligamentous evaluation is performed and com-
pared with the contralateral extremity. The knee is
checked first for valgus or varus instability at both 0 and
30 degrees. The Lachman and pivot-shift exams are then
performed. The presence of a 2þ or 3þ Lachman with
minimal shift may indicate involvement of the AM bundle
with minimal involvement of the PL bundle. It is important
to ascertain whether the patient is guarding or contracting
the hamstrings, as these actions will impair the clinician’s
ability to detect pathologic translations. The patient who
has a large pivot shift with very minimal translation on the
60
Lachman examination may have an isolated injury to the
PL bundle. Rarely will patients have a positive anterior
drawer sign, as the secondary stabilizers (medial meniscus/
posteromedial corner) are usually preserved within this
injury pattern. The exam concludes with determination of
the KT-1000 and its comparison with the contralateral
extremity. A normal KT does not preclude the presence of
injury to a portion of the ACL and is no substitute for a
good physical examination.
Imaging
We obtain plain radiographs in all patients to look for asso-
ciated pathology. These radiographs include bilateral
anteroposterior (AP) flexion weight-bearing views, a lateral
view of the involved knee, and bilateral merchant or sunrise
views. The radiographs are inspected for soft tissue swelling,
an effusion, the presence of any fractures, physeal closure
(for younger patients), and overall alignment. In patients
who have undergone prior ACL reconstruction, the prior
tunnel placement is evaluated as well as prior hardware
placement and presence of tunnel expansion. Determination
of joint space narrowing is paramount in determining prog-
nosis, and any patient who demonstrates any evidence of
arthrosis on the knee series is further evaluated with a long
cassette to determine alignment. If significant side-to-side
difference exists (greater than 3–5 degrees) on the alignment
series, consideration is given to a realignment procedure to
unload the affected compartment. We obtain a magnetic
resonance imaging (MRI) scan in any patient suspected of
having a partial ACL tear or continued laxity after prior
single-bundle ACL reconstruction. The MRI is also useful
to inspect for the presence of any meniscal or chondral
pathology. Reviewing the MRI with an experienced radiol-
ogist is often necessary to accurately make the diagnosis and
properly plan for surgical intervention. Studies have shown
that MRI diagnosis of partial ACL tears can be challen-
ging.14,15 In one series, nine of nine complete tears were
accurately diagnosed by MRI, whereas only 1 of 9 partial
tears were correctly identified.14 Findings that were sugges-
tive of partial ACL tears in this series were the presence of
some intact fibers, thinning of the ligament, a mass postero-
lateral to the ACL, and a wavy or curved ligament. The
MRI is inspected for the presence of a bone contusion, as
this usually indicates a more severe injury. One study
demonstrated that only 12% of patients with a partial tear
of the ACL had a bone contusion in comparison to 72%
with complete tears.16
Additional coronal imaging may help to better delin-
eate injury to the PL bundle, whereas the sagittal images are
usually sufficient to visualize the AM fibers.
471
 Anterior Cruciate Ligament Reconstruction

Indications
The indications for PL bundle augmentation surgery are not
solely based on the preoperative evaluation. A patient who
has undergone a prior single-bundle reconstruction with
adequate graft placement and incorporation but who con-
tinues to experience patholaxity is perhaps the optimal
candidate for this procedure. Patients who have suspected
partial tears of the ACL with a positive pivot-shift examina-
tion, minimal translation with the Lachman maneuver, and
an MRI that confirms the presence of the AM bundle are also
qualified candidates for this procedure; however, these
patients should demonstrate that they have recurrent
laxity after a rehabilitation program and functional bracing
regimen. These parameters are further defined arthroscopi-
cally once the entire injury pattern to the ACL is delineated
and the presence of an intact AM bundle and disrupted PL
bundle is found at surgery. Contraindications to surgical
intervention include a patient who is unwilling to cooperate
with the rehabilitation program and a patient who lacks a full
or near-full range of motion on physical examination. The
presence of open physes is not an absolute contraindication
to using this technique; however, we do advise that younger
patients be braced until they have reached skeletal maturity.
SURGICAL TECHNIQUE
Anesthesia and Positioning
drawn as well as the tibial tubercle. The borders of the patellar
tendon and the anterior crest and posteromedial border of
the tibia are identified. Three portholes are marked on the
knee in the same fashion as in the double-bundle technique.
The lateral porthole is located just off the lateral border of
the patellar tendon with its most inferior border flush with
the inferior border of the patella. The medial porthole is
marked beginning at the inferior pole of the patella and
extending distally just on the medial border of the patellar
tendon. An accessory medial porthole that will later be used
for the PL tunnel is marked approximately 2 cm medial to
the AM porthole just at the level of the joint line. The tibial
incision is marked on the AM aspect of the tibia midway
between the anterior and posterior borders of the tibia. This
incision is approximately 3 cm in length, beginning 2 cm
distal to the medial joint line (Fig. 60-1).
Diagnostic arthroscopy is undertaken after establish-
ment of the lateral and medial portholes. Placement of the
lateral porthole slightly superiorly obviates the need for
excessive fat pad débridement as the arthroscope is intro-
duced proximal to this vital structure through this viewing
porthole. All three portholes are used for viewing during
the procedure, and the surgeon is encouraged to obtain dif-
ferent vantage points from each porthole to ensure proper
anatomical position of the femoral tunnel. We begin our
arthroscopy in the patellofemoral joint, débriding only the

Patients undergoing this procedure receive a femoral nerve

block within the preoperative holding area. Once within the
operating suite, the patient is given conscious sedation and
placed supine on the operating room table. A thorough
examination under anesthesia (EUA) is undertaken to confirm
the findings from the office examination. A tourniquet is
applied to the proximal thigh of the operative limb, and the
contralateral extremity is placed in a padded well leg holder
flexed and abducted at the knee and hip so that the operative
field is cleared of any obstruction. Care is undertaken to pad
the peroneal nerve and heel of the uninvolved leg. The operative
limb is then placed in an arthroscopic leg holder that allows for
greater than 100 degrees of knee flexion, and the foot of the
table is lowered. The leg is then elevated for 5 minutes, and
the tourniquet inflated to 100 mmHg greater than the systolic
pressure. The leg is then prepped with povidone-iodine
(Betadine) solution and draped free in the usual fashion.

Surgical Landmarks and Diagnostic

Arthroscopy
FIG. 60-1 Surface landmarks for surgery (left knee). Note the accessory
The knee is slightly flexed to 45 degrees, and the anatomical medial porthole (AMP) placement and the superior placement of the lateral
landmarks are identified. The inferior pole of the patella is porthole (LP). MP, Medial porthole.

472
 Anterior Cruciate Ligament Reconstruction of Partial Tears: Reconstructing One Bundle
synovium that obstructs our view with a 4.5-mm full radius
resector. The arthroscope is then swung down into the
notch for a clear view of the ACL and posterior cruciate lig-
ament (PCL). Varus stress is then applied to the knee in the
figure-four position, and the lateral hemi-joint is inspected.
Any articular or meniscal pathology is addressed at the time
of inspection. The knee is then placed in slight flexion and
valgus, and the medial hemi-joint is inspected. The scope is
then brought back to the notch with the leg at 90 degrees of
flexion (the neutral position). At this point, a spinal needle
is used to localize the accessory medial porthole. The needle
should be visualized above the anterior horn of the medial
meniscus and should provide direct access to the origin of
the PL bundle on the lateral femoral condyle (LFC). Plac-
ing the arthroscope in the medial porthole may help to
delineate this more clearly. The accessory medial porthole
is then incised with an upturned 11 blade, with care taken
not to transect the anterior horn of the medial meniscus.
The notch is inspected for disruption of the fibers of
the ACL. A probe is used to apply stress to the damaged
ligament. Placing the knee in the figure-four position can
aid in viewing the root of the lateral meniscus as it enters
the tibia. Just anterior to this structure and often confluent
with the lateral meniscus is the insertion of the PL bundle
of the ACL. These fibers are followed proximally to the
LFC and assessed for competence. The knee is then
brought back to the neutral position, and the AM bundle
is assessed. A thermal device and small radius resector are
used to carefully dissect out the fibers of the ACL, removing
only tissue that has no origin or insertion. Once this has
been achieved, the rupture pattern of the ACL is clearly
seen and reconstruction of the damaged portion can be
undertaken. In the setting of prior single-bundle ACL
reconstruction, the graft is inspected for proper position
and preparation is made for insertion of a PL bundle.
60
The graft is marked at two sites on its proximal end, one
line indicating the tunnel length and the other indicating
where the Endobutton can be flipped for femoral fixation
(Fig. 60-2). The graft is then washed with antibiotic solution
and placed in a moistened sponge until it will be used during
the procedure.
Technique for Reconstruction
During the diagnostic examination, the femoral site of the PL
bundle is marked with the thermal device where the fibers are
avulsed. Knowledge of the origin of the ACL bundles on the
LFC is paramount if no fibers of the ACL are remaining
(Fig. 60-3). In the absence of this landmark (as in chronic
cases or augmentation of a prior single-bundle reconstruc-
tion), general guidelines for the PL insertion are a point
8 mm posterior to the anterior articular margin of the lateral
femoral condyle and 5 mm superior to the inferior articular
margin of the LFC. A 3/32-mm Steinman pin is introduced
from the medial accessory porthole directly to this point.
For optimal visualization, the arthroscope can be inserted into
the medial porthole during preparation of the femoral tunnel
FIG. 60-2 The allograft construct for posterolateral augmentation.

Graft Preparation

Once the diagnosis has been confirmed, the graft is prepared

by the surgical assistant on the back table. We prefer to use a
looped tibialis anterior allograft for this procedure because the
width and length of the graft are predictable. The graft is
trimmed so that, when looped over, it will fit snugly into a
7-mm tunnel. A #2 braided suture is whipstitched up and
down both ends of the graft for approximately 3 cm. Using
a graft of at least 24 cm in total length will provide a looped
graft of 12 cm, which is sufficient graft for the reconstruction.
Once doubled over, the graft is secured via a loop to the
Endobutton (Smith & Nephew, Andover, MA) device.
Two sutures are then passed through the Endobutton device
for later graft passage. An absorbable suture is used to suture FIG. 60-3 Anatomical relationship of the anteromedial (AM) bundle,
the graft closed around the loop that secures the Endobutton. posterolateral (PL) bundle, and lateral femoral condyle (LFC).

473
 Anterior Cruciate Ligament Reconstruction

FIG. 60-4 A, The placement of the posterolateral tunnel (PL) is just off the articular surface of the lateral femoral
condyle (LFC). B, The tunnel is then drilled over the Steinman pin. AM, Anteromedial bundle.

(Fig. 60-4). The pin is tapped gently into the LFC to obtain entirely and be almost obscured from view by the fibers of
initial purchase, and then the knee is flexed to approximately the AM bundle.
115 to 120 degrees and the pin is sunk 5 to 10 mm into the A Beath pin with a large looped suture on its distal
condyle. The acorn reamer (7 mm) is then placed over end is then introduced through the accessory medial port-
the Steinman pin through the accessory medial porthole, hole and fashioned through the PL femoral tunnel out
and the femoral tunnel is drilled to a depth of 25 mm. The through the lateral aspect of the thigh. Care is taken to
far cortex is then breached with the Endobutton drill, and hyperflex the knee and retract the biceps manually to pre-
the transcondylar length is measured with a depth gauge. If vent injury to the common peroneal nerve with this maneu-
this length is greater than 35 mm, the tunnel is reamed an ver. The looped suture is then brought into the joint and
additional 5 mm for a total length of 30 mm. The tunnel obtained via a suture grasper through the tibial PL tunnel.
length is then subtracted from the transcondylar length to The sutures attached to the Endobutton are then fashioned
determine the appropriately sized Endobutton, which is through the loop, and the sutures are shuttled to the lateral
then fashioned to the graft by the surgical assistant. aspect of the thigh (Fig. 60-6). The graft is then passed in
Attention is now turned to the tibial tunnel. It is par-
amount during this procedure that the tibial insertion of the
PL bundle is accurately obtained so that the AM bundle is
not compromised in any fashion. An incision is carried
out based on our previous landmark, and the periosteum
of the anteromedial tibia is exposed. The PL tibial insertion
is identified at a site just medial to the attachment of the
posterior horn of the lateral meniscus and slightly anterior
to the PCL. The ACL director guide (Smith & Nephew,
Andover, MA) is brought through the medial porthole
and placed at this insertion site, set to 55 degrees. We prefer
to use the direct “tip-to-tip” guide for accurate placement of
the tunnel because the margin for error in this region is
small. A 3/32-mm Steinman pin is drilled through this guide
on the AM surface of the tibia (typically slightly medial to
the halfway point of the anterior and posterior borders of
the tibia). The pin is drilled so that the tip is visible within
the joint. A curette is used to prevent overpenetration in this
region (Fig. 60-5). The PL tibial tunnel is then reamed to a
FIG. 60-5 A curette is used to prevent overpenetration upon drilling the
diameter of 7 mm, and debris is removed with a full-radius posterolateral (PL) tibial tunnel. Note the presence of the anteromedial (AM)
resector. The PL tunnel should avoid the AM footprint bundle anterior to the PL insertion. LFC, Lateral femoral condyle.

474
 Anterior Cruciate Ligament Reconstruction of Partial Tears: Reconstructing One Bundle
FIG. 60-6 Graft passage is assisted by shuttling the Endobutton sutures
through the posterolateral (PL) tibial and femoral tunnels. AM,
Anteromedial bundle; LFC, lateral femoral condyle.
FIG. 60-7 Final graft construct with crossing of the bundles with the knee
in flexion. AM, Anteromedial bundle; LFC, lateral femoral condyle; PL,
posterolateral bundle.
standard fashion and the Endobutton loop is flipped,
providing femoral fixation (Fig. 60-7). The knee is then
cycled from 0 to 120 degrees 20 times while holding tension
on the tibial side to check for isometry and remove any slack
within the allograft tissue. The PL bundle is then tensioned
between 0 and 10 degrees with a biointerference screw mea-
suring 7
30 mm. This fixation is augmented with a small
staple on the AM aspect of the tibia with the remainder of
the allograft. The knee is then checked for stability and
range of motion.
60
REHABILITATION
The patient is placed in a hinged knee brace that is locked in
extension for 1 week. Crutches are used for 4 to 6 weeks until
quadriceps function returns. The brace is unlocked only for
continuous passive motion (CPM) and range of motion during
the first week. The patient is weight bearing as tolerated,
barring any concomitant meniscal repair. The accelerated
rehabilitation protocol as described by Irrgang is then
followed.17 Return to sports is typically allowed after 6 months,
provided adequate strength gains have been achieved.
All patients are advised to use a functional knee brace when
returning to sports during the first 1 to 2 years after
reconstruction.
COMPLICATIONS
If particular attention to detail is paid with regard to the
insertional anatomy of the ACL, complications are few with
this procedure. In our series of patients, we have had no
early failures, arthrofibrosis, or reported instability. One
patient had to return to the operating room because of an
improperly deployed Endobutton. Potential complications
include symptomatic hardware, fracture of the lateral femo-
ral condyle (which we have not seen with either the double
or the augmentation technique), postoperative infection,
and neurovascular injury.
RESULTS
ACL augmentation surgery is a novel approach to treat
continued instability after prior ACL surgery as well as partial
tears of the ACL. Published data in this area are lacking;
however, our results have been encouraging. To date, the
senior author (FF) has performed 20 PL bundle augmenta-
tion procedures for ACL insufficiency. Twelve of these
patients had undergone prior ACL reconstruction, and the
remaining eight patients had isolated partial tears of the PL
bundle with symptomatic instability. Clinical results have
shown a reduction in the pivot-shift exam from 2þ to 0,
return to sports in all patients, and a total arc of motion of
133 degrees (from 139 preoperatively) at 20-month follow-
up. No patient in our series has shown evidence of or reported
the sensation of instability that was present preoperatively.
CONCLUSION
Several studies have documented the natural history of
partial tears of the ACL. Despite some early encouraging
475
 Anterior Cruciate Ligament Reconstruction
results, the majority of patients never return to their pre-
injury level of activity or sport.18,19 In a study by Barrack
et al, more than 30% of patients had fair or poor results at
the latest follow-up.20 Noyes et al followed 32 patients with
partial ACL tears and found that 12 went on to complete rup-
ture.21 Buckley et al found that 72% of partial ACL tears had
activity related symptoms at early follow-up.22 With these
disappointing results, combined with the residual instability
that occasionally compromises patients who have had a
prior ACL reconstruction, we believe that augmentation
surgery may offer a more definitive solution.
As techniques in ACL reconstruction become more
refined, the surgical procedure will more clearly represent
the original anatomical geometry of the ACL. Early recog-
nition of the specific injury pattern of the ligament as well as
attention to the clinical examination of prior single-bundle
reconstructions are paramount in determining the appropri-
ate procedure for each patient.
References
1. Johnson DL, Harner CD, Maday MG, et al. Revision anterior cruciate liga-
ment surgery. In Fu FH, Harner CD, Vince KG (eds). Techniques in Knee
Surgery, vol 1. Philadelphia, 1994, Williams & Wilkins, pp 877–895.
2. Grontvedt T, Engebretsen L, Benum P, et al. A prospective, rando-
mized study of three operations for acute rupture of the anterior cruci-
ate ligament. Five-year follow-up of one hundred and thirty-one
patients. J Bone Joint Surg 1996;78A:159–168.
3. Sandberg R, Balkfors B, Nilsson B, et al. Operative versus
nonoperative treatment of recent injuries to the ligaments of the
knee. A prospective randomized study. J Bone Joint Surg
1987;69A:1120–1126.
4. Howell SM, Clark JA. Tibial tunnel placement in anterior cruciate
ligament reconstructions and graft impingement. Clin Orthop Relat
Res 1992;283:187–195.
5. Jaureguito JW, Paulos LE. Why grafts fail. Clin Orthop Relat Res
1996;325:25–41.
6. Ritchie JR, Parker RD. Graft selection in anterior cruciate ligament
revision surgery. Clin Orthop Relat Res 1996;325:65–77.
476
7. Newhouse KE, Paulos LE. Complications of knee ligament surgery.
In Nicholas JA, Hershman EB (eds). The lower extremity and spine
in sports medicine. St. Louis, 1995, Mosby, pp 901–908.
8. Getelman MH, Friedman MJ. Revision anterior cruciate ligament
reconstruction surgery. J Am Acad Orthop Surg 1999;7:189–198.
9. Uribe JW, Hechtman KS, Zvijac JE, et al. Revision anterior cruciate
ligament reconstruction surgery: experience from Miami. CORE
1996;325:91–99.
10. Johnson DL, Swenson TM, Irrgang JJ, et al. Revision anterior cruciate
ligament reconstruction surgery: experience from Pittsburgh. CORE
1996;325:100–109.
11. Noyes FR, Barber-Westin SD. Revision anterior cruciate ligament recon-
struction surgery: experience from Cincinnati. CORE 1996;325:116–129.
12. Noyes FR, Barber-Westin SD. Revision anterior cruciate ligament
reconstruction surgery with use of bone-patellar tendon-bone autoge-
nous grafts. J Bone Joint Surg 2001;83A:1131–1143.
13. Gabriel MT, Wong EK, Woo SL-Y, et al. Distribuition of in situ
forces in the anterior cruciate ligament in response to rotatory loads.
J Orthop Res 2004;22:85–89.
14. Lawrance JA, Ostlere SJ, Dodd CA. MRI diagnosis of partial tears of
the anterior cruciate ligament. Injury 1996;27:153–155.
15. Umans H, Wimpfheimer O, Haramati N, et al. Diagnosis of partial
tears of the anterior cruciate ligament of the knee: value of MR
imaging. Am J Radiol 1995;165:893–897.
16. Zeiss J, Paley K, Murray K, et al. Comparison of bone contusion seen
by MRI in partial and complete tears of the anterior cruciate ligament.
J Comput Assist Tomogr 1995;19:773–776.
17. Irrgang JJ. Modern trends in anterior cruciate ligament rehabilitation:
nonoperative and postoperative management. Clin Sports Med
1993;12:797–813.
18. Bak K, Scavenius M, Hansen S, et al. Isolated partial rupture of the
anterior cruciate ligament. Long-term follow-up of 56 cases. Knee Surg
Sports Traumatol Arthrosc 1997;5:66–71.
19. Sommerlath K, Odensten M, Lysholm J. The late course of acute
partial anterior cruciate ligament tears. A nine to 15-year follow-up
evaluation. Clin Orthop Relat Res 1992;281:152–158.
20. Barrack RL, Buckley SL, Bruckner JD. Partial versus complete acute
anterior cruciate ligament tears. The results of nonoperative treatment.
J Bone Joint Surg 1990;72B:622–624.
21. Noyes FR, Mooar LA, Moorman CT III, et al. Partial tears of the
anterior cruciate ligament. Progression to complete ligament
deficiency. J Bone Joint Surg 1989;71B:825–833.
22. Buckley SL, Barrack RL, Alexander AH. The natural history of con-
servatively treated partial anterior cruciate ligament tears. Am J Sports
Med 1989;17:221–225.
 PART N TREATMENT OF ASSOCIATED LIGAMENT INJURIES OR CARTILAGE
DEFICIENCY
Anterior Cruciate Ligament Injury
Combined with Medial Collateral
Ligament, Posterior Cruciate Ligament,
and/or Lateral-Side Injury
INTRODUCTION
A knee dislocation injury is a rare but potentially
devastating injury. The definition of knee dis-
location includes the grossly unstable knee, with
a minimum of two of the four major knee liga-
ments injured, regardless of a reduced joint line.1
Some authors suggest that any combined anterior
cruciate ligament (ACL) and posterior cruciate
ligament (PCL) injuries be considered a knee
dislocation,2 although knee dislocations have
been described without cruciate injury.3–5 The
injury is commonly attributed to high-velocity
motor vehicle accidents and low-velocity sports
injuries, with the rate of knee dislocation
reported to be 0.001% to 0.013% of all knee
injuries.6–8 This may represent an underesti-
mation of this devastating injury, as some knee
dislocations spontaneously reduce before the
patient receives a physical examination and
the patient may suffer other physical injuries that
require medical attention.1
Commonly, a knee dislocation involves
injury to the ACL, PCL, and either the medial
collateral ligament (MCL) or the lateral-side
structures of the knee. Of knee dislocations,
associated medial-side tears represent approxi-
mately 90% of all the injuries, whereas lateral-
side injuries represent approximately 10% of
the knee dislocation injuries.9
We see almost 10 times more knee dis-
locations involving the medial side than we do
involving the lateral side. Nonoperative treat-
ment of knee dislocations involving the lateral
61
CHAPTER
side usually results in a grossly unstable knee and K. Donald Shelbourne
causes severe functional disability for the patient.
Because of these occurrences, acute reconstruc-
tion of all injured structures with all knee disloca-
tions has been advocated; this recommendation
has included knee dislocations involving the
medial side.10,11 This approach has resulted
in many stable but stiff knees after surgery.
The morbidity associated with acute sur-
gery for knee dislocations caused us to alter
our treatment approach for knee dislocations
to consider the healing potential of each torn
structure. Although a knee dislocation involving
the lateral side is an injury that requires surgery
at least semi-acutely, a knee dislocation invol-
ving the medial side is not an injury that
requires immediate surgery, and it may not
require surgery at all.
In this chapter we review our treatment
approach to dislocated knees involving the
ACL, PCL, and either the MCL injury or lat-
eral-side structures. This approach was derived
from an understanding of the injuries to the
individual ligaments and their potential to heal,
the natural history of the injury, and the effects
of the injury in combination.
LIGAMENT HEALING
Anterior Cruciate Ligament
The ACL does not generally heal after injury.12–15
Lyon et al13 found in a histological study that the
477
 Anterior Cruciate Ligament Reconstruction
cellular composition of the ACL resembles that of fibro-
cartilage and that it has a poor capacity to heal. The injured
ACL pulls completely apart as opposed to tearing interstitially,
which diminishes the potential for healing. An incompetent
ACL represents a complete tear. Yao et al16 found in a series
of 21 partial ACL tears evaluated with magnetic resonance
imaging (MRI) and confirmed with arthroscopic evaluation
that the ACL tears showed ACL fibers in continuity and the
ACL resisted probing. They also found that the MRI was
less sensitive for partial tears compared with complete tears.
MRI can occasionally demonstrate interstitial femoral-sided
tears. These tears may heal spontaneously and can result in
functional stability.
Posterior Cruciate Ligament
In contrast to the ACL, PCL injuries have the potential for
intrinsic healing (Fig. 61-1). Evaluation with MRI of acute
PCL injuries has been found to be 99% to 100% sensitive
and specific in documenting acute PCL tears. In contrast,
MRI evaluation of chronic PCL laxity is less accurate than
that of acute injury because the PCL appears to be healed
FIG. 61-1 A, Magnetic resonance image (MRI) of an acute posterior cruciate ligament (PCL) injury. B, A follow-up
MRI image at 3 months after injury shows the PCL is in continuity, which may be read by the radiologist as a
normal PCL.
478
even when the patient has laxity.17–20 Shelbourne et al19
evaluated 40 patients who had acute PCL injuries with
MRI at the time of the acute injury and again at a mean
of 3.2 years after injury. Twenty-three patients had isolated
PCL tears, and 17 patients had combined PCL and addi-
tional ligament injury. The healing of partial and complete
tears was graded with MRI. The results showed 37 of 40
PCLs to be healed with continuity. All partial tears and
most complete (19 of 22) PCL tears regained continuity.
Twelve of 12 combined PCL/MCL injuries healed. In
two patients with acute ACL, PCL, and MCL injuries,
the MCL and PCL healed without treatment. Location,
severity, and associated ligament injuries did not affect heal-
ing. The healed PCL demonstrated abnormal morphology
in 25 of the 37 cases on follow-up.19 In a recent follow-up
study at a mean of 4.6 years after knee dislocations to the
lateral side, the PCL in 16 of 16 patients appeared healed
on the MRI and no patient had more than 1þ laxity upon
examination.21 Tewes et al20 evaluated follow-up MRIs on
13 patients with high-grade PCL injury at an average of
20 months postinjury. Their results showed 10 of 13
patients (77%) had regained MRI continuity of the PCL,
 Anterior Cruciate Ligament Injury Combined with Medial Collateral Ligament, Posterior Cruciate Ligament, and/or Lateral-Side Injury
although with an abnormal appearance. They could not cor-
relate functional or clinical status with degree of clinical lax-
ity.20 The time to obtain healing after acute PCL injury is
yet unknown. However, Shelbourne et al22 described a firm
endpoint and a painless posterior drawer at follow-up exam-
ination of acute PCL injuries about 2 weeks postinjury.
Medial Collateral Ligament
The MCL is an extraarticular ligament with an intrinsic
ability to heal. In contrast to the ACL, the MCL is made
up of fibroblast-type cells with the potential to heal.13
Animal studies indicate the MCL can heal with scar tissue
with strength and stiffness similar to that of native
MCL.23,24 This intrinsic capacity to heal has also been
observed clinically with isolated MCL injury.25,26 The abil-
ity of injured ligaments to heal may also be affected by
extrinsic factors such as surgical apposition, immobilization,
and early protected range of motion.27,28 Prolonged immo-
bilization may adversely affect the mechanical properties by
loss of collagen fiber orientation and decreased strength of
the bone ligament junction.29,30 Long et al31 found in a
rabbit model that the ultimate load of rabbit MCL treated
with intermittent passive motion was four times greater
than immobilized ligament, with improvements in matrix
organization and collagen concentration. The location of
MCL injury has also been found to affect healing potential.
Proximal tears, which have a more pronounced blood
supply, tend to heal rapidly and may lead to knee stiffness.
Distal tears seem to heal more slowly, and patients usually
do not develop range of motion problems.32,33
Lateral-Side Structures
Lateral-side injuries involve several structures, and several
combinations of injuries to these structures can occur with
a knee dislocation. The lateral-side structures from anterior
to posterior are the iliotibial band, lateral capsule, popliteus
tendon, lateral collateral ligament, and biceps. These struc-
tures tend to tear distally and retract proximally and then
heal “en masse” but do not heal in such a way to provide lat-
eral stability. Lateral-side injuries are the only type of liga-
ment knee injury that require acute repair.
CLINICAL EXAMINATION
Listening carefully to the patient explain how the injury
occurred and the position of the limb at the time of the injury
combined with a thorough physical examination should
allow the physician to arrive at a diagnosis. Evaluation of the
uninjured extremity will establish a baseline and gain the
61
patient’s confidence. Initial evaluation may be difficult
because the patient will probably have pain, swelling, muscle
spasm, and limited knee motion and will be apprehensive.
The physician should have a high index of suspicion based
on the history of the patient’s injury, especially with a multi-
ligamentous knee injury, because 50% of knee dislocations
will reduce before evaluation1,32 and capsular tears may pre-
vent the appearance of significant effusion. The complica-
tions that arise from not recognizing associated injuries
can be devastating. Close follow-up and reexamination are
helpful. In addition, imaging studies and vascular surgery
consultation may be needed.
Clinical assessment of the ACL can be done using
the Lachman test. A positive Lachman test, performed
properly, is diagnostic of ACL disruption because the
ACL prevents contribution from secondary stabilizers to
anterior stability.34,35
The PCL is the primary restraint to posterior instabi-
lity in the knee.26 To determine PCL deficiency, the
involved knee should be compared with the noninvolved
extremity to determine the proper relationship of the tibia
to the femoral condyles. When the PCLs are intact, the
anteromedial proximal tibia usually rests 1 cm anterior to
the distal femoral condyles with 90 degrees of knee flexion.
In patients with PCL deficiency, the anteromedial tibia will
“sag” posteriorly in relationship to the femoral condyles.36,37
The most sensitive test for evaluating the PCL is the
posterior drawer test at 90 degrees of flexion.38,39 Rubin-
stein et al39 found the posterior drawer test in conjunction
with palpating anterior tibial step-off to be 96% accurate,
90% sensitive, and 99% specific, with an interobserver grade
agreement of 81% in diagnosing PCL insufficiency. The
posterior drawer test with internal tibial rotation can also
provide assessment of medial structures. Posterior tibial
translation with posterior drawer testing should decrease
with internal rotation of the tibia as the medial capsular
structures tighten. In combined PCL/medial-side injury,
this reduction in the posterior laxity is lost.
In the combined ACL/PCL deficient knee, the tibia
will be subluxated posteriorly, making it more difficult to
quantify the contribution of each ligament to anterior trans-
lation. It is important to compare and examine the nonin-
volved extremity and determine the proper relationship of
the tibia to the femoral condyles. The pivot-shift test and
flexion-rotation drawer test augment evaluation of ACL
insufficiency but may not be useful in an injury involving
the ACL, PCL, and MCL because these tests rely on the
knee pivoting around intact medial structures.
It is difficult to perform ligamentous testing on a
patient with an acute knee dislocation. In particular, PCL
laxity is difficult to determine because the patient may not
be able to bend his or her knee to 90 degrees of flexion.
479
 Anterior Cruciate Ligament Reconstruction
Although MRI is helpful in determining the status of the
PCL, treatment should not be determined based on MRI
findings. It is important to remember that complete grade
III PCL injuries can heal with continuity and little or no
laxity when left in situ.19,20 Predictable healing of the torn
PCL is more important than any laxity in the healed PCL.
The fact that the PCL will heal with continuity is important
to our treatment philosophy for knee dislocation injuries.
An MCL injury is diagnosed and graded by physical
examination. Palpation along the ligament will localize
the site of the injury, which is critical to know in order to
determine the treatment and rehabilitation process. The
MCL is the primary medial restraint to valgus stress at 30
degrees of knee flexion. Valgus stress testing is preformed
at 30 degrees of flexion to isolate the MCL and then again
at 0 degrees of flexion to assess the contribution of capsular
structures as well as the cruciate ligaments. In greater
degrees of knee extension the ACL, PCL, posterior capsule,
and posterior oblique ligaments assume a greater respon-
sibility in preventing medial joint opening.40 Grading of
MCL injury is based on tenderness, laxity, and the presence
of a firm endpoint. A grade I injury has tenderness, no laxity
with valgus stress testing at 30 degrees of knee flexion, and a
firm endpoint. A grade II injury is similar but reveals some
medial laxity and the presence of a firm endpoint. A grade
III injury represents a complete disruption of the MCL with
no palpable endpoint on valgus stress testing.
A lateral-side knee injury usually appears differently
than an isolated ACL injury. The knee has a mild effusion,
but the lateral side of the leg appears swollen with ecchymosis
from the lateral capsule avulsion that allows the hemarthrosis
to dissipate into the lateral leg (Fig. 61-2, A, B). Lateral
stability is evaluated with varus stress applied to the knee at
FIG. 61-2 Knee injury to the anterior cruciate ligament, posterior cruciate ligament, and lateral side. A, The knee
has a mild effusion with increased lateral-side swelling. B, The lateral side shows ecchymosis from the lateral
capsule, allowing the hemarthrosis to dissipate into the lateral side of the leg.
480
0 and 30 degrees of flexion. Grade 1 laxity involves tenderness
over the lateral structures but no laxity and a good endpoint.
Grade 2 lateral laxity involves tenderness and increased laxity
with varus stress, but a good endpoint is felt. Grade 3 laxity
involves tenderness and increased laxity with varus stress,
and no endpoint is felt.
ASSOCIATED NEUROVASCULAR INJURY
Vascular injury with high-velocity knee dislocation has been
reported to be as high as 40% in some series.41 Shelbourne
et al in a series of low-velocity sports injuries found a vascular
injury rate of 4.8% (1 of 21).42 Peroneal nerve injuries have
been reported in 14% to 35% of knee dislocations. Most, if
not all, are associated with lateral-side injury. In a series of
low-velocity sports injuries, four of 21 (19%) patients pre-
sented with peroneal nerve injury.43 All were associated with
lateral-side injury. It should be emphasized that if the lateral
side is injured, the peroneal nerve should be closely evaluated.
Conversely, if the peroneal nerve is injured, careful evaluation
of lateral-side structures is advised.
IMAGING
Radiographic examination of the injured extremity is
imperative to rule out associated fracture or joint subluxa-
tion. Initial views should include posteroanterior, lateral,
and Merchant views.44 In the delayed setting, a flexed,
45-degree weight-bearing view will give more accurate
assessment of tibiofemoral joint space.45 Additionally, a
PCL avulsion fracture may be detected.
 Anterior Cruciate Ligament Injury Combined with Medial Collateral Ligament, Posterior Cruciate Ligament, and/or Lateral-Side Injury
MRI may provide important information about the
injured soft tissues and their site of disruption. MRI can
also be used to radiographically evaluate the healing of the
PCL. Although healing of the PCL on MRI correlates with
clinical healing, there may be residual clinical laxity.19,20
TREATMENT PHILOSOPHY (PRINCIPLES)
Our treatment principles have evolved over the last 22 years
after observing and studying the outcome of injuries to indi-
vidual structures and their potential to heal when left in situ,
as well as the effects of the injuries in combination with
other ligament injuries in the knee. Nonoperative treatment
of knee dislocations has yielded mixed results, with some
patients reporting residual, disabling laxity.10,46 Acute oper-
ative repair of multi-ligament injuries can provide knee sta-
bility but frequently results in permanent stiffness, primarily
when injury to the medial side is involved. Previously, direct
repair of all ligaments was advocated, but as ACL recon-
struction techniques were developed, there was a shift
toward repair of all injured structures in conjunction with
ACL reconstruction. As PCL reconstruction techniques
have improved, many authors now advocate combined
ACL/PCL reconstructions in the acute setting.47,48
Knee dislocations are uncommon, and surgeons are
more comfortable with a stable knee and the possibility of
residual stiffness as opposed to the risk of potential instabil-
ity. We believe that the observation of patients who had dis-
abling problems after knee dislocation involving lateral-side
injury led to a more aggressive approach toward acute surgi-
cal treatment of all combined injuries, without consideration
for the injured structures causing the disability. Because sur-
gical treatment has been favored, the healing potential of
each injured structure has been ignored.
We propose different treatment approaches depend-
ing on the degree and the combination of injured structures.
The initial treatment approach is based on recognizing that
the PCL and MCL can heal without surgery, whereas the
ACL and lateral structures generally do not. Thus most lig-
ament injuries do not require acute surgery, and in most
cases immediate surgery is not desirable because of the
increased incidence of arthrofibrosis and long-term loss of
motion.49 An understanding of the healing response of
individual structures provides an explanation for potential
postoperative stiffness associated with acute surgery. The
goal of treatment is to provide the patient with a function-
ally stable knee with full range of motion. In observing a
young, athletically active population, we have found that
patients who have a stable but stiff knee have disability
and would prefer a knee with full range of motion that
would allow a functional activity level. Once accurate
61
diagnosis has been made and associated injuries evaluated,
the treatment plan for the knee is formalized.
The poor outcome from nonoperative treatment of
knee dislocations has stemmed from inadequate treatment
of the MCL or lateral-side structures. Our treatment
approach revolves around making sure the MCL or lat-
eral-side structures become stable and allowing the PCL
to heal in situ such that it has 2þ laxity or less. The treat-
ment of the MCL and lateral-side structures differs based
on our knowledge of their potential or lack of potential to
heal. An ACL reconstruction can be done as indicated
based on the patient’s lifestyle and goals.
Combined Anterior Cruciate Ligament/
Posterior Cruciate Ligament/Medial
Collateral Ligament Injury
The initial treatment of patients who have a dislocated knee
with a medial-side knee injury involves providing a means
for the MCL to heal. In the past, we used either an immo-
bilizer or a brace to limit valgus stress; however, we found
that these devices were not restrictive enough to completely
prevent the stress. Patients would also remove the device to
shower or sleep.
In 1990, we began using cast immobilization to
totally limit valgus stress. The patient is initially placed in a
cylinder cast with 20 degrees of flexion, and weight bearing
is encouraged. The goal is to prevent valgus stress, allow
healing of the MCL, and prevent stress deprivation of the
joint surface.29 The cast is changed weekly in order to evalu-
ate ligament healing. Gentle valgus stress testing is performed
to check for an endpoint. Once stability is achieved in the
MCL with a stable endpoint and the patient is pain free, the
cast is discontinued. Typically, proximal MCL injuries take
2 weeks to develop an endpoint, and distal injuries require 4
to 5 weeks of serial casting. Casting usually allows the PCL
to heal with a good endpoint on posterior drawer examina-
tion. This treatment approach usually results in no medial lax-
ity, acceptable posterior laxity, and ACL deficiency.
Once the MCL has healed, rehabilitation is begun to
restore normal knee range of motion. By this time, the
patient’s knee should be calm and the physician can perform
a reevaluation of ACL and PCL stability.
Sometimes the ACL and PCL stability will be suffi-
cient to totally avoid surgery. Most of the time, PCL laxity
will have improved and be 2þ or less. In a prospective natural
history study of patients with acute isolated PCL injuries, the
outcome of patients with 1þ PCL laxity did not have better
overall subjective, objective, or radiographic results than
patients with 2þ PCL laxity.22 Additionally, current surgical
techniques have failed to reproducibly restore normal PCL
481
 Anterior Cruciate Ligament Reconstruction
stability.50,51 Therefore surgery to reduce PCL laxity from
2þ to 1þ should not allow improved function or less develop-
ment of degenerative changes. Until operative techniques can
reliably obtain normal PCL stability, and given that 1þ pos-
terior laxity has not been shown to provide better function
than 2þ laxity, we recommend nonoperative treatment of
PCL laxity of 2þ or less.
Depending on the patient’s activity level and athletic
goals, an ACL reconstruction may be warranted. In some
patients, this approach also allows for healing of the ACL,
which may provide enough stability to allow patients to do
well functionally without having the ACL reconstructed.
Only rarely will PCL laxity be greater than 2þ on
posterior drawer testing (the tibia sits behind the femoral
condyles). When the patient’s knee has 3þ PCL laxity
and increased recurvatum is present, semi-acute (7 to 10
days) PCL reconstruction may be indicated to optimize
long-term results, although the author has rarely seen this
in practice. It is possible that 3þ laxity observed at the time
of the acute injury may decrease with a follow-up exami-
nation several days or weeks later. The decision to perform
a PCL reconstruction should not be based on the findings
of the MRI. As stated previously, even with other liga-
mentous damage, the PCL can heal with continuity.
A subsequent physical examination to evaluate PCL laxity
is certainly simpler than surgery, and even when the lateral
side is involved, the physician has 1 week to 10 days to let
the knee calm down to allow for a more accurate physical
examination of ligamentous laxity.
We do not recommend a combined ACL/PCL
reconstruction be performed acutely because of the high
incidence of knee stiffness.52–55 If a PCL reconstruction is
indicated, the reconstruction should be delayed until the
knee has little swelling and good range of motion and the
patient has good leg control. Additionally an antiembolism
stocking and continuous passive range of motion device can
be used to prepare the patient for surgery. To further reduce
operative trauma, we prefer using autogenous patellar
tendon graft from the contralateral knee. If ACL defi-
ciency becomes symptomatic, an ACL reconstruction can
be performed electively at a later date.
When high-grade MCL laxity is present and fails to
heal with the previously described treatment plan, a number
of options are available. Multiple longitudinal perforations
in the MCL can be done to stimulate healing. We have
found this useful in tightening the medial side without
compromising postoperative range of motion. Additional
options include recessing the femoral attachment, advancing
the distal attachment, and reefing the MCL, all of which
will retension the MCL.56–58
482
Combined Anterior Cruciate Ligament,
Posterior Cruciate Ligament, and Lateral-
Side Knee Injury
A lateral side knee injury requires semi-urgent treatment. We
strive to balance being able to obtain range of motion and
decrease swelling with the ability to repair the torn lateral
structures. The torn lateral structures retract proximally and
begin to heal en masse within 3 weeks after injury (Fig. 61-3).
Some surgeons advise to dissect and repair individual
structures.59,60 We prefer to reattach the en masse tissue
versus dissecting out each torn structure to take advantage
of the body’s healing reaction from the injury.21 This
approach is similar to that described by Aglietti et al.56
Lateral-Side Repair
If an ACL or PCL reconstruction is being performed at the
same surgical setting as the lateral-side repair, the recon-
struction should be performed before the lateral-side repair.
A longitudinal skin incision is made laterally from distal
to proximal between the tibial tubercle and fibular head.
A pseudomembrane forms over the injured structures when
the surgery is performed within 3 weeks of the injury. The
underlying structures can be identified once the pseudo-
membrane is entered. The iliotibial band is usually intact,
and the injured structures begin just posterior to the iliotibial
band where the lateral capsule attaches to the tibia. A bare area
of bone will be exposed on the proximal lateral tibia and fibu-
lar head because of the injury. The bare area is easily exposed
with blunt finger dissection. The retracted tissue that has
healed en masse can be easily seen. The tissue, instead of
being dissected into individual structures, is left en masse
FIG. 61-3 Intraoperative picture showing the lateral capsule tear off the
tibia.
 Anterior Cruciate Ligament Injury Combined with Medial Collateral Ligament, Posterior Cruciate Ligament, and/or Lateral-Side Injury
and repaired back to the lateral capsule attachment site.21 An
Ethibond (Ethicon, Somerville, NJ) suture is passed through
the tissue mass by using a modified Kesslar stitch. One suture
is passed anteriorly, and another is passed posteriorly. The
bony attachment site on the tibia is freshened with a curette
or bur. A suture anchor is placed if repair to the fibular head
is also required. The mass of tissue is advanced to the normal
capsular attachment site and fixed with a stable (Fig. 61-4).
If the injury is older than 3 weeks and the tissue is
friable, then a screw and soft tissue washer are used for secure
fixation. The avulsed biceps femoris tendon and lateral
collateral ligament are reattached to the fibula with a suture
anchor or reattached to a cuff of remaining soft tissue.
After repair, the knee is moved from 0 degrees of
extension to at least 90 degrees of flexion or more until the
lateral repair becomes taut. A drain is placed subcutaneously,
and the subcutaneous wound is closed with Vicryl (Ethicon).
The superficial wound is closed with staples or sutures. To
control knee and leg swelling, an antiembolism stocking,
cold/compression device, and immobilizer are placed on
the leg.
Postoperative Rehabilitation
The patient remains in bed with the operative leg in a con-
tinuous passive motion (CPM) machine for the first week
after surgery. The continuous passive motion machine is
set to move from 0 degrees of extension to 30 degrees of
flexion. The patient performs specific range of motion exer-
cises 4 to 5 times a day to increase extension and flexion in
the knee. If the lateral gastrocnemius muscle was intact,
then full extension is allowed; if the muscle was injured,
then extension is limited to 0 degrees for 3 to 4 weeks to
allow healing. Patients are allowed to weight bear as able
FIG. 61-4 The lateral capsule is repaired back to the area of the avulsion
from the tibia just posterior to Gerdy’s tubercle.
61
but are required to wear the immobilizer for 1 to 2 weeks
postoperatively, when good quadriceps muscle control is
usually achieved. The rehabilitation process is similar to
the rehabilitation after ACL reconstruction.61 Patients must
obtain full knee range of motion equal to the contralateral
knee, good leg control, and a normal gait before beginning
aggressive strengthening exercises. The return to activities
is individualized to each patient’s goals and lifestyle.
SUMMARY
Acute surgery in patients with combined ligament injuries
of the knee can lead to stiffness, primarily with medial-side
injuries. All knee dislocations should not be grouped
together because of the difference in healing potential
between medial- and lateral-side injuries. Our approach is
based on the individual healing potential of the injured
structures, and the natural history of these injuries. This
algorithm is based on the following:

Appropriate treatment to provide MCL or lateral-side
stability is key.

Medial-side knee injuries can heal with proper
nonoperative treatment to include firm immobilization
(recommend casting). Distal MCL injuries take longer to
heal than proximal MCL injuries.

PCL tears can heal even in combination with other
ligament injuries; therefore surgery is not usually
indicated. Given that PCL laxity of 2þ or less has not
been shown to be predictive of long-term results, acute
PCL reconstruction is not indicated.

ACL injuries, in general, do not heal. The ACL injury in
combination with MCL and/or PCL injury can initially
be treated nonoperatively and reconstructed later as
dictated by patient symptoms and activity level.

Lateral-side knee injuries do not heal and require semi-
acute surgery. Individual lateral structures do not need to
be dissected out for repair. The en masse tissue formed
after the injury can be repaired by attaching it to the
lateral capsule attachment site on the tibia.
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485
 62
CHAPTER
Treatment of Meniscus Tears with Anterior
Cruciate Ligament Reconstruction
K. Donald Shelbourne INTRODUCTION
Tinker Gray
The treatment of meniscus tears in conjunction
with anterior cruciate ligament (ACL) recon-
struction requires a thorough understanding of
the different types of meniscus tears and their
capacity for healing. The factors to consider are
whether the tear is medial or lateral, degenerative
or nondegenerative, or stable or unstable, as
well as the vascular zone of the meniscus. The
treatment choices are to remove, repair, or leave
the tear in situ.
Meniscus tears with ACL injuries are dif-
ferent than meniscus tears in ACL intact knees.
For a meniscus to tear, either (1) the knee is
unstable, causing excessive movement, which
in turn causes the meniscus to become caught
between the femur and the tibia or (2) the knee
is stable, and the meniscus has a degenerative
component to it. In general, meniscus tears in
ACL intact knees have extensive degeneration.
Meniscus tears with an acute ACL injury are
traumatic and occur mostly in the posterior
and peripheral part of the meniscus. Meniscus
tears in chronic ACL deficient knees can be
degenerative or nondegenerative, depending on
the number and severity of instability episodes.
The incidence of lateral meniscus tears has
been reported to be higher than the incidence of
medial meniscus tears with acute ACL injuries.1
Shelbourne and Gray2 found that of 448 patients
with acute ACL injuries, 62% had lateral menis-
cus tears and 42% had medial meniscus tears,
whereas in 609 patients with chronic ACL
486
deficiency, 49% had lateral meniscus tears and
60% had medial meniscus tears. Cipolla et al3
found that of 218 acute injuries, 59% had lateral
meniscus tears and 28.5% had medial meniscus
tears, whereas in 552 chronic ACL injuries,
41.6% had lateral meniscus tears and 74% had
medial meniscus tears. The lateral meniscus is
mobile and translates 9 to 11 mm in the antero-
posterior plane, whereas the medial meniscus
translates only 2 to 5 mm.4 The lateral meniscus
is more frequently injured acutely because of its
extreme mobility, and the peripheral and poste-
rior portions of the meniscus are prone to getting
caught in the joint during an ACL instability epi-
sode, which may explain the high incidence of
posterior horn avulsion tears with acute ACL
injuries. The less mobile medial meniscus is less
injured with acute ACL injuries, and it may take
consecutive giving-way episodes for the periph-
eral posterior third of the meniscus to become
caught in the joint. When patients do have a
medial meniscus tear with an acute ACL injury,
it is typically a peripheral vertical tear in the pos-
terior third of the meniscus. This tear can extend
anteriorly with additional giving-way episodes
and eventually become a bucket-handle tear.
The fact that more lateral meniscus tears
are seen with acute ACL injuries than with
chronic ACL deficiency can be explained by
the fact that most lateral meniscus tears with
acute ACL injuries can heal without treatment.
In fact, many medial meniscus tears seen at
the time of acute ACL reconstruction can
heal without repair. With the advent of knee

arthroscopy, surgeons have felt compelled to treat many
meniscus tears seen at the time of ACL reconstruction that
would have been unobserved and left alone before knee
arthroscopy was invented. The high meniscus repair success
rate with ACL reconstruction can partially be explained by
the fact that many menisci are being repaired that probably
do not need any treatment at all.
This chapter will discuss the types of meniscus tears
seen with ACL reconstruction, which meniscal tears can
be left in situ, which tears to repair and the repair success
rates, and finally the timing of meniscus repair with ACL
reconstruction surgery.
Treatment of Meniscus Tears with Anterior Cruciate Ligament Reconstruction 62
the almost 100% success with repair of lateral meniscus tears
and came to the conclusion that many of the lateral meniscus
tears being repaired probably did not need repair. Therefore
the senior author began to change his treatment of lateral
meniscus tears from repairing 80% of the tears in 1984 to
repairing 15% in 1992. During that same time, he changed
his treatment from leaving lateral meniscus tears in situ in
4% of tears in 1984 to 70% in 1992. The types of lateral
meniscus tears left alone included posterior horn avulsions
(52 tears; Fig. 62-1), stable vertical tears that were posterior
to the popliteus tendon (99 tears; Fig. 62-2), and nondis-
placed vertical tears that extended anterior to the popliteus
tendon (27 tears).10 With a follow-up at a mean of 2.6 years

MENISCUS TEARS TO LEAVE IN SITU

With acute ACL injuries, most meniscus tears are not
symptomatic for the patient. The patient’s inability to fully
extend the knee is usually due to the ACL stump being
lodged in the intercondylar notch. Shelbourne et al5 found
that joint line tenderness observed at the time of acute
ACL injury does not correlate to the presence or absence
of meniscus tears at the time of surgery. Over a 2-year
period, 173 patients were seen for acute injury and were
evaluated for joint line tenderness, and then the type of
meniscus tear was recorded at the time of surgery. The
investigators found that medial joint line tenderness was
45% sensitive and 34% specific for a medial meniscus tear.
Lateral joint line tenderness was 58% sensitive and 49%
specific for a lateral meniscus tear.5 We now delay ACL
surgery until the patient’s knee has full range of motion
and no swelling and the patient has good leg control. On FIG. 62-1 Posterior horn avulsion tear of the lateral meniscus commonly
seen with acute anterior cruciate ligament (ACL) injuries.
the day of surgery, very few patients have joint line tender-
ness but about 50% have a meniscus tear.6 It appears that
meniscus injuries in conjunction with acute ACL injuries
are difficult to determine preoperatively based on joint line
tenderness exam.
The meniscus has a blood supply provided by the
perimeniscal capillary plexus, and these capillaries extend into
20% to 30% of the body of the medial meniscus and 10% to
25% of the lateral meniscus.7,8 Tears in the peripheral vascular
zone of the meniscus are thought to be ideal for meniscus
repair, but many can heal without specific repair treatment.
The acuteness or chronicity of the ACL injury is not the
deciding factor for determining the treatment of the menis-
cus. Rather, it is the location of the tear and the degenerative
nature of the tear that help determine treatment.

Lateral Meniscus Tears

Complete removal of a torn lateral meniscus has a poor FIG. 62-2 Superior surface of the lateral meniscus, showing a stable
prognosis.9 In the early 1980s, the senior author observed vertical tear.

487
 Anterior Cruciate Ligament Reconstruction

(range 1–9 years), Fitzgibbons and Shelbourne10 found that

no patients returned to the clinic reporting symptoms of a
lateral meniscus tear. One patient twisted his knee playing
basketball at 114 days after ACL reconstruction and had a
displaced bucket-handle medial meniscus tear. At the time
of follow-up arthroscopy, the original vertical lateral meniscus
tear had progressed to a complex T-type tear, but the tear did
not extend anterior to the popliteus.
Shelbourne and Heinrich11 performed another long-
term follow-up of 332 patients who had lateral meniscus tears
left in situ or treated with abrasion and trephination without
suture repair. The patients also had no medial meniscus tears
or chondromalacia greater than grade II to isolate the factor of
lateral meniscus tears in the long-term follow-up analysis.
At a mean of 5.1 years after surgery, 162 patients (95%) had
normal radiographs, six patients had nearly normal radio-
graphs, and two patients had abnormal radiographs for lateral
joint space narrowing using IKDC criteria. Of 70 patients
with posterior horn avulsion tears left in situ, two (2.9%)
underwent a subsequent procedure to remove the tear. Of
50 patients with radial flap tears, three patients (6%) needed
a subsequent surgery for the tear. Of 169 patients with periph-
eral or posterior tears left in situ, three patients (1.8%)
required subsequent surgery for the tear. None of the 43
patients who had peripheral or posterior tears treated with
abrasion and trephination required further surgery.11
Medial Meniscus Tears
Medial meniscus tears seen at the time of acute ACL recon-
struction are traumatic in nature and are usually in the
vascular zone of the meniscus. A common type of tear seen
with acute ACL injury is a peripheral or posterior
stable medial meniscus tear, which can be easily missed
(Fig. 62-3). This type of tear is not symptomatic for the
patient, and it is possible that many of these tears heal on
their own in patients who do not undergo an ACL recon-
struction acutely or semi-acutely.
Shelbourne and Rask12 performed a follow-up study
to determine the outcome of nondegenerative peripheral
vertical medial meniscus tears that were stable and were
treated either by leaving the tear in situ or with abrasion
and trephination without suture repair. All the tears were
greater than 1 cm long but could not be displaced into the
intercondylar notch. Between 1982 and 1988, 139 tears
were treated by leaving the tears in situ. Between 1989
and 1997, the tears were treated with abrasion and trephina-
tion. At a mean of 4.8 years after surgery, the number of
patients who underwent subsequent arthroscopy for symp-
toms of a meniscus tear was 15 (10.8%) for the tears left
in situ and 14 (6%) for the tears treated with abrasion and
trephination. The mean time after ACL reconstruction that
FIG. 62-3 Inferior surface of the medial meniscus, showing a peripheral
vertical posterior third tear commonly seen with acute anterior cruciate
ligament (ACL) injuries.
patients experienced symptoms was 2.5 years for the tears
left in situ and 2.3 years for the tears treated with abrasion
and trephination. As part of the same study, 176 patients
had the same type of meniscus tear, but it was unstable
and required suture repair. The failure rate of the repaired
group was 13.6%.12
Trephination has been shown in both animal and
clinical studies to enhance meniscal healing by creating vas-
cular channels.13–15 Fox et al16 treated 26 incomplete
peripheral vertical meniscus tears by trephination alone
and had 90% clinical success, but all of the tears were less
than 1 cm long. Weiss et al17 showed that medial meniscus
tears of 1 cm or less can heal if left alone, but the study did
not evaluate tears greater than 1 cm long.
It is accepted that peripheral vertical medial meniscus
tears less than 1 cm long that are found at the time of ACL
reconstruction can be left in situ or treated with trephina-
tion. Shelbourne and Rask12 have now shown that tears lon-
ger than 1 cm long can also be left in situ or treated with
trephination and still have a very low rate of causing
subsequent symptoms of a meniscus tear. Trephination is
a simple technique to provide vascular channels in the
meniscus for healing, and it avoids the risks associated with
meniscus repair using sutures.
MENISCUS TEARS TO REPAIR
It would be ideal to attempt to repair all torn menisci
because the menisci transmit load across the medial and lat-
eral compartments of the knee. As more of the meniscus is
removed, the more contact surface between the femur and

488

tibia is lost and contact stress increases. Meniscus repair of
all menisci, however, does not ensure that the repaired
meniscus performs normally for distributing load and
absorbing stress.
McCarty et al18 published an extensive review of the
different types of meniscus repair techniques and their
results. It appears that most techniques can be successful,
with rates ranging from 73% to 99% for clinical success
and 25% to 90% for success of meniscal healing. The factors
for success were similar for the different types of repairs:
success was dependent on meniscus tear type, size, and loca-
tion. To determine the success of meniscus repair, it would
be most helpful for investigators to study specific types of
meniscus tears instead of combining all types together.
Cannon and Vittori13 evaluated meniscal healing in
90 repairs done in conjunction with ACL reconstruction
and 27 repairs in ACL intact knees, and the healing was
related to rim width (vascular versus avascular zones), tear
length (stable versus unstable), and joint compartment (lat-
eral versus medial). Rim widths up to 2 mm had a healing
success rate of 96%. Rim widths of 2 to 4 mm had a healing
success rate of 84%, and rim widths of 4 to 5 mm had a suc-
cess rate of 50%. Tear length less than 2 cm had a 94% suc-
cess rate, and tear lengths of 2 to 4 cm had an 86% success
rate. When the tear length was more than 4 cm, the healing
rate was only 50%. Lateral meniscus tears successfully
healed 93% of the time, whereas medial meniscus tears
healed 73% of the time. Meniscus repair done with ACL
reconstruction was more successful (93%) than repairs done
in ACL intact knees (50% success), but there was no infor-
mation provided as to the differences in rim width, tear
length, or joint compartment between the two groups.13
Asahina et al19 also evaluated the factors that affected
healing of meniscal repair of unstable, full-thickness, verti-
cal, longitudinal tears longer than 15 mm in 98 patients
evaluated by second-look arthroscopy. Of the 98 repairs,
73 completely healed, 13 incompletely healed, and 12 did
not heal. Healing was achieved in 78% of medial meniscus
repairs and 63% of lateral meniscus repairs. Repairs in the
peripheral third zone had a statistically significant better
healing rate of 87%, compared with 59% for repairs in the
central third zone. The statistically significant factors in
healing were rim width and meniscal locking. Meniscus
tears in the central third zone that had been locked in the
knee or could be locked at the time of surgery had a negative
correlation to healing.19
Unstable meniscus tears, such as bucket-handle tears,
are common with chronic ACL instability (Fig. 62-4). Most
bucket-handle meniscus tears are degenerative, which is
why they are very seldom seen with acute ACL injuries. It is
possible for a bucket-handle tear to be nondegenerative in a
patient with chronic ACL laxity if he or she has been able to
Treatment of Meniscus Tears with Anterior Cruciate Ligament Reconstruction 62
protect the knee from instability episodes and has just suffered a
recent giving-way episode prior to the evaluation. In a series of
55 bucket-handle meniscus tears seen with chronic ACL defi-
ciency, 43 tears (78%) were in the white-white nonvascular
zone of the meniscus, 11 were in the red-white vascular zone,
and one was in the red-red vascular zone.20
O’Shea and Shelbourne20 evaluated meniscal healing of
repairs done on bucket-handle meniscus tears that were
unstable and locked in the intercondylar notch in patients
with chronic ACL deficiency. Patients underwent meniscus
repair followed by rehabilitation to regain full knee range of
motion, strength, and function before undergoing an ACL
reconstruction at a later date. The menisci were evaluated
with arthroscopy at the time of the ACL reconstruction,
which occurred at a mean of 77 days after meniscus repair.
Of 43 repairs done in the avascular zone of the meniscus, only
five menisci showed no healing at the repair site. Of 11 repairs
done in the red-white vascular zone of the meniscus, only one
repair showed no healing. The one repair done in the red-red
zone of the meniscus healed completely. At a subsequent
follow-up at a mean of 4.3 years after repair, four patients
had a failed repair that required subsequent arthroscopies to
remove repairs done in the avascular zone of the meniscus
(Fig. 62-5).
Rubman et al21 found similar success rates of meniscal
repair in 198 meniscus tears that had a rim width of 4 mm
or more. Most of the tears were either single (N ¼ 92) or
double (N ¼ 40) longitudinal tears. Clinical success, defined
as the patient being asymptomatic for tibiofemoral joint
symptoms, was found in 80%. Arthroscopic follow-up evalu-
ation of 91 of the tears found that 23 (25%) had completely
healed, 35 (38%) had partially healed, and 33 (36%) failed.
The authors concluded that repairs of the meniscus in the
avascular zone is preferred over partial meniscectomy,
especially in young athletic patients or patients with varus or
valgus lower extremity malalignment. Noyes and Barber-
Westin22 in a similar study found that 26 of 33 repairs of tears
in the avascular zone remained asymptomatic at a mean of 33
months postoperatively for patients 40 years or older.
Thus it appears that meniscus tears, even in the avas-
cular zone of the meniscus, can heal or remain asymptom-
atic with repair. The question remains as to whether
repaired menisci, especially large bucket-handle tears in
the avascular zone, function well enough to protect the joint
and not cause symptoms for the patient in the long term.
Shelbourne and Carr23 compared the results of meniscus
repair versus partial meniscectomy of bucket-handle medial
meniscus tears in ACL reconstructed knees. The patients
had no other intraarticular pathology such as lateral menis-
cus tears or articular cartilage damage greater than Outer-
bridge grade 2. One would expect that patients who
underwent meniscus repair would have better results than
489
 Anterior Cruciate Ligament Reconstruction

FIG. 62-4 Bucket-handle medial meniscus tear. A, Superior surface of the medial meniscus tear, showing the
bucket-handle separation. B, Inferior surface of the tear being trephinated. C, Meniscus after repair with sutures.

patients who had a partial meniscectomy. The mean modi-
fied Noyes subjective score was identical for the two groups,
90.9 points, at 8 years after surgery. Of note, however, was
that when the repair group was analyzed based on whether
the bucket-handle tear was degenerative or nondegenerative,
patients who had a degenerative meniscus tear had a mean
score of 87.1 points, which was statistically significantly
lower than the mean of 93.9 points for patients who had a
nondegenerative meniscus tear. Radiographic evaluation
showed that 11 of 12 patients (92%) in the nondegenerative
group had normal radiographs at follow-up versus only nine
of 12 patients (75%) in the degenerative group. Interest-
ingly, 41 of 52 patients (79%) who had partial meniscect-
omy of the bucket-handle tear also had normal
radiographs. Therefore the authors concluded that repaired
degenerative bucket-handle medial meniscus tears may not
function normally in the knee to provide any advantage over
partial meniscectomy.23
In a similar study, Shelbourne and Dersam24 com-
pared the results of partial meniscectomy versus repair for
bucket-handle lateral meniscus tears with ACL reconstruc-
tion. The patients had no other intraarticular pathology,
such as medial meniscus tears or articular cartilage damage
greater than Outerbridge grade 2. The mean time of subjec-
tive follow-up was 7 years for the repair group and 11 years
for the removal group. The mean total subjective score for
57 patients in the repair group was 92.5 points, and the
mean total score for the removal group was 88.7 points,
which was not statistically significantly different. Patients
in the removal group did have statistically significantly lower

490

FIG. 62-5 Meniscus at 3 months after repair of bucket-handle tear. No sutures are present, and the meniscus
appears healed on the superior surface (A) and inferior surface (B).
pain subscores on the subjective survey than patients in the
repair group. Radiographic evaluation using IKDC criteria
found that 83% of the removal group (8 years postopera-
tively) and 87% of the repair group (6 years postoperatively)
had normal radiographs. The longer follow-up time for the
removal group should have accentuated any detriment of
meniscus removal of the tears versus meniscus repair.
Although the subjective scores between groups were not sta-
tistically significantly different, we believe the P value of
0.2014 indicates a trend toward lower scores in the removal
group.24
Timing of Meniscus Repair with Anterior
Cruciate Ligament Surgery
There is one situation in which meniscus repair should not be
performed at the same time as ACL reconstruction. Patients
who have chronic ACL deficiency commonly seek treatment
when they suffer a meniscus tear that is causing clicking,
locking, or pain in the knee. Sometimes the common
bucket-handle tear seen with chronic ACL instability will
become locked in the intercondylar notch. When patients
seek treatment, they want treatment for the immediate pro-
blem of the meniscus tear and may not be prepared mentally
or socially to undergo an ACL reconstruction. Furthermore,
there is a higher risk of arthrofibrosis when the patient
undergoes ACL reconstruction when the knee does not have
full range of motion equal to the opposite normal knee.25
Shelbourne and Johnson26 found a higher incidence
of arthrofibrosis in patients who underwent meniscus repair
or removal of a locked bucket-handle meniscus tear in con-
junction with ACL reconstruction versus patients who
Treatment of Meniscus Tears with Anterior Cruciate Ligament Reconstruction 62
underwent staged procedures of meniscus repair or removal,
rehabilitation to restore normal knee motion, and ACL
reconstruction at a later date. Four of 16 patients who
underwent meniscus treatment and ACL reconstruction
suffered arthrofibrosis, compared with 0 of 16 patients
who underwent staged procedures. All of the patients had
flexion contractures of 5 to 20 degrees with the locked
bucket-handle meniscus tear, and the mean time that the
meniscus was locked in the knee before surgery could be
performed was 12.4 days.
Loss of knee extension is a common complication
after ACL reconstruction. It is more commonly associated
with ACL reconstruction after acute injury versus chronic
instability, but any loss of normal knee extension to include
normal hyperextension affects the long-term results after
surgery. In a 10- to 20-year follow-up study of ACL recon-
struction, any loss of normal knee extension or flexion after
surgery was the most important factor related to lower
subjective scores. Another significant factor considered in
the regression analysis was partial medial or lateral menis-
cectomy, but any loss of knee motion was more important.27
Although it is certainly possible to perform combined
ACL reconstruction with treatment for a locked bucket-
handle meniscus tear in a chronic ACL deficient knee and
achieve normal knee range of motion, our philosophy for treat-
ment is to approach ACL reconstruction in a way that gives
the patient the best possible outcome in the long term. The sur-
gery and rehabilitation for ACL reconstruction should be
done at a time when it is most convenient for the patient to
miss work or school and perform proper rehabilitation. It is
difficult to function well with a locked bucket-handle meniscus
tear in the knee, and surgery is somewhat of an emergency.
491
 Anterior Cruciate Ligament Reconstruction
Obtaining full knee range of motion can be difficult for patients
even when the only surgery performed is a repair or removal of
the locked meniscus, especially if the knee has been locked in
flexion for more than 1 or 2 weeks. We believe that staging
the treatments for the meniscus tear and ACL deficiency gives
the patient the best possible opportunity to obtain full knee
range of motion.
All other types of meniscus repair can be done effec-
tively in conjunction with ACL reconstruction. It is impor-
tant that physicians not limit the ACL rehabilitation when a
meniscus repair is done at the same time. Exercises to achieve
full, symmetrical knee range of motion should begin on the
day of surgery, and there is no reason to limit weight bearing.
In the study by Shelbourne and Johnson26 in which patients
underwent staged procedures for treatment of a locked
bucket-handle meniscus tear followed by ACL reconstruc-
tion, 14 patients underwent meniscus repair. The rehabilita-
tion allowed unrestricted weight bearing and full knee range
of motion, and patients underwent ACL reconstruction at a
later date when rehabilitation goals had been achieved. At
the time of ACL reconstruction, an arthroscopy was per-
formed to evaluate meniscal healing. The average time of
evaluation was 72 days, and all repaired menisci had evidence
of healing. Only one patient subsequently had a tear to the
repaired meniscus at 18 months after repair. We believe that
weight bearing with the knee in full extension pushes the
meniscus toward the capsule and may promote healing.26
CONCLUSIONS
Not all meniscus tears require a formal repair. Many stable
menisci can be left in situ or treated with trephination to
create vascular channels for healing. The surgeon must con-
sider what would happen to the torn meniscus if arthro-
scopic evaluation of the knee were not done at the time of
ACL reconstruction. Although degenerative medial menis-
cus tears in the avascular zone can heal, they may not func-
tion normally and may cause a loss of knee range of motion
or other adverse symptoms for patients.
References
1. Bellabara C, Bush-Joseph CA, Bach BR Jr. Patterns of meniscal injury
in the anterior cruciate-deficient knee: a review of the literature.
Am J Orthop 1997;26:18–23.
2. Shelbourne KD, Gray T. Anterior cruciate ligament reconstruction
with autogenous patellar tendon graft followed by accelerated
rehabilitation: a two- to nine-year followup. Am J Sports Med
1997;25:786–795.
3. Cipolla M, Scala A, Gianni E, et al. Different patterns of meniscal
tears in acute anterior cruciate ligament (ACL) ruptures and in
chronic ACL-deficient knees. Knee Surg Sports Traumatol Arthrosc
1995;3:130–134.
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4. Maitra RS, Miller MD, Johnson DL. Meniscal reconstruction. Part I.
Indications, techniques, and graft considerations. Am J Orthop
1999;28:213–218.
5. Shelbourne KD, Martini JD, McCarroll JR, et al. Correlation of joint
line tenderness and meniscal lesions in patients with acute anterior
cruciate ligament tears. Am J Sports Med 1995;23:166–169.
6. Shelbourne KD. Unpublished data, 2006.
7. Arnoczky SP, Warren RF. Microvasculature of the human meniscus.
Am J Sports Med 1982;10:90–95.
8. Arnoczky SP, Warren RF. The microvasculature of the meniscus and
its response to injury: an experimental study in the dog. Am J Sports
Med 1983;11:131–141.
9. Yocum LA, Kerlan RK, Jobe FW, et al. Isolated lateral meniscectomy.
A study of twenty-six patients with isolated tears. J Bone Joint Surg
1979;61A:338–342.
10. Fitzgibbons RE, Shelbourne KD. “Aggressive” nontreatment of lateral
meniscal tears seen during anterior cruciate ligament reconstruction.
Am J Sports Med 1995;23:156–159.
11. Shelbourne KD, Heinrich J. The long-term evaluation of lateral
meniscus tears left in situ at the time of anterior cruciate ligament
reconstruction. Arthroscopy 2004;20:346–351.
12. Shelbourne KD, Rask BP. The sequelae of salvaged nondegenerative
peripheral vertical medial meniscus tears with anterior cruciate liga-
ment reconstruction. Arthroscopy 2001;17:270–274.
13. Cannon WD Jr, Vittori M. The incidence of healing in arthroscopic
meniscal repairs in anterior cruciate ligament-reconstructed knees ver-
sus stable knees. Am J Sports Med 1992;20:176–181.
14. Zhang Z, Arnold JA, Williams T, et al. Repairs by trephination and
suturing of longitudinal injuries in the avascular area of the meniscus
in goats. Am J Sports Med 1995;23:35–41.
15. Zhang ZN, Kaiyuan T, Yinkan X, et al. Treatment of longitudinal
injuries in avascular area of meniscus in dogs by trephination. Arthros-
copy 1988;4:151–159.
16. Fox JM, Rintz KG, Ferkel RD. Trephination of incomplete meniscal
tears. Arthroscopy 1993;9:451–455.
17. Weiss CB, Lundberg ML, Hamberg P, et al. Non-operative treat-
ment of meniscal tears. J Bone Joint Surg 1989;71A:811–822.
18. McCarty EC, Marx RG, DeHaven KE. Meniscus repair: considera-
tions in treatment and update of clinical results. Clin Orthop
2002;402:122–134.
19. Asahina S, Muneta T, Yamamoto H. Arthroscopic meniscal repair in
conjunction with anterior cruciate ligament reconstruction: factors
affecting the healing rate. Arthroscopy 1996;12:541–545.
20. O’Shea JJ, Shelbourne KD. Repair of locked bucket-handle meniscal
tears in knees with chronic anterior cruciate ligament deficiency. Am
J Sports Med 2003;31:216–220.
21. Rubman MH, Noyes FR, Barber-Westin SD. Arthroscopic repair of
meniscal tears that extend into the avascular zone: a review of 198 sin-
gle and complex tears. Am J Sports Med 1998;26:87–95.
22. Noyes FR, Barber-Westin SD. Arthroscopic repair of meniscus tears
extending into the avascular zone with or without anterior cruciate lig-
ament reconstruction in patients 40 years of age and older. Arthroscopy
2000;16:822–829.
23. Shelbourne KD, Carr DR. Meniscal repair compared with meniscect-
omy for bucket-handle medial meniscal tears in anterior cruciate
ligament-reconstructed knees. Am J Sports Med 2003;31:718–723.
24. Shelbourne KD, Dersam MD. Comparison of partial meniscectomy ver-
sus meniscus repair for bucket-handle lateral meniscus tears in anterior
cruciate ligament reconstructed knees. Arthroscopy 2004;20:581–585.
25. Shelbourne KD, Wilckens JH, Mollabashy A, et al. Arthrofibrosis in
acute anterior cruciate ligament reconstruction: the effect of timing of
reconstruction and rehabilitation. Am J Sports Med 1991;19:332–336.
26. Shelbourne KD, Johnson GE. Locked bucket-handle meniscal tears in
knees with chronic anterior cruciate ligament deficiency. Am J Sports
Med 1993;21:779–782.
27. Shelbourne KD. Unpublished data, 2006.
Anterior Cruciate Ligament Reconstruction
Combined with High-Tibial Osteotomy,
Autologous Chondrocyte Implantation,
Microfracture, Osteochondral, and/or
Meniscal Allograft Transplantation
INTRODUCTION
Knees with chronic anterior cruciate ligament
(ACL) tears often have degenerative changes.
If these changes are severe, cartilage restorative
procedures may be necessary in addition to
ACL reconstruction (ACLR). The question in
such cases is whether to perform the restorative
procedures simultaneously with the ACLR. If
they are not done simultaneously, the question
becomes one of proper sequencing and the nec-
essary time interval between procedures.
INDIVIDUALIZATION
Cases requiring combined procedures are inher-
ently complicated. Some patients will need
ACLR plus one other restorative procedure, but
some patients may need a total of three or four
such procedures. Decision-making can be helped
by the application of certain principles, which will
be discussed later. However, each patient’s
individual characteristics should be carefully
studied and weighed in decision-making. The
patient’s pathology is most important, but work
and life circumstances must be carefully consi-
dered to avoid disruption to the extent possible.
SURGEON FACTORS
The surgeon must also realistically weigh his or
her own skill and experience. When in doubt, it
is better to sequence procedures than to perform
difficult procedures simultaneously with which
63
CHAPTER
the surgeon may have limited experience. Chadwick C. Prodromos
Patients generally prefer simultaneity, but this
Brian T. Joyce
should not be done if it will subject the patient
to greater risk of failure.
SUCCESS RATES
In the literature and in our experience, success
rates with appropriate combined procedures
have been high. Table 63-1 summarizes the
relevant literature. Surgery and aftercare must
be meticulous. Reimbursement may not be com-
mensurate with the amount of work performed.
Not all surgeons will wish to perform these types
of procedures. However, if the procedures are
satisfactorily performed, and if the patients
are carefully chosen, the results can be gratifying.
PATIENT EXPECTATIONS
Patients must be counseled that success is by no
means guaranteed with these combined proce-
dures. It is important to discuss the possibility
of failure and what the next steps would be.
We believe that patients who do not comfor-
tably accept the possibility of failure are best
served by first seeing other surgeons to receive
second opinions.
RESTORATION OF MOTION
The overriding concern in preoperative plan-
ning is the avoidance of loss of motion as a result
493
 Anterior Cruciate Ligament Reconstruction

TABLE 63-1 Success Rates For Combined Procedures

Author Year Success Rate

ACLR with OATS

Klinger20 2003 81% normal or nearly normal on IKDC

21
Bobic 1996 10/12 patients had promising response at 2-year follow-up

ACLR with ACI

Amin8 2006 7/9 patients improved; 2/9 described no improvement

ACLR with MAT

Graf12 2004 1/8 patients had nearly normal results; 7/8 had abnormal or severely abnormal on IKDC scale

Sekiya11 2003 86% normal or nearly normal on IKDC

14
Yoldas 2003 19/20 reported normal or nearly normal on IKDC

Wirth15 2002 Recorded substantial improvement in both Lysholm and Tegner scores
16
Rath 2001 Significantly reduced pain and increase function (SF-36)

Cameron17 1997 80% of patients who had ACLR þ MAT had good-excellent results; 86% of those who had ACLR, MAT, and HTO had good to
excellent results

ACLR with HTO

Williams24 2003 Found statistically significant increases in Lysholm, HSS, Tegner score; 92% of patients were satisfied
25
Noyes 2000 Pain was reduced in 71% of knees; 71% of patients reported their knees as very good/normal or good

Stutz26 1996 8/13 patients had normal or nearly normal subjective IKDC scores
29
Lattermann 1996 3/8 patients had pain even with light activity

Neuschwander27 1993 4/5 patients had good or excellent result; one had fair

Noyes25 1993 94% of patients reported significant improvement

ACI, Autologous chondrocyte implantation; ACLR, anterior cruciate ligament reconstruction; HSS, Hospital for Special Surgery; HTO, high-tibial osteotomy; IKDC, International Knee
Documentation Committee; MAT, meniscal allograft transplantation; OATS, osteochondral autograft transfer system.

of the surgical procedures. We will discuss the relative risk
for each procedure in this regard. Above all, the knee must
be flexible and noninflamed before surgery is performed.
The reliability of the patient and access to appropriate
physical therapy resources must also be factors in decision-
making.
ANTERIOR CRUCIATE LIGAMENT
RECONSTRUCTION AND MICROFRACTURE
Microfracture has been shown to be an effective procedure
for generating a fibrocartilaginous fill for full-thickness
articular cartilage defects.1–3 It can easily be performed
together with ACLR and should be performed simulta-
neously whenever possible to save the patient an extra and
unnecessary anesthetic. The 6-week postoperative period
of touchdown weight bearing that is required after
microfracture (MF) does not adversely affect the ACLR.
It is important only to make sure that good passive range
of motion (ROM) is achieved. Decreased activity after
ACLR has actually been associated with less tunnel widen-
ing in one study.4 For those who believe in aggressive
strengthening immediately after ACLR, this regimen will
seem restrictive. However, in the long term there should
be no adverse effect. We have not found the addition of
ACLR to adversely affect the expected good results after
microfractures. There is no 2-year follow-up literature on
ACLR with microfracture of which we are aware. However,
our clinical experience has been favorable with lesions less
than 2 cm. We have found larger lesions to not fare as well
and in earlier years had to revise several microfractures to
autologous chondrocyte implantations (ACI). Although
the ultimate results in those cases were good, in recent years
we have proceeded directly to ACI when encountering
lesions greater than 2 cm.

494
 Anterior Cruciate Ligament Reconstruction Combined with High-Tibial Osteotomy 63
ANTERIOR CRUCIATE LIGAMENT
RECONSTRUCTION AND AUTOLOGOUS
CHONDROCYTE IMPLANTATIONS
ACI5–7 is the first procedure that has successfully generated
hyaline-like cartilage in full-thickness articular cartilage
defects. It is usually not carried out simultaneously with
ACLR because the ACLR is usually performed before the
need for ACI has been discovered. Thus the articular carti-
lage biopsy (ACB), rather than the ACI, is usually per-
formed at the time of the ACLR. Generally the ACI will
be performed as a staged subsequent procedure. If the lesion
is on the femoral condyles, as opposed to the trochlea, we
prefer to wait 4 to 6 months before performing ACI after
ACLR. The reason is that ACI can involve hyperflexion
FIG. 63-1 This 3.5-cm2 femoral condyle lesion occurred in a 17-year-old
of the knee to sew to the posterior aspect of many lesions. girl with a torn anterior cruciate ligament (ACL). She had hamstring ACL
This hyperflexion will stress the graft, and we prefer not reconstruction with simultaneous articular cartilage biopsy, with autologous
to subject newly implanted grafts to this stress. During the chondrocyte implantation (ACI) to follow as a staged procedure.

revascularization phase in the first few months postopera-

tively, grafts are severely weakened and are subject to plastic
deformation if stressed. Trochlear grafts are implanted
without hyperflexion and thus are safe early after ACLR.
Allograft ACL grafts may need to be protected longer. If
ACI and ACLR are performed simultaneously, the more
restrictive ACI protocol needs to be adopted. This should
not adversely affect the ACLR results. In general it is not
advisable to perform ACI before ACLR because a stable
knee is considered necessary for successful ACI. Also, this
type of sequencing would require three procedures because
the ACB needs to precede the ACI. However, in cases
when the ACB has been performed prior to the ACLR,
the ACI and ACLR may then be carried out simultaneously
at a subsequent procedure. Good results have been reported
after the combined procedures.8 Young patients with acute
lesions, such as the 17-year-old girl shown in Fig. 63-1,
are ideal candidates. Older patients with acute lesions
can also obtain excellent results with ACLR and ACI, such FIG. 63-2 53-year-old woman with acute anterior cruciate ligament (ACL)
as was the case with a 53-year-old woman who tore her tear and large medial femoral condyle (MFC) lesion in an otherwise healthy
knee.
ACL while snow skiing (Fig. 63-2). When the ACL tear
is somewhat chronic even in a young patient, such as the performing MAT simultaneously with ACLR because there
27-year-old woman with a failed ACLR performed at is a propensity in some knees for stiffness after MAT. Crowd-
age 20 (Fig. 63-3), early degenerative changes can make ing also occurs between the tibial tunnel for the ACLR and
treatment more difficult. the trough for lateral MAT as well as the bone tunnel(s) for
medial MAT. However, if these are the only two procedures
necessary and if the surgeon has sufficient experience with
ANTERIOR CRUCIATE LIGAMENT both procedures, then it is possible to perform them simul-
RECONSTRUCTION AND MENISCAL ALLOGRAFT taneously to save the patient the discomfort of a second
IMPLANTATION procedure. The rehabilitation protocols are compatible, and
avoidance of stiffness needs to be prioritized by using appro-
Meniscal allograft implantation (MAT) has been associated priately aggressive rehabilitation. If the ACLR is performed
with generally high success rates.9–11 There is some risk in first, we prefer to wait 4 to 6 months before performing the

495
 Anterior Cruciate Ligament Reconstruction
FIG. 63-3 This 27-year-old woman, with a failed anterior cruciate ligament
(ACL) reconstruction performed at age 20, already has significant
degenerative articular cartilage disease.
MAT to allow the graft to mature as described in the section
on ACLR and ACI. In theory, MAT should not performed
before ACLR because a stable knee is a prerequisite for the
performance of MAT. However, MAT followed within a
few months by ACLR should not subject the graft to undue
stress because the patient will not be vigorously active during
this period. Indeed, if the procedures are staged it may be
technically easier to perform the ACLR second because the
MAT will be more easily performed in the knee with greater
laxity before the ACLR.12–17 The patient whose radiographs
are shown in Fig. 63-4 had severe pain and was unable to
perform his job as a federal law enforcement agent at 38
years of age, 16 years after ACL tear and meniscectomy.
He underwent high-tibial osteotomy (HTO) with substantial
improvement. ACLR was then performed with further
improvement but with residual medial pain still persisting.
MAT was then performed, leading to almost complete
resolution of symptoms 1 year after surgery. These procedures
allowed him to resume his career, including his 1-mile-run
test, without pain.
ANTERIOR CRUCIATE LIGAMENT
RECONSTRUCTION AND OSTEOCHONDRAL
ALLOGRAFT OR OSTEOCHONDRAL AUTOGRAFT
TRANSFER SYSTEM
Osteochondral autograft transfer system (OATS)18 and
osteochondral allograft (OCAI)19 are widely used proce-
dures. Either can be performed simultaneously with ACLR
if the surgeon has sufficient experience. They can also be
performed sequentially before or after ACLR. The literature
has shown good results.20,21
496
ANTERIOR CRUCIATE LIGAMENT
RECONSTRUCTION AND HIGH-TIBIAL
OSTEOTOMY
HTO has shown good results over many decades of use.22,23
Numerous newer reports show good results after combined
ACLR and HTO,24–28 although the complication rate can
be significant.29 This combination also entails a potentially
greater risk of stiffness relative to the other combined proce-
dures. The reason is that all osteotomies, regardless of the
surgical technique used, are somewhat unstable in the first
few months postoperatively. Thus if the ACLR/HTO sur-
gery does result in significant stiffness, it is harder to treat
because aggressive mobilization of the knee cannot be per-
formed in the first few months post-HTO due to the risk
of displacing the osteotomy, even if rigid internal fixation
is used. This is also somewhat dependent on the HTO
technique used. Techniques performed above the tibial
tubercle involve the periarticular structures. These HTO
procedures add their own propensity to stiffness to that of
the ACLR. Procedures performed below the tibial tubercle
should involve less such risk. The surgeon must therefore
assess the risks attendant to both the ACLR and HTO
procedures as best as possible and decide whether there is
excessive risk in performing both procedures simultaneously.
We perform a bone transport osteotomy below the tubercle
using an external fixator and no hardware, which has little
risk of stiffness. Our hamstring ACLR procedure has also
had excellent ROM results.30 However, some ACLRs have
required aggressive rehabilitation to regain full extension.
Even though the number is small, it is difficult to predict
with which knees this will occur. HTO patients often have
some degree of medial arthrosis. These knees are also
somewhat predisposed to stiffness.
Therefore, where possible, we prefer to perform the
ACLR first, establish full ROM, and then perform the
HTO on a staged basis as soon as full motion is obtained.
If this staged schedule is too difficult for the patient, the
HTO can be performed simultaneously with a full discus-
sion of potential stiffness risk. Although the senior author
has not had a permanent motion problem with the com-
bined procedures, he nonetheless considers the staged pro-
cedure to be safer in these complicated knees.
We have found HTO to be an extremely reliable pro-
cedure for unicompartmental varus and have found the
results of the combined procedure (simultaneously or
staged) to be excellent. Initially we worried that ACLR in
the presence of medial arthrosis might aggravate the arthro-
sis. However, we have never seen this occur and instead
have found the ACLR to consistently result in clinical
improvement in the symptoms of even moderate arthritis.
 Anterior Cruciate Ligament Reconstruction Combined with High-Tibial Osteotomy 63

FIG. 63-4 A and B, This 38-year-old federal law enforcement agent had chronic pain and was limited to primarily
sedentary work after anterior cruciate ligament (ACL) tear and medial meniscectomy 16 years earlier. He had
high-tibial osteotomy (HTO) and ACL reconstruction with marked improvement but still had limiting medial pain.
He then underwent meniscal allograft implantation (MAT). One year later, he was pain free and able to perform his
1-mile run without pain.

497
 Anterior Cruciate Ligament Reconstruction
We will perform ACLR/HTO in the presence of a moder-
ate diminution in the medial joint space in a young patient.
We will not, however, perform ACLR with HTO if bony
deformity, subluxation, or severe loss of joint space is
present. If all else is equal, greater aggressiveness is more
justified in younger patients to avoid progression to joint
replacement arthroplasty.
HTO is performed far less often in the United States
than in Europe, apparently due to reasons of patient accep-
tance. However, with proper discussion patients are usually
quite willing to undergo HTO. With the external fixator
technique, patient acceptance is increased by the fact that
alignment is precisely controlled on an outpatient basis, pre-
cluding excessive unattractive valgus. The use of only a small
incision without retained hardware is also appealing. The
presence of protruding pins is distasteful to some patients,
but this is mitigated by the fact that the pins are only temporary.
Other methods have their own advantages and disadvantages.
FIG. 63-5 Anterior cruciate ligament reconstruction with high-tibial osteotomy (ACLR/HTO). A, Preoperative view.
B, Postoperative view.
498
We perform HTO when mechanical axis radiographs
(on standing hip-knee-ankle films) show four degrees or
more of varus. It is important to point out that medial com-
partment cartilage restoration procedures generally have
been shown to have a higher failure rate if HTO is not per-
formed in the presence of significant varus. Thus although
HTO is a procedure that many orthopaedic surgeons may
not feel comfortable performing, it is important to perform
where indicated.
HTO procedures are not without complications, and
these patients must be operated on carefully and followed
closely. Most, however, have a smooth course. Fig. 63-5
shows a patient 8 months after simultaneous ACLR and
HTO. The osteotomy is well healed. The tibial fixation
screw for the ACL graft can be seen proximal to the osteot-
omy. The medial joint space on these standing views shows
increased cartilage space in the postoperative radiograph
compared with preoperatively.
 Anterior Cruciate Ligament Reconstruction Combined with High-Tibial Osteotomy
MULTIPLE CARTILAGE RESTORATIVE
PROCEDURES
Some patients require multiple procedures in addition to
ACLR. The surgeon should separately consider the following
five components of knee health: (1) articular cartilage, (2)
menisci, (3) limb alignment, (4) bone deficiency, and (5)
ACL deficiency. Thus a patient may need, for example,
HTO for varus, MAT for symptomatic meniscal deficiency,
ACI or MF for articular cartilage deficiency, and possibly
a bone graft for osteochondritis desiccans. Staging becomes
even more complicated in these cases. In general it is advisable
to avoid combining more than two major procedures at once
to avoid the risks of stiffness and infection. We have not had
a deep infection in these combined cases, and an increased
infection rate is not reflected in the literature.
CARTILAGE PRESERVATION VERSUS
ARTHROPLASTY
Cartilage preservation is perhaps the most important reason
to perform ACLR. In those cases in which articular cartilage
damage has also occurred and the patient is symptomatic,
restorative procedures may be necessary. If the surgeon
performing the ACLR is not comfortable with these proce-
dures, the patient may be referred to a surgeon either initially
or after ACL reconstruction is completed. The references
cited in this chapter indicate that success rates are high. Treat-
ment of their pathology would seem to be preferable to advis-
ing patients that they should wait for further degeneration and
have a joint replacement arthroplasty, as patients young
enough to be ACLR candidates are generally too young to
be good candidates for joint replacement. We wish to empha-
size that, with some exceptions, only symptomatic patients
should be treated. Asymptomatic varus is generally not a
reason to perform HTO, nor is asymptomatic meniscal
deficiency a reason to perform MAT. The exception to
this rule may be articular cartilage deficiency in a younger
patient. Even asymptomatic, full-thickness lesions in this
population probably warrant treatment to prevent propaga-
tion. The sooner the patient’s cartilage deficiencies are
treated, the better his or her outcome is likely to be.
CONCLUSIONS
1 HTO, MF, ACI, MAT, OATS, and OCAI have
demonstrated good results in the literature in conjunction
with ACLR. Whether to perform them simultaneously or
sequentially is dependent on the characteristics of each case.
63
2 Restoration of satisfactory motion is of primary
importance.
3 Correction of significant varus with HTO is advisable so
that other medial cartilage restoration procedures will
enjoy an optimal success rate.
4 Patients young enough to be ACLR candidates are
generally too young to be good candidates for joint
replacement arthroplasty, and correction of their
pathology is preferable.
5 These cases are complicated and require extra time and
care.
References
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full-thickness chondral injuries. Oper Tech Sports Med 2000;8:138–140.
2. Gobbi A, Nunag P, Malinowski K. Treatment of full thickness chon-
dral lesions of the knee with microfracture in a group of athletes. Knee
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3. Miller BS, Steadman JR, Briggs KK, et al. Patient satisfaction and
outcome after microfracture of the degenerative knee. J Knee Surg
2004;17:13–17.
4. Hantes ME, Mastrokalos DS, Yu J, et al. The effect of early motion
on tibial tunnel widening after anterior cruciate ligament replacement
using hamstring tendon grafts. Arthroscopy 2004;20:572–580.
5. Bentley G, Biant LC, Carrington WJ, et al. A prospective, rando-
mised comparison of autologous chondrocyte implantation versus
mosaicplasty for osteochondral defects in the knee. J Bone Joint Surg
2003;85:223–230.
6. Minas T, Chiu R. Autologous chondrocyte implantation. Am J Knee
Surg 2000;13:41–50.
7. Peterson L, Minas T, Brittberg M, et al. Two- to 9-year outcome
after autologous chondrocyte transplantation of the knee. Clin Orthop
Relat Res 2000;374:212–234.
8. Amin AA, Bartlett W, Gooding CR, et al. The use of autologous
chondrocyte implantation following and combined with anterior cruci-
ate ligament reconstruction. Int Orthop 2006;30:48–53.
9. Fukushima K, Adachi N, Lee JY, Moore GG. Meniscus allograft
transplantation using posterior peripheral suture technique: a prelimi-
nary follow-up study. J Orthop Sci 2004;9:235–241.
10. Ryu RKN, Dunbar WH, et al. Meniscal allograft replacement: a
1-year to 6-year experience. Arthroscopy 2002;18:989–994.
11. Sekiya JK, Giffin JR, Irrgang JJ, et al. Clinical outcomes after com-
bined meniscal allograft transplantation and anterior cruciate ligament
reconstruction. Am J Sports Med 2003;31:896–906.
12. Graf KW Jr, Sekiya JK, Wojtys EM. Long-term results after com-
bined medial meniscal allograft transplantation and anterior cruciate
ligament reconstruction: minimum 8.5-year follow-up study. Arthros-
copy 2004;20:129–140.
13. Sekiya JK, Giffin JR, Irrgang JJ, et al. Clinical outcomes after com-
bined meniscal allograft transplantation and anterior cruciate ligament
reconstruction. Am J Sports Med 2003;31:896–906.
14. Yoldas EA, Sekiya JK, Irrgang JJ, et al. Arthroscopically assisted
meniscal allograft transplantation with and without combined anterior
cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc
2003;11:173–182.
15. Wirth CJ, Peters G, Milachowski KA, et al. Long-term results of
meniscal allograft transplantation. Am J Sports Med 2002;30:174–181.
16. Rath E, Richmond JC, Yassir W, et al. Meniscal allograft transplanta-
tion. Two- to eight-year results. Am J Sports Med 2001;29:410–414.
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17. Cameron JC, Saha S. Meniscal allograft transplantation for unicom-
partmental arthritis of the knee. Clin Orthop Relat Res
1997;337:164–171.
18. Gudas R, Stankevicius E, Monastyreckiene E, et al. Osteochondral
autologous transplantation versus microfracture for the treatment of
articular cartilage defects in the knee joint in athletes. Knee Surg Sports
Traumatol Arthrosc 2006;14:834–842.
19. Aubin PP, Cheak HK, Davis AM, et al. Long-term followup of fresh
femoral osteochondral allografts for posttraumatic knee defects. Clin
Orthop Relat Res 2001;391S:S318–S327.
20. Klinger HM, Baums MH, Otte S, et al. Anterior cruciate reconstruc-
tion combined with autologous osteochondral transplantation. Knee
Surg Sports Traumatol Arthrosc 2003;11:366–371.
21. Bobic V. Arthroscopic osteochondral autograft transplantation in
anterior cruciate ligament reconstruction: a preliminary clinical study.
Knee Surg Sports Traumatol Arthrosc 1996;3:262–264.
22. Koshino T, Wada S, Ara Y, Saito T. Regeneration of degenerated
articular cartilage after high tibial valgus osteotomy for medial com-
partmental osteoarthritis of the knee. Knee 2003;10:229–236.
23. Sprenger TR, Doerzbacher JF. Tibial osteotomy for the treatment of
varus gonarthrosis. J Bone Joint Surg 2003;85A:469–474.
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24. Williams RJ III, Kelly BT, Wickiewicz TL, et al. The short-term out-
come of surgical treatment for painful varus arthritis in association
with chronic ACL deficiency. J Knee Surg 2003;16:9–16.
25. Noyes FR, Barber-Westin SD, Hewett TE. High tibial osteotomy
and ligament reconstruction for varus angulated anterior cruciate liga-
ment-deficient knees. Am J Sports Med 2000;28:282–296.
26. Stutz G, Boss A, Gachter A. Comparison of augmented and non-
augmented anterior cruciate ligament reconstruction combined with high
tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 1996;4:143–148.
27. Neuschwander DC, Drez D Jr, Paine RM. Simultaneous high tibial
osteotomy and ACL reconstruction for combined genu varum and
symptomatic ACL tear. Orthopedics 1993;16:679–684.
28. Noyes FR, Barber SD, Simon R. High tibial osteotomy and ligament
reconstruction in varus angulated, anterior cruciate ligament-deficient knees.
A two- to seven-year follow-up study. Am J Sports Med 1993;21:2–12.
29. Lattermann C, Jakob RP. High tibial osteotomy alone or combined
with ligament reconstruction in anterior cruciate ligament-deficient
knees. Knee Surg Sports Traumatol Arthrosc 1996;4:32–38.
30. Prodromos CC, Han YS, Keller BL, et al. Stability of hamstring ante-
rior cruciate ligament reconstruction at two- to eight-year follow-up.
Arthroscopy 2005;21:138–146.
 PART O REHABILITATION
Anterior Cruciate Ligament Strain Behavior
During Rehabilitation Exercises
This chapter describes the devices, methods, and
approaches used to measure anterior cruciate
ligament (ACL) strain in vivo and provides
insight into the strain behavior of the normal
ACL during various rehabilitation activities.
The effectiveness of functional knee bracing on
the ACL and the strain behavior of the bone–
patellar tendon–bone (BPTB) graft after the
reconstruction of the ACL are also reviewed.
DESCRIPTION OF THE DEVICES,
METHODS, AND APPROACHES USED
TO MEASURE ANTERIOR CRUCIATE
LIGAMENT BIOMECHANICS IN VIVO
Henning et al1 were the first researchers to
measure the elongation behavior of the ACL
in vivo. A hooked pin was attached to the par-
tially disrupted ACL in two patients, and the
peak displacement of the pin was measured dur-
ing different rehabilitation activities. Absolute
strain values were not reported. The displace-
ment measurements for various activities were
compared with that produced by a 350N,
anteriorly directed shear load applied to the tibia
during the Lachman test. Although this method
has several obvious limitations, it was one of the
first studies that measured the ACL in vivo.
Subsequent to this work, ACL strain
measurements have been performed in vivo using
both the Hall Effect Strain Transducer (HEST,
MicroStrain, Williston, VT) and the Differential
Variable Reluctance Transducer (DVRT,
64CHAPTER
MicroStrain, Williston, VT) (Fig. 64-1). Both Petteri Kousa
displacement transducers are small (4–5 mm in
James R. Slauterbeck
length), are highly compliant, have a similar
barbed attachment technique, can be sterilized, Bruce D. Beynnon
and can be implanted arthroscopically to the
anteromedial aspect of the ACL in vivo.2,3
Although the devices have many similarities, the
sensing technology is different, and the DVRT
is now more frequently used than the HEST,
mainly due to its improved accuracy, better
precision, and lower profile.3
The HEST is composed of an inner tube
that slides with an outer tube. At the end of
each tube are barbs that attach the sensor to
the ligament. The inner tube houses a magnet,
and the outer tube has a Hall effect magnetic
sensor. As the length of the ligament changes,
the magnet moves relative to the Hall effect
sensor, and this produces the relative change in
length between the two barbs. In comparison,
the DVRT detects the movement of the two
barbs attached to the ligament by measuring
the differential change in reluctance produced
by the position change of a magnetically perme-
able core within two small coil windings that are
excited with an alternating current (AC) signal.2
The DVRT is currently the displacement
transducer of choice.2,3 The monotonic sensing
range of a 5-mm DVRT is 1.75 mm, creating
a linear sensing range of 35%. The displacement
sensitivity is typically 2 V/mm, and the signal:
noise ratio is 1000:1. The DVRT has 3.5 mm
of nonlinearity, 1 mm of hysteresis, 1 mm nonre-
peatability, 0.1 mm/ C temperature error coeffi-
cient, and 7 mm root mean square (RMS) error
501
 Anterior Cruciate Ligament Reconstruction
Posterior
cruciate
ligament
Anterior
cruciate
ligament
DVRT
Removal
sutures
To data
acquisition
FIG. 64-1 A schematic drawing showing the differential variable
reluctance transducer (DVRT) applied to the anteromedial portion of the
anterior cruciate ligament (ACL).
(or 0.1% strain). The DVRT is calibrated with a specially
designed micrometer system (AutoCal, MicroStrain, Bur-
lington, VT).2,3
The displacement transducer is implanted into the
knee joint through a lateral parapatellar arthroscopic portal
(incision) of the joint capsule with the knee at approximately
90 degrees of flexion. The sensing axis of the device is
aligned with the anteromedial fibers of the ACL. The two
fixation barbs of the device are then pressed into the liga-
ment. Repeated anteroposterior shear loading tests (Lach-
man) are performed at the beginning and end of a
protocol to determine the reference for strain calculation
and to serve as a “repeated normal” test to ensure that the
transducer measurements are reproducible.2,3
For calculations of ACL strain, it is important to
determine a reference length (the length of the transducer
when the ACL becomes taut in response to palpation).4
When a posteriorly directed shear load is applied to the tibia
with the knee at 30 degrees of flexion, the ACL becomes
unstrained and is unloaded in response to palpation. When
an anteriorly directed shear load is applied to the tibia, the
ACL becomes taut.2–4 This slack–taut transition is identi-
fied from the applied anteroposterior loading versus DVRT
output plot as the inflection point.4 For the anteromedial
502
portion of the ACL, this slack–taut transition point can
estimate the absolute reference within 0.7% strain.4 The
wire connections for data acquisition and transducer
removal are allowed to course through the lateral portal,
and the function of the sensor through the desired range
of motion is checked prior to closing the arthroscopic por-
tals and applying sterile dressing such as Tegaderm.3
The DVRT has many advantageous characteristics for
measuring ACL strain in vivo. It is relatively small (approx-
imately 5 mm), is lightweight, and can be attached to the
ACL arthroscopically. Ligaments have a strain distribution
about their length and cross-section, and the DVRT allows
accurate, reliable, and repeatable strain measurements of
specific regions of a ligament. In addition, the calibration
remains stable in environments that range between room
temperature and body temperature, making it very practical.
Over the years, the DVRT has been shown to be biotoler-
able and safe, without any adverse long-term reactions.2,3
The limitations of the DVRT must be appreciated.
First, although the DVRT is small, the anatomy of the fem-
oral intercondylar notch, combined with the constraints
produced by the arthroscopic portals, constrains placement
of the sensor to the anteromedial portion of the ACL in
humans.2,3 Although the current ACL reconstruction tech-
niques aim to reproduce the function of the anteromedial
bundle, recent reports suggest that it may be important to
replicate the function of both bundles of the ACL to better
restore rotational and anteroposterior limits of motion of the
knee.5,6 Second, impingement of the device against the roof
of the femoral intercondylar notch does not allow measure-
ment of ACL strain when the knee is in extension or hyper-
extension. Therefore it is difficult to study activities such as
gait and landing from a jump.
An in vitro technique measuring both strain and
resultant force in the entire ACL was developed by Markolf
et al7 and is useful in interpreting the DVRT data. The
technique involves mechanically isolating the bone insertion
of the ACL and attaching a load cell to the bone–ligament
complex. Throughout the procedure the anatomical origin
and insertion are maintained in space.7 Loads and torques
can be applied to the knee, and forces, stresses, and strains
can be directly measured.8–12 Markolf et al13,14 tested the
DVRT and the ACL mechanical isolation technique in
the same experiment, creating calibration curves to estimate
resultant forces in the ACL from strain measurements made
in vivo. In so doing, all the data from the prior DVRT mea-
surements can be related to resultant force measurements for
common activities when the forces and moments produced
across the knee in vivo are replicated in vitro.2,3,15–17
Recently, noninvasive imaging techniques have been
introduced for measuring the in vivo kinematics of the tibia
relative to the femur, and these data have been used to

estimate ACL biomechanics.5,18,19 Sheehan and Rebmann19
used a cine–phase contrast magnetic resonance imaging
(MRI) technique to evaluate the orientation of the attach-
ment sites of the ACL during non–weight-bearing flexion,
whereas Li et al5,18 used a combined imaging and three-
dimensional (3D) computer-modeling technique to evaluate
the orientation of the attachment sites of the ACL during
weight-bearing flexion of the knee (one-legged lunge).
Although these new, MRI-based, noninvasive techniques
have apparent limitations, they have opened a new era for
measuring the in vivo kinematics of the knee.
For the cine–phase contrast MRI technique, the cine
MRI produced the anatomical images during periodic
motion, and phase contrast MRI measured the 3D velocities
in the imaging plane.19 The ACL strain was calculated by
combining the velocity and anatomical data obtained from
the cine–phase contrast MR images. The insertions of the
ACL were identified, and the lengths of the anterior and
posterior regions of the ACL were calculated for a selection
of different knee flexion angles. When compared with DVRT
measurements, the cine–phase contrast MRI method
revealed a similar strain pattern of the anterior region of the
ACL during active extension of the knee. However, for
the cine–phase contrast MRI method, the strain values
were more than three times greater, approaching the failure
strains of the ACL, and thus this approach may over-
estimate the ACL strain values.19
For the technique that combined imaging and 3D
computer modeling, MR images were first taken of human
subjects to construct a 3D model for each knee.5,18 After
modeling, each subject performed a lunge, and two orthog-
onal fluoroscopic images were taken at four selected flexion
angles to re-create the in vivo knee positions. These orthog-
onal images and the 3D knee model were then manually
matched to reproduce the kinematics of the knee. The tibial
and femoral insertion sites were identified to investigate the
ACL attachment site’s biomechanics. The position of knee
at full extension was used as reference. During the one-
legged lunge, Li et al18 demonstrated that the anteromedial
bundle of the ACL decreased in length by 7% when the
knee moved from extension to flexion. These results are in
agreement with those measured with the DVRT.
REVIEW OF STUDIES THAT HAVE
CHARACTERIZED ANTERIOR CRUCIATE LIGAMENT
STRAIN BEHAVIOR DURING REHABILITATION
EXERCISES
In vivo ACL strain measurements of patient volunteers with
normal ACLs have been carried out to describe the strain
Anterior Cruciate Ligament Strain Behavior During Rehabilitation Exercises 64
behavior of the ACL during commonly prescribed rehabili-
tation exercises and have been used to establish clinical cri-
teria for ACL reconstruction. These studies also serve as a
basis for development of rehabilitation programs that do
not jeopardize the survival of the ACL graft but still allow
exercises for optimal recovery of muscle strength and range
of motion following ACL reconstruction. Rank comparison
of peak ACL strain values produced during common reha-
bilitation activities are summarized in Table 64-1.
Most of the strain transducer measurements have
been performed under local (intraarticular) anesthesia,
allowing the patients to have full control of their muscles.
Typically the study participants have been candidates for
arthroscopic partial meniscectomy or diagnostic arthroscopy
without known ligament trauma. Preoperatively the patients
have had normal gait, range of motion, and normal ligament
function as documented by clinical examination and arthro-
scopic visualization.2,3
The ACL strain measurements have revealed that
during passive flexion–extension motion of the lower leg
with the thigh held in a horizontal position, the ACL is
unstrained between 110 and 11.5 degrees of flexion and
becomes strained as the knee is moved into terminal exten-
sion.20 Although the impingement of the strain transducer
against the roof of the femoral intercondylar notch has not
allowed measurements of the ACL strain during hyperex-
tension of the knee in all patients, these findings indicate
that the ACL strain continues to increase with increasing
extension of the knee and is greatest when the knee is in
hyperextension. To support this, in vitro studies have
demonstrated that ACL strain and force increase as the
knee is passively moved from a flexed position to an
extended (0 degrees) position and then to a hyperextended
position.9–11,21,22
The following general conclusions can be made
regarding the effect of externally applied loads on ACL
strain values: The ACL is a primary restraint to anterior dis-
placement of the tibia relative to the femur when the knee is
near extension, and it also restrains internal (but not exter-
nal) axial rotation of the tibia.2,3,17 Although cadaver studies
have revealed that the ACL serves as an important second-
ary restraint to applied varus-valgus moments, in vivo mea-
surements have revealed that ACL strain values are not
increased when varus and valgus moments are applied to
the knee at 20 degrees of flexion.3,17 In addition, in vivo
measurements have shown different ACL strain values dur-
ing non–weight-bearing versus weight-bearing conditions.
For example, transitioning from non–weight-bearing to
weight-bearing conditions increases ACL strain values
when varus-valgus moments and external torque are applied
to the knee.17 In addition, when anteriorly directed shear
loads are applied to the tibia, the strain values are higher
503
 Anterior Cruciate Ligament Reconstruction

TABLE 64-1 Rank Comparison of Average Peak Anterior Cruciate Ligament Strain Values Measured During Various Rehabilitation Activities
Rehabilitation Activity Resistance Peak Strain

Isometric quadriceps contraction at 15 degrees 30 Nm of extension torque 4.4%

Squatting Sport Cord 4.0%

Active flexion–extension 45N weight boot 3.8%

Lachman test 150N anterior shear load 3.7%

Squatting 3.6%

Gastrocnemius contraction at 15 degrees of knee flexion 15 Nm of ankle torque 3.5%

Active extension of the knee 12 Nm of extension torque 3.0%

One-legged sit to stand 2.8%

Active extension Leg weight only 2.8%

Combined isometric quadriceps and hamstring contraction at 15 degrees 2.8%

Gastrocnemius contraction at 5 degrees of knee flexion 15 Nm of ankle torque 2.8%

Stair climbing 2.7%

Isometric quadriceps contraction at 30 degrees 30 Nm of extension torque 2.7%

Step-down (during extension phase of the exercise cycle) 2.6%

Step-up 2.5%

Lunge (during extension phase of the exercise cycle) 2.0%

Anterior drawer 150N anterior shear load 1.8%

Stationary bicycling 1.7%

Active flexion of the knee 12 Nm of flexion torque 1.5%

Isometric hamstring contraction at 15 degrees 10 Nm of flexion torque 0.6%

Combined isometric quadriceps and hamstring contraction at 30 degrees 0.4%

Passive flexion–extension 0.1%

Gastrocnemius contraction at 30 and 45 degrees of knee flexion 15 Nm of ankle torque 0%

Isometric quadriceps contraction at 60 degrees 30 Nm of extension torque 0%

Isometric quadriceps contraction at 90 degrees 30 Nm of extension torque 0%

Combined isometric quadriceps and hamstring contraction at 60 degrees 0%

Combined isometric quadriceps and hamstring contraction at 90 degrees 0%

Isometric hamstring contraction at 30, 60, and 90 degrees 0%

during weight-bearing conditions in comparison with non–
weight-bearing conditions.17
When compared with the fully relaxed condition,
extension torque produced by isometric quadriceps muscle
contraction has been shown to strain the ACL near exten-
sion of the knee, but not beyond 60 degrees of flexion.15
Isometric hamstring contraction, on the other hand, has
not been shown to produce ACL strain at any knee flexion
angles.15 When compared with the relaxed condition, com-
bined contraction of quadriceps and hamstring muscles has
been shown to produce a significant increase in strain at
15 degrees of knee flexion, but not at 30, 60, or 90 degrees
of knee flexion.15 Isometric gastrocnemius muscle contrac-
tion has been shown to strain the ACL when the knee is
near extension (at 5 and 15 degrees of flexion), and when
gastrocnemius muscle contraction was combined with

504

quadriceps or hamstring muscle contraction, the strain was
increased in comparison with isolated contractions of these
muscles.23
It has been common practice to consider rehabilita-
tion programs as comprising open and closed kinetic chain
exercises. Closed kinetic chain exercises, such as squats, are
performed with the foot fixed against resistance, whereas
during an open kinetic chain exercise, such as knee exten-
sion, the foot is not constrained by a platform and is
unloaded. Compressive loading of the tibiofemoral joint
produced during closed kinetic chain exercise has been
thought to protect the injured ACL or healing ACL graft
because of the increased joint stiffness and decreased ante-
rior displacement of the tibia relative to the femur. In addi-
tion, co-contraction of the hamstring muscles during closed
kinetic chain exercises has been considered to protect the
injured knee from excessive ACL strains.
Active extension–flexion motion of the knee (an open
kinetic chain exercise) between the limits of 10 and 90
degrees produces peak ACL strains near extension, and
these values gradually decrease with increasing knee flex-
ion.15 Beyond 35 degrees of knee flexion, the ACL becomes
unstrained.15 Application of weight during this exercise
(applied to increase extension torque about the knee) pro-
duces significant increases of ACL strain values at 10 and
20 degrees of flexion and shifts the strained–unstrained
transition to 45 degrees of knee flexion. A subsequent fol-
low-up study confirmed that the peak ACL strain values
increased when knee extension torque increased.16 It was
also shown that application of compressive loading, such
as that produced by body weight, did not reduce peak
ACL strains during extension exercises.16 Application of
flexion torque during flexor exercise produced significant
decreases of ACL strain values; however, when compressive
loading was added, such a decrease was not observed.16
Stair climbing is a closed kinetic chain exercise, and
because step-up exercise has been shown to reduce anterior
translation of the tibia with respect to the femur, it is com-
monly considered safe for rehabilitation following ACL
reconstruction.24 In vivo measurements during stationary
stair-climbing exercises have demonstrated that ACL strain
is increased when the knee moves from a flexed to an extended
position, and the average strain values were moderate when
compared with other commonly prescribed rehabilitation
activities tested with the same technique.25 However, the
strain values were highly variable, with peak values ranging
as much as 7%. These strain magnitudes may produce detri-
mental effects to the healing graft, and therefore caution
should be exercised when making any recommendations for
stationary stair climbing following ACL reconstruction.
Most clinicians have considered bicycling to be a rela-
tively safe rehabilitation exercise with many therapeutic
Anterior Cruciate Ligament Strain Behavior During Rehabilitation Exercises 64
qualities, and therefore it is commonly recommended for
rehabilitation following ACL injury or reconstruction. In vivo
ACL strain measurements during stationary bicycling also
support this observation.26 In an in vivo study, stationary
biking was performed at six different riding conditions (three
power levels and two cadences).26 Power levels 75 Watts (W),
125W, and 175W simulated downhill, level, and uphill riding
conditions, respectively. The results revealed that with this
selection of power and cadence levels, stationary bicycling
produces relatively low peak strain values (mean 1.7%) when
compared with other rehabilitation activities commonly
prescribed after ACL injury or reconstruction, and thus
stationary bicycling can be considered safe for rehabilitation
after ACL reconstruction without excessively straining the
graft. However, the safety and efficacy of bicycling, or of any
rehabilitation exercise for that matter, following ACL
reconstruction can only be determined via clinical studies.
Closed kinetic chain squatting exercises are commonly
prescribed to improve muscle strength after ACL reconstruc-
tion. Because of the compressive joint load and co-contraction
of muscles spanning the knee, advocates of closed kinetic
chain exercise consider it safer than active flexion–extension
exercises. It has been demonstrated that squatting and active
flexion–extension exercises produce similar strain patterns
(strain is greatest near full extension and gradually decreases
toward flexion) and maximum strain values, indicating that
compressive joint force does not necessarily protect a healing
ACL graft.27 It has to be emphasized, however, that in con-
trast to active extension of the knee, the increasing resistance
during squatting to the limit of 134N did not significantly
increase ACL strain values.27
Recently Heijne et al28 measured the strain behavior
of the ACL during four different closed kinetic chain exer-
cises: (1) step-up, (2) step-down, (3) lunge, and (4) one-leg-
ged sit to stand. They found that the strain produced during
these four exercises was not significantly different at all knee
positions (knee flexion angles of 30, 50, and 70). The largest
strain values were measured when the knee was near exten-
sion (at 30 degrees of knee flexion), and the strain values
decreased significantly as the knee was flexed.
The importance of rehabilitation following ACL
reconstruction is greatly appreciated; however, there is little
consensus regarding how different restrictions and exercises
should be administered and how they influence the long-term
outcome and healing response of the graft and knee. The
previously mentioned studies characterizing the behavior of
the ACL during different activities have been used to design
accelerated and nonaccelerated rehabilitation programs that
gradually increase the strain experienced in the graft. The
accelerated program (19 weeks) produces high graft strain
early after the reconstruction by allowing immediate full
range of motion, weight bearing as tolerated, quadriceps
505
 Anterior Cruciate Ligament Reconstruction
activity with the knee near extension, and return to unre-
stricted activity within 6 months of reconstruction, whereas
in the nonaccelerated program (32 weeks) these same
activities are prescribed over a delayed time interval and the
graft is therefore not strained as vigorously. The effects of
these programs have been subsequently studied via a pro-
spective, randomized, double-blinded clinical trial.29 At
2-year follow-up, both rehabilitation programs produced
the same increase of anterior knee laxity and the same effect
with regard to clinical assessment, patient satisfaction,
functional performance, and the biomarkers of articular
cartilage metabolism.29
REVIEW OF STUDIES THAT HAVE MEASURED THE
STRAIN OF THE BONE–PATELLAR TENDON–
BONE GRAFT
Proper graft placement directly affects knee biomechanics
and has been considered one of the most critical surgical
variables in determining a successful long-term clinical out-
come. In an attempt to place the graft optimally during ACL
reconstruction, “isometers” were introduced to help with
placement of ACL graft tunnels. In vivo strain measurements
of the BPTB graft at the time of reconstruction have, however,
shown that local graft elongation did not correlate with the
isometric measurements of displacement made prior to pre-
paring the graft tunnels.30 Consequently, isometers are not
currently in routine use in ACL reconstructions.
Immediately following fixation of a BPTB graft, cycli-
cal passive extension of the knee between the limits of full
extension and 90 degrees of flexion produces a complex
seating response of the graft. Unlike the normal ACL, the
graft demonstrated a seating behavior by decreasing in
length in some patients but increasing in others. Early slip-
page of the graft bone blocks past the interference screw
explains the decrease in length, whereas a creep response
of the improperly positioned or overtensioned graft explains
the increase in length. Both of these phenomena were found
to be associated with increased anteroposterior displacement
of the knee during healing.31
The relationship between BPTB graft elongation
behavior at the time of surgery and the changes in antero-
posterior knee laxity at long-term follow-up have also been
evaluated.32 Subjects from the previously mentioned study31
were divided into two groups based on elongation biome-
chanics of the graft measured after graft fixation. Although
both groups had similar anteroposterior knee laxity values at
the time of ACL reconstruction, those patients with graft
elongation values that were significantly greater than the nor-
mal ACL at the time of surgery (outside the 95% confidence
interval of the normal ACL) demonstrated a significant
506
increase in anteroposterior knee laxity at the 5-year follow-
up, whereas those with elongation values similar to the
normal ACL (within the 95% confidence interval of the nor-
mal ACL) did not.32 These results suggest that (1) the
elongation behavior of the BPTB graft during flexion–
extension cycles at the time of surgery may provide impor-
tant information for long-term success of the knee and (2)
anteroposterior laxity measurements at the time of surgery
may not adequately predict changes of anteroposterior laxity
of the knee during healing and long-term follow-up.
REVIEW OF STUDIES INVESTIGATING HOW
FUNCTIONAL KNEE BRACING AFFECTS ANTERIOR
CRUCIATE LIGAMENT STRAIN BEHAVIOR
Functional knee braces are designed to protect an injured
ACL or ACL graft and to prevent further intraarticular dam-
age by reducing anterior translation of the tibia with respect to
the femur. Although these braces are commonly prescribed,
their effectiveness is controversial and not well documented
on human subjects. Several investigations of functional knee
braces have been performed using arthrometers or roentgen
stereophotogrammetric analysis to measure the displacement
of the tibia relative to the femur.33–35 Common limitations of
these studies are that the combined effects of compressive
load and muscle loading during weight-bearing activities were
not included. In vivo strain measurements of the normal ACL
have also been performed during various loading conditions
to evaluate the efficacy of functional knee braces.36–38 The
results reveal that when the subject is non–weight bearing
and weight bearing, bracing the knee reduces ACL strains
produced in response to anteriorly directed shear loads.36–38
Additionally, in response to applied internal–external torques
with the knee non–weight bearing, the ACL of the braced
knee was significantly less strained when 2 to 8 N/m of inter-
nal torque was applied compared with the unbraced knee.38
At 9 N/m of internal torque, the difference was not statisti-
cally significant; however, there was a strong trend that brac-
ing the non–weight-bearing knee reduces ACL strain
values.38 In contrast, when the subject was weight bearing,
the brace was no longer able to reduce the strain produced
during application of internal torque about the tibia.38
SUMMARY
The effect of externally applied loads on ACL strain values
is as follows:
1 When the knee is non–weight bearing, anteriorly directed
shear load and internal axial torque applied to the tibia
strain the ACL.

2 When the knee is non–weight bearing, application of
varus–valgus torques and external axial torque to the tibia
does not strain the ACL.
3 Transition of the knee from non–weight bearing to
weight bearing increases ACL strain values.
The strain behavior of the ACL during rehabilitation
exercises is as follows:
1 Rehabilitation exercises that produce the greatest ACL
strain values are produced by contraction of the
quadriceps muscles with the knee between 60 degrees of
flexion and full extension (i.e., isometric quadriceps
contraction, squatting, active extension of the knee, stair
climbing, step-up, and step-down).
2 In contrast to common belief, the compressive knee
joint load, produced by body weight, strains the ACL
during rehabilitation exercises. Adding resistance during
closed kinetic chain exercises such as squatting is not
associated with a proportional increase in ACL strain
values; in contrast, adding resistance during an open
kinetic chain active extension exercise increases ACL
strain values.
3 Low- or unstrained-ACL values have been observed in
response to (1) contraction of the hamstring muscle
group (isometric hamstring muscle contraction and active
contraction of the flexors at all flexion angles),
(2) isometric contraction of quadriceps muscle beyond 60
degrees of knee flexion, (3) co-contraction of quadriceps
and hamstring muscle groups with the knee flexed at
30 degrees or greater, and (4) active knee
flexion–extension motion without resistance between
35 and 90 degrees.
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8. Markolf KL, Burchfield DM, Shapiro MM, et al. Combined knee
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9. Markolf KL, Burchfield DM, Shapiro MM, et al. Biomechanical
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posterior testing. J Bone Joint Surg 1996;78A:1720–1727.
10. Markolf KL, Burchfield DM, Shapiro MM, et al. Biomechanical
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11. Markolf KL, Wascher DC, Finerman GA. Direct in vitro measure-
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plane loading in the intact knee. J Bone Joint Surg 1993;75A:377–386.
12. Markolf KL, Wascher DC, Finerman GA. Direct in vitro mea-
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section of the posterolateral structures. J Bone Joint Surg
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13. Markolf KL, Willems MJ, Jackson SR, et al. In situ calibration of
miniature sensors implanted into the anterior cruciate ligament part
I: strain measurements. J Orthop Res 1998;16:455–463.
14. Markolf KL, Willems MJ, Jackson SR, et al. In situ calibration of
miniature sensors implanted into the anterior cruciate ligament part II:
force probe measurements. J Orthop Res 1998;16:464–471.
15. Beynnon BD, Fleming BC, Johnson RJ, et al. Anterior cruciate
ligament strain behavior during rehabilitation exercises in vivo.
Am J Sports Med 1995;23:24–34.
16. Fleming BC, Ohlén G, Renström PA, et al. The effects of compres-
sive load and knee joint torque on peak anterior cruciate ligament
strains. Am J Sports Med 2003;31:701–707.
17. Fleming BC, Renstrom PA, Beynnon BD, et al. The effect of weight-
bearing and external loading on anterior cruciate ligament strain.
J Biomech 2001a;34:163–170.
18. Li G, DeFrate LE, Sun H, et al. In vivo elongation of the anterior cruciate
ligament during knee flexion. Am J Sports Med 2004;32:1415–1420.
19. Sheehan FT, Rebmann A. Non-invasive, in vivo measures of anterior
cruciate ligament strains. Trans Orthop Res Soc 2003;28:264.
20. Beynnon BD, Howe JG, Pope MH, et al. The measurement of
anterior cruciate ligament strain in vivo. Int Orthop 1992;16:1–12.
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cruciate ligament rehabilitation and reconstruction. Am J Sports Med
1984;12:8–18.
22. Markolf KL, O’Neill G, Jackson SR. Effect of applied quadriceps and
hamstring muscle loads on forces in the anterior and posterior cruciate
ligaments. Am J Sports Med 2004;32:1144–1149.
23. Fleming BC, Renström PA, Ohlén G, et al. The gastrocnemius mus-
cle is an antagonist of the anterior cruciate ligament. J Orthop Res
2001b;19:1178–1184.
24. Jonsson H, Karrholm J. Three-dimensional knee joint movements
during a step-up: evaluation after anterior cruciate ligament rupture.
J Orthop Res 1994;12:769–779.
25. Fleming BC, Beynnon BD, Renström PA, et al. The strain behavior
of the anterior cruciate ligament during stair climbing: an in vivo
study. Am J Sports Med 1999;15:185–191.
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of the anterior cruciate ligament during bicycling. An in vivo study.
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27. Beynnon BD, Johnson RJ, Fleming BC, et al. The strain behavior of
the anterior cruciate ligament during squatting and active flexion-
extension. Am J Sports Med 1997b;25:823–829.
28. Heijne A, Fleming BC, Renström PA, et al. Strain on the anterior
cruciate ligament during closed kinetic chain exercises. Med Sci Sports
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29. Beynnon BD, Uh BS, Johnson RJ, et al. Rehabilitation after
anterior cruciate ligament reconstruction. A prospective, randomized,
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double-blind comparison of programs administered over 2 different
time intervals. Am J Sports Med 2005;33:347–359.
30. Fleming BC, Beynnon BD, Nichols CE, et al. An in vivo comparison
between intraoperative isometric measurement and local elongation of
the graft after reconstruction of the anterior cruciate ligament. J Bone
Joint Surg 1994b;76:511–519.
31. Beynnon BD, Johnson RJ, Fleming BC, et al. The measurement of
elongation of anterior cruciate-ligament grafts in vivo. J Bone Joint
Surg 1994;76A:520–532.
32. Beynnon BD, Uh BS, Johnson RJ, et al. The elongation behavior of
the anterior cruciate ligament graft in vivo. A long-term follow-up
study. Am J Sports Med 2001;29:161–166.
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A roentgen stereophotogrammetric comparison of three designs. Acta
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34. Wojtys EM, Kothari SU, Huston LJ. Anterior cruciate ligament
functional brace use in sports. Am J Sports Med 1996;24:539–546.
35. Wojtys EM, Loubert PV, Samson SY, et al. Use of a knee-brace for
control of tibial translation and rotation. A comparison, in cadavera,
of available models. J Bone Joint Surg 1990;72A:1323–1329.
36. Beynnon BD, Johnson RJ, Fleming BC, et al. The effect of functional
knee bracing on the anterior cruciate ligament in the weightbearing
and nonweightbearing knee. Am J Sports Med 1997a;25:353–359.
37. Beynnon BD, Pope MH, Wertheimer CM, et al. The effect of
functional knee-braces on strain on the anterior cruciate ligament
in vivo. J Bone Joint Surg 1992;74A:1298–1312.
38. Fleming BC, Renstrom PA, Beynnon BD, et al. The influence of
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Med 2000;28:815–824.
 Principles of Anterior Cruciate Ligament
Rehabilitation
INTRODUCTION
Rehabilitation with anterior cruciate ligament
(ACL) reconstruction has evolved considerably
since the 1970s when intraarticular ACL recon-
structions were first being performed. We have
evolved from using casts on the leg for 6 weeks
after surgery to no immobilization at all, from
restricting weight bearing to encouraging
weight bearing, from limiting range of motion
to foster stability to emphasizing exercises to
achieve full knee extension and flexion, and
from restricting the return to sports until 1 year
after to surgery to allowing participation in
sports as soon as the patient is able to do so.
We made this progression by systematically
evaluating how different factors about surgery
and what patients actually did during rehabilita-
tion affected our patients’ results, and then we
made improvements in our rehabilitation tech-
niques to improve the overall outcome.
Proper perioperative rehabilitation with
ACL reconstruction is just as important as proper
graft placement with surgery. We suggest that the
orthopaedic surgeon needs to be intimately
involved with the rehabilitation process to
provide a consistent and effective program for
patients to follow. It is most helpful to develop a
close relationship with one or two physical
therapists who will treat all the physician’s
patients. The repetition of seeing many patients
after ACL reconstruction done by the same
surgeon allows the physical therapist to become
familiar with what condition the knee will be in
65
CHAPTER
after surgery, to learn the best way to treat any K. Donald Shelbourne
problems that arise, and to develop a rehabi- Tinker Gray
litation program that prevents postoperative
complications. Furthermore, when the surgeon
has a good working relationship with a physical
therapist, the physical therapist can do pre-
operative rehabilitation and testing to let the
physician know when a patient is physically
ready for surgery.
The main complication after ACL recon-
struction has been the limitation of knee range
of motion or arthrofibrosis. Arthrofibrosis is
defined as abnormal proliferation of fibrous tissue
in and around a joint that can lead to loss of
motion, pain, and muscle weakness. It is believed
that arthrofibrosis is more common with the
patellar tendon autograft, but it is found with all
graft sources.1–4 We believe that improper peri-
operative rehabilitation, not the graft source
itself, is the culprit for causing arthrofibrosis and
that it can be avoided with all ACL reconstruc-
tion surgery if the proper rehabilitation is applied
before and after surgery.
Regardless of surgical technique or graft
source, the goal for all patients after ACL recon-
struction is to have a normal knee—one that has
full range of motion, strength, and function. If
the ACL reconstructed knee feels different than
the contralateral normal knee, then the patient
can function only at the level of the worst leg.
Therefore symmetry between legs is the ultimate
goal, not just ACL stability.
People have symmetrical knees that are
unique to the individual. In evaluating full range
509
 Anterior Cruciate Ligament Reconstruction

of motion, an important consideration is that 99% of

women and 95% of men show some degree of hyper-
extension in their knees with averages of 5 and 6 degrees,
respectively.5 Current data analysis of results of ACL recon-
struction shows that any loss of knee extension or flexion is
the major factor related to lower subjective scores at 10 to 20
years after surgery. Even the loss of 3 to 5 degrees of exten-
sion compared with the opposite knee can result in lower
postoperative subjective scores.6 Thus the definition of full
range of motion must depend on symmetry between the
knees rather than the conventional practice of gauging
knee motion against a fixed standard.
To measure knee extension, the heel of the foot
should be placed on a bolster so that the knee can fall into
hyperextension (Fig. 65-1). The motion should be com- FIG. 65-2 The examiner can get a kinetic feel for how easily the knee
pared with the opposite normal knee. To get a kinetic feel moves into hyperextension by placing one hand above the knee to fix the
for how easily the knee moves into hyperextension, the femur and placing the other hand on the patient’s foot to lift the heel off
the table.
examiner can evaluate hyperextension by placing one hand
above the knee to fix the femur and placing the other hand
on the patient’s foot to lift the heel off the table (Fig. 65-2).
Knee flexion can be measured by having the patient pull the
heels toward the buttocks. When the knee is normal, the
patient can kneel and sit back on the heels comfortably
(Fig. 65-3). These evaluation tools should be used to deter-
mine whether the patient has full symmetrical knee motion.
With the knowledge that full range of motion is essen-
tial—not only for athletes to function at a high level, but also
for less active patients to be able to comfortably perform
everyday activities such as squatting, kneeling, ascending,
and descending stairs—we have designed our perioperative
rehabilitation program with the principal goal of achieving
postoperative symmetry between knees. The program begins
at the time of the initial evaluation to include preoperative
rehabilitation through the time the patient is fully recovered

FIG. 65-3 Patients who have normal knee flexion can sit back on their
heels without having any tilt in the hips.

and has returned to full activities. Patients follow a cascade

of events that has few time constraints but must be followed
sequentially to be most effective.

FIG. 65-1 The heel of the foot should be placed on a bolster so that the
knee can fall into hyperextension. A goniometer is used to measure
extension.
PREOPERATIVE REHABILITATION
After an acute ACL injury, the knee almost always develops
a hemarthrosis. The hemarthrosis and inflammatory reac-
tion cause the knee to lose range of motion and the leg to
lose some quadriceps muscle strength. Patients typically

510

walk with a bent-knee gait and require crutch assistance.
Preoperative rehabilitation is divided into two areas of
emphasis. First, physically the patient should regain normal
knee range of motion with very little swelling and should be
able to walk with a normal gait. Secondly, the patient
should be prepared mentally for the operative procedure
and subsequent rehabilitation.
The initial emphasis after an acute injury to the ACL
is to control and then decrease the amount of swelling and
pain. We use the knee Cryo/Cuff (Aircast, Summit, NJ),
which combines cold with compression to reduce the
hemarthrosis. The second goal of rehabilitation after an
acute ACL injury is to restore normal knee range of motion,
including full hyperextension equal to the noninjured knee.
Obtaining full range of motion before surgery reduces the
likelihood of motion problems postoperatively.7–9
A habit of performing full hyperextension exercises is
important to develop preoperatively so that the exercises are
easily a part of a daily routine after surgery. Several exercises
and modalities are used to gain full normal hyperextension.
Towel stretches are performed as a passive self-mobilization
technique using a towel looped around the midfoot. The
towel ends are held in one hand while the other hand is used
to press and hold the thigh to the table. The towel is used to
lift the heel of the affected lower extremity to end-range
hyperextension by pulling the end of the towel upward toward
the shoulder, where it is held for a count of 5 seconds, and
then the heel is lowered back to the table (Fig. 65-4). For
patients who have decreased quadriceps muscle control, an
active heel-lift exercise can easily be added to the towel
stretch. The active heel lift is accomplished by contracting
the quadriceps musculature after the towel stretch is per-
formed, trying to keep the heel of the affected leg elevated
without using the towel to hold it in the air. Initially after
injury, patients often display some degree of quadriceps
FIG. 65-4 Towel stretch exercise. The towel is used to lift the heel of the
affected lower extremity to end-range hyperextension by pulling the end
of the towel upward toward the shoulder.
Principles of Anterior Cruciate Ligament Rehabilitation 65
muscle inhibition, making a normal gait pattern difficult. It
is important that the patient continue to try to actively elevate
the heel to the height of the passive stretch.
Passive extension in a seated position can be obtained
by performing a heel prop on a towel or other type of bol-
ster. The bolster should be high enough to elevate both
the calf and the thigh of the affected extremity off the level
of the table. A small weight can be added to the proximal
tibia to facilitate full extension.
The standing extension habit focuses on the patient’s
ability to stand on the affected leg with the knee in a full
hyperextended position. It is normal to stand on one leg
with the knee locked into full hyperextension, and following
an injury, patients will tend to favor their injured leg and
stand on the nonaffected leg. To stand comfortably on one
leg, patients must regain full hyperextension to rest on the
passive joint structures. Forcing patients to stand on their
affected lower extremity ensures that full hyperextension is
regained and maintained.
Regaining full knee flexion is achieved through
performing wall slide and heel slide exercises. Wall slides are
performed while lying supine with both legs extended up
the wall. The heel of the injured leg is allowed to slide down
the wall so that the knee is put into a flexed position with
assistance from the noninjured leg until a stretch is felt
in the knee. This is maintained for approximately 10 to 15
seconds; the leg is then extended back to the starting position,
where the quadriceps muscle is squeezed and the leg is locked
out for 5 seconds, and then the exercise is repeated. Heel slide
exercises are started once the patient has at least 90 degrees of
flexion. They are performed while in a long sitting position as
the patient grasps the ankle of the involved extremity and
passively pulls the leg into knee flexion. This is held for 10
to 15 seconds, and then the leg is allowed to fully extend
back to a resting position. Patients should be instructed to
watch for compensation in the hip during these flexion
exercises. It is common for patients to substitute hip retrac-
tion in place of knee flexion when first trying to perform
these flexion exercises. This should be avoided in order to
maximize full flexion of the knee.
Full weight bearing is allowed as tolerated by the
patient, but a normal gait pattern must be achieved.
Crutches are used to assist ambulation if the patient exhibits
an antalgic gait pattern. Once a normal gait pattern is
obtained, patients are allowed to ambulate without the use
of any assistive device or prophylactic braces. Once the
patient has achieved full range of motion, good leg control,
and a normal gait with minimal swelling, he or she can
begin a low-impact strength and conditioning program until
surgery. Appropriate activities include the use of a stationary
bicycle, elliptical machine, or stair-stepping machine, along
with closed kinetic chain strengthening exercises for the
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 Anterior Cruciate Ligament Reconstruction
lower extremity such as leg press, hip sled, and step-down
exercises. Education on avoidance of high-risk activities that
include twisting and rotation of the knee should be empha-
sized with the patient so that instability episodes prior to
surgery can be avoided.
We perform preoperative testing so that we can have
objective measures for closely monitoring postoperative
progress and to assist the patient in setting performance goals.
The testing includes KT-1000 arthrometer testing of anterior
translation, isokinetic strength at 180 degrees/sec and 60
degrees/sec, and isometric leg press test. The single leg–hop
test is performed on the uninjured leg only. Strength is
measured as a percentage of the involved lower extremity
against the noninvolved lower extremity. Differences
observed between the two lower extremities should be within
25% of each other before surgery when using an ipsilateral
patellar tendon graft source. If the differences between the
two legs are greater than 25%, a delay in surgery may be
recommended so that the patient can work on strengthening
the weaker lower extremity. When using a contralateral
patellar tendon graft source, strength differences of greater
than 25% are allowable as long as the patient has good
quadriceps muscle control and normal ambulation. These
data are used again postoperatively, starting at 1 month, to
compare the athlete’s status with his or her preoperative
strength and function.
The overall goal of physical therapy in the preopera-
tive phase is to control and decrease pain and swelling,
restore full range of motion, aid in the resumption of a
normal gait pattern, and initiate a strengthening program.
By accomplishing these goals, the patient will present to
the operative room for the reconstructive procedure with a
normal-appearing and functioning knee except for the
absence of the ACL.
Mental Preparation
The second important factor in the preoperative preparation
of an ACL reconstruction procedure is the mental prepara-
tion of the patient. Physical therapists follow patients closely
and communicate with the surgeon regarding a patient’s men-
tal and physical preparation for surgery, as the success of
reconstruction depends on both factors.10 The physician must
explain the nature of the injury to the athlete and family. The
patient benefits from a detailed explanation of the operative
procedure and the postoperative rehabilitation. The physical
therapist should also review with the patient exactly what will
be performed in all phases of the postoperative rehabilitation
and how each phase of rehabilitation will be accomplished.
The patient should approach the reconstruction procedure
with a positive mental outlook. A “let’s just get it over with”
attitude is not acceptable and can lead to less than superior
512
results, even with perfect surgical and rehabilitation techni-
ques. The patient should arrive in the operating room ready
to go with an attitude of looking forward to the reconstructive
procedure and with an understanding of the postoperative
rehabilitation.
POSTOPERATIVE REHABILITATION
Ipsilateral or Contralateral Graft
Rehabilitation after ACL reconstruction involves two differ-
ent rehabilitation efforts with different goals. First is the reha-
bilitation of the knee as it pertains to the placement of the
ACL graft intraarticularly. Second is the rehabilitation of
the graft donor site. To do both effectively in the same knee,
one rehabilitation effort must take precedence over the other
to prevent the main complication of arthrofibrosis in the knee.
Of utmost importance for the ACL graft in the short and long
term is achieving full knee range of motion equal to the
normal knee. This includes full hyperextension and the
patient’s ability to kneel and sit back on his or her heels, as
shown in Figs. 65-1 to 65-3. To rehabilitate the graft donor
site, repetitive stress must be applied to the patellar tendon
to stimulate it to regrow in size and strength. The sooner
this repetitive stress can be provided, the more one can take
advantage of the inflammatory response from harvesting the
middle third of the patellar tendon. These two immediate
goals for the ACL graft and the graft donor site are difficult
to achieve simultaneously in the same knee without causing
swelling and difficulty with achieving full range of motion.
Therefore when a graft is harvested from the ipsilateral knee,
the goal of achieving full range of motion takes precedence
over rehabilitating the graft donor site.
Our choice of whether to use an ipsilateral or a con-
tralateral patellar tendon graft is based solely on the individ-
ual patient goals. The senior author used ipsilateral grafts for
primary ACL surgery from 1982 to 1994 but used contra-
lateral grafts during that time period for revision ACL
reconstruction when patients had already had the patellar
tendon graft used in their involved knees for primary recon-
struction. We observed the ease of rehabilitation experi-
enced by patients when the contralateral patellar tendon
was used for revision surgery, especially with regard to the
quick return of knee range of motion in the ACL recon-
structed knee.10–12 Patients also reported that the ACL
reconstructed knee felt normal to them very early after sur-
gery, and they were able to return to their normal activities
and sports very quickly. We initially began using the contra-
lateral graft for primary ACL reconstruction in high-level
athletes who wanted a quick return to sport. With its suc-
cess and ease for achieving full symmetrical range of motion

and strength, we realized that the use of the contralateral
graft was appropriate for any patient.13 We currently use
the contralateral graft source for about 75% of patients.
The rehabilitation program explained in this chapter
can be followed regardless of the graft source or surgical
technique used because the principles of rehabilitation and
goals for patients are the same: to obtain knee symmetry
for range of motion, strength, stability, and function. If
the rehabilitation program provided follows the progression
shown in Fig. 65-5, all the patient’s goals can be met.
Operative Considerations
Postoperative rehabilitation begins in the operating room
after graft placement. It is critical that full range of motion,
including hyperextension and flexion so that the patient’s heel
touches his or her buttocks, is achieved at this point to ensure
the graft has not been overtensioned, resulting in a captured
joint that prevents full motion. The success of the operation
is initially dependent upon correct graft placement and then
subsequently dependent upon providing proper rehabilitation
to the ACL graft and the graft donor site in the knee.
We apply a local anesthetic to the patellar tendon in the
operating room. This allows for relatively painless flexion
exercises to begin permitting the tendon to remain at its full
Cascade of events
Pre-op rehab: No swelling, full ROM, good leg control
Surgery: Full ROM after graft placement and fixation
ACL rehab: Post-op–full ROM and no swelling
Conflicting
goals
Donor site rehab: Increase tendon/leg strength
Proprioception and agility drills
Sport-specific drills
Competition
FIG. 65-5 Effective rehabilitation involves following a progression of
rehabilitation goals before and after anterior cruciate ligament (ACL)
reconstruction. ROM, Range of motion.
Principles of Anterior Cruciate Ligament Rehabilitation 65
length. Later, heel-slide exercises and quadriceps muscle
contractions during weight bearing and straight leg raises will
similarly draw the patella proximally and stretch the tendon
to its full length. The combination of these two exercises
decreases patellar tendon stiffness and contracture, processes
that could otherwise occur after graft harvest and cause
donor site pain.
Another important concept we use, allowing the patient
to fully participate in phase I rehabilitation, is the avoidance of
narcotic medications in the perioperative period. Although the
occasional use of oral narcotic medication is necessary for some
patients, parenteral narcotics decrease a patient’s ability to
physically and cognitively participate in the exercise program.
With the use of a ketorolac infusion, continuous cold/compres-
sion therapy, supplemental oral nonnarcotic pain medication,
and immediate motion, narcotics can be avoided altogether in
most instances. A regimen focused on preventing rather than
treating pain increases both patient participation and satis-
faction. Since instituting this pain prevention program, the
average amount of nonnarcotic pain medication needed for
patients has been 1.3 doses/day, with 73% of patients taking
no pain medication by 6 days after surgery.
Finally, in the operating room, external drains are
placed in the region of the fat pad. Along with leg elevation
and cold/compression therapy, external drains decrease the
incidence and volume of postoperative hemarthrosis. Patients
are kept in 23-hour outpatient observation to prevent hemar-
throsis and allow initiation of immediate rehabilitation.
Prior to leaving the operating room, antiembolism
stockings are placed on both lower extremities. A Cryo/Cuff
is placed on the ACL reconstructed knee, and an elastic sleeve
with a frozen gel pack (Durasoft Patellar Tendon Wrap, DJ
Orthopedics, Vista, CA) is placed over the contralateral
donor side. Suprapatellar compression is not needed on the
graft donor knee because graft harvest is an extraarticular
procedure and there is no risk for an intraarticular effusion.
As the patient arrives in the postoperative recovery area,
the ACL reconstructed leg is placed into a continuous passive
motion (CPM) machine set to move the knee from 0 to 30
degrees of flexion. CPM not only provides gentle motion,
but more importantly also elevates the lower leg. The graft
donor leg is also elevated on pillows to the same level to avoid
increased strain on the lower back that can lead to lumbosacral
pain. Both knees are elevated above the level of the heart
(Fig. 65-6).
Outpatient Anterior Cruciate Ligament
Surgery
Most ACL surgery in the United States is performed on an
outpatient basis, with the regular routine being that the
patient goes home the day of surgery and then goes to a
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 Anterior Cruciate Ligament Reconstruction
FIG. 65-6 After surgery, the anterior cruciate ligament (ACL) reconstructed
leg is placed in a continuous passive motion machine so that the knee is
elevated above the heart.
physical therapy unit a day or so after surgery to begin phys-
ical therapy. We believe that by having the patient stay in
the hospital overnight, we have the means to prevent a
hemarthrosis from forming in the knee. The patient’s
ACL reconstructed leg remains elevated with the cold com-
pression device on the knee except when specific exercises
are being performed. Preventing hemarthrosis is key for
controlling pain, preventing a quadriceps muscle shutdown,
and achieving full knee range of motion. When the patient
is sent home a few hours after surgery, the activity of getting
out of bed, getting to a car, riding home, and getting into
the house causes the knee to swell, which is contrary to
the primary goal of preventing a hemarthrosis after surgery.
Then when the patient is required to leave the house for
physical therapy a day or so after surgery or several times
in the first week after surgery, a knee hemarthrosis is almost
inevitable.
We believe that the success of our rehabilitation pro-
gram may lie in our requiring our patients to remain in
the hospital overnight, receive patient education before
going home, and remain on bedrest for the first 5 days after
surgery. If the surgeon must do ACL reconstructions on an
outpatient basis and send the patient home the day of sur-
gery, major swelling in the knee may still be able to be pre-
vented by having the patient understand and perform
rehabilitation exercises at home. The physical therapist can
communicate with the patient before surgery and daily after
surgery to monitor the patient’s progress, and the patient
could be actively treated by the physical therapist 5 to 7 days
after surgery. This approach does require that the surgeon
work with physical therapists who fully understand the reha-
bilitation program, that patients undergo preoperative reha-
bilitation and patient education, and that the physical
therapist contact the patient daily by phone to monitor the
patient’s progress.
514
Phase I: Early Postoperative Period
Phase I rehabilitation continues on arrival to the outpatient
hospital unit where targeted physical therapy begins. The
patient and the family caregiver are given an exercise diary that
outlines the rehabilitation exercises to be performed. Check-
marks or measurements are placed in boxes next to each
exercise as they are completed. This practice aids in com-
pliance by giving the patient a visual reference to specific exer-
cises. Another additional benefit of performing preoperative
rehabilitation is that the patient can become familiar with
the postoperative exercises to be performed, thus reducing
the chance of confusion or improper exercise technique.
We start with exercises for range of motion with
assisted flexion in a CPM machine for the ACL recon-
structed leg. The patient is instructed to maximally flex the
CPM to 125 degrees and hold this position for a period of
3 minutes. The CPM is progressed to maximum flexion
slowly and as tolerated by the patient. Heel-slide exercises
are performed next for both the ACL reconstructed leg and
the contralateral donor site leg. A yardstick is positioned next
to the leg with the zero end aligned with the end of the heel
(Fig. 65-7). The yardstick provides a visual cue for patients
to easily monitor the progress of knee flexion. Next, the
patient flexes the knee with the help of a towel looped under
the thigh until further flexion becomes difficult. Terminal
flexion is held for 1 minute. The number of centimeters the
heel has traveled is recorded. This number makes it easy for
the patient and physical therapist to communicate changes
in range of motion over the phone during the first week when
the patient is at home. Flexion in the ACL reconstructed leg
should be approximately 110 to 120 degrees immediately
postoperatively. Flexion in the contralateral graft donor knee
should be full and equal to preoperative measurements
because harvesting the graft alone does not cause swelling
and the patellar tendon has been stretched to maximal length
while still in the operating room.
The patient then props both legs into extension with
the heels resting on the Cryo/Cuff canister, allowing for any
hyperextension. A small 2.5-pound weight is placed just distal
to the incision on the ACL reconstructed leg. This exercise is
maintained for 10 minutes. Following the heel prop exercise,
the patient performs three to five knee thunk exercises on each
knee, in which the patient flexes the knee to a height of several
inches and then allows the leg to relax and “thunk” into hyper-
extension. Thunk exercises can be difficult for patients to per-
form on the ACL reconstructed leg at first for fear of
damaging the ACL reconstruction. Typically, therefore,
thunk exercises are performed first on the graft donor leg so
that the patient understands how hyperextension feels. Five
to ten towel stretch exercises are performed for each leg as
 Principles of Anterior Cruciate Ligament Rehabilitation 65

FIG. 65-7 A yardstick is positioned next to the leg with the zero end aligned with the end of the heel. With
heel-slide exercises (A), the patient can easily monitor the amount of flexion as it corresponds to the number of
centimeters on the yardstick (B).

described previously. Active heel-lift exercises are combined

with the towel stretch to achieve good quadriceps control
(Fig. 65-8).
Straight leg raise exercises for leg control are per-
formed on both legs by having the patient first initiate a
quadriceps muscle contraction and then focus on maintain-
ing the knee in a locked-out position while lifting the leg so
that the heel is 2 to 3 feet in the air above the mattress
(Fig. 65-9). To provide high repetition stress to the graft
donor site while still remaining in bed, we use the Shuttle
(Contemporary Design, Glacier, WA). The Shuttle is a
light-weight, low-resistance portable leg press machine
(Fig. 65-10). Resistance is provided by the placement of
FIG. 65-9 The straight leg raise exercise facilitates good leg control.
weighted rubber cords, each adding additional resistance.
This weight is applied during both the concentric and
eccentric movements. Twenty-five repetitions with one cord
(7 pounds) are then completed with the emphasis on slow,
controlled motion.

FIG. 65-10 The Shuttle machine provides a means for the patient to
perform low-resistance leg press exercise while still remaining in bed.

Following these exercises, the Cryo/Cuff and gel pack

are applied to the ACL reconstructed knee and graft donor
FIG. 65-8 Active heel-lift exercise. After the patient does a towel stretch
exercise, he or she contracts the quadriceps muscle to actively lift the heel knee, respectively, and the ACL reconstructed leg is placed
into extension. back into the CPM set from 0 to 30 degrees, with the graft

515
 Anterior Cruciate Ligament Reconstruction
donor leg again propped up on pillows. The water in the
Cryo/Cuff is changed once every waking hour. The patient
is confined to bedrest with the use of a portable urinal and
bedpan if needed. The patient may ambulate at this time
but does so at the risk of developing a hemarthrosis.
The drains are removed from both knees the following
morning, and an identical set of exercises is performed. At the
end of this session, the patient ambulates for the first time.
This is accomplished carefully to avoid a fall. First, the patient
sits at the edge of the bed and, when it is clear that the patient
is steady and not dizzy, standing is encouraged. Standing is
allowed for a few minutes, with the clinician close by to make
sure a vasovagal episode does not occur. Next, the patient is
instructed to shift his or her weight over to the ACL
reconstructed leg and lock that leg into hyperextension with
a quadriceps muscle contraction (Fig. 65-11). The patient
then ambulates to the door of the room and back using
small steps and focusing on a point high on the wall in the
direction of ambulation. Patients are allowed to ambulate
with full weight bearing as tolerated; however, the use of
FIG. 65-11 Standing habit. The patient is instructed to stand on the
anterior cruciate ligament (ACL) reconstructed leg so that the leg is
extended into full hyperextension.
516
crutches or a walker is allowed for patients who are unsteady
on their feet and are at risk of falling.
Patients are released home from the hospital the day
after surgery. Before release from the hospital, each patient
must demonstrate full extension of the ACL reconstructed
leg equal to the contralateral graft donor leg, flexion of at least
110 degrees on the ACL reconstructed leg, full or near-full
flexion of the graft donor leg, the ability to lift both legs inde-
pendently with quadriceps muscle contraction, the ability
to ambulate independently, and a complete understanding
of the home exercise program. Patients are advised that
flexion may decrease from the previous day in the ACL
reconstructed knee, but the flexion obtained initially after
surgery should return gradually by 2 to 3 days after surgery.
In general, patients are counseled against pushing flexion
too hard in this period, as maintaining full extension is more
important. Flexion in the contralateral graft donor knee
should remain full.
Following discharge from the hospital, physical thera-
pists call patients at home daily for the first week to monitor
progress and answer questions that might arise. The previ-
ous list of exercises is carried out five to six times daily with
the exception of the Shuttle, which is used three times daily
and on the contralateral donor leg only. Patients are
instructed not to use the Shuttle at the first morning exer-
cise session and to discontinue its use until further
instructed by the physical therapist if the knee becomes
too sore at the graft site or if they begin to lose knee flexion
on daily measurements. Daily flexion measurements are
made using the yardstick, measuring the distance the heel
travels on both knees. Barring these events, patients are
allowed to increase the number of repetitions performed
during each session on a daily basis, up to 10 additional
repetitions per day. When 100 repetitions become easy for
the patient, an additional cord can be added for progressive
resistance, but the number of repetitions is decreased to 50
per session. The patient is allowed to then begin progressing
up to 100 repetitions again with the increased weight. If
flexion in the graft donor leg starts to decrease (as measured
by yardstick daily), the patient is advised to either decrease
the Shuttle exercise weight, frequency, or both until full
flexion returns in the graft donor leg.
In the ACL reconstructed leg, knee extension is
emphasized more than flexion during this phase. If the
amount of knee extension plateaus or decreases, the amount
of exercise to increase flexion should be deceased accordingly.
Patients are warned that exercises will become more difficult
at day 2 or 3 after surgery before gradually improving as a
result of the body metabolizing the ketorolac medication
from the hospital. During the first week after surgery, patients
are allowed out of bed only two to three times daily for
bathroom needs.
 Principles of Anterior Cruciate Ligament Rehabilitation 65
Postoperative Rehabilitation Phase II encouraged but is not required if swelling is adequately con-
trolled. Shuttle exercises for the contralateral graft donor leg
The first postoperative visit is at 1 week after surgery. Reha- are progressed as described previously as long as the patient
bilitation remains unique to each leg. The patient continues retains full flexion. Front step-down exercises are initiated at
to work on maintaining full extension of the ACL recon- this point, and patients start with 50 repetitions three times
structed knee while concentrating on patellar tendon remo- per day on the 2-inch step. This is progressed in a similar
deling and regrowth in the graft donor knee through the use manner to the Shuttle until the patient is performing 100
of strengthening exercises and maintaining full flexion. repetitions on the 2-inch step. The patient independently
The primary goal is full extension of the ACL recon- advances this progression based on the amount of donor site
structed leg; 110 degrees of knee flexion is a secondary goal soreness. The step box, a hinged, foldable device, allows step
and represents the average flexion in this period. No exercises from heights up to 8 inches. Patients are instructed
patients should have less than 90 degrees of flexion. Full to perform front step-down exercises, focusing on quality of
flexion is expected in the graft donor knee. form and technique rather than quantity of the number per-
Next, quadriceps muscle control is assessed. Each patient formed (Fig. 65-12). Balancing on the graft donor leg with
should be able to perform a straight leg raise without a lag and the hands placed on the hips, the patient lowers the heel of
perform an active heel lift, contracting the quadriceps muscle the opposite leg to the floor in front of the step box until it
with the knee in a hyperextended position. The patient should touches the floor. It is important for the patient to keep the
also have sufficient quadriceps muscle control to ambulate stairs pelvis in a neutral position during the descent phase to prevent
using only the handrail for balance. If achieving an active heel compensation from the hip musculature.
lift through voluntary contraction is not possible, the condition If the patient continues to maintain good knee motion
may be a result of quadriceps muscle inhibition. Clinically, this and avoid joint effusion during the second postoperative
condition manifests itself in a poor gait pattern. Stance and gait week, he or she is allowed to increase the time spent upright
training includes using a mirror to help the patient visualize and
understand the correct position of a hyperextended knee in
stance, as well as working on gait using a decreased step length
and focusing on terminal extension during initial contact with
overemphasized heel contact.
Whenever sitting, the patient should be performing a
heel prop to work on passive extension on the ACL recon-
structed leg. Whenever standing, weight should be shifted
to the ACL reconstructed leg locking the knee into hyper-
extension. Towel stretches are continued through this
phase. The importance of full symmetrical hyperextension
cannot be overemphasized. If asymmetrical hyperextension
is noted and not correctable by the end of this follow-up
appointment, then a more vigorous technique to regain full
extension is needed. These techniques will be explained later
in this chapter with regard to problems with rehabilitation.
Knee flexion exercises are also implemented for the
ACL reconstructed knee. The goal for the end of week
2 is 120 degrees. Exercises including heel slides and wall
slides are routinely given. Flexion hangs, which involve
holding the posterior thigh with the hip flexed to 90 degrees
and allowing gravity to passively flex the knee, can be added
at this point for patients whose flexion is less than 120
degrees. All range of motion exercises are performed two
to four times a day during the intermediate phase.
During week 2, the CPM is discontinued while cold/
compression therapy continues. The cold/compression device
FIG. 65-12 Step-down exercise provides light strengthening. The patient
is used by the patient as needed throughout the day to control stands on the step and lowers the heel of the opposite leg to the floor
swelling, and continued use throughout the night is while keeping the pelvis in a neutral position.

517
 Anterior Cruciate Ligament Reconstruction
by 1 to 2 hours per day. Patients can usually attend school
or work half-days starting about 1.5 weeks postoperatively.
By day 10 to 12 postoperatively, if motion remains good
and effusion is not an issue, patients are allowed to be up
for 1 full day with brief periods of elevated rest as needed.
The second postoperative visit takes place 2 weeks
after surgery. Knee range of motion, gait, and quadriceps
muscle control are again carefully examined. By this time,
patients should report that they are back to performing
their full normal activities of daily living independently
without difficulty or other compensatory strategies. In the
ACL reconstructed knee, 120 degrees of flexion is expected
in addition to full extension. Effusion should be well con-
trolled. Excessive effusion is indicative of an overly intense
activity level and should be addressed immediately. Patients
should be instructed to return to a decreased level of activity
with the leg elevated on pillows and continuous usage of
the Cryo/Cuff until the swelling level has returned to an
expected baseline amount of swelling. During this time,
patients still perform range of motion exercises. Full flexion
and extension in the graft donor knee should be maintained.
Normal gait should be demonstrated, and patients should
be able to ambulate up and down stairs without holding
onto the handrail.
When a graft from the contralateral knee is used, the
goal of rehabilitation for the graft donor site between weeks
2 and 4 is remodeling and regrowth of the donor patellar
tendon through high-repetition, low-resistance exercise car-
ried out several times daily. These exercises are essential to
avoid long-term donor site pain. Patients are instructed in
leg press and knee extension exercises, as well as continua-
tion of the step-down exercises. These exercises should not
be performed on the ACL reconstructed leg until full knee
range of motion is obtained. Typically, patients are asked
to start with half their body weight or less for the leg press
and 2 to 5 pounds with the knee extension exercise. These
exercises can be performed every other day to ensure that
the graft donor site does not become overly sore. Three to
five sets of 10 to 12 repetitions of each exercise are usually
sufficient. The weight used for both exercises can be pro-
gressed slowly as the patient improves in strength.
In our experience, patients can easily overexert them-
selves with either the leg press or the knee extensions and
make the donor tendon site sore. If the patient develops
soreness that persists and is not decreased with cryotherapy,
these exercises may need to be discontinued for a period of
time. Most important is that the patient continues to dem-
onstrate full range of motion with continued strength
improvement without developing unrelenting donor site
pain. Step-down exercises are progressed during this visit
as able so that they are providing an appropriate challenge
to the patient. If the patient has maximized the number of
518
repetitions during the second week (100 reps, four to six
times per day), he or she is allowed to progress up to the
4-inch step; otherwise the patient stays at 2 inches and
continues to progress on the 2-inch step. The number of
repetitions is decreased to 50 on the 4-inch step, and the
patient can progress this number back up to 100 per session
as able. Once 100 repetitions is reached on the 4-inch step,
the patient is allowed to go up to the 6-inch step, again
reducing the number of repetitions performed to 50 and
progressing the number performed as able. Soreness in the
tendon should be relieved with cryotherapy, not interfere
with normal gait or stairs, and be absent from the tendon
prior to the next session. If the graft donor leg begins to
become overly sore or if a decrease in knee flexion is noticed
during exercises, the graft donor leg strengthening intensity
should be decreased until full flexion returns. It remains vital
to maintain full extension of the ACL reconstructed knee
and to make progress in flexion.
By the 1-month visit, the goal is for patients to be
able to comfortably sit on their heels with their ankles in
maximal plantarflexion, indicative of full knee flexion.
Motion exercises for the ACL reconstructed knee remain
the same as weeks 1 and 2. Extension habits are again
reviewed and reinforced because some patients have trouble
integrating them into their daily routine.
Postoperative Rehabilitation Phase III:
Advanced Strengthening
Four weeks after surgery, the patient returns for a full round
of strength testing, as well as KT-1000 arthrometer evaluation.
The single leg–hop test is not included in this visit usually
because most patients have not had a full return in confidence
and are not ready to return to sports activities. The results of
these tests are helpful to assess the patient’s progress over the
previous 4 weeks and to develop a plan for further activity.
When an ipsilateral graft is used, patients can begin
strengthening the ACL reconstructed leg if the knee has full
range of motion and very little swelling. The exercises and
progression for strengthening the ACL reconstructed leg
are the same as those prescribed for the graft donor leg, with
the concentration on single leg strengthening exercises as
described previously. The patient adjusts the amount and
intensity of the strengthening exercises based on whether
he or she experiences any decrease in range of motion or
an increase in knee swelling. Typically, patients have about
60% quadriceps muscle strength in the ACL reconstructed
leg compared with the normal leg. Patients should perform
single leg strengthening until they achieve 90% strength in
the ACL reconstructed leg; then they can continue with
bilateral leg strengthening exercises.

When a contralateral graft is used, the recovery of
strength to preoperative normal levels is not as important
as symmetry between the ACL reconstructed leg and the
graft donor leg. For a patient doing well, isokinetic strength
in the graft donor leg should be within 10% of the ACL
reconstructed knee.
The ability to return to activities depends on the
strength of the graft donor knee, the presence of full motion
in both knees, and the lack of an effusion in the ACL recon-
structed knee. If symmetrical quadriceps muscle strength (dif-
ferences of less than 10% on testing) is achieved, the patient
begins bilateral strengthening and conditioning exercises.
Leg press, knee extension, and step-down exercises are now
performed on both legs, with the patient doing the exercises
with each leg independently and continuing to progress the
intensity by adding weight as able. If the quadriceps muscle
strength is not within 10% between legs, the patient continues
with strengthening the graft donor leg only.
Low-impact conditioning, including stationary bike,
stair-stepping machine, or elliptical trainer, is added. These
activities need to be started very slowly and cautiously as the
amount of swelling in the ACL reconstructed knee is
monitored. Typically, most patients tolerate starting with
10 minutes every other day and increasing to 20 to 30
minutes over the course of the next 4 weeks. Patients
who have had an ipsilateral graft need to know that these
low-impact conditioning exercises will not help to
strengthen the leg. Given that both legs are involved, it is
difficult for patients to use both legs equally when there
is more than a 10% discrepancy in strength between legs.
Therefore these exercises should not replace the specific
single leg exercises prescribed.
Straight-line forward and backward jogging, lateral
slides, and crossover agility steps can be introduced. Shoot-
ing baskets or other individual noncompetitive sport-specific
drills are performed as tolerated. These agility activities are
done in controlled situation and do much to keep athletes
motivated toward their goals, but again these activities
should not replace specific strengthening exercises. No com-
petitive situations are allowed at this time.
Postoperative Rehabilitation Phase IV:
Return to Competition
There are no strict guidelines as to when a patient may
return to sports. Patients return to the clinic for follow-up
testing and adjustment to their home exercise programs
and activity level regularly at 2-, 4-, and 6-month visits.
Rehabilitation continues to be monitored as the patient
returns to his or her preoperative, fully competitive level of
activity. Symmetry, in the form of equal strength, full range
Principles of Anterior Cruciate Ligament Rehabilitation 65
of motion, and joint effusion, is evaluated at each visit.
Once symmetry is achieved between both knees, the level
of activity can be increased slowly to include return to sports
activities.
During the return to full activities, the patient must
monitor swelling and range of motion daily. If swelling
occurs or the knee loses any extension or flexion, the patient
must back off on activities, ice the knee, and perform range
of motion exercises. Increased activity causes stress on the
ACL graft, which is desirable because it stimulates the graft
to mature. However, the maturation process in the ACL
graft causes it to become stiffer, and patients must fully
extend and flex the knee several times daily to keep the
ACL graft stretched and to prevent capturing the knee.
When the patient first returns to athletic practice or
competition, it should be done on an every-other-day basis.
The initial return to activities is similar to that of a weight-
lifting program. The athlete, while doing the activity, may
feel and perform normally but may become quite sore after-
ward. Thus the athlete can practice as usual one day but
then needs to take a day off to allow the knee (or knees)
to recover. We have found that coaches sometimes do not
understand this process and put pressure on the athlete to
practice and compete every day. It is important for the phy-
sician and physical therapist to communicate directly with
the coach to explain that having athletes practice every other
day will allow them to do the sport with better quality when
they are practicing and to eventually return to full competi-
tion faster instead of having long-term problems with knee
soreness that is difficult to resolve with everyday activity.
COMMENT
Some physicians believe that patients should not be allowed
to return to competitive sports until 6 months to 1 year after
surgery because they believe that it takes that long for the
ACL graft to mature and that graft maturation is what will
prevent ACL graft rupture in the future. There is nothing
magical about an arbitrary time of 6 months that makes it
safe for a patient to return to sports. We have found that
it takes patients 3 to 4 months of playing their sport before
they feel that the knee has returned to normal. Interestingly,
patients who do suffer an ACL graft rupture do so after they
have been back to playing and are at the level of feeling nor-
mal, and not during the first few months of playing. We
have not found a specific time after surgery where the
ACL graft is most vulnerable. The average time of ACL
graft tear is 2.1 years (range, 3 months–9.2 years) after sur-
gery, and the time of graft tear is equally distributed over
that time.14
519
 Anterior Cruciate Ligament Reconstruction
Regardless of the surgeon’s philosophy for returning
patients back to sports, we believe that the rehabilitation
should be done such that patients can regain their normal
knee range of motion and strength as soon as possible after
surgery. There is no reason to limit full hyperextension and
full flexion in the knee at any time after surgery if the ACL
graft is placed properly in the knee. As previously explained,
the immediate goal after surgery is to limit a knee hem-
arthrosis and regain full knee range of motion before
beginning an aggressive strengthening routine. Throughout
the entire rehabilitation process, maintaining full knee range
of motion is emphasized and takes precedence over other
rehabilitation goals. Knees that have full range of motion
respond better to strengthening exercises. Furthermore,
patients who have knees with normal range of motion with
no swelling are able to perform their normal everyday
activities without concern. Although patients can have
normal-feeling knees by 1 to 2 months after surgery with
the described rehabilitation program, the physician can
still restrict the patient from returning to sports until the
time he or she feels is appropriate. There is no reason,
however, to limit the patient from achieving the other
rehabilitation goals.
SUMMARY
Proper rehabilitation before and after ACL reconstruction is
just as important as performing a technically sound surgical
procedure. The principles outlined in this chapter, if fol-
lowed closely, allow patients to achieve the best possible
outcomes after surgery. Paramount to regaining full function
is that patients obtain full symmetrical knee range of motion
and strength. The progression described in this chapter
allows patients to achieve these important goals.
520
References
1. Chang SK, Egami KD, Shaieb MD, et al. Anterior cruciate ligament
reconstruction: allograft versus autograft. Arthroscopy 2003;19:453–462.
2. Corry IS, Webb JM, Clingeleffer AJ, et al. Arthroscopic reconstruc-
tion of the anterior cruciate ligament. A comparison of patellar tendon
autograft and four-strand hamstring tendon autograft. Am J Sports
Med 1999;27:444–454.
3. Ejerhed L, Kartus J, Sernert N, et al. Patellar tendon or semitendino-
sus tendon autografts for anterior cruciate ligament reconstruction?
A prospective randomized study with a two-year follow-up. Am
J Sports Med 2003;31:19–25.
4. Eriksson K, Anderberg P, Hamberg P, et al. A comparison of
quadruple semitendinosus and patellar tendon grafts in recon-
struction of the anterior cruciate ligament. J Bone Joint Surg
2001;83B:348–354.
5. DeCarlo MS, Sell KE, Shelbourne KD, et al. Current concepts on
accelerated ACL rehabilitation. J Sport Rehab 1994;3:304–318.
6. Shelbourne KD. Unpublished data, 2005.
7. Mohtadi NG, Webster-Bogaert S, Fowler PJ. Limitation of motion
following anterior cruciate ligament reconstruction. A case-control
study. Am J Sports Med 1991;19:620–624.
8. Shelbourne KD, Patel DV. Timing of surgery in anterior cruciate
ligament-injured knees. Knee Surg Sports Traumatol Arthrosc
1995;3:148–156.
9. Shelbourne KD, Wilckens JH, Mollabashy A, et al. Arthrofibrosis
in acute anterior cruciate ligament reconstruction. The effect of
timing of reconstruction and rehabilitation. Am J Sports Med
1991;19:332–336.
10. Rubinstein RA Jr, Shelbourne KD, VanMeter CD, et al. Isolated
autogenous bone-patellar tendon-bone graft site morbidity. Am
J Sports Med 1994;22:324–327.
11. Shelbourne KD, Thomas JA. Contralateral patellar tendon and the
Shelbourne experience. Part 1. Revision anterior cruciate ligament
reconstruction and rehabilitation. Sports Med Arthrosc Rev
2005;13:25–31.
12. Shelbourne KD, Thomas JA. Contralateral patellar tendon and
the Shelbourne experience. Part 2. Results of revision anterior cruciate
ligament reconstruction. Sports Med Arthrosc Rev 2005;13:69–72.
13. Shelbourne KD, Urch SE. Primary anterior cruciate ligament using
the contralateral autogenous patellar tendon. Am J Sports Med
2000;28:651–658.
14. Shelbourne KD. Unpublished data, 2006.
 The Stability-Conservative Anterior
Cruciate Ligament Reconstruction
Rehabilitation Protocol
INTRODUCTION
The primary goal of anterior cruciate ligament
reconstruction (ACLR) is to restore stability
without sacrificing mobility or strength. The
primary purpose of ACLR rehabilitation is to
restore mobility and strength without sacrificing
stability. It is the central hypothesis of this
chapter that overly aggressive rehabilitation is
both unnecessary and potentially sacrifices knee
stability. The stability-conservative rehabilita-
tion protocol can best be summarized as follows:
Avoid graft strain and abrasion while
restoring motion and strength in the early
postoperative period.
It is based on the following premises and
principles:
Premises
1 Stability after ACLR can be compromised by
an overly aggressive rehabilitation protocol.
2 Full motion and strength can reliably be
obtained with a less aggressive approach
designed to minimize ACL strain and
abrasion in the graft in the first 3
postoperative months when the fixation
points and the graft are weak.
3 No fixation device will ever be able to
guarantee that grafts will not slip and/or
elongate during healing if they are
strenuously and repetitively strained prior to
tunnel healing.
4 Because only about half of reconstructed
knees currently achieve stability that is
66
CHAPTER
roughly symmetrical with the other knee (see Chadwick C. Prodromos
later discussion), it is important to not
sacrifice stability in the name of faster
rehabilitation.
Principles
1 Restoration of full extension and almost full
flexion should be aggressively pursued
immediately after surgery, but not
hyperextension and hyperflexion, which
strain the graft.
2 Strengthening, especially of the quadriceps,
must be performed only within safe arcs of
knee motion to avoid compromising stability.
3 Cyclical loading should be avoided within the
first 3 postoperative months to avoid strain
and tunnel abrasion of the ACL graft beyond
that found during activities of daily living.
HISTORY
Until the late 1980s, ACL rehabilitation was
rendered cautiously on the theory that stability
was fragile and strain in the graft needed to be
minimized in the early postoperative period to
avoid loss of stability. It was well known that
grafts lose much of their tensile strength in the
first few postoperative months.1–3 It was recog-
nized that grafts require time to heal into bone
tunnels before which they are subject to loosen-
ing2,4 (see Chapter 56). Finally, it was also known
that quadriceps contractions in the terminal 50
degrees of extension exerted a powerful anterior
521
 Anterior Cruciate Ligament Reconstruction
translational moment on the tibia that strains the ACL.5,6 As
bone–patellar tendon–bone (BPTB) grafts became popular
during the 1980s, it became apparent that many knees became
stiff and had prolonged quadriceps weakness. This stiffness
was potentially a worse problem than the laxity of ACL defi-
ciency. A stable but stiff knee was more likely to be worse than
an unstable knee. In 1990 Shelbourne published his classic
paper7 introducing accelerated rehabilitation. This challenged
the then-accepted view that grafts needed to be carefully pro-
tected during the first few postoperative months. He stated
that his patients who were somewhat noncompliant with his
postoperative restrictions and were more active had no greater
incidence of instability than the compliant patients. However,
these more active patients had less stiffness and weakness. He
postulated that “accelerated” early aggressive rehabilitation
was thus not harmful and also necessary to ensure restoration
of motion and strength. Based on these observations he devel-
oped his accelerated rehabilitation protocol, which is currently
used in some form by most ACL surgeons.
SYMMETRIC STABILITY AFTER ANTERIOR
CRUCIATE LIGAMENT RECONSTRUCTION IS
NOT ASSURED
Many surgeons commonly use exercises such as cycling and
squats that cause quadriceps contractions in the terminal 50
degrees of extension in the early postoperative period.
As shown by the research of Beynnon and others8,9 (see
Chapter 64), these activities exert a significant strain on the
ACL. The accelerated rehabilitation protocol states that
stability will not be compromised by such ACL-straining
activities if the surgery is properly performed. Yet, as shown
in the most recent meta-analysis10 to review all such papers
and as discussed elsewhere in this book (see Chapter 69),
symmetrical stability after ACLR is currently achieved in
only about half of all reconstructed knees, even in the hands
of the very experienced ACL surgeons. Accelerated rehabi-
litation was developed, in particular, to overcome stiffness
and weakness in BPTB patients. However, mean KT-1000
scores for BPTB from the literature showed that 34% of
reconstructed knees had more than 2 mm of increased laxity
than the normal knee, the stability level usually seen with a
partially torn ACL. Of the 66% that were within 2 mm, it is
estimated that one-fourth or 17% had exactly 2 mm of
increased laxity. Thus 34% þ 17% or 51% in all had 2 mm
or more increased laxity. This leaves only about half with
restoration of stability that is the same as the opposite knee.
In addition, 5.9%, or roughly 1 in every 17 knees, had
abnormal stability (i.e., a failed graft). Thus some of the most
experienced knee surgeons in the world in the current
522
literature are only restoring even approximately symmetrical
stability—within 1 mm of the other knee—to half of the
operated BPTB knees. Half have stability at a level seen with
a partially torn ACL or worse.
WHY PROTECT THE GRAFT IN THE FIRST
3 MONTHS POSTOPERATIVELY?
Fixation Point Healing
The studies of Milano and others,2 which are discussed
in Chapter 56, show that soft tissue healing into tunnels
can take 2 months or longer. During this time, strain on
the graft has the potential to make the fixation slip and
the graft lax. This healing occurs several weeks earlier in
BPTB grafts than in soft tissue grafts.
Graft Strength
Grafts undergo cell death, edema, and then revasculariza-
tion in the first few months postoperatively (see Chapter
55). During this time the graft loses approximately 75% of
its strength.
Thus both fixation strength and interstitial strength
are compromised during the first few postoperative months.
Strain of the graft can induce laxity by both fixation point
slippage and graft elongation from plastic deformation.
Cyclical loading has the potential to damage the graft by
tunnel abrasion before tunnel healing has occurred.
MUSCULAR INHIBITION AFTER ANTERIOR
CRUCIATE LIGAMENT RECONSTRUCTION
Effusions,11–13 ACL injury,14,15 and knee pain16,17 have all
been shown to have an inhibitory effect on knee muscula-
ture, especially the quadriceps, apparently through afferent
inhibition of motor neuron activity. This means that during
roughly the first 3 postoperative weeks, when most patients
have a large hematoma and some knee pain, it may be
difficult or impossible to generate large-enough muscle con-
tractions to strengthen or effectively prevent atrophy. In the
past when we attempted to begin strengthening imme-
diately after surgery, we noticed that strength gains did
not occur, probably for this reason. In addition, the exercises
produced significant patient discomfort. For this reason we
no longer begin strengthening until roughly the end of the
third postoperative week for isometric quadriceps and later
for other muscle groups in which atrophy is less of a
concern.
 The Stability-Conservative Anterior Cruciate Ligament Reconstruction Rehabilitation Protocol
CYCLICAL LOADING DOES CAUSE LAXITY
Every study that has looked at this subject has shown that
cyclical loading induces elongation of the graft–fixation con-
struct. These studies typically show several millimeters of
elongation.18–20 The best such study showed 1 mm after
the first 100 cycles. Many of these studies look only at the
first 1000 cycles.18 One thousand cycles is equal to the
number of steps taken in less than 1 week of normal activity
and less than 1 week of cycling during rehabilitation. It is
highly likely that this elongation would further increase if
more cycles were performed. It is important to realize that
only 2 mm of elongation from cyclical loading is enough
to change the side-to-side difference from –1 mm to
–3 mm, converting good stability to the stability level seen
in a partial ACL tear.
WHY AVOID HYPEREXTENSION?
The studies of Beynnon (see Chapter 64) have shown that
hyperextension strains the graft significantly. Thus hyperex-
tension should be avoided for that reason. Also, hyperexten-
sion is not used during normal gait. In our large long-term
study21 of patients after hamstring (HS) ACLR, patients
were told to avoid hyperextension for the first year after
surgery. At follow-up (as long as 8 years postoperatively)
most patients had recovered symmetrical hyperextension.
All patients had essentially full extension. No patient expe-
rienced any clinical motion deficit. Thus nothing was lost by
avoiding hyperextension in our rehabilitation protocol, and
we believe a potential stability benefit was obtained by
avoiding the strain that hyperextension would have exerted
on the graft. Others have thought that achieving full hyper-
extension is necessary to achieve full painless motion. We
have not found this to be the case with our patients. We
should point out, however, that our experience is limited
to soft tissue grafts. It is possible that hyperextension may
provide some benefit for BPTB grafts that it does not for
HS grafts.
WHY INSIST ON FULL EXTENSION AND HOW
TO ACHIEVE IT
Full extension is necessary to avoid walking on a flexed knee.
During full extension the quadriceps is lax, thus diminishing
tension on the patellar tendon and avoiding compressive force
on the patella. If full extension is not achieved, causing the
patient to walk on a flexed knee, there is greatly increased
patellar tendon tension and patellofemoral compressive force.
66
Either or both of these phenomena can produce pain from
patellar tendonitis or patellar chondromalacia, respectively.
Thus obtaining full extension is the single most important
aspect of ACL rehabilitation because it allows painless
walking. We obtain full extension via an extensional force
applied to the supine patient’s proximal tibia from the physical
therapist and/or the patient’s family members, as well as various
stretching exercises. We do not use or allow quadriceps contrac-
tions to help achieve it because quadriceps contractions in termi-
nal extension result in a powerful strain on the ACL (Fig. 66-1).
WHY AVOID FULL FLEXION?
Flexion of 110 degrees is necessary to descend stairs. We
work to achieve flexion of 115 to 120 degrees to provide a
flexion reserve in this regard. However, we avoid hyperflex-
ion in the first 6 months because it increases strain in the
graft6 and serves no functional purpose. Again, our long-
term follow-up study showed that patients almost always
regained full extension on their own after their discharge
at a later time, when the graft was able to withstand the
powerful strain thus induced.
THE TIMING OF STRENGTHENING IN PHYSICAL
THERAPY
In most patients we do not begin HS strengthening until
the fourth month, when gains occur more quickly. In most
cases we have had no difficulty achieving full HS strength
by their full activity release at the 6-month postoperative
mark. We believe that it is wasteful of time and resources
for patients to come to the therapy clinic continuously for
6 months. Therefore we take a break from the time when
FIG. 66-1 Passive extension by the therapist in the clinic and the family at
home, avoiding hyperextension, is very effective in regaining full extension.
523
 Anterior Cruciate Ligament Reconstruction
full motion is achieved (usually 2 weeks postoperatively)
until the end of the third month or beginning of the fourth.
This gives the patient 3 months to achieve full strength
before being released after 6 months, which is usually more
than adequate. It also concentrates their therapy visits at a
time when increased healing and reduced inflammation pro-
vide greater stability and faster strength gains.
QUADRICEPS STRENGTHENING
Quadriceps contraction, whether open or closed chain (see
Chapter 64), strains the ACL significantly from 0 to roughly
50 degrees of flexion depending on the study.22,23 Contrary to
prior thought, Beynnon (see Chapter 64) has shown that this
strain is not decreased in closed chain exercises relative to
open chain. We do not begin quadriceps strengthening until
110 degrees of knee flexion is obtained because strengthening
of a muscle can decrease its elasticity and thus could inhibit
attempts to achieve flexion. However, when 110 degrees of
flexion is achieved (usually by the end of the second week),
we believe it is safe to begin protected quadriceps strengthen-
ing. To avoid cyclical loading we use an isometric exercise
called the “wall push” (Fig. 66-2). This produces an isometric
quadriceps contraction with the knee flexed 90 degrees. This
90-degree mark is easy for patients to remember when doing
the exercise on their own. Patients lie on their back on the
floor and flex the hips and knees to 90 degrees, putting the flat
foot on the wall. A family member or friend holds a bathroom
scale between the foot and the wall to record the compressive
pressure achieved. This can be charted at home to mark the
progression of strength and gives the patient a goal to achieve
and exceed as strength increases. Only the operated extremity
is strengthened to promote symmetry between the legs. This
exercise has the benefit of being able to be done entirely at
home, without clinic visits, once the exercise has been
properly demonstrated to the patient.
FIG. 66-2 The 90-degree wall push using a scale as a dynamometer is a
valuable home quadriceps exercise.
524
HAMSTRING STRENGTHENING
Leg curls are the primary exercise and are usually performed
prone. However, we take care to avoid hyperextension,
which can strain the graft. As with the wall pushes, only
the operated extremity is strengthened to promote symmetry
between the legs. Generally this is begun at the end of the
third month or the beginning of the fourth month.
ADDUCTOR/ABDUCTOR STRENGTHENING
Hip abductor and adductor strengthening is done with the
knees flexed and the quadriceps relaxed to avoid ACL
strain, often in the sitting position with elastic tubing. In
month 5 it is also done in full extension. Isometric squeez-
ing of a ball placed between the knees is also performed.
THE GASTROCNEMIUS AND TRICEPS SURAE
Beynnon’s work has shown that gastrocnemius contraction
imparts strain to the ACL with no good way to counteract
it. Because the triceps surae is the strongest lever in the body
and triceps surae weakness has not been found to be a signifi-
cant rehabilitative problem after ACLR, we avoid gastrocne-
mius exercises (e.g., toe raises) until the fourth postoperative
month. Furthermore, we have found that specific isolated
triceps surae exercises can result in Achilles tendonitis.
We therefore usually rely more on cycling, elliptical training,
and running to rehabilitate this muscle group.
STAIRS
We encourage patients to step up with the normal leg and
down with the affected leg during the first 3 postoperative
months. Again, Beynnon’s research has shown stairs to
impart significant ACL strain.
LOWER EXTREMITY CYCLICAL LOADING
Cycling, Running, and Elliptical Training
There is no lower extremity cyclical loading exercise that
does not strain the ACL. Graft abrasion can also occur
before full tunnel healing has occurred. We therefore view
this as the highest-risk part of the rehabilitation protocol
and delay it until the fourth postoperative month, when all
fixation points should be well healed. Grafts are still weak
and still remodeling at this time but should be much better
able to withstand strain and tunnel abrasion than in the
 The Stability-Conservative Anterior Cruciate Ligament Reconstruction Rehabilitation Protocol
FIG. 66-3 The elliptical trainer provides excellent cardiovascular and
balanced muscular training.
earlier postoperative period. We begin with elliptical train-
ing (Fig. 66-3) and cycling in month 4. We allow running
in month 5. We delay the onset of running because it is
more likely than cycling and elliptical training to cause
patellofemoral symptoms. If tendonitis or patellar symptoms
start, we stop these exercises for a week or two and begin
again. Freestyle swimming can also be started at this time.
GAIT TRAINING
We keep patients non–weight bearing for 3 days in a brace
with range of motion (ROM) of 20 to 120 degrees. The brace
elevates the affected leg during gait, avoiding hamstring
fatigue. We keep patients non–weight bearing during this
time for their comfort. On the third or fourth postoperative
day, the brace is changed to 0 degrees of extension and full
flexion. At this time patients may continue wearing it or dis-
card it, as they prefer. Physical therapy is started for ROM and
also gait training. Gait training has two requirements: “no
pain and no limp.” To achieve this, the typical patient will
use two crutches for 2 to 3 weeks partial weight bearing, then
one crutch for 1 to 2 weeks. As they progress, patients will
continue to use more walking assistance for longer distances
walked. We stress that they should have a perfect gait without
any limp or pain before progressing from two to one to no
crutches. The goal is to develop smooth mid-stance knee flex-
ion without pain and inflammation. We counsel patients that
they should be in no hurry to discard their crutches.
PROPRIOCEPTION
The value of proprioceptive exercise is controversial, but we
begin them also in month 4 to allow healing of neural elements.
66
HAMSTRING VERSUS BONE–PATELLAR
TENDON–BONE
Our experience with this protocol is limited to the use of
HS grafts because we do not perform patellar tendon grafts.
It is possible that it is less suited for BPTB grafts due to
their greater tendency toward stiffness and quadriceps atro-
phy. Also, the more rapid healing of the bone plug in the
tunnel may decrease the risk of some of the features of the
accelerated program. Even if the accelerated program were
to decrease BPTB stability, it might be justified to avoid
greater problems with motion and atrophy. We think that
studies comparing somewhat less accelerated protocols after
BPTB would be useful in this regard. We would also sug-
gest that those using the accelerated program review
Dr. Shelbourne’s excellent chapter reviewing it in this text
(see Chapter 65). We believe the protections he provides,
especially in the first postoperative week, are not clearly
known to many and bear reviewing.
ALLOGRAFT REHABILITATION
Allografts are associated with lower stability rates (see
Chapter 69) and delayed recellularization (see Chapter 55).
For this reason we believe it is prudent to progress at a
slightly slower rate with allografts. We have no supporting
data, but we begin cyclical loading after 4 months instead
of 3 and allow full activities at 9 months instead of 6.
HOME VERSUS CLINIC THERAPY
In the first phase of therapy, when motion is being
restored, patients come to the clinic three times per week.
We teach patients how to perform their exercises at home
and taper the clinic visits quickly depending on the patient.
This is more convenient for the patient and helps conserve
scarce healthcare resources. Similarly, during strengthening
many patients attend only once per week.
EQUIPMENT
We do not use isokinetic strengthening equipment. We
believe that nonisokinetic resistive equipment provides a
more natural workout, particularly eccentrically. We use a
leg table for prone leg curls, a total gym for the quadriceps,
and exercise tubing. We use an elliptical trainer, a stationary
bike, and a NordicTrack cross-country ski machine for aer-
obic conditioning.
525
 Anterior Cruciate Ligament Reconstruction
STRENGTH TESTING
We strength test all patients by first testing their nonaffected
leg. Resistance is set so that they can accomplish between 10
and 25 repetitions of the given exercise. A clock or metro-
nome is used to control rate. A goniometer is used to specify
ROM. Their number of repetitions is recorded. For example,
for the leg curl a patient may be able to perform 20 prone leg
curls from 5 to 90 degrees with 15 pounds of weight with the
normal leg. The patient would then be tested on the
reconstructed extremity using the same parameters.
If the patient can perform 10 repetitions, the therapist
would report this as 50% hamstring strength or power
because, in this example, they performed 20 with the opposite
extremity. We strength test every 2 to 4 weeks. Many patients
from out of town perform rehabilitation on their own and
come in only for monthly or bimonthly physician visits. Prior
to this visit our therapist sees the patient and performs a
strength test, the results of which are then reported to me at
the visit. Hamstrings, quadriceps, adductors, and abductors
are tested in this fashion. Patients are followed until they have
achieved at least 95% strength. The overwhelming majority of
patients achieve this level by the time of their release to full
unrestricted activities at 6 months, and many exceed 100%.
RESULTS
This protocol has been associated with a 0% rate of graft
failure20 in both primary and revision ACLRs with no sig-
nificant permanent motion problems. Complete restoration
of strength by 6 months postoperatively has been routinely
obtained. Patients lose strength early postoperatively but
generally have little difficulty getting it back. The only
exceptions to this have been a small number of patients with
patellar degeneration, in whom intensive quadriceps loading
is avoided to avoid exacerbation of their symptoms.
SUMMARY OF PROTOCOL
Phase I: Restoration of Motion (brace use optional):
Timing: Begins postoperative day 3 until goals met,
usually by end of second postoperative week.
Range of motion: Exclusively passive ROM activities
by physical therapist, supplemented by patient’s family
or friends.
Goal: 0 to 115–120 degrees ROM. Hyperextension
and flexion beyond 120 degrees are specifically
prohibited.
526
Gait training: Weight bearing as tolerated gait with
two crutches progressing to one and then no crutches.
Goal: Pain- and limp-free gait to allow progression
from two to one to no crutches.
Phase II: Restoration of Strength—Affected Leg Only
Timing: Begins postoperative week 3 for
quadriceps wall push exercise, postoperative
month 4 for other muscle groups, until goals met.
We will sometimes begin the nonquadriceps muscle
group strengthening earlier for high-performance
athletes.
Hamstrings: Prone leg curls and other exercises,
avoiding hyperextension.
Quadriceps: Wall pushes (isometric supine at 90
degrees) progressing to short arc, 60 to 90 degrees
isotonic, in postoperative month 4 (see Phase III).
Abductors/Adductors: Performed sitting with knees
flexed.
Goal: Symmetrical strength. Strength tests are
performed every 2 to 4 weeks.
Phase III: Aerobic and Quadriceps Intensive Phase
Timing: Postoperative month 4 until goals met.
Elliptical/stationary bicycle/freestyle swimming:
Two to three times weekly, not to exceed 20 minutes,
at beginning of month 4.
Running: Begins fifth postoperative month if desired
by patient, two to three times weekly.
Quadriceps strengthening: 60- to 90-degree arc
begun in month 4. Full-arc quadriceps allowed in
month 5.
Goal: Aerobic fitness, full restoration of quadriceps
strength.
Phase IV: Unrestricted Activities
Timing: 6 months postoperative, if strength is at least
80% of opposite extremity.
Pivoting: Pivoting/jumping and all other activities
allowed without restriction and without bracing.
References
1. Blickenstaff KR, Grana WA, Egle D. Analysis of a semitendinosus
autograft in a rabbit model. Am J Sports Med 1997;25:554–559.
2. Milano G, Mulas PD, Sanna-Passino E, et al. Evaluation of bone
plug and soft tissue anterior cruciate ligament graft fixation over time
using transverse femoral fixation in a sheep model. Arthroscopy
2005;21:532–539.
 The Stability-Conservative Anterior Cruciate Ligament Reconstruction Rehabilitation Protocol
3. Weiler A, Peters G, Maurer J, et al. Biomechanical properties and vas-
cularity of an anterior cruciate ligament graft can be predicted by con-
trast-enhanced magnetic resonance imaging. Am J Sports Med
2001;29:751–761.
4. Rodeo SA, Arnoczky SP, Torzilli PA, et al. Tendon-healing in a bone
tunnel: a biomechanical and histological study in the dog. J Bone Joint
Surg 1993;75A:1795–1803.
5. Beynnon BD, Fleming BC, Johnson RJ, et al. Anterior cruciate
ligament strain behavior during rehabilitation exercises in vivo. Am
J Sports Med 1995;23:24–34.
6. Beynnon BD, Howe JG, Pope MH, et al. The measurement of
anterior cruciate ligament strain in vivo. Int Orthop 1992;16:1–12.
7. Shelbourne KD, Nitz P. Accelerated rehabilitation after anterior cruci-
ate ligament reconstruction. Am J Sports Med 1990;18:292–299.
8. Fleming BC, Beynnon BD, Renstrom PA, et al. The strain behavior
of the anterior cruciate ligament during bicycling: an in vivo study.
Am J Sports Med 1998;26:109–118.
9. Markolf KL, O’Neill G, Jackson SR. Effects of applied quadriceps and
hamstrings muscle loads on forces in the anterior and posterior
cruciate ligaments. Am J Sports Med 2004;32:1144–1149.
10. Prodromos CC, Joyce BT, Shi K, et al. A meta-analysis of stability
after anterior cruciate ligament reconstruction as a function of ham-
string versus patellar-tendon graft and fixation type. Arthroscopy
2005;21:1202–1208.
11. DeAndrade JR, Grant C, Dixon AS. Joint distension and reflex mus-
cle inhibition in the knee. J Bone Joint Surg 1966;47A:313–322.
12. Fahrer H, Rentsch HU, Gerber NJ, et al. Knee effusion and reflex
inhibition of the quadriceps. J Bone Joint Surg 1988;70B:635–638.
13. Jones DW, Jones DA, Newham DJ. Chronic knee effusion and aspira-
tion: the effect on quadriceps inhibition. Br J Rheumat 1987;26:370–374.
66
14. Konishi Y, Suzuki Y, Hirose N, et al. Effects of lidocaine into knee on
QF strength and EMG in patients with ACL lesion. Med Sci Sports
Exerc 2003;35:1805–1808.
15. Konishi Y, Fukubayashi T, Takeshita D. Possible mechanism of quad-
riceps femoris weakness in patients with ruptured anterior cruciate
ligament. Med Sci Sports Exerc 2002;34:1414–1418.
16. Morrissey MC. Reflex inhibition of thigh muscles in knee injury:
causes and treatment. Sports Med 1989;7:263–276.
17. Stokes M, Young A. The contribution of reflex inhibition to arthro-
genous muscle weakness. Clin Sci 1984;67:7–14.
18. Coleridge SD, Amis AA. A comparison of five tibial-fixation systems
in hamstring-graft anterior cruciate ligament reconstruction. Knee Surg
Sports Traumatol Arthrosc 2004;12:391–397.
19. Kousa P, Jarvinen TLN, Vihavainen M, et al. The fixation strength of
six hamstring tendon graft fixation devices in anterior cruciate
ligament reconstruction. Part II: tibial site. Am J Sports Med
2003;31:182–188.
20. Giurea M, Zorilla P, Amis AA, et al. Comparative pull-out and
cyclic-loading strength tests of anchorage of hamstring tendon grafts
in anterior cruciate ligament reconstruction. Am J Sports Med
1999;27:621–625.
21. Prodromos CC, Han YS, Keller BL, et al. Stability results of ham-
string anterior cruciate ligament reconstruction at two- to eight-year
follow-up. Arthroscopy 2005;21:138–146.
22. Renstrom P, Arms SW, Stanwyck TS, et al. Strain within the anterior
cruciate ligament during hamstring and quadriceps activity. Am
J Sports Med 1986;14:83–87.
23. Durselen L, Claes L, Kiefer H. The influence of muscle forces and
external loads on cruciate ligament strain. Am J Sports Med
1995;23:129–136.
527
67
Hamstring Regeneration Following
Harvest for Anterior Cruciate Ligament
Reconstruction: A Review of the Current
CHAPTER Literature
Andrew Riff Anterior cruciate ligament (ACL) reconstruction
is one of the most prevalent orthopaedic proce-
Mark D. Miller
dures, with more than 100,000 performed annu-
ally.1 The majority of these operations use
autograft donor tissue, with hamstring tendons
(either semitendinosus [ST] or semitendinosus
with gracilis [ST/Gr]) recently gaining approval
in relation to the traditionally favored bone–
patellar tendon–bone (BPTB) graft. Historically,
the BPTB graft has been advocated for a number
of reasons, including its well-described regrowth
phenomenon, which involves the reconstitution
of its central third following harvest. However,
supporters of hamstring grafts cite potential
patellofemoral pain, patellar tendonitis, tendon
rupture, and patellar fracture as possible disad-
vantages of BPTB use.2–5 In 1992, Cross et al
reported the regeneration of the hamstring ten-
dons following harvest, a notion that has been
supported with increasing evidence in the litera-
ture.6 Overall, as a result of this regeneration of
the harvested tendon, hamstring strength has
been found to reach near-normal levels 1 year
postoperatively. This regeneration is termed the
lizard tail phenomenon. The validation of such a
phenomenon may offer an additional advantage
for the use of hamstrings in ACL reconstruction.
This chapter will review and summarize the
literature to date examining the morphological
and functional regeneration of harvested ST/Gr
tendons from a radiographic, functional, and
histological standpoint. It must be noted that
relevant studies are somewhat difficult to com-
pare due to unavoidable differences in follow-
up, rehabilitation protocol, and testing methods
528
found in the literature. Additionally, some stud-
ies confer results following ST/Gr harvest,
whereas others evaluate those involving only
ST harvest.
RADIOGRAPHIC STUDIES
A number of studies have attempted to describe
the morphological aspect of regeneration using
the radiographic images of the ST and Gr
tendons following harvest. These studies have
provided information concerning the extent of
regeneration, the location of the regenerate tissue,
and the presence or absence of muscle atrophy. In
the study conducted by Cross noted previously,
magnetic resonance imaging (MRI) evaluation of
four patients (6 months postoperatively) displayed
tendonlike tissue extending from the hamstring
muscle bellies to the medial gastrocnemius
(Fig. 67-1).6 In this case, insertion appeared to
be diffused into the medial popliteal fascia, but
electromyographic examination revealed normal
muscle activity and innervation patterns in the
hamstring. Simonian et al similarly reported prox-
imal insertion of the regenerate ST tendon.7 In
contrast with common trends in the literature,
however, no compensatory hypertrophy of the
biceps femoris, semimembranosus (SM), or sarto-
rius was appreciable when compared with the
unaffected side.
A number of papers by Eriksson et al have
reported MRI imaging of regenerate hamstring
following harvest of the ST tendon. In the first
(1999), they reported ST regeneration to the
 Hamstring Regeneration Following Harvest for Anterior Cruciate Ligament Reconstruction: A Review of the Current Literature
FIG. 67-1 This T1-weighted sagittal magnetic resonance image of the knee
shows a “thickened band of tissue” where the hamstring tendon has
regenerated.
level of the proximal tibia in 8 of 11 patients evaluated 6 to 12
months postoperatively, whereas in the other three patients
the remnant ST fused with the SM tendon proximal to the
joint line.8 Those patients with regenerate distal ST demon-
strated fusion of the ST and Gr approximately 30 mm distal
to the joint line with insertion as a conjoint tendon on the
pes anserinus. The authors suggested that the precise level
of union is insignificant as long as it is distal to the joint line.
The proximal cross-sectional area of the ST also differed
between groups. This measure averaged 91% of the contralat-
eral tendon in those with distal regeneration and 79% in
those without distal regeneration. In a second study (2001),
Eriksson et al evaluated six patients who ranged from 7 to
28 months following ACL reconstruction, using only the
ST graft.9 MRI imaging displayed regeneration of ST tissue
in five of the six patients to the pes insertion site, averaging
approximately 30 mm distal to the joint line. The sixth
patient had no evidence of a new tendon 24 months after
surgery. Concurrently in 2001, Eriksson and Hamberg
published another study in which patients underwent MRI
between 6 and 12 months after ST harvest.7 In this case, 12
of the 16 patients displayed radiological evidence of ST
regeneration in which the new tendon fused with the (non-
harvested) Gr 10 to 30 mm below the joint line and inserted
on the pes as a conjoined tendon. Although some ST atrophy
was notable in all patients, significantly more was appreciable
in patients without tendon regeneration. In those patients
without regeneration, however, compensatory SM hyper-
trophy was more extensive.
Rispoli et al performed their study in a different man-
ner, attempting to provide radiographic documentation
67
of tendon regeneration in 21 patients at distinct time intervals
ranging from 2 weeks to 32 months following ACL surgery
using ST/Gr.5 However, they did not sequentially image
any individuals. At the points shortly following surgery, fluid
and edema in the tendon tracts were noted, and tendonlike
tissue reached the superior patellar pole 6 weeks after surgery.
Presence of the tendons below the joint line arose at variable
intervals, arising anywhere from 3 to 12 months postopera-
tively. Papandrea et al also observed similar linear develop-
ment in a study using sequential ultrasounds of 40 patients
at 2 weeks, and 1, 2, 3, 6, 18, and 24 months after surgery
using ST/Gr.10 This study documented a course of matura-
tion proceeding from ill-defined hypoechogenic tissue early
on to hamstring hypertrophy in the first year, before a distinct,
well-defined tendon signal developed between 18 and 24
months. This study noted a more proximal insertion into
the medial popliteal fascia than normal.
This process has been further documented by multiple
other studies as recently as 2004. Nakamura et al used MRI
and three-dimensional computed tomography (3D-CT)
scans in a retrospective study assessing ST regeneration in
eight patients, each a minimum of 2 years postoperative.11
In five of eight patients, distinct tendonlike tissue was
observed running along the same course as the native
hamstrings, the most notable difference being distal attach-
ment to the medial popliteal fascia. In the remaining three
subjects, the residual ST fused proximally into the SM muscle
belly. The study apparently observed similar regeneration of
the Gr, but an explicit description was not included. Tadokoro
et al also imaged 28 patients with MRI at a minimum of
2 years following ACL reconstruction with ST/Gr.12 This
study reported regeneration of 22 of 28 ST tendons and 13
of 28 Gr tendons, with no differences in cross-sectional area
between surgical and contralateral knees. More impor-
tantly, they found that there was no correlation between
morphological regeneration and peak flexion strength in
high degrees of flexion (90 and 110 degrees) in both prone
and supine positions despite less strength in affected limbs.
Williams et al also performed MRI on eight patients
both preoperatively and at the point of return to sports (an
average of 6 months after reconstruction using ST/Gr).13
Seven of the eight patients exhibited regenerate tendons;
however, the majority of the tendons had not yet inserted
on the tibia at the point of imaging. Overall volume of the
ST and Gr muscles diminished by an average of 30%, and
in contrast with Tadokoro’s study, this extent appeared to
correlate well with the extent of tendon regeneration. Addi-
tionally, much like Eriksson’s study, compensatory hyper-
trophy of the SM and biceps femoris muscles was noted.
Nakamae et al also used 3D-CT to gain a better sense
of the full-length morphology of the regenerate tissue by
imaging 29 patients at various time points.14 A 3D-CT
529
 Anterior Cruciate Ligament Reconstruction
FIG. 67-2 Gross morphology of regenerate (R) and native (N) rabbit
hamstring tendons. Compared with the native tendon, the regenerate
tendon is highly variable in size and was found to attach to the tibia at
variable locations.
examination was performed in all patients preoperatively,
24 patients at 1 month, 8 patients at 3 months, 21 patients
at 6 months, and 20 patients at 12 months postoperatively
following ST harvest only. Although no patients had evidence
of regeneration at 1 month after surgery, a regenerate tendon
was detected in all but two patients at 12 months after
surgery, with the regenerate tissue coursing as expected
from the muscle bellies to the normal insertion site on the
proximal tibia.
Although there is a perception that regeneration occurs
almost universally, it is not an entirely predictable phenome-
non. For reasons not fully understood, a small percentage of
patients in a number of studies lack regenerate tendons.
Notably, two studies by Eriksson and one by Hioki et al report
17%, 18%, and 45% of patients with failed regrowth, respec-
tively.3,9,15,16 Additionally, among the population with evi-
dence of regrown tissue, the regenerate tendon frequently
ranges in size and diverges from the expected insertion site,
inserting proximally and medially to the pes anserinus
(Fig. 67-2). This varied insertion could have important bio-
mechanical consequences that explain varied strength of knee
flexion and internal rotation. A more proximal insertion
shortens the tendon’s moment arm, inhibiting the muscle’s
ability to flex the knee. Additionally, in the case of documen-
ted insertion on the medial popliteal fascia, a more lateral
insertion hinders the hamstring muscles from generating
internal torque and resisting external rotation of the tibia.
FUNCTIONAL STUDIES
Numerous studies have also examined hamstring strength
following tendon harvest. Postoperative leg strength has been
530
a concern since at least 1982, when Lipscomb et al published
a retrospective evaluation of 482 cases involving either
ST or ST/Gr harvest.17 Impressively, none of the subjects
in this study displayed significant loss of knee flexion
strength at an average of 26 months postoperatively. Speci-
fically, hamstring strength averaged 99% of the normal
knee when ST/Gr was used and 102% when the Gr was not
harvested.
More widespread interest in the subject of strength
regeneration peaked in the early 1990s, aroused by two
noteworthy studies. The aforementioned four-patient study
by Cross et al demonstrated minimal decreases (averaging
less than 10%) in peak flexion and extension strength in
three of the four patients, whereas the fourth patient actually
displayed improved strength measurements.6 Concurrently,
Marder et al published contradictory results in a study com-
paring hamstring strength between patients with ipsilateral
ST/Gr grafts and BPTB grafts.18 In the group who under-
went ST/Gr graft harvest, the study noted a 17% decrease in
isokinetic knee flexion strength. Eriksson et al similarly
documented vast strength deficiencies relative to the unaf-
fected leg in the peak torque of hamstrings (–25%) and
quadriceps (–50%) during both concentric and eccentric
testing in 16 patients ranging between 8 and 18 months
after surgery.3 This comprehensive, overwhelming weakness
may indicate inadequate postoperative rehabilitation. Details
of the postoperative protocol were not provided.
Despite these inconsistent findings, more recent
studies examining knee flexion strength have generally
documented minimal or no deficits in peak torque following
both ST and ST/Gr harvest.19,20 Yasuda et al demonstrated
this most favorably in their prospective examination of peak
torque after ST/Gr harvest from either the ipsilateral or con-
tralateral leg.21 Neither circumstance exhibited significant
decrease in flexion strength after the immediate postopera-
tive period was surpassed. More detailed examinations,
however, have found slight divergence in torque assessment.
A study conducted by Adachi et al evaluated 58 patients
with regard to peak torque, peak torque angle, and total
work at an average of 2 years after ACL reconstruction using
ST, ST/Gr, or allograft tissue.2 Much like their counter-
parts, they found very little difference in peak strength or
total work between groups; however, the autograft groups
exhibited peak torque at a significantly shallower angle than
in the allograft group. Ohkoshi et al likewise noted no dif-
ference in peak torque flexion and quantified the significant
decrease in peak torque angle at about 11 to 15 degrees after
evaluating 25 patients following ST harvest.22 The study
theorized that this decrease in peak torque angles is attribut-
able to compensation by flexor muscles that have peak
torque at a shallower angle than the hamstrings. Irie and
Tomatsu used cybex testing to assess the flexor strength of
 Hamstring Regeneration Following Harvest for Anterior Cruciate Ligament Reconstruction: A Review of the Current Literature 67
13 patients at 12 to 16 months after ST/Gr or Gr har- possible. Additionally, on account of the overwhelming
vest.23 Such testing yielded no difference in maximum decrease in strength, the authors encourage a rehabilitation
torque but demonstrated a 25% deficiency in total work protocol with exercises specifically focused on improving
possible at angles of flexion greater than 75 degrees. internal rotation strength. Nevertheless, studies have yet to
In a more recent study, Nakamura et al evaluated 74 correlate deficiencies in either knee flexion strength or inter-
consecutive patients 2 years after ST or ST/Gr surgery and nal rotation strength with functional shortcomings or
found that peak torque flexion was greater than 90% of that impaired athletic performance.
in the unaffected knee.24 Consistent with other studies,
peak torque at 90 degrees was again deficient in the ST
and ST/Gr groups alike. In one of the only prospective ran- HISTOLOGICAL STUDIES
domized analyses of the subject, Tashiro et al randomly
It has long been theorized that neotendons observed on
assigned 90 patients to ACL reconstruction with either
MRI were merely scar tissue. Although radiographic and
ipsilateral ST or ST/Gr autograft.25 The authors examined
functional studies have demonstrated conclusively that har-
peak flexion torque at 6, 12, and 18 months, finding that
vested hamstring tendons regenerate in the same orientation
the ST and ST/Gr groups did not differ significantly from
and with the same strength as native tendons, only recently
one another and that torque was only diminished at the
have surgeons performed histological or biomechanical
6-month point, after which it returned to preoperative
studies to assess the quality of the regenerate tissue. In the
levels. This study also noted significantly less recovery at
Eriksson and Hamberg study assessing MR images of
high angles in both groups, with hamstring strength
regenerate tissue, biopsies of hamstring muscle tissue preop-
decreases of up to 30% at angles greater than 70 degrees.
eratively and postoperatively were also evaluated.3 Evalua-
In the CT imaging study by Nakamae et al described previ-
tion revealed that the cross-sectional area of the muscle
ously, isokinetic measurements at 60 degrees of knee flexion
fibers trended toward small values in regenerate tissue;
demonstrated a strength deficiency in which peak torque
however, the fiber composition and citrate synthetase activ-
was an average of 68% of the control side at 6 months and
ity remained consistent with native tissue (Fig. 67-3). In
increased to 83% by 12 months.14
another study of the same group, Eriksson at al examined
All in all, the studies universally demonstrate that defi-
and compared the peripheries of five regenerate ST tendons
cits in postoperative knee strength, especially in flexion, are
with normal tendons.9 In this case, the regenerate collagen
minimal in cases of both ST and ST/Gr tendon harvest.
fibers held the same alignment and breadth as the control
The only exception to this conclusion is somewhat dimin-
tendons and exhibited uniform staining, with the excep-
ished strength at high angles of flexion. Due to the limits of
tion of the appropriate forms of collagen. There were also
strength testing, it cannot be discerned whether the mainte-
appreciable small areas of irregularity in collagen
nance of flexion strength is a result of hamstring regeneration
orientation and increased fibroblast and capillary formation,
or the compensatory hypertrophy of other hamstring muscle–
indicating the presence of scar-like tissue.
tendon units. A few recent studies suggest that internal tibial
Likewise, Ferretti performed histological analysis of
rotation torque may be a better indication of the extent of
regenerate tissue from three patients at 6, 24, and 27 months
regeneration than pure flexion strength. Viola et al found that
after surgery at the time of routine hardware removal.29 At the
among 23 patients who had undergone ACL reconstruction
histological level, the neotendon is initially (at 6 months) a
with ST/Gr, internal tibial rotation torque was approximately
fibrous structure with fibroblastic proliferation and capillaries
10% to 15% of the contralateral limb at an average of 51
but few collagen fibers. However, over time (at the latter two
months postoperatively (observed at all velocities; 60, 120,
time points) the neotendon acquires qualities consistent
and 180 degrees/sec).26 Similarly, Armour et al discovered
with a healthy tendon demonstrating thicker, longitudinally
internal rotation deficits in the operated leg measuring
oriented fibers. However, small focal regions of scar tissue and
between 12% and 15% at a 2-year minimum follow-up.27
irregular collagen orientation often persist long after harvest.
This study more specifically targeted the knee joint by limit-
This compositional inconsistency may alter biomechanical
ing motion at the ankle joint during strength testing. Segawa
properties of the reconstituted tendon.
et al also observed comparable results in assessing internal tib-
ial torque in 32 patients with ST grafts and 30 patients with
ST/Gr grafts at 1 year postoperative.28 Internal rotation ANIMAL MODELS
strength was again considerably less than the contralateral
leg. The diminished internal rotation strength was more Animal models of tendon regeneration are quite useful in
markedly present when the Gr was also harvested, leading offering trends in regeneration for a large data source.
the authors to recommend harvest of only the ST whenever Two studies by Miller et al used MRI as well as

531
 Anterior Cruciate Ligament Reconstruction

R N

100

Native
90 Regenerate
Poly. (Native)
80 Poly. (Regenerate)

70

60
Fibril number

50

40

30

20

10

0
14 28 42 56 70 84 98 112 126 140 154 168 182 196 210 224 266
Tendon fibril diameter (nm)
FIG. 67-3 Electron microscopy of 500 fibrils counted at 76,000 magnification and distribution of collagen fibril
diameters from native (N) and regenerate (R) rabbit hamstring tendons at 28 weeks after harvest. The average
diameter of the collagen fibrils in the regenerate tendon is significantly smaller than that of the native tendon.

histological and biomechanical evaluation of New Zealand

white rabbits to evaluate tendon regeneration. In the first
study, each of 10 rabbits demonstrated radiologic evidence
of some regenerate tissue at 16 or 28 weeks.30 MRI indi-
cated a process from wavy regenerate tissue stopping short
of the tibia at 16 weeks, becoming taut and inserting on
the ST insertion site by 28 weeks. This course of matura-
tion was mirrored in histological examination. Microscopic
examination at 16 weeks displayed wavy collagen fibers
turning into healthy tendinous fibers by 28 weeks. The ten-
dons also appeared to strengthen with maturation as indi-
cated by tensile biomechanical testing (Fig. 67-4).
However, at both time points the regenerate tissue with-
held significantly less maximum load to failure than native FIG. 67-4 Tendon undergoing biomechanical tensile strength testing to
tissue (by 77% at 16 weeks and 48% at 28 weeks). assess tissue strength.

532
 Hamstring Regeneration Following Harvest for Anterior Cruciate Ligament Reconstruction: A Review of the Current Literature
A more comprehensive analysis of regenerate rabbit
tendons was reported in a follow-up study conducted by
Miller and Gill et al.31 In follow-up, ST tendons appeared
to regenerate at 9 to 12 months after harvest in 26 of 31
of the rabbits evaluated. However, the neotendon was highly
variable in size and tibial insertion site. The tissue resembled
native tendon in cellularity and immunolocalization of type
I collagen, fibril size was markedly smaller, fibril orientation
was more irregular, and regenerate tendon composition
contained significantly lower levels of proteoglycan than
native tissue. Detailed biomechanical examination in the
same study demonstrated significantly lower maximum
loads to failure and structural stiffness (approximately 25%
of control tendons) in regenerate tissue. The regenerate
tendons’ inferior biomechanical qualities strongly suggest
inferior material properties of the tissue. However, because
measures were not precisely taken, it may also be at least
partly attributable to smaller cross-sectional areas of the
regenerate tissue.
FUTURE DIRECTIONS
The precise mechanism of regeneration and the desirable
qualities for strong biomechanical performance are not well
understood. It is hypothesized that the regeneration process
likely begins at the more proximal vascular areas and extends
distally as extrasynovial hematoma collects along fascial
planes and acts as a scaffold for fibroblast precursor cells.
Carofino et al notes, however, that the fascial planes could
not possibly constrict a regenerate tendon to dimensions
and shape similar to the original because the medial knee
does not form a well-defined tubular structure necessary
for precise reconstitution.15 Despite the primitive state of
our knowledge, surgeons have begun to propose the use of
regenerate tendon for revision surgeries. Yoshiya et al
describe the reharvesting of hamstrings for revision ACL
reconstruction, 8 months following the index reconstruction
in a 2004 case study.32 At the time of surgery, Yoshiya
obtained a biopsy of the regenerate tissue that displayed
significant smaller diameter of collagen fibrils compared
with normal tendons. Although it is premature to make an
overarching assessment, the patient was reportedly doing
well at 6 months postoperatively. The authors appropriately
note that it is too early to make a determination on the via-
bility of regenerate grafting on a routine basis.
CONCLUSIONS
The current literature has overwhelmingly established that
despite a small subset of the patient population having an
67
unexplainable lack of regrowth, the ST and Gr tendons
regenerate to some degree in the vast majority of patients.
Additionally, nearly all subjects, including those without full
regeneration, recover preoperative levels of flexion strength
with minimal functional deficit. This recovery is a conse-
quence of simultaneous regeneration of the ST and Gr ten-
dons and compensatory hypertrophy of the SM and biceps
femoris muscles. In any given patient, however, the extent
of tissue regeneration and reinsertion site for the neotendon
are unpredictable. The new tissue has been shown to insert
on the popliteal fascia and medial gastrocnemius in addition
to the pes anserinus. The quality of the regenerate tissue
has been shown to be histologically inferior as well.
Although the new tissue has collagenous properties, it is less
ordered and performs poorly in biomechanical testing rela-
tive to normal tendons. The intrinsic low morbidity of ham-
string harvest coupled with increasing documentation of
tendon regeneration makes ST and ST/Gr grafts increas-
ingly popular options for ACL reconstruction. Future stud-
ies will be necessary to verify natural and controllable factors
that improve the likelihood of anatomical regeneration and
the feasibility of reharvesting regenerate tissue for revision
ACL reconstruction.
References
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ACL reconstruction influences postoperative hamstring muscle perfor-
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 Anterior Cruciate Ligament Reconstruction
12. Tadokoro K, Matsui N, Yagi M, et al. Evaluation of hamstring
strength and tendon regrowth after harvesting for anterior cruciate
ligament reconstruction. Am J Sports Med 2004;32:1644–1649.
13. Williams GN, Snyder-Mackler L, Barrance PJ, et al. Muscle and
tendon morphology after reconstruction of the anterior cruciate liga-
ment with autologous semitendinosus-gracilis graft. J Bone Joint Surg
2005;86A:1936–1946.
14. Nakamae A, Deie M, Yasumoto M, et al. Three-dimensional com-
puted tomography imaging evidence of regeneration of the semitendi-
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myth, and clinical implication. Arthroscopy 2005;21:1257–1264.
16. Hioki S, Fukubayashi T, Ikeda K, et al. Effect of harvesting the
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17. Lipscomb AB, Johnston RK, Snyder RB, et al. Evaluation of ham-
string strength following use of semitendinosus and gracilis tendons
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18. Marder RA, Raskind JR, Carroll M. Prospective evaluation of arthros-
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21. Yasuda K, Tsujino J, Ohkoshi Y, et al. Graft site morbidity with
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22. Ohkoshi Y, Inoue C, Yamane S, et al. Changes in muscle strength
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23. Irie K, Tomatsu T. Atrophy of semitendinosus and gracilis and flexor
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24. Nakamura N, Horibe S, Sasaki S, et al. Evaluation of active knee
flexion and hamstring strength after anterior cruciate ligament recon-
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25. Tashiro T, Kurosawa H, Kawakami A, et al. Influence of medial
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26. Viola RW, Sterett WI, Newfield D, et al. Internal and external tibial
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Suggested Reading
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 Proprioception and Anterior Cruciate
Ligament Reconstruction
Many modern rehabilitation programs for
patients who have undergone anterior cruciate
ligament (ACL) reconstruction incorporate
exercises and drills that are directed toward
improving neuromuscular function and coor-
dination. They are often loosely referred to as
proprioceptive training exercises. This chapter
explores the basis for the incorporation of such
exercises into rehabilitation following ACL
reconstruction.
The human ACL has been shown to con-
tain mechanoreceptors including Golgi tendon
organs, Pacinian corpuscles, and Ruffini nerve
endings.1,2 These receptors contribute to pro-
prioception about the knee joint and are also
believed to form part of a reflex arc in which
an anterior displacement of the tibia results in
hamstring muscle contraction. Such a reflex
presumably serves to protect the knee, and the
ACL in particular, from such stresses. ACL
rupture can therefore be expected to result in
disruption or alterations of these pathways.
The term proprioception has proved diffi-
cult to define succinctly and has similarly been
tested and measured by a variety of techniques.
The definition of proprioception is generally
agreed to include joint position sense and the
ability to detect joint movement (kinesthesia).
These have been measured by joint position
matching tasks and by threshold to detection
of passive movement tasks, respectively. Overall,
it appears that threshold to detection methods
have proved more reliable, although the two
types of tests address different aspects of
proprioception.
68
CHAPTER
Another approach has been to use tests of Julian A. Feller
neuromuscular function. These involve both
Kate E. Webster
afferent and efferent components and therefore
test not only proprioception but also the muscu-
lar response. Examples of such tests are (1)
measurement of latency of hamstring muscle
contraction following the application of an
anterior displacement force to the tibia and (2)
stabilometric tests in which the movement of
the center of pressure is measured during a
single leg stance. More global functional tests
include the various hop tests.
When assessing proprioception or neuro-
muscular function following ACL rupture and
subsequent reconstruction, some fundamental
issues need to be considered. Because alterations
in the uninjured limb have been reported by
some authors, it is important to include a group
of control subjects. Longitudinal studies are
probably of greater benefit than studies using
only one point in time, as deficits have been
demonstrated to change over time following
both injury and reconstructive surgery. The type
of graft used is also relevant for tests involving a
hamstring muscle response.
Using a threshold to detection of passive
movement test, Barrack et al3 demonstrated a
significantly higher threshold value in ACL
deficient limbs compared with the normal con-
tralateral limb in a group of 11 patients tested
3 months following ACL rupture. A group of
control subjects showed virtually identical
threshold values for both knees. The higher
threshold values were attributed to a loss of pro-
prioceptive function. Numerous authors have
535
 Anterior Cruciate Ligament Reconstruction
also described the presence of deficits attributable to loss of
proprioception in ACL deficient knees, whereas some
authors have shown no differences between injured and
contralateral or healthy control subject knees (for review,
see Reider et al4). For instance, Pap et al5 found a higher
rate of failure to detect passive movement in ACL deficient
knees compared with the contralateral knee or healthy con-
trol subjects’ knees. However, unlike Barrack et al, they did
not find any difference in the threshold to detect passive
movement among any of the knees.
Beard et al6 measured the latency of reflex hamstring
contraction in response to an anteriorly directed shear force
to the upper calf in 30 patients with an ACL rupture. They
found significantly greater latencies in the ACL deficient
knees compared with the contralateral knees. Interestingly,
the frequency of giving-way episodes reported by the
patients correlated with the latency differential between
their two limbs.
Many authors have evaluated proprioception follow-
ing ACL reconstruction, but they have reported conflicting
results. This may be due in part to the different methodol-
ogies employed. Various tests of proprioception have been
used (joint position sense, threshold to detect passive move-
ment, reaction time, and stabilometric testing). ACL recon-
structed knees have been compared with either the
contralateral knee, healthy control subject knees, or in some
instances to both. Most studies have evaluated patients at
only one time point, although some have followed patients
over time from preoperatively to as long as 3.5 years postop-
eratively. The results of studies that have either used a con-
trol group of subjects or provided longitudinal follow-up
have been summarized in Tables 68-1 and 68-2.
From Table 68-1 it can be seen that the ACL recon-
structed knees have been shown to be either equivalent to or
worse than healthy control subject knees. The length of
follow-up does not appear to explain the disparate findings.
Four of the five studies that found no difference used joint
position sense as a measure of proprioception, whereas only
two of the five studies that found the ACL reconstructed knees
to be inferior used this method of testing proprioception.
Two of the longitudinal studies used joint position
sense as a measure of proprioception, whereas one used
threshold to detect passive movement and another used
both joint position sense and threshold to detect passive
movement. Iwasa et al7 evaluated joint position sense in
38 subjects before ACL reconstruction using a hamstring
tendon graft and every 3 months after surgery to 24 months.
There was an improvement in joint position sense from
9 months through 18 months, but there was a small group
of eight in whom joint position sense did not improve.
A correlation was observed between better stability and
better joint position sense.
536
Fremerey et al8 measured joint position sense in 20
patients with chronic ACL deficiency who underwent a
patellar tendon ACL reconstruction as well as in 20 control
subjects and 20 patients with an acute ACL rupture. Preop-
eratively the chronic ACL deficient knees had significantly
better joint position sense than acute ACL deficient knees
but were worse than control subjects’ knees. Following sur-
gery there was an improvement, most of which occurred
between 3 and 6 months. There was some further improve-
ment at 3 years, although a small deficit remained in the
operated knee for mid-range positions.
Reider et al4 undertook a longitudinal study of 26
patients undergoing ACL reconstruction and measured
both joint position sense and threshold to detect passive
movement preoperatively at 3 and 6 weeks and at 3 and 6
months postoperatively. They used both the contralateral
knees as well as the knees of healthy volunteers as controls.
The authors concluded that threshold to detect passive
movement was a more reliable method than joint position
sense for testing proprioception. In the patient group there
was no significant difference in the threshold between the
injured and contralateral knee at any of the time points.
Both knees were significantly worse than the healthy con-
trols preoperatively. However, both knees improved postop-
eratively such that they were not significantly different than
healthy control knees at 6 months postoperatively.
The authors noted that improvements in propriocep-
tion were seen as early as 6 weeks following ACL recon-
struction. Such a short time period is not consistent with
reinnervation of the graft being the basis of the improve-
ment. The authors, as well as Iwasa et al,7 suggest that the
improvement is probably due to the provision of a static
restraint that reduces abnormal afferent activity from the
capsule and other ligaments.
A number of authors have investigated the role of
rehabilitation protocols designed to improve proprioception
and neuromuscular function in patents with ACL ruptures
(for review, see Cooper at al9). Such protocols have been
associated with some limited improvements in joint position
sense and hop testing as well as muscle strength and subjec-
tive rating when compared with traditional strengthening
programs. In a group of 50 patients with ACL deficiency,
Beard et al10 compared a muscle-strengthening rehabi-
litation protocol with a program designed to enhance
proprioception and reduce the latency of reflex hamstring
contraction. The proprioceptive program was associated
with greater improvements in reflex hamstring contraction
latency and functional scores compared with the strength-
ening program.
Perhaps as a result of the use of such proprioceptive
programs in patients with ACL rupture, proprioception-
related exercises are now frequently included in
 Proprioception and Anterior Cruciate Ligament Reconstruction 68
TABLE 68-1 Studies Comparing Proprioception Between Patients after Anterior Cruciate Ligament Reconstruction (ACLR) and Controls
Study Sample Details Proprioception Outcome
Measure

ACLR Group Equivalent to Control Group

Al-Othman, 22 ACLR, all male, all PT graft, 1–6 yr post surgery (mean 3.6 yr), 30 controls Joint position sense (standing
15
2004 position)
16
Ochi et al, 1999 23 ACLR, 13M:10F, 22 HS graft, 1 fascia lata graft, minimum 18 mo postsurgery, 14 controls Joint position sense
(9M:5F)

Roberts et al, 20 ACLR, 15M:5F, all PT grafts, mean 24 mo postsurgery, 19 controls (14M:5F) Joint position sense
200017

Co et al, 199318 10 ACLR, 5M:5F; 8 PT grafts, 2 HS grafts, mean 31.6 mo postsurgery, 10 controls (5M:5F) Joint position sense
Threshold to detect passive
movement

Risberg et al, 20 ACLR, 8M:12F, all PT grafts, 11–32 mo postsurgery (mean 24 mo), 10 controls (5M:5F) Threshold to detect passive
199919 movement
ACLR Group Worse than Control Group

Barrett et al, 45 ACLR, 33M:12F, all PT grafts, 1–7 yr postsurgery (mean 3.2 yr), 20 age-matched controls Joint position sense
199120

Bonfim et al, 10 ACLR, 7M:3F, 12–30 mo postsurgery (mean 18 mo), 10 controls (7M:3F), height and Joint position sense
200321 weight matched Hamstring muscle latency
Performance at maintaining upright
stance
Threshold to detect passive
movement

Roberts et al, 20 ACLR, 15M:5F, all PT grafts, mean 24 mo postsurgery, 19 controls (14M:5F) Threshold to detect passive
17
2000 movement

Kaneko et al, 17 ACLR, 8M:9F, all HS/Leeds-Keio grafts, 2–3 mo post surgery, 18 controls, 20 athletes Maximum voluntary isometric
200222 (training control group) contraction

Shiraishi et al, 53 ACLR, 22M:31F, all facia lata grafts, minimum 2 yr post surgery, 30 controls (15M:15F) Stabilometric assessment
23
1996

F, Female; HS, hamstring; M, male; PT, patellar tendon.

rehabilitation programs following ACL reconstruction (for
an example, see Risberg et al11). However, there is very little
literature on the effects of the inclusion of such exercises.
Liu-Ambrose et al12 studied 10 patients at a mini-
mum of 6 months following ACL reconstruction with a
semitendinosus tendon graft. They were randomly allocated
to an isotonic strength-training program or a proprioceptive
training program. Both programs involved three sessions per
week for a period of 12 weeks. The proprioceptive training
program was based on previously described exercises. Pro-
gression was achieved by decreasing the base of support,
decreasing the stability of the surfaces on which the exer-
cises were performed, increasing the number of repetitions,
reducing visual feedback, and increasing the speed and
complexity of the tasks. Progression of the strength-training
program was achieved by increased loading.
Outcome measures included average isokinetic tor-
ques for the quadriceps and hamstring muscle groups at
45 degrees/sec, two hop tests (single leg hop for distance
and single leg timed hop), and the peak torque time of the
hamstring muscle group. The latter is the time to generate
maximal torque in response to a sudden forward movement
of the dynamometer arm.
The proprioceptive training group demonstrated
greater percentage gains in average isokinetic torques for
concentric quadriceps contraction and eccentric hamstring
contraction in the operated limb. However, it should be
noted that the proprioceptive training group had lower

537
 Anterior Cruciate Ligament Reconstruction

TABLE 68-2 Longitudinal Studies

Study Sample Size Testing and Follow- Proprioception Outcome Results Summary
Up Time Measures

Fremery Group 1: Group 1: within 12 Joint position sense Acute ACL worse than chronic ACL group.
et al, acute ACL days of injury ▪ Reproduction of passive positioning Chronic ACL group worse than control
20008 rupture, Group 2: before at a constant velocity preoperatively but showed significant improvement
N ¼ 10 surgery, 3 mo, 6 mo, ▪ Testing intervals of extension 6 mo after ACLR with values similar to control
Group 2: and 3–4 yrs after ACLR (0–20 degrees), mid-range (40–60 group and contralateral side, except for mid-range
chronic ACL degrees), flexion (80–100 degrees) positions. Continued to improve to 3 yr, although
rupture, a small deficit was still present for mid-range
N ¼ 20 positions.
Control,
N ¼ 20

Iwasa ACL rupture, Before surgery, then Joint position sense Significant improvement from preoperative values
et al, N ¼ 38 every 3 mo for 24 mo ▪ Active reproduction of passive knee seen from 9 mo onward. Most patients improved by
7
2000 after ACLR position 18 mo, but 21% failed to show any improvement.
▪ Tested every 5 degrees from 5–25
degrees of flexion

Reider ACL rupture, Before surgery, 3 wk, Joint position sense Joint position sense: Reconstructed knee equivalent
et al, N ¼ 26 6 wk, 3 mo, and 6 mo ▪ Active reproduction of passive or better than both contralateral knee and
20034 Control, after ACLR knee position control group at all time points.
N ¼ 26 ▪ 10 randomly selected positions Threshold to detect passive movement: ACL
Threshold to detect passive movement group worse than control group preoperatively but
▪ 15 degrees start position with the no difference at any other time point after
knee moved into flexion or reconstruction.
extension

Valeriani ACL rupture, Before surgery, greater Threshold to detect passive movement: ACL group worse than contralateral side
et al, N¼7 than 2 yr after ACLR 40 degrees start position with movement preoperatively and showed no improvement after
199924 between 30 and 40 degrees ACL reconstruction.

ACLR, Anterior cruciate ligament reconstruction.

baseline average isokinetic torque values for both quadriceps
and hamstring muscle groups. This may relate to the greater
proportion of females or to the shorter time from surgery in
this group. There was no difference between the groups for
the hop tests or in peak torque time.
In a larger study of 29 patients, Cooper et al13 com-
pared two different rehabilitation protocols following pri-
mary ACL reconstruction. Thirteen subjects in each group
had undergone a four-strand hamstring tendon reconstruc-
tion, with the remainder having had a patellar tendon
reconstruction. The patients were randomized to one of
two 6-week physiotherapy programs, commencing between
4 and 14 weeks postoperatively, once they had achieved
the following criteria: ability to walk without aids, 0 to
120 degrees of range of motion in the operated knee,
straight leg raising without any extensor lag, and no or min-
imal joint effusion.
Both physiotherapy programs consisted of two 40- to
60-minute physiotherapy sessions per week and a 1-hour
home exercise program on the other days. The propriocep-
tive and balance exercise program was based on previously
described exercises used for nonoperative management of
ACL ruptures, which were adapted to suit wobble boards,
mini trampolines, inflatable balance discs, and exercise balls.
The strengthening program used exercises designed to
improve muscular strength and endurance but did not
specifically address balance or proprioception.
At the conclusion of the 6-week program there were
no differences between the two groups in terms of the Cin-
cinnati Knee Rating System, the Patient Specific Functional

538

Scale, or range of knee motion. Three hop tests (single leg
hop for distance, timed 6-meter hop, and the single leg
crossover triple hop for distance) were used as an objective
measure of neuromuscular function. No differences were
seen between the two groups.
In both of these studies the proprioception-orientated
program did not appear to confer any advantage in terms of
tests of neuromuscular function. Interestingly, neither study
used a specific test of proprioception, although the peak
torque time test used by Liu-Ambrose et al included a sen-
sory component. The benefits of such proprioceptive train-
ing programs therefore remain to be demonstrated.
Not only do the effects of such training need to be
more clearly established, but also the question of whether
proprioception per se can be trained at all still needs to be
answered. As Aston-Miller et al14 have noted, scenarios in
which proprioception might be improved remain largely
theoretical. If proprioception can indeed be improved by
training, there remains the issue of what such improvement
might achieve. The time required to develop protective
muscle contraction in response to a stimulus is such that
successful proprioceptive training might only be able to pre-
vent injury as a result of relatively slow provocations, rather
than the more rapidly applied forces that occur in a sporting
situation. Thus the aim of proprioceptive training following
ACL reconstruction needs to be clarified. Is it to restore
normal function, to improve function beyond the indivi-
dual’s preinjury level, or to prevent reinjury? If it is the latter,
perhaps it is the improved patterns of muscular contraction
as well as the awareness of and attention to various cues that
are the real benefits of such training. Clearly, further studies
are required to establish the role of proprioceptive training
following ACL reconstruction.
References
1. Schultz RA, Miller DC, Kerr CS, et al. Mechanoreceptors in human
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cruciate deficient knee. Am J Sports Med 1989;17:1–6.
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539
 PART P STABILITY RESULTS
69
CHAPTER
Stability Results After Anterior Cruciate
Ligament Reconstruction
Chadwick C. Prodromos The primary purpose of anterior cruciate liga-
ment reconstruction (ACLR) is to restore knee
Brian T. Joyce
stability. This chapter will provide meta-analytic
data on hamstring, bone–patellar tendon–bone
(BPTB), quadriceps tendon, and allograft stabil-
ity. The stability data are measured by instrumen-
ted Lachman testing, usually but not exclusively
KT-1000 (Medmetric, San Diego, CA). Pivot-
shift data are not included because the high
interobserver variability makes it impossible to
quantify and it is an insensitive test in the non-
anesthesitized patient.1 Although it is theoreti-
cally possible to have normal stability with
instrumented Lachman testing and still have a
pivot slide or even pivot shift present, this can
only happen if the graft is put in a very vertical
position. The data in this chapter are from the
peer-reviewed literature, and the authors of these
studies are all accomplished knee surgeons who
are unlikely to place vertical grafts. Thus the data
shown should be a good index to the relative
stabilities of the knees tested.
STUDY CRITERIA
All studies met three criteria for inclusion, as
follows:
1 Minimum 2-year follow-up
2 Application of at least 30 pounds or
maximum manual testing force
3 Stratified presentation of stability data, not
just averages
540
STATISTICAL METHODS
Meta-analytic methods were used to compare the
groups. Weighted means for normal and abnor-
mal stability were generated as follows: For each
treatment group, the proportion of individuals
for an outcome event was determined by adding
the number of events that occurred through all
studies and dividing by the number of the patients
in all the studies. The number of patients for any
single-center, but not multi-center, study was
capped at 100 to avoid disproportionate influence
of any given study. In any study, if the number of
patients for a given outcome was not recorded,
the study was eliminated from the analysis of that
outcome. For example, with one exception, if a
study did not record the number of patients who
have less than 2 mm of difference, then the study
was not included in the <2 mm comparison.2–66
RESULTS
Table 69-1 shows all studies broken down by
graft and then by fixation type for all graft types.
Only About Half of Reconstructed
Knees Achieve Stability
Symmetrical with the Other Knee
The goal of ACL surgery is to restore the prein-
jury level of stability, which should be the same
as that of the other knee. True symmetry is
(Text continued on p. 547)
 TABLE 69-1 Clinical Series Divided by Graft and Fixation Method
Author Year Graft KT
2
2x
3 >2 3–4 3–5 >3 4 4–5 >4 >5 6–7 >7 Fixation– Fixation–
Pop. Tib Fem

HAMSTRING GROUPS

EB2–4HS: Endobutton used on femur, second

-generation fixation used on tibia (Subgroup 1)

Cooley* 2001 4ST 20 100 0 0 Sc-WS EB

Eriksson 2001 4ST 74 43 50 7 Sc-WS EB

Feller* 2003 4STG 27 85 15 0 Sc-WS EB

Gobbi* July 4ST 40 90 8 2 Fastlok EB

2003

Gobbi* Sept 4ST 80 90 9 1 Fastlok EB

2003

Prodromos* 2005 4STG 98 86 97 14 14 14 3 3 3 0 0 0 0 Sc-WS EB

Yasuda* 2004 4STG 57 80 14 0 ST-Buckle EB

Weighted mean (Subgroup 1) 396 80 1.7

OC-4HS: Other cortical 4HS (XP-4HSþSC

-4HSþBu-4HS) (Subgroup 2)

Stability Results After Anterior Cruciate Ligament Reconstruction

XP-4HS: Cross-pin femoral fixation (Subgroup 3)

Aglietti 2004 4STG 60 67 43 0 WL BMS

Howell* 1999 4STG 67 91 6 3 2ST or LW BMS

Harilainen 2005 4STG 25 72 8 20 Sc-LW Transfx

Fabbriciani 2005 4STG 18 61 72 28 0 ISþST Transfix

Weighted mean (Subgroup 3) 73 4.1

Sc-4HS: cortical screw on tibia and femur (Subgroup 4)

Aglietti Feb 4STG 30 23 47 30 STþSc-WS Sc-Lp

1997 or Sc-WS

Goradia* 2001 3STG 93 90 9 1 1 Sc-LW Sc-LW

Howell 1999 4STG 41 90 3 7 Sc-Lp 2 Sc-LWs

(continued)
541

69
542

Anterior Cruciate Ligament Reconstruction

TABLE 69-1—Clinical Series Divided by Graft and Fixation Method (Cont’d)
Author Year Graft KT
2
2x
3 >2 3–4 3–5 >3 4 4–5 >4 >5 6–7 >7 Fixation– Fixation–
Pop. Tib Fem

Weighted mean (Subgroup 4) 78 7.8

Bu-4HS: simple button on tibia and/or femur (Subgroup 5)

Hamada* 2000 4STG 86 81 94 3 5 2 0 Bu or Sc-WS Bu or

Sc-WS

Maeda 1996 4STG 41 63 73 17 10 Bu or Sc-WS Bu or

Sc-WS

Noojin 2000 4ST 65 71 83 11 6 Bu or Sc-WS EB

Williams 2004 4STG 79 71 82 12 6 St or IS or Bu EB

Weighted mean (Subgroup 5) 73 85 4.7

Weighted mean (OC-4HS with extrapolation) 74 5.4

(Subgroup 2)

Weighted mean (OC-4HS without extrapolation) 72

(Subgroup 2)

AIS-4HS: Augmented interference screw fixation:

2IS plus augmentation

Hill* 2005 4STG 21 86 14 0 ISþSt IS

2IS-4HS: Double interference screw used (Subgroup 6)

Charilton 2003 4STG 36 72 17 11 IS IS

Harilainen 2005 3ST/4STG 29 62 21 17 IS IS

Hill 2005 4STG 27 74 26 0 IS IS

Scranton* 2002 4STG 120 88 9 3 IS IS

Shaieb 2002 4STG 22 45 41 14 IS IS

Wagner 2005 4STG 55 69 31 0 IS IS

Weighted mean (Subgroup 6) 75 5.4

WEIGHTED MEAN (All 4HS with extrapolation) 76.3 4.2

WEIGHTED MEAN (All 4HS without extrapolation) 77.2 4.2

2HS
 Author Year Graft KT
2
2x
3 >2 3–4 3–5 >3 4 4–5 >4 >5 6–7 >7 Fixation– Fixation–
Pop. Tib Fem

Aglietti 1996 2STG 62 50 66 39 11 NI St-Buckle

Anderson 2001 2STG 34 62 38 NI St

Anderson 2001 2STG 33 62 48 NI NI

Beynnon 2002 2STG 22 45 55 St ST-Buckle

Feagin 1997 2ST 91 17 Sc-LW BB

Meyestre 1998 2ST 27 26 56 18 BB Sc-LW or

Clip

O’Neill 1996 2STG 40 75 83 18 10 7 St St

Nebelung 1998 2ST 29 55 35 10 St-Buckle EB

WEIGHTED MEAN (all 2HS) 54 13

BTB GROUPS

2IS BTB: two interference screws used; both tibia and femur
(Subgroup 7)

Aglietti 2004 BTB 60 65 35 0 IS IS

Arciero 1996 BTB 51 73 20 7 IS IS

Stability Results After Anterior Cruciate Ligament Reconstruction

Arciero 1996 BTB 31 65 25 9 IS IS

Bach 1995 BTB 62 90 5 5 IS IS

Bach 1998 BTB 100 83 14 3 IS IS

Bach 1998 BTB 94 70 26 4 IS IS

Barrett* 1996 BTB 83 89 10 1 IS IS

Beynnon 2002 BTB 22 77 23 IS IS

Eriksson 2001 BTB 80 49 48 3 IS IS

Feagin 1997 BTB 91 11 IS IS

Marumo 2000 BTB 42 28 62 10 5 IS IS

O’Neill 1996 BTB 40 78 93 17 2 5 IS IS

O’Neill 1996 BTB 45 78 87 20 11 2 IS IS

(continued)
543

69
544

TABLE 69-1—Clinical Series Divided by Graft and Fixation Method (Cont’d)

Anterior Cruciate Ligament Reconstruction

Author Year Graft KT
2
2x
3 >2 3–4 3–5 >3 4 4–5 >4 >5 6–7 >7 Fixation– Fixation–
Pop. Tib Fem

Plancher 1998 BTB 75 67 29 4 3 1 IS IS

Sgaglione 1997 BTB 45 75 18 7 IS IS

Sgaglione 1997 BTB 41 78 15 7 IS IS

Shaieb 2002 BTB 24 79 8 13 IS IS

Tan 1997 BTB 41 90 7 3 IS IS

Wagner 2005 BTB 55 55 40 5 IS IS

Weighted mean (Subgroup 7) 68 5.0

O-BTB: Other BTB fixation: non-interference screw fixation on

tibia, femur, or both (Subgroup 8)

Aglietti Feb BTB 30 40 43 17 Sc-WS Sc-WS

1997

Aglietti Mar BTB 89 49 35 16 ISþBu IS–Bu

1997

Aglietti 1992 BTB 62 56 32 12 ISþSP PFBþSP

Aglietti 1991 BTB 65 63 20 17 IS Sc-WS

Anderson 2001 BTB 35 71 29 WS EB

Barrett 2002 BTB 37 86 8 6 PFB PFB

Buss 1993 BTB 56 64 84 29 9 7 St IS

Feller* 2003 BTB 21 95 5 0 Sc-WS PFB

Gobbi* July BTB 40 90 8 2 IS EB

2003

Heier 1997 BTB 40 78 10 12 ISþBu ISþBu or

St

Hertel 2005 BTB 95 59 41 0 ISþBu PFBþBu

O’Brien 1991 BTB 79 76 16 4 4 ISþBu Bu

Patel 2000 BTB 32 87 13 0 Sc-LW IS

Shelbourne 2000 BTB 100 84 13 2 Bu Bu

 Author Year Graft KT
2
2x
3 >2 3–4 3–5 >3 4 4–5 >4 >5 6–7 >7 Fixation– Fixation–
Pop. Tib Fem

Weighted mean (Subgroup 8) 63 7.4

T-BPTB: Total BPTB: 21S-BPTB and O-BPTB combined 66 5.9

weighted mean

Quadriceps tendon graft

Lee 2004 Quad 67 75 19 6.0

T-autograft 71 5.2

ALLOGRAFT SERIES

BPTB: Nonirradiated (Subgroup 9)

Barrett 2005 10-mm 38 74 86 5 7.0 SPþIS or Bu IS, EB, or FF

BPTB IS/EB

Bach*{ 2005 10-mm 60 82 95 5 0.0 2 IS IS FF

BPTB

Kleipool 1998 10-mm 36 65 75 19 5.6 IS IS

BPTB

Siebold{ 2003 10-mm 183 58 27 4.0 15 IS IS FF

BPTB

Stability Results After Anterior Cruciate Ligament Reconstruction

Harner 1996 BPTB 64 20.0 IS IS IS

Peterson{ 2001 15-mm 30 63 73 27 0.0 3 IS IS FF

BPTB

Shelton 1997 15-mm 30 63 73 23 3.3 IS IS FF

BPTB

Noyes{ 1991 9-10-mm 64 45 52 33 12.0 16 IS IS FF

BPTB

Weighted mean (Subgroup 9) 62 11.5 FF

BPTB: Irradiated (Subgroup 10) FF

Noyes{ 1997 BPTB 34 44 32 24.0 30 2.5 Mrad

{
Gorschewsky 2005 Tutoplast 85 27 45 IS IS 1.5 Mrad/
acetone
(continued)
545

69
546

Anterior Cruciate Ligament Reconstruction

TABLE 69-1—Clinical Series Divided by Graft and Fixation Method (Cont’d)
Author Year Graft KT
2
2x
3 >2 3–4 3–5 >3 4 4–5 >4 >5 6–7 >7 Fixation– Fixation–
Pop. Tib Fem

Weighted mean (Subgroup 10) 32 40.7

Weighted mean (all BPTB allograft) 56 17.1

Soft-tissue graft: nonirradiated

Indelli 2003 Achilles 50 66 32 2.0 IS IS CP

{
Siebold 2003 Achilles 42 71 21 2.0 7 St/IS IS FF

Nyland 2003 Tibialis 18 72 22 6.0 IS IS FF or FD

anterior

Pritchard{ 1995 Fascia lata 39 77 15 8.0 19 St St D

Mixed grafts: nonirradiated

Levitt 1994 Achilles or 181 13.0 IS IS FF or FD

BPTB

Noyes{ 1991 9-10-mm 40 63 73 22 5.0 7 Sc-P Sc-P FF

BPTBþITB

Roberts{ 1991 BPTB or 36 15 17 22.0 36 WSP WSP FD, EO

BPTBþITB

Noyes 1996 Fascia lata 66 74 20 3.0 ? ? FD, EO, FF

or BPTB
{
Chang 2003 14-mm 37 65 76 8 8.0 16 IS IS ?
BPTBþITB

WEIGHTED MEAN (all soft tissue and mixed) 64 12

WEIGHTED MEAN (all nonirradiated grafts) 63 12

WEIGHTED MEAN (all allografts) 59 15

*After author indicates high-stability series (80% normal and
3% abnormal stability).
{For allograft series, graft failures that did not result in a side-to-side laxity difference of >5 mm were included in our calculations in the >5þ column.
Note: Arthrometric data were reported differently by different authors. The various categories in the column headings reflect the different criteria used in millimeters of side to side difference.
2x denotes extrapolated
2 data, as
described in the text.
BB, Bone bridge; BMS, bone mulch screw; Bu, simple button; CP, cryopreserved; EB, Endobutton; EO, ethylene oxide; FD, freeze-dried; FF, fresh frozen; IS, interference screw; KT Pop, KT-1000 study population; NI, natural insertion left intact;
PFB, press-fit bone; Sc-Lp, graft looped around cortical screw; Sc-LW, cortical screw with ligament washer; Sc-WS, cortical screw with whipstitches; St, staple; WL, WasherLoc; BTB, bone–tendon–bone; BPTB, bone–patellar tendon–bone.

achieved when the side-to-side difference (SSD) between
the knees is 0. Measurement error increases this criterion
to 1 mm. Thus we propose a SSD of 1 mm as defining knee
stability symmetry. The IKDC “normal” criterion of up to a
2-mm difference may be satisfactory, but it is not truly nor-
mal. Indeed, a 2-mm SSD is what is commonly seen with
partially torn ACLs.67 When the 1-mm criterion is applied,
we see the following: For all autografts, about 30% have
greater than 2-mm SSD.68 The remaining 70% fall into
four categories: 2 mm, 1 mm, 0, or less than 0. If we assume
that one-fourth of the 70% falls into each of these four cate-
gories, then it is reasonable to estimate that one-fourth of
70%, or 18%, are exactly 2 mm different. Adding this 18%
(exactly 2 mm) to the 30% (greater than 2 mm) would mean
that 48% of the reconstructed population has a 2-mm or
greater SSD. This leaves about 52% with 1 mm or less
SSD (i.e., true symmetry with the other knee). Thus
roughly one-half of the autograft ACLRs, in the hands of
the experienced knee surgeons who are the authors of these
studies, have stability that is either equivalent to a partially
torn ACL or worse. The allograft data68 show significantly
lower stability rates (see Table 69-1).
Table 69-1 presents the raw data for stability from all
the studies. The principal areas of interest are the “normal”
and “abnormal” stability columns. Abnormal stability in
most cases is equivalent to graft failure. The primary table
subdivision is by graft type. These are four-strand hamstring
(4HS) autograft, two-strand hamstring (2HS) autograft,
BPTB autograft, and quadriceps tendon autograft and allo-
graft. The secondary subdivision is by graft subgroup and by
fixation type. Subdividing by fixation groups is possible to
do with the autografts because of the large number of stud-
ies. It is only possible with the allografts to break out a
BPTB/interference subgroup because of the smaller number
of studies.
Stability Rates by Graft Type
The principal findings were as follows:
1 The 4HS graft group normal stability rate of 77% was
significantly higher than the BPTB rate of 66% (P < 0.001).
The 4HS abnormal rate of 4.2% was significantly lower
than the BPTB rate of 5.9% (P ¼ 0.029).
2 The autograft normal stability rate of 71% was
significantly higher than the allograft normal stability rate
of 59% (P <0.001). The autograft abnormal stability rate
of 5.2% was significantly lower than the allograft
abnormal stability rate of 15% (P <0.001).
3 The BPTB autograft normal stability rate of 66% was
significantly higher than the BPTB allograft normal
Stability Results After Anterior Cruciate Ligament Reconstruction 69
stability rate of 56% (P <0.001). The BPTB autograft
abnormal stability rate of 5.9% was significantly lower
than the BPTB allograft abnormal stability rate of 17%
(P <0.001).
4 Radiated allografts had significantly lower stability rates
than nonirradiated allografts. Normal and abnormal rates
for radiated were 32% and 41%, respectively, versus 63%
and 12% for nonirradiated grafts (P <0.001).
5 The two-strand hamstring normal stability rate of 53% and
abnormal stability rate of 13% were both significantly
worse than the rates for both 4HS and BPTB (P <0.001).
6 There is only one published quadriceps tendon study with
2-year follow-up and stratified stability rates. The normal
stability rate was 75%, and the abnormal rate was 6%.
Stability Rate by Graft Fixation Subgroups
Stability rates for these subgroups are as follows:
1 The 4HS-EB2 subgroup, which used an Endobutton on
the femur and second-generation fixation on the tibia,
had the highest stability rates of any graft fixation
subgroup. Its normal and abnormal stability rates were
77% and 1.7%, respectively. By comparison, the 4HS
group with interference screws on both the tibia and
femur, 4HS-2IS, had normal and abnormal rates of 75%
and 5.4%, respectively.
2 For BPTB, interference screw fixation had slightly higher
stability rates than noninterference screw fixation: normal
and abnormal rates of 68% and 5.0%, respectively, for
interference screws versus 63% and 7.4% for
noninterference screws. However, some of the overall
highest stability rates were obtained by noninterference
screw fixation methods.
Aperture Versus Nonaperture Fixation
For soft tissue grafts, there was no stability advantage for aper-
ture fixation. Indeed, as just described, the 4HS-EB2 group,
which had entirely nonaperture cortical fixation, had the
highest stability rates of any graft fixation subgroup. Thus
the so-called “bungee effect” would appear to be nonexistent.
This is not surprising, as studies have shown that fixation on
rigid cortical bone enhances stiffness much more than the
greater length of the construct diminishes it.69 Also, varia-
tions in fixation stiffness are eliminated once the graft heals
into the bone tunnel because the fixation is no longer load
bearing. What really matters is how much the graft may elon-
gate during this healing period from either slippage or plastic
deformation. Neither of these is related to fixation stiffness.
547
 Anterior Cruciate Ligament Reconstruction
Four-Strand Hamstring Versus Bone–
Patellar Tendon–Bone Stability Rates
Because BPTB has long been considered the “gold stan-
dard” for ACLR. it may be surprising to some that 4HS
was found to have higher stability rates. However, as the
4HS graft is a significantly stronger graft (see Chapter
10), the excellent 4HS stability rates do make sense if mod-
ern fixation is used. Prior analyses have seemed to show that
hamstring grafts had lower stability rates than BPTB.70,71
However, these studies commingled the much-lower-stabil-
ity 2HS studies with the higher-stability 4HS studies. If the
2HS studies are removed, it turns out that there was no sta-
bility advantage to BPTB in those studies by comparison
with 4HS. Also, many of the highest-stability 4HS series
were published after those studies. They were thus not
included in those analyses but contribute significantly to
the higher 4HS stability rates found here.
Allograft Versus Autograft
Allograft use has been steadily increasing. Surgeons who wish
to avoid the morbidity of BPTB as well as the harvest of
hamstrings are among the many who have been turning
increasingly to allografts. The data presented here show sig-
nificantly lower stability rates for allografts, with an abnormal
stability rate, which usually represents graft failure, about
three times higher than for autografts. These low-stability
results also would indicate that ligamentization may indeed
proceed differently for allogeneic tissue. This may be due in
part to the less-effective and slower rate of recellularization
that occurs with allografts.72 There is anecdotal evidence that
late failure rates may be higher for allografts,73,74 which may
be related to this same phenomenon.
Many now believe that some form of sterilization is
necessary for allografts over and above sterile processing (see
Chapter 70). Although higher levels of radiation have been
believed to provide good sterilization, they have also long
been considered to decrease graft strength. However, the
radiated grafts in this study had lower stability rates than the
nonirradiated grafts, even though the radiation levels in these
studies were below 3 MRADs.49,63 This level is below that
required to kill the human immunodeficiency virus (HIV)75
but is still apparently high enough to diminish graft strength.
Some have felt the answer lies in radioprotectant that allows
virucidal 5 MRAD level sterilization while potentially avoid-
ing graft weakening.76 Clinical studies to test this hypothesis
are ongoing.
A variety of chemical treatments of allografts are also
variably carried out by different tissue banks.77,78 It is
unknown how these treatments affect graft ligamentization,
548
cellular repopulation, and ultimate strength. Careful clinical
follow-up will be required to assess which allograft treat-
ments are optimal regarding both sterility and stability.
CONCLUSIONS
1 Four-strand hamstring grafts had higher stability rates
than BPTB grafts.
2 Cortical fixation produced higher stability rates than
aperture fixation for soft tissue grafts, indicating that no
bungee effect exists.
3 Allografts had lower stability rates than autografts, with
abnormal stability rates that were three times higher.
4 Radiated allografts had lower stability rates than
nonirradiated allografts.
5 BPTB allografts had lower stability rates than BPTB
autografts.
6 The quadriceps tendon performed similarly to BPTB in
the one suitable study, but more data are needed.
7 Symmetrical knee stability appears to be restored in only
about half of ACL reconstructed knees overall.
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48. Hamada M, Shino K, Horibe S, et al. Preoperative anterior knee laxity
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49. Gorschewsky O, Klakow A, Riechert K, et al. Clinical comparison of
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51. Pritchard JC, Drez D Jr, Moss M, et al. Long-term followup of
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55. Bach BR Jr, Aadalen KJ, Dennis MG, et al. Primary anterior cruciate lig-
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59. Indelli PF, Dillingham MF, Fanton GS, et al. Anterior cruciate
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65. Peterson RK, Shelton WR, Bomboy AL. Allograft versus autograft
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68. Prodromos CC, Joyce BT, Shi K, et al. A meta-analysis of stability
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69. To JT, Howell SM, Hull ML. Contributions of femoral fixation
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71. Freedman K, D’Amato M, Nedeff D, et al. Arthroscopic anterior cruci-
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May, 2006.
 PART Q COMPLICATIONS
Infections in Anterior Cruciate Ligament
Surgery
INTRODUCTION
Infection following anterior cruciate ligament
(ACL) surgery is an uncommon but serious
complication. The infectious process, if not
controlled adequately, will jeopardize the integ-
rity of the articular cartilage and may lead to
irreversible damage of the knee joint.
The low prevalence of this complication
limits the experience of any individual surgeon,
and the relevant literature consists of few series
with small numbers of patients treated with man-
agement protocols ranging in aggressiveness
from arthroscopic irrigation to radical débride-
ment with graft and hardware removal.1–9
This chapter presents management
guidelines for treatment of infections in ACL
surgery, discusses the potential role of allografts
in development of septic complications, and
reviews management of the intraoperatively
contaminated graft.
PREVALENCE OF INFECTION
The prevalence of infection following ACL
reconstruction is very low. In studies reporting
on septic complications, the infection rate ranged
from 0.14% to 1.74%1–5,7–9 (Table 70-1). Over-
all these eight studies reported 66 infections
following 12,684 procedures, resulting in a mean
infection prevalence of 0.52%.1–5,7–9
Matava et al surveyed directors of sports
medicine fellowship programs about their
70
CHAPTER
experience with infections after ACL surgery. 10
Charalampos G. Zalavras
The 61 surgeons who responded performed on
Michael J. Patzakis
average 98 ACL reconstructions per year; 18 sur-
geons (30%) had treated an ACL infection within
the past 2 years, and 26 (43%) had treated an
infection within the past 5 years. Therefore even
experienced surgeons have managed a limited
number of cases in their career.
PATHOGENESIS: PREDISPOSING
FACTORS
Infections in ACL surgery result from contami-
nation of the operative site with microbes,
which is followed by a complex interaction of
the inoculated microorganisms with the local
and systemic host environment. In the presence
of systemic compromise of the host, decreased
vascularity of the local environment, and viru-
lence of the microorganism, the host mechan-
isms may prove inadequate to eradicate the
inoculated microorganisms, thus leading to
development of infection.
Systemic Factors
The importance of host physiology in muscu-
loskeletal infections has been emphasized in the
literature.11 Systemic host factors include comor-
bidities, such as diabetes mellitus, malignancy,
malnutrition, immunocompromised status, or
other disease that may compromise the host
defense against microbial pathogens. However,
551
 Anterior Cruciate Ligament Reconstruction

TABLE 70-1 Prevalence of Infection Following Anterior Cruciate Ligament secondary procedures in development of infection is not
(ACL) Surgery clear, as the existing studies have not performed a compari-
Study Number of ACL Number of Prevalence of son between infected and control patients.
Surgeries Infections Infection
Contamination
Burks et al3 1918 8 0.42%

Fong et al7 472 7 1.48% Contamination of the operative site may occur from use of
inadequately sterilized instruments or implantation of con-
Indelli et al4 3500 5 0.14%
taminated grafts. Contaminated in-flow cannulas have been
2
McAllister et al 831 4 0.48% identified as the source of infection. Viola et al reported a
Musso and 1094 11 1.01% sudden increase in their infection rate from 0.1% in the
McCormack8 period from 1991 to 1996 (2 in 1724 ACL reconstructions)
to 14.2% in the period from December 1996 to February
Schollin-Borg 575 10 1.74%
1996 (10 of 70).5 “Sterile” sets of in-flow cannulas used
et al9
for ACL reconstructions were found to be contaminated
Viola et al5 1794 14 0.78% with coagulase-negative Staphylococcus. Following the dis-
covery of the contaminated instruments, the infection rate
Williams et al1 2500 7 0.30%
dropped to 0.25% (1 in 400 cases). In another study, con-
Total 12684 66 0.52% tamination with coagulase-negative Staphylococcus was pres-
ent on supposedly sterile suture clamps on graft
preparation boards.9 Inadequate disinfection of arthroscopic
systemic host factors are not as prevalent in ACL surgery com- equipment12 and flash sterilization of meniscus repair can-
pared with other procedures because most patients undergoing nulas with residual debris in the lumen13 have been reported
ACL reconstruction are relatively young, active, and healthy. as potential causes of septic arthritis following arthroscopy.
In the series with postoperative infections after ACL surgery Undetected intraoperative contamination of the graft
presented in Table 70-1, the mean age of the patients ranged may take place as well. Hantes et al14 obtained culture
from 21 to 34 years, and no comorbidities were reported. A specimens before implantation of autografts and reported that
study on persistent infections reported comorbidities in three cultures were positive in 12% of cases (7 of 60). Diaz-de-Rada
of five patients.6 et al15 reported that allograft cultures were positive in 13% of
cases (24 of 181). The source and significance of this con-
Local Factors tamination remain unclear. However, in both studies no clin-
ical infections developed after a minimum 1-year follow-up.
Local risk factors for infection after ACL reconstruction Contamination of allografts used in ACL reconstruction as
include previous or concomitant secondary knee proce- a source of infection is discussed in detail later.
dures.1–3 Williams et al1 reported that six of seven patients
with infections had concomitant procedures performed, such Biofilm Formation
as “outside-in” meniscal repair with polydiaxone (PDS)
suture, medial collateral ligament reconstruction, and pos- Biofilm formation is a key mechanism for persistence or
terolateral corner reconstruction. In the series of McAllister recurrence of infection. The biofilm is an aggregation of
et al,2 three of four patients had previous knee surgery and microbial colonies enclosed within an extracellular polysac-
two of four patients had an “inside-out” meniscal repair. charide matrix (glycocalyx) that adheres on the surface of
Burks et al3 reported that five of eight patients in their series implants or devitalized tissue.16,17 Gristina and Costerton18
had concomitant procedures performed at the time of ACL reported that 59% (10 of 17) of orthopaedic biomaterial–
reconstruction. In the series of Musso and McCormack,8 five related infections had positive findings of glycocalyx-enclosed
of nine patients also underwent meniscal procedures. organisms on electron microscopy. Presence of an avascular
Potential explanations include the increased operative graft and metal fixation devices in ACL reconstruction create
time, additional or larger incisions with more extensive dis- conditions conducive to biofilm development if a post-
section in cases where complex reconstructive surgery takes operative infection is not treated early and adequately.
place, and implantation of foreign material such as suture. The biofilm protects the organism from antibiotics
However, other authors did not report concomitant proce- and host defense mechanisms, such as antibody formation
dures in their infected ACL reconstructions.4 The role of and phagocytosis; therefore infection may exist in a

552
 Infections in Anterior Cruciate Ligament Surgery 70
subclinical state and eventually recur. In chronic musculo- 2 months), and late (more than 2 months).1 The mean time
skeletal infections, removal of the biofilm by removal of for development of infection following ACL surgery ranged
implants and débridement of devitalized tissue are necessary from 8 days5 to 25 days8 (Table 70-2).
for successful treatment of infection.19
Laboratory Findings

DIAGNOSIS Peripheral white blood cell (WBC) count may be within

Clinical Findings
The typical clinical presentation includes knee pain, effusion,
local erythema, and warmth. Such symptoms in the first
2 postoperative days may be due to the procedure, but persis-
tence beyond the second day, especially if the pain is increas-
ing, should raise the suspicion of infection. Fever is usually
present. Drainage from the surgical incision may be present.
An alterative presentation is with emergence of symp-
toms at a later time following a symptom-free interval. In
some cases, the clinical picture may consist of mild pain,
effusion, and difficulty performing physical therapy without
the systemic signs of infection. As Burks et al3 warned, the
surgeon should not interpret this relatively benign presenta-
tion as the absence of infection. A high index of suspicion is
necessary, and patients who do not demonstrate steady post-
operative improvement; present with increased pain, effu-
sion, or stiffness following a symptom-free interval; or
develop systemic symptoms (fever, chills, malaise) should
be considered to have a septic knee until proven otherwise.
Patients should be instructed to contact their physician
immediately if knee symptoms develop postoperatively,
which should be evaluated without delay.
Infections have been classified as acute (presenting
less than 2 weeks postoperatively), subacute (2 weeks to
normal limits. In contrast, markers of inflammation, such
as the C-reactive protein (CRP) and erythrocyte sedimenta-
tion rate (ESR), are elevated and are helpful in the diagno-
sis. Elevated CRP has been invariably reported in patients
with ACL postoperative infections; the mean CRP levels
ranged from 2.6 mg/dL2 to 12.3 mg/dL7 in the existing
studies (see Table 70-2). Elevated levels of ESR have been
similarly reported in the literature, with mean values ranging
from 48 mm/hr3 to 87 mm/hr.5
The anticipated increase of ESR and CRP in the
immediate postoperative period may confound the diagnos-
tic picture in the first week. Viola et al5 evaluated 15
patients with a normal postoperative course and reported
that 5 days after ACL surgery they had elevated CRP levels
with a mean of 2.7 mg/dL (range 0.6–12.3 mg/dL). Mar-
gheritini et al20 reported a postoperative increase of both
CRP and ESR peaking on the third and seventh days,
respectively. The CRP returned to nearly normal levels by
postoperative day 15, which was faster than the ESR; the
authors concluded that CRP is a more sensitive indicator
of postoperative septic complications.20 Elevated levels of
CRP beyond the postoperative day 15 strongly point toward
a septic etiology for the patient’s symptoms.
Aspiration of the involved knee joint is necessary and
yields turbid fluid that should be sent for Gram stain, WBC
count and differential, and culture (both aerobic and

TABLE 70-2 Time for Development of Infection and Laboratory Findings

Study Onset of Infection (days) CRP (mg/dL) ESR (mm/hr) Blood WBC Aspirate WBC Aspirate PMNs (%)
(103/mm3) (103/mm3)

Burks et al3 19 (NA) NA 48 (1–110) 8.4 (4.7–10.6) 61 (18–100) 94 (91–97)

Fong et al7 24 (7–56) 12.3 (2.5–21.5) 72 (10–95) 11.7 (10–16) NA 93 (90–95)

4
Indelli et al 20 (9–34) NA NA NA 91 (64–129) NA

McAllister et al2 11 (8–18) 2.6 (2.0–3.2) 79 (19–118) 9.7 (4–11) 50.8 (7.7–81.2) 90 (NA)
8
Musso et al 25 (4–42) 5.5 (1.6–7.6) 50 (16–76) 9.4 (6.2–13.5) 77.2 (32.2–222) 94 (90–98)

Schollin-Borg et al9 9 (4–20) 9.2 (1.0–19.9) 62 (22–102) 8.4 (7.4–10.6) 49.4 (NA) 92 (NA)

Viola et al 5
8 (2–20) 10 (3.7–18.6) 87 (56–191) 10.2 (7.5–19.9) NA NA
1
Williams et al 22 (3–79) NA 82 (50–112) 10.8 (616) 75.4 (27–136.7) 92 (NA)

CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; NA, not applicable; PMN, polymorphonuclear cell; WBC, white blood cell.

553
 Anterior Cruciate Ligament Reconstruction

anaerobic). The mean WBC count has ranged from 49,400 TABLE 70-3 Microbiology of Postoperative Autograft Anterior Cruciate
per mm3 in the study by McAllister et al2 to 91,000 per Ligament Infections
mm3 in the study by Indelli et al.4 Despite this variability Study Number of Number of Identified
in the absolute number of WBC in the joint aspirate, the Cases with Cases with Organisms
differential count reveals mean values of 90% to 94% of Joint Aspirate Positive (Number)
polymorphonuclear (PMN) cells (see Table 70-2). Cultures Cultures (%)

Burks 4 4 (100%) SA(3), PA (1)

et al3
Imaging Studies
Fong 7 7 (100%) SA (4), PS (3), EB
7
Magnetic resonance imaging (MRI) can help determine the et al (1), KL (1)*
extent of infection and the presence of any extraarticular Indelli 6 6 (100%) SA (3), SE (2), NHS
fluid collections that otherwise could have been missed.21 et al{4 (1)

McAllister 4 4 (100%) SA (4)

et al2
Microbiology
Musso 9 5 (560%) CNS (5)
Forty-three (74%) of 58 joint fluid cultures were positive in et al8
studies reporting on postoperative autograft ACL infections
Schollin- 10 8 (80%) CNS (6), SA (1),
(Table 70-3). Staphylococcus aureus was the most common 9
Borg et al PB (1)
pathogen, present in 21 of 43 cases with positive cul-
tures (48.5%). Coagulase-negative Staphylococcus (including S. Viola 11 2 (18%) SE (2)
epidermidis) was cultured in 17 of 43 cases (39.5%). Overall, et al5
septic arthritis following ACL surgery was caused by staphylo- Williams 7 7 (100%) SA (6), SE (2), PS
coccal species in the vast majority of cases (88%). Anaerobic et al1 (1)*
infections (Peptostreptococcus, Propionibacteriaceae) were present
Total 58 43 (74%) SA (21)
in 11.5% of cases (5 of 43). Gram-negative bacteria (Pseudomo-
CNS/SE (17)
nas aeruginosa, Enterobacter, Klebsiella) were relatively uncom-
Anaerobes: PS,
mon and were identified in 7% of cases (3 of 43).
PB (5)
Case reports of unusual infections following autograft
Gram negative:
ACL reconstruction have been reported, including infection
PA, EB, KL (3)
with S. caprae,22Erysipelothrix rhusiopathiae,23 mucormyco-
sis,24 and necrotizing fasciitis.25 Reports of infections follow- CNS, Coagulase-negative Staphylococcus; EB, Enterobacter; KB, Klebsiella; NHS,
ing allograft ACL surgery are discussed later. nonhemolytic Streptococcus; PA, Pseudomonas aeruginosa; PB, Propionibacteriaceae; PS,
Peptostreptococcus; SA, Staphylococcus aureus, SE, Staphylococcus epidermidis.
*Numbers do not add up to the total number of positive cultures because some
patients had more than one organism present.
MANAGEMENT PROTOCOL {
Two of six grafts were allografts.

Prompt management is imperative for two reasons. First, Antibiotic Administration

evacuation of the purulent effusion as soon as possible will
minimize the duration of the adverse effect of the secreted
enzymes and toxins that degrade proteoglycans and collagen,
thereby leading to damage of the articular cartilage. Second, a
delay in treatment will allow the pathogens to gradually form a
biofilm on the avascular graft and on implanted hardware as
time progresses. Biofilm formation will preclude eradication
of the pathogens; in this case the infection may be initially
controlled only to recur later.
The management protocol consists of two key com-
ponents: antibiotic administration and surgical management
with irrigation and débridement of the knee joint.
Intravenous antibiotics should be started as soon as possible.
Empirical coverage should be provided for Gram-positive
cocci and then modified according to the culture and sensitiv-
ity results. Vancomycin can be used as the initial antibiotic
because it is active against coagulase-negative staphylococcal
species and against oxacillin-resistant S. aureus, which is
becoming a progressively more common pathogen. When
culture results become available, antibiotic therapy should be
modified accordingly and continued for 6 weeks.
In infections developing after implantation of an allo-
graft, broad-spectrum antibiotic therapy may be preferable

554

due to the potential for allograft contamination with anae-
robes or Gram-negative organisms.
Surgical Management
Surgical management of septic arthritis with irrigation and
débridement of the knee joint is a critical component of the
management protocol. Some investigators have suggested
that initiation of antibiotics may suffice, and they have pro-
posed an expectant policy, reserving surgical management
for cases not responding to antibiotics.5,8 However, this
approach has several disadvantages: evacuation of the puru-
lent effusion is incomplete, débridement of the joint is not
performed, and thereby an increased bacterial count remains,
which may compromise eradication of the infection.
Therefore immediate surgical management has been
proposed by several authors.1–3,7,9 In a survey of directors of
sports medicine fellowship programs,10 98% of respondents
(60 of 61) selected surgical irrigation as part of their manage-
ment protocol in conjunction with intravenous antibiotics.
Details of the surgical management remain controver-
sial. Is arthroscopic or open débridement preferable? What
should be the fate of the graft and any implanted hardware?
Unfortunately, definitive answers to these questions cannot
be provided based on the limited existing literature, but we
will attempt to summarize and present the available data
for the initial management of infections and for the man-
agement of persistent cases.
Initial Management
Irrigation and Débridement
Arthroscopic irrigation and débridement appear to be the
most commonly used methods of initial management for
the patient presenting with a septic knee following ACL
surgery.1–5,7,9
In addition to irrigation of the joint with copious
amounts of saline, débridement of necrotic or inflamed tissue
should be performed. Synovectomy has been proposed by some
authors1,2 in order to decrease the bacterial count and aid in the
resolution of infection. Particular attention should be paid to
the graft; its stability and macroscopic appearance should
be carefully evaluated, and débridement should include a
fibrinous exudate that may be found covering the graft.
Any incisions from concomitant procedures should
be opened and irrigated to avoid missing an extraarticular
collection of fluid that could reseed the knee joint and lead
to persistence of infection. Kohn26 described a case where
the infection spread from the knee joint to the subcutaneous
tissues of the operative wound and warned that in the pres-
ence of large surgical incisions, arthroscopic irrigation may
spread purulent intraarticular material to adjacent
Infections in Anterior Cruciate Ligament Surgery 70
extraarticular locations. Drains should be placed into the
knee joint and in any incisions present; drains can be
removed 48 hours later.
Graft Retention Versus Removal
Most authors have attempted to retain the graft in the initial
management of septic arthritis after ACL surgery, but
removal of the graft at a later time was necessary in some
persistent cases.1–5,7,9
Williams et al1 removed acutely one of seven grafts
because the graft appeared to be loose and nonfunctional. In
three of the six knees with retained grafts, the infection per-
sisted and a repeat procedure was performed; the graft was
removed in another three cases, and, overall the graft was suc-
cessfully salvaged in three of seven cases. Indelli et al4
attempted to retain all grafts; repeat procedures were needed
in five of six patients and two grafts were subsequently
removed, such that finally four of six grafts were retained.
Other investigators were able to retain all implanted grafts.2,7
In contrast, Burks et al3 proposed an aggressive protocol
that included graft removal at the initial irrigation and débride-
ment procedure; the four patients in this series had no recurrence
of infection, and all underwent repeat ACL reconstruction.
In our opinion, preservation of the graft may be justified
in acute postoperative infections that are diagnosed and treated
without a delay. Graft removal during the initial procedure
should be performed if the graft is loose and nonfunctional.1
Graft removal should be considered if there is a delay in presen-
tation and an ongoing infection has been untreated for more
than a few days, if the articular cartilage seems to be already
affected, or if a virulent organism is present.4 Although
unlikely, the presence of patient comorbidities is a factor in
favor of graft removal because the defense mechanisms of the
host may be compromised due to chronic disease. The type of
graft is another consideration; allograft contamination has been
reported, and surgeons are more prone to acutely remove an
allograft compared with an autograft.10
Postoperative Management
The physical therapy program should focus on preventing
stiffness with passive and active-assisted range of motion
exercises. Continuous passive motion can also be used.
A hinge knee brace is applied, and toe-touch weight
bearing is implemented until all wounds are clinically
healed. Weight bearing then progresses as tolerated by the
patient.
Clinical and laboratory monitoring for control of
infection and possible recurrence is necessary, especially if
the graft has been retained. The threshold for a repeat irri-
gation and débridement should be very low if symptoms of
knee pain, limitation of motion, and effusion recur in the
postoperative period.
555
 Anterior Cruciate Ligament Reconstruction
Management of Persistent Cases
Initial management with arthroscopic irrigation and débride-
ment, graft preservation, and antibiotic therapy may not con-
trol the infection in all cases. The infection recurrence rate was
83% (5 of 6 cases) in the series by Indelli et al,4 50% (3 of 6
cases) in the series of Williams et al,1 and 29% (2 of 7 cases)
in the series by Fong et al.7 McAllister et al2 reported that,
despite the acute presentation of infections (8 to 18 days)
and the immediate (within 24 hours) intervention, two to four
repeat surgical procedures were necessary in each patient to
control the infection and restore range of motion of the knee.
Indelli et al4 have clearly established the goals of manage-
ment in their manuscript; the first goal is to protect the articular
cartilage, and the second goal is to protect the graft. The artic-
ular cartilage may undergo irreversible damage from an ongo-
ing or inadequately treated infectious process, and currently
options for restoring articular cartilage are very limited.
Persistent septic arthritis following failure of the arthro-
scopic irrigation and débridement procedure with graft reten-
tion to control the infection is of particular concern; the
infectious process has not been controlled by the initial proce-
dure, the articular cartilage has been exposed to the detrimen-
tal effects of a persistent infectious process for a prolonged
period of time, and the avascular graft and hardware provide
substrate for biofilm formation,17 which may prevent eradica-
tion of infection. McAllister et al2 were able to retain the graft
by managing persistent infections with two to four subsequent
débridement procedures. However, degenerative changes
developed in all four of their patients at a mean follow-up of
36 months, possibly because of the adverse effect of ongoing
infection on articular cartilage. On the contrary, Burks et al3
reported that the four patients managed by graft removal
and repeat ACL reconstruction in their series had no joint
space narrowing at a mean follow-up of 21 months.
Therefore persistent septic arthritis calls for a more
aggressive approach to avoid articular cartilage damage and
arthrofibrosis. Persistence of infection has been proposed as a
reason for graft removal in the literature.1,3,4 However, a survey
of directors of sports medicine fellowship programs showed no
agreement regarding the fate of the graft and implanted hard-
ware.10 In the event of a persistent infection unresponsive to
the initial treatment, 36% of surgeons (22 of 61) would proceed
with graft removal, whereas 64% would elect to retain the graft.
The treating surgeon may be reluctant to remove the
graft in persistent infections because the knee joint will be
destabilized and a subsequent procedure will be necessary for
repeat reconstruction of the ACL. However, there are unique
advantages to this approach. First, the articular cartilage is
protected from permanent damage, which would adversely
affect the final outcome. Second, removal of the graft does
556
not preclude ACL reconstruction at a later stage; the treating
surgeon can employ alternative autograft or allograft techniques
to address the unstable knee following removal of an infected
graft, resulting in a satisfactory outcome.3 Third, although
the additional procedure appears to be a drawback, it may actu-
ally decrease hospitalization time and overall cost because graft
retention has been associated with repeat surgeries in order to
control the infection.1,2,4,7 In the series by McAllister et al,2
two to four subsequent procedures were needed per patient
and the mean hospital stay was 12.5 days. In contrast, Burks
et al reported a total hospitalization time of 4 days for manage-
ment of infection and repeat ACL reconstruction in patients
managed with an aggressive protocol.3
Authors’ Protocol for Persistent Septic
Arthritis of the Knee
In our opinion, an aggressive approach offers the best
chance of controlling inadequately treated, persistent infec-
tions following ACL reconstruction and should be strongly
considered in such cases.
Our protocol for persistent infections is based on radical
débridement consisting of the following elements: open
arthrotomy, complete synovectomy, graft removal, removal of
any interference screws or other implants, and curettage and
débridement of both the femoral and tibial tunnel.6 Aerobic,
anaerobic, mycobacterial, and fungal cultures are obtained from
multiple sources: joint fluid, synovium, graft, and bone
(from the vicinity of both the femoral and the tibial tunnels).
Organism-specific antibiotic therapy is given for 6 weeks.
This protocol was used in five consecutive patients with
persistent septic arthritis of the knee following arthroscopic
ACL reconstruction.6 Patients had previously undergone
one to three unsuccessful débridement procedures with recur-
rence of the infection and were referred to the senior author
(M.J. Patzakis). The time elapsed from the initial diagnosis of
infection to definitive management with radical débridement
ranged from 11 days to 22 months. At a median follow-up time
of 20 months (6 to 27 months), all patients were free from
infection, but degenerative changes of the involved knee joint
developed and one patient underwent total knee arthroplasty.
Three of five infections were polymicrobial. Interest-
ingly, in all three polymicrobial cases different organisms
grew from the multiple tissue samples that included joint
fluid, synovium, graft, and bone. It has been proposed that
different organisms may be preferentially growing in
isolated microenvironments,27 and a study on chronic osteo-
myelitis evaluating cultures from multiple sites showed that
the same organisms grew on culture of the specimens
from every site in only 47% (14 of 30) of patients.28 There-
fore multiple cultures from different sources may help

identify additional pathogens that otherwise may have been
undetected.
In persistent cases, the presence of an unusual organ-
ism may explain the poor response to therapy; aerobic,
anaerobic, mycobacterial, and fungal cultures should be
obtained, and tissue samples should be sent for pathology.
Burke and Zych24 reported a case of persistent infection fol-
lowing ACL surgery that was diagnosed as mucormycosis
approximately 7 months after the initial presentation, lead-
ing to osteomyelitis and destruction of the proximal tibia.
It should be noted that cultures of bone specimens were
positive in three of five persistent infections, indicating the
presence of tunnel osteomyelitis. Graft removal allows for
débridement of the femoral and tibial tunnels. This under-
scores the importance of aggressive management of the septic
knee following ACL reconstruction once the initial attempt
at graft retention has failed to control the infection.
ALLOGRAFTS AND INFECTIONS IN ANTERIOR
CRUCIATE LIGAMENT SURGERY
Reconstruction of the ACL with autograft tissue, BPTB, or
hamstrings, has been well described in the literature.29–31
Alternatively, allograft tissue can be used to provide a source
of graft material in revision cases, preserve the extensor or
flexor mechanisms, and decrease the operative time; however,
allograft structural properties may be compromised by sterili-
zation and storage procedures, incorporation may be slow and
incomplete, an immunological response may take place, the
cost is increased, and an infection risk is present.29,32,33
Contaminated allografts may result in transmission of viral
disease or bacterial infections from the donor to the recipient.
Viral Disease
Viral disease, including human immunodeficiency virus
(HIV) infection, hepatitis B, and hepatitis C, has been
transmitted by transplantation of musculoskeletal allografts
harvested from infected donors prior to implementation of
a screening process.34
Therefore adherence to screening methods is critical to
exclude grafts from infected individuals from being used. The
Food and Drug Administration (FDA) initiated oversight of
tissue banking in 1993 and requires that potential donors
undergo a screening process that includes serologic tests for
HIV-1, HIV-2, hepatitis B, and hepatitis C viruses.35
However, a time window exists from infection with one of
these viruses to development of a detectable antibody response,
and transmission of hepatitis B and C has been reported after
allograft implantation for ACL reconstruction.36,37
Infections in Anterior Cruciate Ligament Surgery 70
Bacterial Infections
Implantation of contaminated allograft tissue has been
reported as a source of unusual infections following ACL
reconstruction and other knee procedures.32,38–42
The Centers for Disease Control and Prevention
(CDC) in 2001 reported four cases of septic arthritis follow-
ing ACL reconstruction associated with contaminated
BPTB allografts; the report warned that when septic arthri-
tis develops after allograft use, contamination of the allograft
should be suspected.41 This is particularly important in
polymicrobial, gram-negative, or anaerobic organism infec-
tions. Other reports included a patient who developed Clos-
tridium sordellii septicemia and died within 1 week of
receiving an osteochondral allograft,40,42 as well as a patient
who developed an invasive Streptococcus pyogenes infection
after ACL reconstruction with an allograft.38
As of March 2002, the CDC had identified 26 cases
of bacterial infections associated with musculoskeletal allo-
grafts.39 Thirteen infections were caused by Clostridium spe-
cies and 11 by gram-negative bacilli (5 were polymicrobial),
and in two cases cultures were negative. Eighteen of these
26 infections (69%) occurred following allograft implanta-
tion for ACL reconstruction. Only 3 of 26 allografts
(12%) were reported to have undergone gamma irradiation
for sterilization.
Crawford et al43 investigated an outbreak of infections
following ACL reconstruction in one outpatient surgical
center. The infection rate was 3.3% (11 of 331), and all
infections occurred in the subgroup of patients in whom
aseptically processed—but not sterilized—allografts were
used. The infection rate in this subgroup was 4.4% (11 of
250) compared with 0% (0 of 41) in the autograft group
and 0% in the sterilized allograft group. Gram-negative
organisms were identified in 6 of 11 cases and Candida
glabrata in 2 of 11 cases.
These outbreaks of infections highlight the need for
allograft sterilization. Aseptic processing and preservation
of the graft without sterilization do not ensure patient safety
because endogenous contamination of the allograft may
exist at the time of harvesting.44,45
Deijkers et al44 evaluated the bacterial contamination
of 1999 bone allografts retrieved from 200 cadaver donors
under sterile operating conditions and reported that organ-
isms of low pathogenicity (such as coagulase-negative sta-
phylococci) were cultured from 50% of the allografts,
whereas organisms of high pathogenicity (such as S. aureus,
streptococcal species, Clostridium species, and Gram-
negative organisms) were cultured from 3%. The authors
described two mechanisms of contamination. Exogenous
contamination, which was influenced by the procurement
557
 Anterior Cruciate Ligament Reconstruction
team, was considered mainly responsible for organisms of
low pathogenicity; endogenous contamination, which was
influenced by the status of the donor, was considered the
probable source of virulent organisms. The risk of contami-
nation with organisms of high pathogenicity was 3.4 times
higher in donors with a traumatic cause of death.
Martinez et al45 reported that positive blood cultures
were present in 8.6% of “beating heart cadaver” donors com-
pared with 38% of postmortem donors. This increase may
be attributed to the postmortem dissemination of endogenous
bacteria (such as normal intestinal flora) secondary to loss of
the intestinal barrier. Microorganisms were isolated from
the bones of 59% (118 of 201) of donors who had negative
blood cultures; thus blood cultures alone are not useful indi-
cators of sterility of the tissues recovered for transplantation.
Therefore, in addition to aseptic harvesting and pro-
cessing, allograft tissue should undergo a sterilization pro-
cess, such as ethylene oxide or gamma irradiation, to avoid
transmission of infectious agents.46 However, concerns exist
regarding the current processes; gamma irradiation may
cause structural damage to the allograft,47,48 whereas ethyl-
ene oxide may penetrate tissue inadequately and cause
inflammatory intraarticular reactions.49 New sterilization
techniques are being developed with the aim of killing
microorganisms and spores while at the same time preserv-
ing the biomechanical integrity of the processed tissues.46
INTRAOPERATIVE GRAFT CONTAMINATION
Intraoperative contamination of the graft may occur by acci-
dentally dropping the graft on the floor or by contacting the
graft with a nonsterile object. A recent survey of 196 sports
medicine fellowship directors showed that 49 of the
responding surgeons (25%) had experienced contamination
of 57 grafts; it occurred once in 43 surgeons (22%) and
two to four times in six surgeons (3%).50 Another study
reported that the graft was dropped on the operating room
floor in four of 1038 ACL reconstruction cases, resulting
in a 0.4% rate of accidental graft contamination.51
In this unfortunate event, the surgeon is faced with
the dilemma of implanting a contaminated graft following
a cleansing procedure or discarding the contaminated graft
and employing an alternative one. Cleansing the graft car-
ries the potential risk for septic arthritis. However, the alter-
natives are not without potential problems; use of an
alternative autograft creates further morbidity for the
patient, whereas an allograft increases the cost and may
not be readily available. The survey by Izquierdo et al50
reported that cleansing of the graft is the most common
practice; graft cleansing was used for 75% of contaminated
grafts (43 of 57), whereas an alternative autograft was used
558
in 18% of cases (10 of 57) and an allograft in 7% (4 of
57). Solutions of chlorhexidine gluconate, antibiotics, povi-
done-iodine, or combinations thereof were used for cleans-
ing of the graft, and none of the 43 decontaminated grafts
was associated with a postoperative infection.50 Casalonga
et al51 sequentially soaked four contaminated grafts in rifa-
mycin and gentamicin solutions, and no infections occurred
at a mean follow-up of 2 years.
An in vitro study warned that soaking the graft for 15
minutes in an antibiotic solution (bacitracin and polymyxin
B) will not sterilize the graft in 30% of cases (3 of 10).52
Another study found that soaking for 30 minutes in a
10% povidone-iodine or a triple-antibiotic solution (genta-
micin, clindamycin, polymyxin) was not able to sterilize
grafts contaminated with two different species of coagu-
lase-negative staphylococci, whereas 4% chlorhexidine glu-
conate effectively decontaminated the grafts.53 The same
study reported that when grafts were contaminated with five
virulent organisms (S. aureus, Escherichia coli, P. aeruginosa,
K. pneumoniae, and Enterococcus faecalis), 4% chlorhexidine
gluconate was able to eliminate all organisms except
K. pneumoniae. Using a triple-antibiotic solution after
chlorhexidine gluconate eliminated this organism as well.53
Molina et al54 evaluated three antibacterial solutions for
decontamination of ACL specimens harvested during total
knee arthroplasty and dropped on the floor. Soaking in chlor-
hexidine gluconate solution for 90 seconds appeared to be the
most effective with positive cultures in broth only in 1 of 50
specimens (2%). Grafts soaked in antibiotic solution of neo-
mycin and polymyxin B had 3 of 50 specimens positive
(15%), whereas grafts soaked in 10% povidone-iodine solu-
tion had 12 of 50 specimens positive (24%).
Burd et al55 reported that power irrigation with a 2%
chlorhexidine gluconate was effective in decontaminating
grafts within 10 to 12 minutes, thus expediting the decon-
tamination process. It should be noted that chlorhexidine
may cause articular cartilage damage.56 Subsequent soaking
in an antibiotic solution and rinsing of the graft prior to
implantation may be beneficial if a chlorhexidine solution
has been used.
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49. Jackson DW, Windler GE, Simon TM. Intraarticular reaction
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50. Izquierdo R Jr, Cadet ER, Bauer R, et al. A survey of sports medicine
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51. Casalonga D, Ait Si Selmi T, Robinson A, et al. [Peroperative
accidental contamination of bone-tendon-bone graft for the
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53. Goebel ME, Drez D Jr, Heck SB, et al. Contaminated rabbit patellar
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54. Molina ME, Nonweiller DE, Evans JA, et al. Contaminated anterior
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55. Burd T, Conroy BP, Meyer SC, et al. The effects of chlorhexidine
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 Allograft Complications and Risk Factors
INTRODUCTION
Allograft use has been increasing because donor
site morbidity is avoided. Although this benefit
is well understood, the drawbacks are more com-
plicated and less well understood. The purpose of
this chapter is to collect information on potential
allograft risk and allograft complications to help
surgeons in their risk-benefit analyses. Some of
the information contained in this chapter can be
found elsewhere in the chapters on stability
results (see Chapter 69) and infections (see
Chapter 70). Potential allograft complications/
risks can be divided into three categories: (1) graft
failure or increased laxity and late graft laxity;
(2) infection; and (3) disease transmission. The
first two also occur with autografts; the third is allo-
graft specific. Potential causes for increased
allograft laxity are: (1) radiation sterilization;
(2) nonradiation sterilization; (3) freezing;
(4) increased donor age; and (5) increased allo-
graft shelf life. Potential causes for increased
allograft infection and disease transmission risk
are: (1) failure to follow tissue-handling guide-
lines; (2) fraudulent procurement practices;
(3) lack of sterilization; (4) foreign body effects;
and (5) harvest/preparation contamination.
These are summarized in Box 71-1. It is of
interest to note that two of these factors involve
human error by individuals not within the sur-
geon’s control. This highlights the inherently
increased risk in allografts versus autografts
attendant to the fact that so many delicate and
exacting tasks must be properly performed
before the graft gets to the operatingroom.
71
CHAPTER
Most tissue banks are run meticulously and Chadwick C. Prodromos
with great care. However, human error, or
Brian T. Joyce
intentional human misbehavior, can occur with
the surgeon unaware.
AREAS OF MORBIDITY
Graft Failure and Laxity
The meta-analytic data presented in Chapter 69
showed allografts to have a failure rate two to
three times that of autografts, even when radiated
grafts were removed from consideration. It also
showed the allograft normal stability rate to
be significantly lower. This effect occurred in
both bone–patellar tendon–bone (BPTB) and
soft tissue grafts. This material is covered in more
detail in that chapter. Despite these overall worse
stability results, it should be pointed out that
some reports show excellent allograft stability
rates.1
Delayed Graft Failure
There is some evidence that allografts have a
tendency toward late failure,2–4 whereas auto-
grafts have shown very little tendency to late
failure.5 This perhaps mirrors the experience
with bone allografts, which can fracture years
after clinical implantation. This late failure
has been accompanied by biopsy evidence of
late or absent recellularization,2,3,6 which may
be causally related. It may be that allograft-
implanted patients should be counseled that late
561
 Anterior Cruciate Ligament Reconstruction
BOX 71-1 Allograft Complications
Areas of Potential Allograft Morbidity
Graft failure/laxity
Late graft failure
Infection
Disease transmission
Potential Causes of Laxity/Failure
Radiation sterilization
Chemical treatments
Freezing
Increased donor age
Increased graft shelf time
Immunological response to graft
Risk Factors for Infection/Disease Transmission
Human error
Human fraudulent behavior
Lack of sterilization
Foreign body effects
Contamination
failure can occur. A longer period of follow-up for allograft
patients may be indicated than is necessary with autografts.
Infection
It is not clear whether the overall infection rate is higher for
allografts than for autografts, but there is evidence that it
may be so. The Centers for Disease Control and Prevention
(CDC), in a well-known analysis of one surgicenter’s experi-
ence, showed no infections in autografts and sterilized
allografts but a 3% infection rate7 in unsterilized allografts.
In our clinical experience the only infected anterior cruciate
ligament reconstruction (ACLR) failures we have seen
have been in allografts. We have seen one patient with two
infected allografts from two different tissue banks operated
at two different hospitals by different surgeons for each
procedure. This patient went on to autograft revision
without incident.
Disease Transmission
The rate of disease transmission risk is difficult to evaluate
because routine viral testing of post-allograft patients is not
carried out, although it is certainly very low. A recent report,
however, included a patient who had hepatitis B transmitted
from a donor who initially tested negative for hepatitis B and
whose allograft was radiated. After the recipient contracted
hepatitis, repeated, more sophisticated testing showed that that
the donor was indeed the source of the hepatitis virus.8 Studies
would indicate that the current sub–3Mrad levels of radiation
now most often employed would be expected to kill neither
the hepatitis nor human immunodeficiency viruses.9,10 Higher
levels in the 5Mrad range are probably necessary. Newer
562
protocols using such higher doses with radioprotectant
may provide the answer.11
POTENTIAL CAUSES OF INCREASED LAXITY
Radiation Sterilization
Radiation has been clearly shown to weaken grafts.12–20
Newer protocols are intended to mitigate or eliminate this
effect, but 2-year follow-up data are currently lacking.
Chemical Treatments
Non-radiation cleaning (e.g., Allowash, Lifenet, Virginia
Beach, VA), sterilization (e.g., Biocleanse, Lifenet),21 cryo-
protectant,22 radioprotectant (e.g., Clearant, Los Angeles,
CA), tutoplasty, ethylene oxide, and other techniques are
used on allografts. The more aggressive these procedures,
the more they affect the material properties of the graft. In
one recent study the mechanical properties of the grafts were
substantially altered by a cryoprotectant technique such that
the surgeon was unable to use the graft.22 Questions about
these grafts can only partially be answered by studies that
analyze strength at time zero. It is the response of the graft
to cellular and vascular ingrowth and ligamentization that
determines ultimate strength. The effects of such treatments
on this process have been little studied.
Freezing
Most grafts are frozen and rethawed at least twice. Grafts
are initially frozen after procurement pending the results
of cultures. Typically they are then thawed and prepared
and then refrozen while a recipient is identified. Freezing
has been shown to adversely affect tissue properties.23
Cryoprotectants are used to protect grafts from the dele-
terious effects of freezing, but it is unknown how well they
work. The temperature of freezing also plays a role. Thus
it is reasonable to wonder how much a single cycle of
freezing may alter the graft or the subsequent ligamentiza-
tion remodeling process. Further complicating this issue is
the fact that some grafts are only frozen, whereas some are
freeze-dried or lyophilized. It is unknown whether the
addition of drying to freezing is a benefit because it removes
potentially damaging ice crystals, is of no consequence, or is
deleterious because it further modifies the tissue.
Increased Donor Age
Kurzweil8 found a strong trend toward greater laxity with
increased donor age in patients undergoing tendo–Achilles
ACLR. Criteria for donor age vary widely, and no standard
criteria exist for upper age limit.

Increased Shelf Time
A correlation between laxity after ACLR and the time the graft
spent on the shelf prior to use was found in one study.24 This
parameter is generally not monitored and needs further study.
Immunological Response
It has been shown that allografts generate an increased
immunological response relative to autografts.25,26 It may
be that this response inhibits ligamentization and cellular
repopulation, leading to graft laxity or failure.
POTENTIAL CAUSES OF INFECTION AND
DISEASE TRANSMISSION
Failure to Follow Tissue-Handling
Procedures
Examples include one death and several infections that
occurred in 2001 as a result of failure to follow established
procedures from one leading tissue bank. Another was a
Food and Drug Administration (FDA) recall in December
2004 of several knee allografts due to the tissue having been
“incorrectly tested for viral markers” from another leading
tissue bank. Thus although tissue banks pay extraordinary
attention to quality control, human error can still occur.
Fraudulent Tissue Procurement of
Unsuitable Tissue
Dubbed the “Frankenstein” or “body snatching” scandal by
the media, this highly publicized 2005 episode involved pro-
curement of nonsterile, aged, and often diseased body parts
from funeral homes that were then represented as having
been taken under sterile conditions from hospitals.
A significant number of ACL grafts were implanted. Debates
and lawsuits are now in process over what complications are
attributable to these grafts. With government inspections
having fallen from one in three tissue companies annually in
2001 to one in eight in 2006 as the number of companies
has increased from 406 to 2030,27 the possibility of undetected
problems is very real. The surgeon must thus be familiar not
only with the tissue bank but also with its graft feeder sources.
Lack of Sterilization
It is believed by many (see Chapter 70) that sterile procurement
by itself is inadequate to guard against disease transmission.
Foreign Body Effects
The allograft is a foreign body and as such is predisposed to
infection relative to host tissue.
Allograft Complications and Risk Factors 71
Contamination
Even with the best technique, the extensive handling of the
graft necessary for procurement and preparation increases
the chances of graft contamination
CONCLUSIONS
1 Overall allografts have been found to have a higher
failure rate, greater laxity, and perhaps a higher late failure
rate than autografts. The reasons are not clearly
understood.
2 It appears that allografts may have a higher infection
rate than autografts, although the overall rate is low.
3 Disease transmission is a risk present in allografts but
not autografts. The risk is very low but unquantified.
4 The effects of freezing, cryoprotection, drying, radiation,
radioprotection, chemical cleaning, and chemical
sterilization on the material properties of the graft after
ligamentization and on the ability of the graft to be
adequately revascularized and repopulated with cells are
unknown. Extensive study is needed. Time-zero
mechanical studies are not adequate to predict ultimate
viability and strength of allografts.
5 Graft preparation and procurement are not within
the surgeon’s direct control. Human error and
fraudulent behavior have led to severe complications.
Surgeons should familiarize themselves with the tissue
bank(s) they wish to use, as well as their graft sources,
and become familiar with the banks’ policies and
procedures.
6 Nonsterilized grafts may pose a risk of disease
transmission. However, graft sterilization techniques
may adversely affect the material properties of the grafts.
Radioprotectant and higher-dose radiation may provide
an answer pending ongoing studies.
References
1. Bach BR Jr, Aadalen KJ, Dennis MG, et al. Primary anterior cruciate
ligament reconstruction using fresh-frozen, nonirradiated patellar
tendon allograft: minimum 2-yeasr follow-up. Am J Sports Med
2005;33:284–292.
2. Prodromos CC, Fu F, Howell S, et al. Controversies in soft tissue ACL
reconstruction. Presented at symposium at the 2006 meeting of the
American Academy of Orthopaedic Surgeons, Chicago, March,
2006.
3. Siegel MG. Personal communication, May, 2006.
4. Risinger RJ, Bach BR Jr. Late anterior cruciate ligament reconstruc-
tion failure by femoral bone plug dislodgement. J Knee Surg
2006;19:202–205.
563
 Anterior Cruciate Ligament Reconstruction
5. Prodromos CC, Han YS, Keller BL, et al. Stability of hamstring
anterior cruciate ligament reconstruction at two- to eight-year
follow-up. Arthroscopy 2005;21:138–146.
6. Scheffler S, Unterhauser F, Keil J, et al. Comparison of tendon-to-bone
healing after soft tissue autograft and allograft ACL reconstruction in a
sheep model. Presented at the 2006 meeting of the European Society
of Sports Traumatology, Knee Surgery, and Arthroscopy, Innsbruck,
Austria, May, 2006.
7. Crawford C, Kainer M, Jernigan D, et al. Investigation of postopera-
tive allograft-associated infections in patients who underwent muscu-
loskeletal allograft implantation. Clin Infect Dis 2005;41:195–200.
8. Grafe MW, Kurzweil PR. ACL reconstruction with Achilles tendon
allografts in revisions and patients over 30. Presented at the 2005
meeting of the Arthroscopy Association of North America, Vancou-
ver, BC, Canada, May, 2005.
9. Fideler BM, Vangsness CT Jr, Moore T, et al. Effects of gamma
irradiation on the human immunodeficiency virus. J Bone Joint Surg
1994;76A:1032–1035.
10. Tomford WW. Transmission of disease through transplantation of
musculoskeletal allografts. J Bone Joint Surg 1995;77A:1742–1754.
11. Forng RY, Willkommen H, Almeida J, et al. Terminal sterilization of
human tissue allografts: application of high-dose gamma irradiation
using the clearant process. Unpublished data.
12. Smith CW, Young IS, Kearney JN. Mechanical properties of
tendons: changes with sterilization and preservation. J Biomed Eng
1996;118:56–61.
13. Maeda A, Inoue M, Shino K, et al. Effects of solvent preservation
with or without gamma irradiation on the material properties of canine
tendon allografts. J Orthop Res 1993;11:181–189.
14. Maeda A, Horibe S, Matsumoto N, et al. Solvent-dried and gamma-
irradiated tendon allografts in rats. J Bone Joint Surg 1998;80B:731–736.
15. Goertzen MJ, Clahsen H, Burrig KR, et al. Sterilisation of canine
anterior cruciate allografts by gamma irradiation in argon. J Bone Joint
Surg 1995;77B:205–212.
16. Curran AR, Adams DJ, Gill JL, et al. The biomechanical effects of
low-dose irradiation on bone-patellar tendon-bone allografts. Am
J Sports Med 2004;32:1131–1135.
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17. Gibbons MJ, Butler DL, Grood ES, et al. Effects of gamma irra-
diation on the initial mechanical and material properties of goat
bone-patellar tendon-bone allografts. J Orthop Res 1991;9:209–218.
18. Salehpour A, Butler DL, Proch FS, et al. Dose-dependent response of
gamma irradiation on mechanical properties and related biochemical
composition of goat bone-patellar tendon-bone allografts. J Orthop
Res 1995;13:898–906.
19. Toritsuka Y, Shino K, Horibe S, et al. Effect of freeze-drying or
gamma irradiation on remodeling of tendon allograft in a rat model.
J Orthop Res 1997;15:294–300.
20. Hamer AJ, Stockley I, Elson RA. Changes in allograft bone irradiated
at different temperatures. J Bone Joint Surg 1999;81B:342–344.
21. Mroz TE, Lin EL, Summit MC, et al. Biomechanical analysis of
allograft bone treated with a novel sterilization process. Spine J
2006;6:34–39.
22. Caborn D, Nyland J, Chang HC, et al. Tendon allograft cryoprotectant
incubation and rehydration time alters mechanical stiffness properties.
Presented at the 2006 meeting of the European Society of
Sports Traumatology, Knee Surgery, and Arthroscopy, Innsbruck,
Austria, May, 2006.
23. Clavert P, Kempf JF, Bonnomet F, et al. Effects of freezing/thawing
on the biomechanical properties of human tendons. Surg Radiol Anat
2001;23:259–262.
24. Sterling JC, Meyers MC, Calvo RD. Allograft failure in cruciate liga-
ment reconstruction: follow-up evaluation of eighteen patients. Am
J Sports Med 1995;23:173–178.
25. Arnoczky SP, Warren RF, Ashlock MA. Replacement of the anterior
cruciate ligament using a patellar tendon allograft: an experimental
study. J Bone Joint Surg 1986;68:376–385.
26. Schulte K, Thompson W, Jamison J, et al. The immune response to
allograft anterior cruciate ligament reconstruction: clinical correlation. Pre-
sented at the 1996 meeting of the American Academy of Orthopaedic
Surgeons, February 1996, Atlanta.
27. Hays T. Profit began before the grave in Frankenstein case. Chicago
Sun Times, June 12, 2006, p 27. Available online at www.suntimes.
com/output/news/cst-nws-flesh12.html.
 Stiffness: Prevention and Treatment
Anterior cruciate ligament (ACL) reconstruction
has evolved into a highly successful procedure,
with recent studies reporting good outcomes in
more than 90% of the patients.1–3 Although the
patellar tendon continues to be the most popular
type of graft in North America, the quadruple
hamstrings graft is emerging as the “other gold
standard.” Multiple comparison studies docu-
ment no difference in the outcomes between the
two types of graft.4–6 Perhaps the two main
reasons for the equal success rates are advances
in the fixation methods of tendon grafts as well
as an increase in our understanding of the biology
of healing of ACL grafts.
However, complications following ACL
reconstruction do occur, and motion loss is one of
the most common. The reported incidence is
between 2% and 11%,7,8 and its management can
be quite frustrating for both the patient and the sur-
geon. In this chapter we will discuss factors that are
associated with development of arthrofibrosis after
ACL reconstruction, propose strategies to avoid
this complication, and present treatment options.
ETIOLOGY
Genetic Predisposition
The tendency of certain patients to develop
excessive scarring following trauma or surgery
is well known. A history of arthrofibrosis from
previous surgery or trauma should alert the sur-
geon. The exact reason behind this excessive
connective tissue proliferation is not known.
72
CHAPTER
Several mechanisms have been proposed. Two Anastassios Karistinos
cytokines, the platelet-derived growth factor-ß
Lonnie E. Paulos
(PDGF-ß) and the transforming growth fac-
tor-ß (TGF-ß), have a central role in the heal-
ing process. Over-expression of TGF-ß has
been associated with unresolved inflammation
and fibrotic events.9 In animal models, neutral-
ization of its isoforms (TGF-ß-1 and TGF-ß-
2) has reduced scarring.10 Interestingly, exoge-
nous addition of the isoform TGF-ß-3 achieved
the same effect. More recently, a possible asso-
ciation between arthrofibrosis and certain
human leukocyte antigen (HLA) types has been
suggested. Skutek et al11 performed HLA typ-
ing in a pool of patients who developed primary
arthrofibrosis following ACL reconstruction.
Patients with secondary reasons for arthrofibro-
sis, such as prolonged immobilization, infection,
or other surgical complications, were excluded.
In their patient group, the phenotype HLA-
Cw*08 was detected significantly more often
compared with the control group. Additionally,
in the same group of patients the phenotypes
HLA-Cw*07 and HLA-DQB1 were detected
significantly less frequently compared with the
control group. The importance of the fat pad
in the fibrotic process following surgical trauma
to the knee has long been recognized.12 Adipose
tissue is capable of releasing cytokines in an
endocrine, autocrine, and paracrine manner.13
Ushiyama et al14 demonstrated that the infra-
patellar fat pad produces a variety of growth
factors and pro-inflammatory cytokines such as
basic fibroblast growth factor (bFGF), vascular
endothelial growth factor (VEGF), tumor
565
 Anterior Cruciate Ligament Reconstruction
necrosis factor alpha (TNF-a) and interleukin (IL)-6,
much like an endocrine organ. Additionally, Murakami
et al15 found elevated concentrations of PDGF-ß and
TGF-ß in the fat pad after ACL reconstruction. From
this research, it is evident that the knee fat pad is capable
of mounting a response much like the articular synovium
and enhances the inflammatory reaction to the surgical
insult. Preservation and minimal disturbance of this struc-
ture during ACL reconstruction may minimize excessive
scarring and motion loss.
Surgical Factors
The timing of surgery following acute ACL tear and its
association with motion loss have been the subject of many
studies and an issue of controversy. Although some authors
believe that early reconstruction (i.e., within 2 weeks from
the injury) does not affect the ultimate knee range of motion
(ROM) that the patient achieves,16–18 it seems that the
majority of surgeons favor a delay varying from 1 to 3 weeks
to allow resolution of the acute inflammation and restoration
of ROM.7,19–21 Furthermore, even in studies where no
motion complications were documented after early interven-
tion, no advantage in terms of the outcome of the reconstruc-
tion was identified. Shelbourne et al22 found that patients
who had delayed ACL reconstruction at a mean of 40 days
after injury had earlier return of quadriceps strength and were
able to progress to sport-specific rehabilitation sooner than
patients who had their knee reconstructed early at a mean
of 11 days after injury. It must be realized, however, that sig-
nificant variability exists among patients in the intensity of
the observed inflammation following acute ACL tear, and
this is at least partially related to the energy of injury. Rather
than relying on timetables or strictly followed protocols, we
believe that the decision on surgical timing should be based
on clinical observation of subsidence of the posttraumatic
inflammation, restoration of ROM, and normalization of
gait. The patient is advised to follow a classic RICE (rest,
ice, compression, and elevation) regimen and is referred to
physical therapy (i.e., prehab). This allows the patient to
become familiar with the physical therapist and the exercises
and equipment that will be used after the surgery, become
emotionally prepared, and make other necessary arrange-
ments for the upcoming surgery. These are all factors that
contribute to correct patient education and, in our opinion,
enhance compliance and chances for a successful outcome.
The issue of timing becomes even more important when
the ACL tear is combined with other ligament injuries.
Associated medial collateral ligament (MCL) injury has been
recognized as a combination that is particularly prone to loss
of motion. The location of the MCL tear influences the
return of motion, and patients with proximal (above the joint
566
line) injury are more likely to experience motion loss postop-
eratively.23 Low-grade injuries are successfully treated with
an initial period of functional bracing to allow healing of
the MCL. This waiting period is used to prehab the knee
before the ACL reconstruction. In cases of associated severe
grade III MCL or multi-ligamentous injury, priority is gen-
erally given to early restoration of knee stability. Attention
during surgery is given to anatomical repair of the MCL,
especially in injuries where the ligament is avulsed from its
tibial attachment. Fixation of the superficial MCL near the
joint line will prevent the normal posterior displacement of
the ligament during knee flexion and will result in postoper-
ative loss of flexion. Generally, in cases of multi-ligament
reconstruction, slow return of motion should be anticipated
and treated aggressively in the postoperative period.
Graft malpositioning due to nonanatomical tunnel
placement either in the tibia or the femur is one of the most
common errors in the surgical technique of ACL reconstruc-
tion and is believed to be responsible for a high percentage of
graft failures. Noyes and Barber-Westin24 reviewed a series of
114 consecutive ACL revisions and found that 30% involved
cases of improper graft placement. Errant tunnel placement
subjects the graft to excessive strains and, depending on its stiff-
ness, can lead either to loss of motion or plastic deformation
and elongation of the graft. The normal ACL has a complex
anatomy, which the current, essentially cylindrical grafts are
unable to reproduce. In theory, during reconstruction, an
attempt is made to place the graft in an isometric position
and at the same time avoid impingement of the graft on the
surrounding anatomical structures. Hefzy et al25 found that of
the two fixation points of the graft, the one that most affects
graft isometry is the femoral. They identified a zone near the
center of the femoral insertion of the normal ACL that was
the most isometric, as defined by a length change of 2 mm or
less. The axis of this zone has a nearly vertical orientation with
the knee extended. Its width varies from 3 to 5 mm and tapers
from proximal to distal. Anterior placement of the femoral tun-
nel was one of the most common errors during ACL recon-
struction. Placing the graft too far anteriorly results in a graft
that is lax in extension and tight in flexion. Often the end result
is a joint with limited postoperative flexion. Attempts to regain
full flexion in such a knee, as during postoperative rehabilita-
tion, will subject the graft to excessive strains and compromise
its integrity. Recognizing the problems associated with anterior
femoral tunnel placement, some surgeons use the over-the-top
position. Attachment of the graft in the over-the-top position
essentially reverses the situation and results in a graft that is
tight in extension but lax in flexion. Currently most surgeons
prefer to place the entrance of the femoral tunnel high in the
notch at the 10- or 2–o’clock position, at the proximal end of
the zone described by Hefzy et al,25 where this zone is wider.
Depending on the graft choice, a 1- to 2-mm back wall

is left to allow safe fixation of the graft. We use three meth-
ods to identify the center of the femoral tunnel and place
the femoral guide pin. This point may be selected using
freehand technique, femoral over-the-top offset guides, and
(less frequently) an isometer.
Clear visualization of the over-the-top position is
important with every method to avoid errors. When the
surgeon uses a transtibial technique to drill the femoral
tunnel, the orientation of the tibial tunnel dictates to a great
extent the position of the femoral guide pin, especially when
it is inserted through an offset guide. Correct placement of
the tibial tunnel in the coronal and sagittal plane is important
to avoid either anterior placement of the femoral pin or pene-
tration of the back wall of the femur. In cases of suboptimal
tibial tunnel placement, where the tendency of the guide pin
is to point anteriorly, we have found it helpful to use a
freehand technique and start the insertion of the femoral
guide pin and subsequent drilling with the knee somewhat
more extended (60 to 70 degrees) and complete the process
with the knee flexed to 90 degrees or even more. This maneu-
ver helps us to achieve posterior placement of the femoral tun-
nel and avoid penetration of the posterior wall. Other options
are to convert to a two-incision technique and drill the femo-
ral tunnel independent of the tibial tunnel or drill the femoral
tunnel through the anteromedial arthroscopic portal.
In the study of Hefzy et al,25 altering the tibial attach-
ment site had a smaller effect on isometry of the graft. Never-
theless, the tibial attachment site is important if one is to avoid
impingement of the graft on the intercondylar roof or the
posterior cruciate ligament (PCL). Sapega et al26 noted that
even in the normal ACL, only a few fibers are truly isometric
(length change of 1 mm or less) over the full ROM of the
knee. In their cadaveric study the fibers of the anteromedial
bundle of the ACL demonstrated the least deviation from
isometry. Many authors27–30 shared the same view and placed
the tibial tunnel in the anteromedial footprint of the tibial
ACL insertion in an attempt to re-create these fibers.
However, anterior placement of the tibial tunnel anterior to
an imaginary line and tangential to the intercondylar roof
(Blumensaat’s line) with the knee in full extension results in
roof impingement of the graft and loss of extension. Howell
and Taylor31 found poor results in patients with impinged
grafts in terms of extension loss and graft failure. They
reported a 100% failure rate in the severely impinged grafts
where the entire articular opening of the tibial tunnel was
anterior to the slope of the intercondylar roof. The tibial inser-
tion of the native ACL has an eccentric anterior extension32
that cannot be re-created without impingement of the graft
in the intercondylar roof. Jackson and Schaefer33 reported a
series of patients who presented with loss of extension follow-
ing ACL reconstruction with patellar tendon autograft. Sec-
ond-look arthroscopy revealed the presence of a fibrous
Stiffness: Prevention and Treatment 72
nodule, reminiscent of a “cyclops,” in front of the ACL graft,
which blocked extension. Excision of the nodule resulted in
improvement of knee extension in all patients. Marzo et al34
described the same pathology in a group of patients follo-
wing ACL reconstruction with patellar tendon or hamstring
autograft. In both instances it was believed that the fibrous
nodule was the result of anterior tibial tunnel placement and
impingement of the graft in the intercondylar roof. Romano
et al35 studied the effect of tibial tunnel placement on
ROM. They found that placement of a portion of the tunnel
medial to the medial tibial spine was associated with loss of
flexion. Interestingly, in the same study, it was found that
anterior placement of the tunnel was associated with loss of
both extension and flexion. Lateral placement of the tibial
tunnel can cause attrition of the graft on the lateral wall of
the intercondylar notch and recurrent synovitis.36 A very pos-
terior positioning of the tunnel in the tibia should be avoided
because it is the least isometric and can cause excessive graft
tension in extension, thus risking flexion contracture.
Another cause of postoperative loss of flexion may be impin-
gement of the graft on the PCL. This is determined by the
angle of the tibial tunnel in the coronal plane. A tibial tunnel
with an angle greater than 75 degrees with respect to the
medial joint line will place the femoral tunnel close to the
12-o’clock position and cause impingement of the ACL graft
on the PCL during knee flexion.37 Among the different
landmarks that can guide tibial tunnel placement (i.e., medial
tibial eminence, the PCL, the “over-the-back” position, the
true posterior border of the tibia, and the posterior border of
the anterior horn of the lateral meniscus), it appears that the
PCL is the most reproducible.38 In an attempt to ameliorate
errors in tunnel placement, avoid roof impingement of the
graft, and account for individual anatomy, Howell39 intro-
duced the one-step tibial guide that allows the surgeon to
customize the sagittal and coronal position of the tibial tunnel
to the specific combination of roof angle and extension (or
hyperextension) in the reconstructed knee. Other options that
may help correct placement of the tunnels and avoidance of
roof impingement are the use of impingement rods or intra-
operative fluoroscopy. It is our opinion that there is no fool-
proof method and the surgeon should use a combination of
all of these methods to avoid nonanatomical graft placement
and postoperative motion loss.
Tensioning of the graft is another area that deserves
special attention to prevent motion loss following ACL
reconstruction. The optimal force for graft tensioning as well
as the angle of knee flexion that such force should be applied
are unknown. Clinically, the risk of undertensioning the graft
and therefore not correcting the posttraumatic laxity should
be balanced with the risk of overconstraining the knee. It
has been suggested that the magnitude of tension should be
graft specific and that hamstring grafts need higher initial
567
 Anterior Cruciate Ligament Reconstruction

tension.40 However, the surgeon has to keep in mind that an reconstruction. Early recognition of this process and avoid-
equally tensioned four-strand hamstring tendon graft has ance of forced motion are extremely important so as not to
higher stiffness than a 10-mm bone–patellar tendon–bone further propagate inflammation and fibrosis.
(BPTB) graft.41 As the stiffness of new fixation devices for
tendon grafts continues to improve, the risk of capturing the
Rehabilitation
knee by overtensioning the quadruple hamstrings graft is very
real. In a prospective clinical randomized study, Heis and
A well-delineated rehabilitation program is critical to avoid
Paulos42 compared laxity and flexion results using initial graft
motion complications following ACL reconstruction. It has
tensions of 68N and 88N. At the latest follow-up, the average
long been recognized that prolonged immobilization adversely
side-to-side laxity measured 1.7 mm in the 68N group and
affects the results of the procedure and increases the risk of
2.8 mm in the 88N group. Flexion angles at 4 weeks showed
arthrofibrosis.44 Immobilization of the knee in flexion after
statistically significant difference between the two groups
surgery has been abandoned, and today the operated knee is
with average flexion of 109 degrees in the 68N and 88 degrees
braced in extension. This practice has reduced the incidence
in the 88N group. In terms of overconstraining the knee, the
of postoperative knee flexion contracture. Accelerated rehabili-
flexion angle at which the tension is applied may have a
tation programs are in widespread use and have minimized
greater impact than the applied force itself. Bylski-Austrow
motion complications. However, a common error is a strict
et al43 noted greater increases in force applied to the graft
adherence to timetables, which at times can be counterproduc-
and greater posterior shifts in tibial position by changing the
tive and have the opposite from the desired effect. We use a
flexion angle at tensioning from 0 to 30 degrees than by
“criteria-based rehabilitation protocol” that respects the indi-
increasing the initial tension from 22N to 44N. From a prac-
vidual response to the surgical insult and the ensuing healing
tical standpoint, in order to avoid motion loss postoperatively,
process. The patient is advanced through the various phases
we prefer to tension the graft at 20 to 30 degrees of flexion and
of the rehabilitative protocol when certain criteria have been
neutral rotation with 12 to 15 pounds of tension unless the
met and the knee is physiologically ready. The initial phase of
graft shortens more than 3 mm or more than 10% of its length
this program focuses on reversal of the physiological imbalance
between the two fixation points when the knee is brought into
of the knee. The main goals early are to decrease the postoper-
full extension. If such shortening is observed, tensioning is
ative swelling and pain (RICE), reverse the muscular inhibition
performed in extension.
of the quadriceps (electrical stimulation, biofeedback), preserve
patellar mobility (glides and tilts), achieve early unassisted
Infrapatellar Contracture Syndrome
ambulation, and restore knee motion with emphasis in exten-
sion (quadriceps isometric sets; slow, nonmanual passive range
Infrapatellar contracture syndrome represents an abnormal
of motion exercises; opposite-leg active assisted knee extension
fibrosclerotic healing response through the anterior retin-
exercises). Once the patient has knee flexion of at least 110
aculum, patellomeniscal ligaments, and fat pad tissues,
degrees, is able to perform straight leg raises with no quad
which entraps the patella and leads to loss of extension
lag, has full passive knee extension, has minimal swelling and
and flexion of the knee and, in advanced stages, to patella
pain, and has good or improving patellar mobility, he or she
baja and patellofemoral arthrosis. The syndrome can
can be advanced to the next phase(s), where the focus is shifted
develop after knee injury or surgery but more often is seen
to strengthening and progressive neuromuscular challenging of
after ACL reconstruction due to errors in the surgical tech-
the knee. It is important that these therapeutic interventions
nique or rehabilitation.12 The syndrome has three stages
are nonpainful and do not further inflame the knee. Failure to
each, with distinctive characteristics. In stage I (2–8 weeks)
recognize such responses can lead to patellar entrapment and
the patient presents with periarticular inflammation and
arthrofibrosis. Close follow-up of the patient in the early post-
edema, immobility of the knee, and quadriceps weakness
operative period and good communication with the physical
and lag. Later, in stage II (weeks 6–20), the knee demon-
therapist are important for early detection of motion complica-
strates limited patellar mobility and an inferior tilt of the
tions, which in the majority of cases can resolve easily with
patella (shelf sign), and the quadriceps lag “disappears” but
appropriate intervention and avoidance of forceful and painful
the patient ambulates with a bent knee gait. In stage III,
range of motion exercises.
generally from the eighth month onward, patellar mobility
is somewhat improved but the knee develops patella baja
and degenerative changes in the patellofemoral joint. The Other Causes
fat pad appears to have a central role in the pathogenesis
of this syndrome; therefore every effort should be made to Another, less common cause of postoperative stiffness is
disturb this structure as little as possible during ACL reflex sympathetic dystrophy (RSD) or complex regional

568

pain syndrome. It represents an exaggerated sympathetic
response after trauma or surgery. Clinical manifestations
include pain out of proportion after injury or surgery,
decreased skin temperature and mottling, hypersensitivity
to touch, atrophic skin changes, osteopenia, and restricted
ROM. The syndrome has been divided in three stages,
and the best treatment is prevention. Preemptive analgesia
in the form of local anesthetics and preoperative administra-
tion of nonsteroidal antiinflammatory medications and/or
opioids can help decrease the incidence of this complication.
The theoretical basis of preemptive analgesia is that it blocks
nociceptive inputs generated during surgery that can trigger
a state of hyperexcitability in the central nervous system. We
routinely preinject the knee before the procedure with a
solution of bupivacaine (Marcaine) and morphine. Poehling
et al,45 in a study of patients with clinically significant RSD,
found evidence of injury to the infrapatellar branch of the
saphenous nerve in all of the patients. The saphenous nerve
may give multiple infrapatellar branches that frequently
cross over extensively into the lateral side of the knee and
upper leg. Incisional neuromas of these branches after
ACL reconstruction have received little attention in the lit-
erature but can be a source of significant morbidity extend-
ing beyond numbness or dysesthesia. Injury to the
infrapatellar branch or the saphenous nerve itself may hap-
pen at various stages of the reconstructive procedure, such
as during the superficial dissection, semitendinosus or graci-
lis tendon harvesting, and medial meniscus repair.
Another cause of soft tissue irritation and restricted
motion after ACL reconstruction is protruding hardware.
Suspension devices used for femoral fixation of tendon
grafts in the femur have been reported as a source of postop-
erative arthrofibrosis.46 The surgeon must ensure adequate
seating within the bone of such implants.
Stiffness: Prevention and Treatment 72
operative records and obtain orthogonal x-rays of the knee
with the joint in extension to evaluate tunnel placement
and hardware position. Occasionally, a knee magnetic
resonance image (MRI) may give further insight. It allows
evaluation of the graft and its position as well as the fat
pad. An impinged graft will demonstrate increased signal
in the distal two-thirds and deflection under the roof.48 In
cases of suspected “Cyclops” lesion, an MRI is the study
of choice (Fig. 72-1). The images should be scrutinized
for other missed pathology, such as meniscal tears, failed
meniscal repairs, and so on, that can hinder knee motion.
Other laboratory workup such as complete blood count with
differential, erythrocyte sedimentation rate (ESR) and C
reactive protein (CRP) knee aspiration, and synovial fluid
analysis and cultures may be indicated in cases of
suspected infection.
The patient is approached initially using the same
criteria-based rehabilitation program that we routinely use
after ACL reconstruction. A return to an earlier phase of
rehabilitation—and in the majority of cases, this is usually
the first phase—is necessary in order to reverse the inflamma-
tion and physiological imbalance of the joint. The knee joint
should have adequate time for rest, and therefore physical
therapy sessions are scheduled every other day. Occasionally,
for the same reason it may be necessary to cease physical
therapy altogether. Emphasis is placed in reversing the

TREATMENT
Whether motion loss following ACL reconstruction is due to
genetic predisposition, errors in surgical timing or technique,
the expression of a developing infrapatellar contracture
syndrome, or merely the result of lack of appropriate rehabilita-
tion, early recognition of this complication is crucial. It is our
experience as well as that of others47 that early treatment yields
better results. The clinical presentation is nearly identical in
every case: an inappropriately painful and swollen knee, with
significant periarticular inflammation, quadriceps inhibition
and lag, inability to gain extension, limited passive patellar
mobility, and failure to make progress during rehabilitation.
In most cases, a careful history and physical examina-
tion focused on the previously discussed factors can point to FIG. 72-1 In cases of suspected “Cyclops” lesion, magnetic resonance
the cause of the postoperative stiffness. It is useful to review imaging (MRI) is the study of choice.

569
 Anterior Cruciate Ligament Reconstruction
quadriceps inhibition with active ROM exercises, opposite-
leg active assisted knee extension exercises, and liberal use of
modalities such as electrical stimulation, biofeedback, and so
on. Patellar mobility is maintained with passive mobilization
exercises such as tilts and glides in the nonpainful range. It
is much more important in this early stage to preserve and
regain extension rather than flexion because loss of extension
is poorly tolerated. Any forceful manipulation is strictly
contraindicated, and the patient as well as the therapist should
specifically be educated on this issue.
Pharmacological management includes use of nonste-
roidal antiinflammatory medications and, in more resistant
cases, a brief course (1 to 2 weeks) of a tapered dose of
methylprednisolone followed by indomethacin. In our expe-
rience, this has no deleterious effects on the healing graft
and greatly facilitates physical therapy efforts. Manipulation
under anesthesia is most successful to restore flexion
than extension, usually follows arthroscopic releases, and is
never used in a reactive knee.
In cases where an anatomical block to motion is identi-
fied (e.g., graft impingement, Cyclops lesion) surgical treat-
ment is advocated. In the early period following ACL
reconstruction, loss of extension is due to pathology between
the graft and the fat pad, and loss of flexion is usually due to
adhesion formation in the suprapatellar pouch and medial
and lateral gutters. Arthroscopic débridement of fibrotic
nodules in front of the graft, roofplasty, or lysis of adhesions
in the suprapatellar pouch and gutters can successfully address
postoperative loss of motion.33,49 In more severe cases of
global knee arthrofibrosis or advanced stages of infrapatellar
contracture syndrome, open débridement is necessary. Delay
for several months to allow subsidence of the inflammation
of the knee may be necessary. Attempts to mobilize an
inflamed knee usually prove unsuccessful, and therefore it is
preferable to work on muscle strength through the available
ROM while waiting for resolution of the inflammation.
A thorough débridement of scar tissue is performed through
a lateral and/or limited medial arthrotomy, with special
attention paid to the anterior compartment of the knee. A
malpositioned, overtensioned, or impinged graft that blocks
motion is excised. Protruding hardware is removed or
trimmed. In long-standing cases, posterior capsular releases
may rarely be required to correct a flexion contracture.
CONCLUSIONS
The growing body of knowledge on ACL reconstruction has
helped to reduce the incidence of postoperative stiffness. To
further minimize this complication, the surgeon should
carefully evaluate the connective tissue profile of the patient,
delay surgery whenever possible to allow subsidence of the
570
posttraumatic inflammation, and apply meticulous surgical
technique especially in issues such as handling of the fat
pad, tunnel placement, graft isometry, and tensioning. In
the postoperative period, prolonged immobilization should
be avoided and the rehabilitation protocol should respect the
individual response of the operated knee. Early recognition
of failure to gain knee motion is paramount, as appropriate
intervention can ameliorate this complication in the
majority of cases.
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6. Shaieb MD, Kan DM, Chang SK, et al. A prospective randomized
comparison of patellar tendon versus semitendinosus and gracilis
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J Sports Med 2002;30:214–220.
7. Harner CD, Irrgang JJ, Paul J, et al. Loss of motion after anterior
cruciate ligament reconstruction. Am J Sports Med 1992;20:499–506.
8. Shelbourne KD, Patel DV, Martini DJ. Classification and manage-
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11. Skutek M, Elsner HA, Slateva K, et al. Screening for arthrofibrosis
after anterior cruciate ligament reconstruction: analysis of association
with human leukocyte antigen. Arthroscopy 2004;20:469–473.
12. Paulos LE, Rosenberg TD, Drawbert J, et al. Infrapatellar contracture
syndrome: an unrecognized cause of knee stiffness with patella entrap-
ment and patella infera. Am J Sports Med 1987;15:331–341.
13. Mohamed-Ali V, Pinkney JH, Coppack SW. Adipose tissue as an
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15. Murakami S, Muneta T, Ezura Y, et al. Quantitative analysis of
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571
73
CHAPTER
Osteoporosis After Anterior Cruciate
Ligament Reconstruction?
Lars Ejerhed ANTERIOR CRUCIATE LIGAMENT
Jüri Kartus INJURIES AND THEIR TREATMENT
Anterior cruciate ligament (ACL) injuries are
usually sustained by a young and active popula-
tion, often under heavy pressure to continue
heavy labor or sports activities at a competitive
or recreational level. The natural history of an
ACL injury still remains unclear. Conservative
(nonsurgical) treatment has been reported to pro-
duce unsatisfactory results, such as chronic insta-
bility, muscle weakness, and osteoarthritis (OA),
but also to render acceptable function for some
patients.1 It is a common algorithm that surgical
intervention is recommended if the patient
requests a return to high-risk pivoting sports or
if symptoms of giving way are persistent after a
conservative program. To our knowledge, how-
ever, this has not been scientifically proven in
randomized controlled studies.
ACL surgery and reconstruction with dif-
ferent types of autograft such as patellar or ham-
string tendons have been shown to produce
good and predictable results. The majority of
patients can return to heavy labor and sports
activities, but normally on a lower level than
before the injury. However, the reconstructions
are often associated with donor site problems that
are well documented in the literature. These pro-
blems involve anterior knee pain, patellofemoral
tenderness and the development of OA, patellar
tendon shortening, loss of sensitivity in the ante-
rior knee region, discomfort during kneeling and
knee-walking, and loss of muscular strength.
572
Another less documented but reported
side effect after ACL injury and ACL surgery
is the risk of localized or systemic bone loss.
In some respects, the ACL injured patient
is selection biased. The injury usually occurs
during sporting activities. The patients are often
young, well-trained athletes and have all the
requirements to have a good bone mass. We
know that athletes have higher bone density
than the normal population, a combined effect
of training and selection, as it is probably more
likely that people with good muscle strength
choose to play soccer/football compared with
smaller individuals.
PEAK BONE MASS AND NATURAL
BONE LOSSES
We start adult life with a peak bone mass, 80% of
which is determined by genetic factors. This is
also the case for fat and muscle tissue, 65% to
80% of which are genetically determined. Men
have a higher peak bone mass than women
(Fig. 73-1). During childhood and adolescence,
it is possible to increase bone mass with sufficient
nutrition and physical activity. However, the
positive effect of training during childhood and
adolescence appears to be lost with the cessation
of a sporting career.2
From the peak bone mass at the age of 25
years, there is an annual loss of approximately
0.5% to 1%. The loss for women is accelerated
in connection with menopause and, during the

Bone mass
Peak bone mass
Menopause
Age
25 years 45-55 years
FIG. 73-1 Schematic bone mass curves showing the peak bone mass and
the subsequent loss with age. (Men are represented by the unbroken line
and women by the dotted line.)
subsequent 10 years, the annual loss is as much as 2% to 4%
(see Fig. 73-1). The bone metabolism turnover rate is 4 to
10 times higher in trabecular bone compared with cortical
bone. The content of trabecular bone in the calcaneus is
95%; in the lumbar vertebrae, 40%; and in the neck of the
femur, 40%. In a period of 8 years, the bone tissue is
completely replaced. The potential as an adult to compensate
for a low peak bone mass or significantly to increase bone mass
by strenuous exercise or an excessive intake of calcium/vita-
min D appears to be virtually nonexistent. However, the
female athlete triad, a disorder in young females characterized
by eating disturbances, amenorrhea, and osteoporosis, could
be an exception. For these individuals, there is still the poten-
tial for “catch-up” in bone mass in the third decade of life if
the condition is reversed. The normal physiological bone loss
seen during pregnancy and breastfeeding also appears to be
reversible.
OSTEOPOROSIS
The World Health Organization (WHO) has proposed a
definition for osteoporosis based on bone mineral density
measured using the dual-energy X-ray absorptiometry
(DXA) technique in the hip, vertebra, or distal radius in
postmenopausal women. Osteoporosis is defined as bone
mineral density more than 2.5 standard deviations below
the mean value for young adults in the same population.
Osteoporosis and its consequences, with an increasing
fracture incidence among the aging population in Western
countries, have become a challenge to general public health
and the welfare system. There are many known risk factors
for osteoporosis and/or fractures. They can be divided into
(1) nontreatable risk factors such as older age, previous frac-
ture, female gender, menopausal age, heredity, ethnicity,
Osteoporosis After Anterior Cruciate Ligament Reconstruction? 73
and body height and (2) treatable risk factors such as physical
inactivity, low body weight/low body mass index (BMI),
cortisone treatment, low bone density, tendency to fall,
tobacco smoking, alcohol consumption, low exposure to sun-
light, impaired vision, and calcium and vitamin D deficiency.3
Older age and a history of previous fractures are regarded as
by far most important risk factors.
Osteoporosis is a silent condition with no symptoms,
and the clinical manifestation is usually a low-energy fracture
in the vertebra, distal radius, proximal humerus, or hip. The
Scandinavian countries of Norway, Iceland, Sweden, and
Denmark top the global list for the incidence of hip fractures.
The incidence of hip fractures will be an increasing problem
worldwide due to an aging population.
BONE LOSS AND MUSCULOSKELETAL INJURIES
Local and generalized bone loss is reported in the literature
to be associated with musculoskeletal injury and physical
inactivity. The bone loss caused by inactivity might be pre-
vented at least in the early phase of inactivity through
increased weight bearing, exercise, or medication. Fractures
in the lower extremities are reported to cause bone loss.
Andersson and Nilsson4 reported a loss of 25% in the prox-
imal tibia and fibula 1 year after tibial shaft fractures. The
loss was found irrespective of treatment in a below-knee
brace with weight bearing or a long leg plaster without
weight bearing. Nine years after tibial fractures, Kannus
et al reported approximately 10% lower bone mineral
density in the spine and in the knee region in the injured
leg compared with the noninjured leg.5 Andersson and
Nilsson6 also found a loss of bone mineral in the knee
region after knee ligament injuries. The average loss after
1 year was 10% in the nonoperated group treated with a
knee bandage for a short time and 18% in the operated
group treated with a plaster cast for 5 weeks.
To summarize, fractures, knee ligament injuries, and
meniscal tears cause a loss of bone mineral. This degrada-
tion process appears to be rapid, but the bone formation
process is slow and it is unclear whether this loss can ever
be completely recovered.
ANTERIOR CRUCIATE LIGAMENT SURGERY
AND THE EFFECT ON BONE TISSUE
Kannus et al reported a 3% to 9% lower bone mineral den-
sity in the knee region compared with the noninjured knee
10 to 11 years after ACL injuries treated surgically. The
injured knee had a reduction of 6% in the distal femur,
9% in the patella, and 3% in the proximal tibia. However,
no differences were found in the calcaneus and femoral
573
 Anterior Cruciate Ligament Reconstruction
neck. When examining patients with medial collateral liga-
ment injuries, no reduction was found compared with the
noninjured side, although the immobilization period was
the same (cast for 6–7 weeks). The authors speculated that
using rehabilitation braces and early weight bearing instead
of immobilization in a plaster cast after ACL reconstruction
could prevent osteoporosis.7
In a cross-sectional study, Kartus et al8 reported that
male patients with unilateral ACL injury had a significantly
lower bone mass in the calcaneus on the injured side com-
pared with the noninjured side before primary reconstruc-
tion, 2 years after primary reconstruction, and 2 years after
revision surgery. Furthermore, the time period between the
injury and the index operation did not correlate with
the bone mass. However, a high level of activity correlated
with the bone mass on both the injured and the uninjured
side 2 years after primary reconstruction.
Leppala et al9 found a bone loss of 14% to 21% in the
knee region in the affected extremity 1 year after ACL
reconstruction. In a conservatively treated group (complete
or partial ACL tears), they found a small yet significant
bone loss in the patella (3%) and proximal tibia (2%) on
the affected side. The “healthy” extremity was not measured,
however.
Ejerhed et al10 reported a bone loss of approximately
17% in both calcanei 2 years after ACL reconstruction using
the arthroscopic technique, bone–patellar tendon–bone
(BPTB) grafts, and aggressive rehabilitation. The patients
underwent surgery 1 year after ACL injury, and by that time
they had a low activity level but still had bone mineral values
above those of the normal population. Two years after the
reconstruction, the patients had regained most of their desired
activity level more than 1 year earlier, but with bone mineral
values far below the normal (Fig. 73-2). The previously
proposed explanation for excessive bone loss due to inactivity
0.6
0.55
0.5
BMA (g/cm2)
Normal
Female
0.45
Normal
Male
0.4
0.35
0.3
Preop 2 years
FIG. 73-2 A schematic representation of the bone mineral loss found by
Ejerhed et al10 in the calcanei from the preoperative assessment and
2 years after anterior cruciate ligament (ACL) reconstruction (dotted lines).
The unbroken lines show the expected loss due to aging for males and
females, respectively.
574
therefore appeared to be of minor importance, at least in
that study.
It might be that bone mineral decreases in the knee
region as a result of the surgical trauma to the knee during
reconstruction. The technique used for the reconstruction,
BPTB, removes a substantial amount of bone tissue in the
knee region (femoral condyle, patella, and tibial condyle).
Another proposed explanation for the localized bone loss
in the knee region is that harvesting the central third of
the patellar tendon causes a weakening in an intact tendon.
This leads to reduced forces acting on this region, with a
subsequent bone loss in the patella and the proximal tibia.11
It therefore appears to be suboptimal to measure the
bone mass in the knee region when the aim is to evaluate
the effect of early weight bearing and rehabilitation.
Another reason to perform measurements in the calcanei is
that this bone consists of about 95% trabecular bone and
could therefore be a fast, sensitive indicator of the bone
remodeling process.
SURGERY: A RISK FACTOR FOR OSTEOPOROSIS?
The reported bone loss of 10% to 20% in young adults after
ACL surgery and a suspicion that this is not a reversible
process might cause future problems. The question is
whether the surgical trauma itself could be a risk factor for
osteoporosis later in life. Can surgery initiate increased and
accelerated bone resorption and a negative bone balance
metabolism? Is there any support for this speculation in
the literature? It is worth noting that no study focusing on
surgery and bone mineral loss has actually been found in
the literature.
Alfredson et al reported that a group of patients selected
for operative treatment of chronic Achilles tendinosis had a
bone loss of 16.4% on the injured side compared with the
noninjured side, 12 months postoperatively. In a group of
patients selected for heavy-loaded eccentric calf-muscle train-
ing, there was no side-to-side difference in bone mass in the
calcanei 9 months after the start of the training program. Both
groups had good clinical results with recovery in muscle
strength on both the injured and noninjured sides.12
The study by Leppala et al9 is the only study found in
the literature relating to bone loss after ACL injuries treated
either surgically or conservatively. The authors found bone
loss in the patella of 17% versus 2% and in the proximal tibia
of 17% versus 3% in the surgically and nonsurgically treated
groups, respectively. This represents a fivefold to eightfold
difference in the loss of bone between the study groups. The
explanations proposed by the authors were the different
treatments (either surgical or conservative). The patients
had different types of injury and rehabilitation; in the

conservatively treated group there were also some partial
tears, and in the surgically treated group, a longer non–
weight-bearing period.
The finding in the study by Ejerhed et al that the bone
loss was 16% and 17% in both calcanei 2 years after ACL
reconstruction is unexpected.10 In spite of the relatively long
period of reduced activity level before reconstruction, the
aggressive rehabilitation program, and significantly higher
activity level postoperatively, the authors were not able to find
any restoration of bone mass during the follow-up period of
2 years. The strength of this study was that the bone mass
was measured in a prospective manner on both the injured
and noninjured sides. Frequently in previous studies, a com-
parison has been made between the injured side and the
“healthy” contralateral side. By doing so, there is an obvious
risk of drawing the wrong conclusion if small or no differences
are found. It is easy to miss a progressive process. For instance,
if the 2-year assessment had just been made in this study, a
difference of only 2.5% would have been found between the
injured and noninjured sides.
The excessive reduction in bone mass in both calcanei
in this study, together with the results of other studies, indi-
cates that the described bone loss can be an effect of the sur-
gical intervention. Furthermore, it appears that the positive
effect of increased activity level is of minor importance.
Could ACL injury followed by reconstructive surgery
be a risk factor for osteoporosis later in life? It is hoped that
forthcoming studies will examine the impact of surgery on
bone loss and the subsequent development of osteoporosis.
Another question for the future, which is not discussed in
this chapter, is the alteration in subchondral bone mass
and its connection with the development of OA.
In the case of ACL injury, every patient should have
an individual treatment plan based on the symptoms and
the need to continue with heavy labor or the desire to
Osteoporosis After Anterior Cruciate Ligament Reconstruction? 73
participate in competitive/recreational sports. The patient
should be informed of the realistic expectations of
reconstructive surgery and its known limitations and
complications.
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5. Kannus P, Järvinen M, Sievanen H, et al. Osteoporosis in men with a
history of tibial fracture. J Bone Miner Res 1994;9:423–429.
6. Andersson SM, Nilsson BE. Changes in bone mineral content follow-
ing ligamentous knee injuries. Med Sci Sports 1979;11:351–353.
7. Kannus P, Sievanen H, Järvinen M, et al. A cruciate ligament injury
produces considerable, permanent osteoporosis in the affected knee. J
Bone Miner Res 1992;7:1429–1434.
8. Kartus J, Stener S, Nilsen R, et al. Bone mineral assessments in the
calcaneus after anterior cruciate ligament injury. An investigation of
92 male patients before and two years after reconstruction or revision
surgery. Scand J Med Sci Sports 1998;8:449–455.
9. Leppala J, Kannus P, Natri A, et al. Effect of anterior cruciate liga-
ment injury of the knee on bone mineral density of the spine and
affected lower extremity: a prospective one-year follow-up study. Calcif
Tissue Int 1999;64:357–363.
10. Ejerhed L, Kartus J, Nilsen R, et al. The effect of anterior cruciate lig-
ament surgery on bone mineral in the calcaneus: a prospective study
with a 2-year follow-up evaluation. Arthroscopy 2004;20:352–359.
11. Rittweger J, Maffulli N, Maganaris CN, et al. Reconstruction of the
anterior cruciate ligament with a patella-tendon-bone graft may lead
to a permanent loss of bone mineral content due to decreased patellar
tendon stiffness. Med Hypotheses 2005;64:1166–1169.
12. Alfredson H, Nordström P, Pietila T, et al. Bone mass in the
calcaneus after heavy loaded eccentric calf-muscle training in recrea-
tional athletes with chronic achilles tendinosis. Calcif Tissue Int
1999;64:450–455.
575
 74
CHAPTER
Tunnel Widening After Anterior Cruciate
Ligament Reconstruction
Chadwick C. Prodromos INTRODUCTION
Brian T. Joyce
Tunnel widening after anterior cruciate ligament
reconstruction (ACLR) has been noted for many
years. Initially there were concerns that this wid-
ening would be progressive. However, it is now
clear that tunnel widening only occurs in the first
postoperative year1,2 and is not progressive after
that period. A number of variables have been
hypothesized to cause or contribute to tunnel
widening. These include the following:
1 Hamstring (HS) versus bone–patellar
tendon–bone (BPTB) graft
2 Allograft versus autograft
3 Fixation location: cortical versus apertural
4 Rehabilitation: the aggressiveness of the
postoperative rehabilitation protocol
5 Synovial fluid: the degree to which synovial
fluid penetrates into the tunnel
These potential etiologies and the signifi-
cance of tunnel widening will be discussed in
this chapter.
METHODS OF ANALYZING TUNNEL
WIDENING
Quantifying Tunnel Widening
There is no established standard method for
quantifying tunnel widening. Most authors have
compared tunnel widths at a specified point(s)
within the tibial and/or femoral tunnels and
576
calculated the increase in tunnel size relative to
the original tunnel size. The elapsed interval of
time after the surgery is also specified. Plain
radiographs are usually measured, but computed
tomography (CT) or magnetic resonance imag-
ing (MRI) may also be used.
Literature Analysis
The literature with regard to tunnel widening can
be evaluated in two ways. The first is to aggregate
and analyze the amount of tunnel widening
reported in all series that use one surgical tech-
nique and contrast it to that found in all series
using a contrasting surgical technique (i.e., inter-
series analysis). This can be used to compare, for
example, mean tunnel widening in HS series ver-
sus BPTB series. The second method is to look
at those series that use both techniques within
a given series (i.e., intra-series analysis). Both
methods were used in this analysis so that the
entirety of the tunnel widening literature could be
analyzed. Both methods contributed useful infor-
mation. In general, good agreement was also found
between each method for a given parameter.
SPECIFIC FACTORS ASSOCIATED WITH
INCREASED TUNNEL WIDENING
Hamstring Versus Bone–Patellar
Tendon–Bone Graft
It has been hypothesized that HS grafts are
associated with more tunnel widening than

BPTB grafts. Tunnel widening has been found with the use
of both grafts. Seven series specifically compared HS with
BPTB. However, because fixation is different for the HS
and BPTB grafts in all these series and because fixation type
is one of the leading hypothetical causes of tunnel widening,
the isolated effect of graft type is difficult to discern. Of
these seven series,2–8 two report tunnel widening that is
roughly equal for HS and BPTB and five report more tun-
nel widening with HS. These seven series are presented in
bar graph form in Fig. 74-1.
Allograft Versus Autograft
Two clinical series9,10 have shown increased tunnel widen-
ing in allografts versus autografts. In addition, a recent
sheep study by Weiler showed increased tunnel widening
in allografts at all time periods measured, beginning at 6
weeks and ending at 1 year.11 Possible causes include an
increased immunologic response to the graft or the presence
of chemical residua in the grafts from processing, cleansing,
cryoprotectant, radioprotectant, or the like.
Effects of Fixation Location
It has been suggested that the increased incidence of tunnel
widening in HS ACLR may be due to fixation. Specifically,
a “windshield wiper” effect resulting in greater tunnel widen-
ing when the fixation is further from the joint, as is more often
Aglietti Clatworthy Hersekli
4HS (Tibial)
BPTB (Tibial)
FIG. 74-1 Tunnel widening by graft and fixation type. BPTB, Bone–patellar tendon–bone; HS, hamstring.
Tunnel Widening After Anterior Cruciate Ligament Reconstruction 74
the case with HS than BPTB graft fixation techniques, has
been hypothesized. It is theorized that with knee motion,
the pressure of the graft on the tunnel wall will vary more with
cortical or mid-tunnel (cross-pin) than aperture fixation, pro-
ducing attrition of the tunnel wall. A review of the literature
in this regard does not show a consistent effect of the location
of the fixation.12–17 The four studies comparing aperture to
cortical or cross-pin fixation are presented in Fig. 74-2.
Aggressive Versus Conservative
Rehabilitation
The effect of motion and rehabilitation has been addressed
in three studies in which different postoperative protocols
were used by the same surgeon after ACLR.18–20 The study
by Hantes et al18 showed significantly decreased tunnel wid-
ening when motion was restricted after ACLR. The study
by Yu and Paessler20 also showed significantly decreased
tunnel widening when motion, weight-bearing, and
strengthening activities were all restricted. The study by
Murty et al19 showed the opposite: significantly increased
tunnel widening when motion was restricted after ACLR.
Synovial Fluid Infiltration
Synovial fluid in the bone tunnels has been hypothesized as
a possible cause of tunnel widening without a specific mech-
anism; it has been suggested that “enzymes” in synovial fluid
Harilainen L’Insalata Webster Zysk
4HS (Femoral)
BPTB (Femoral)
577
 Anterior Cruciate Ligament Reconstruction
Aperture (Tibial) Aperture (Femoral)
Cortical (Tibial) Mid-tunnel (Femoral)
FIG. 74-2 Tunnel enlargement by fixation type.
may in some fashion break down bone. It has been hypothe-
sized that applying an apertural seal may prevent this break-
down. In one of the only studies to look at this issue,21 no
tunnel widening was found with HS grafts despite the pres-
ence of synovial fluid in bone tunnels.
ADVERSE EFFECTS
Direct Adverse Effects
No direct adverse event such as fracture or graft failure has
yet been reported as a result of tunnel widening. The reali-
zation that the phenomenon is not progressive over time has
assuaged early fears that progressive widening might result
in significant weakening of the bony elements.
Effects on Revision Surgery
The only indirect adverse consequence of tunnel widening
is its potential effect on revision of failed ACLRs. Tunnel
widening adversely affects revision surgery, depending
partially on the revision technique used. A detailed descrip-
tion is presented in Chapter 57.
578
Interference Screw Fixation
For those surgeons who use interference screws, a widened tun-
nel will generally make interference screw usage impossible
with the original tunnel if the original tunnel was reasonably
well placed. However, if the widened tunnel was severely mis-
placed far from its proper location, the surgeon may be able to
make an entirely new tunnel that does not overlap the widened
tunnel and use an interference screw in the new tunnel.
Noninterference Screw Fixation
For those using cortical or mid-tunnel cross-pin fixation, a
reasonably well-placed original tunnel may still be able to
be used in a one-stage revision. The surgeon will have
a looser fit but may wish to accept this and allow greater
time for tunnel healing to avoid the morbidity and
second-stage requirement of bone grafting, depending on
the amount of tunnel enlargement.
Strategies to Decrease Tunnel Widening
Until the causes of tunnel widening are better understood,
strategies to diminish it will be speculative. Many believe
that the use of either bone graft22 or osteoconductive inter-
ference screws such as the Milagro (Mitek, Raynham, MA)
or Collaxo (Smith & Nephew, Andover, MA) will be likely
to decrease tunnel widening. However, although anecdotal
corroborative evidence exists, we are not aware of any pub-
lished report that validates this hypothesis.
CONCLUSIONS
1 No standardized method exists for reporting tunnel
widening.
2 Tunnel widening occurs only in the first postoperative
year.
3 Allografts appear to cause more tunnel widening than
autografts.
4 HS grafts appear to be associated with greater tunnel
widening than BPTB grafts.
5 Fixation location, fixation type, and synovial fluid appear
to have no effect on tunnel widening.
6 Postoperative motion and activity have been to shown to
both decrease and increase tunnel widening, with more
evidence showing restricted activity to diminish tunnel
widening.
7 No direct adverse consequence of tunnel widening has yet
been reported.

8 Revision surgery, especially with interference screws, is
often made more difficult by tunnel widening.
9 No strategy has thus far been shown to decrease tunnel
widening, although some surgeons believe tunnel bone
grafting may prove effective.
References
1. Lajtai G, Noszian I, Humer K, et al. Serial magnetic resonance imag-
ing evaluation of operative site after fixation of patellar tendon graft
with bioabsorbable interference screws in anterior cruciate ligament
reconstruction. Arthroscopy 1999;15:709–718.
2. Clatworthy MG, Annear P, Buelow J-U, et al. Tunnel widening in
anterior cruciate ligament reconstruction: a prospective evaluation of
hamstring and patella tendon grafts. Knee Surg Sports Traumatol
Arthrosc 1999;7:138–145.
3. Aglietti P, Giron F, Buzzi F, et al. Anterior cruciate ligament
reconstruction: bone-patellar tendon-bone compared with double
semitendinosus and gracilis tendon grafts. J Bone Joint Surg
2004;86A:2143–2155.
4. Hersekli MA, Akpinar S, Ozalay M, et al. Tunnel enlargement after
arthroscopic anterior cruciate ligament reconstruction: comparison of
bone-patellar tendon-bone and hamstring autografts. Adv Ther
2004;21:123–131.
5. L’Insalata JC, Klatt B, Fu FH, et al. Tunnel expansion following ante-
rior cruciate ligament reconstruction: a comparison of hamstring and
patellar tendon autografts. Knee Surg Sports Traumatol Arthrosc
1997;5:234–238.
6. Webster KE, Feller JA, Hameister KA. Bone tunnel enlargement fol-
lowing anterior cruciate ligament reconstruction: a randomized com-
parison of hamstring and patellar tendon grafts with 2-year follow-
up. Knee Surg Sports Traumatol Arthrosc 2001;9:86–91.
7. Zysk SP, Fraunberger P, Veihelmann A, et al. Tunnel enlargement
and changes in synovial fluid cytokine profile following anterior cruci-
ate ligament reconstruction with patellar tendon and hamstring tendon
autografts. Knee Surg Sports Traumatol Arthrosc 2004;12:98–103.
8. Harilainen A, Linko E, Sandelin J. Randomized prospective study of
ACL reconstruction with interference screw fixation in patellar tendon
autografts versus femoral metal plate suspension and tibial post fixa-
tion in hamstring tendon autografts: 5-year clinical and radiological
follow-up results. Knee Surg Sports Traumatol Arthrosc 2006;14:517.
9. Fahey M, Indelicato PA. Bone tunnel enlargement after anterior
cruciate ligament replacement. Am J Sports Med 1994;22:410–414.
Tunnel Widening After Anterior Cruciate Ligament Reconstruction 74
10. Zijl JAC, Kleipool AEB, Willems WJ. Comparison of tibial tunnel
enlargement after anterior cruciate ligament reconstruction using patel-
lar tendon autograft or allograft. Am J Sports Med 2000;28:547–551.
11. Scheffler S, Unterhauser F, Keil J, et al. In Comparison of tendon-to-
bone healing after soft-tissue autograft and allograft ACL reconstruction
in a sheep model. Presented at the 2006 meeting of the European Soci-
ety of Sports Traumatology, Knee Surgery, and Arthroscopy,
Innsbruck, Austria, May, 2006.
12. Buelow J-U, Siebold R, Ellermann A. A prospective evaluation of tun-
nel enlargement in anterior cruciate ligament reconstruction with
hamstrings: extracortical versus anatomical fixation. Knee Surg Sports
Traumatol Arthrosc 2002;10:80–85.
13. Harilainen A, Sandelin J, Jansson KA. Cross-pin femoral fixation versus
metal interference screw fixation in anterior cruciate ligament recon-
struction with hamstring tendons: results of a controlled prospective
randomized study with 2-year follow-up. Arthroscopy 2005;21:25–33.
14. Ma CB, Francis K, Towers J, et al. Hamstring anterior cruciate liga-
ment reconstruction: a comparison of bioabsorbable interference screw
and endobutton-post fixation. Arthroscopy 2004;20:122–128.
15. Sakai H, Yajima H, Hiraoka H, et al. The influence of tibial fixation
on tunnel enlargement after hamstring anterior cruciate ligament
reconstruction. Knee Surg Sports Traumatol Arthrosc 2004;12:364–370.
16. Simonian PT, Erickson MS, Larson RV, et al. Tunnel expansion after
hamstring anterior cruciate ligament reconstruction with 1-incision
Endobutton femoral fixation. Arthroscopy 2000;16:707–714.
17. Simonian PT, Monson JT, Larson RV. Biodegradable interference
screw augmentation reduces tunnel expansion after ACL reconstruc-
tion. Am J Knee Surg 2001;14:104–108.
18. Hantes ME, Mastrokalos DS, Yu J, et al. The effect of early motion
on tibial tunnel widening after anterior cruciate ligament replacement
using hamstring tendon grafts. Arthroscopy 2004;20:572–580.
19. Murty AH, Zebdeh MY, Ireland J. Tibial tunnel enlargement follow-
ing anterior cruciate reconstruction: does post-operative immobiliza-
tion make a difference? Knee 2001;8:39–43.
20. Yu JK, Paessler HH. Relationship between tunnel widening and dif-
ferent rehabilitation procedures after anterior cruciate ligament recon-
struction with quadrupled hamstring tendons. Chin Med J
2005;118:320–326.
21. Sanders TG, Tall MA, Mulloy JP, Lesis HT. Fluid collections in the
osseous tunnel during the first year after anterior cruciate ligament
repair using an autologous hamstring graft: Natural history and clinical
correlation. J Comput Assist Tomogr 2002;426:617–621.
22. Howell SM, Roos P, Hull ML. Compaction of a bone dowel in the
tibial tunnel improves the fixation stiffness of a soft tissue anterior cru-
ciate ligament graft: an in vitro study in a calf tibia. Am J Sports Med
2005;33:719–725.
579
 75
CHAPTER Numbness/Saphenous Nerve
Tomoyuki Mochizuki INTRODUCTION
Keiichi Akita
Leg numbness due to nerve damage is one of the
Takeshi Muneta considerable complications after anterior cruciate
ligament (ACL) reconstruction using both
bone–patellar tendon–bone (BPTB) and medial
hamstring tendons. Such patients especially
complain of uncomfortable feelings when falling
on their knees. Harvesting a BPTB graft includes
risks of damaging nerves and causes sensory
disturbance.1,2 Pagnani et al3 pointed out the risk
of saphenous nerve damage by harvesting medial
hamstring tendons in the region of the pes
anserinus.
Many authors have reported the nerve distri-
bution patterns of the infrapatellar regions.2,4–12
It is well known that both the medial cutaneous
nerve of the femoral nerve and the infrapatellar
branch of the saphenous nerve are distributed
throughout the infrapatellar region and the anterior
lower leg region.9,10,12 The saphenous nerve des-
cends laterally along the femoral artery and enters
the adductor canal. It then leaves the artery at the
distal end of the canal to proceed vertically along
the medial side of the knee and runs between the
sartorius and gracilis tendons. In contrast, the
medial femoral cutaneous nerve originates from
the anterior cutaneous branches of the femoral
nerve. The medial femoral cutaneous nerve runs
laterally to the femoral artery, and then it crosses
anteriorly to the artery at the apex of the femoral
triangle to be distributed to the anteromedial thigh
and the infrapatellar region. Branches of the medial
femoral cutaneous nerve and the infrapatellar
580
branch of the saphenous nerve connect to each
other9,10,12 and form the subsartorial plexus in the
infrapatellar region.13
BONE–TENDON–BONE AUTOGRAFT
Anterior knee pain including leg numbness has
been reported as a main complication of ACL
reconstruction using BPTB grafts. In previous
reports, the rate of postoperative anterior knee
pain ranged from 4% to more than 40%.8,14,15
Mishra et al at first described a technique using
two horizontal incisions for patellar tendon harvest
for the purpose of more cosmetic scarring and
reducing pain and flexion limitation.16 Kartus
et al17 changed to two vertical incisions and
reported of an insensitive area compared with
the insensitive area that resulted from a traditional
vertical incision, which averaged 24 cm. Tsuda
et al18 changed the method of approaching the
retinaculum layer, opening it horizontally rather
than splitting it to protect nerves using two hori-
zontal incisions, and they reported a 17% rate of
postoperative leg numbness. Portland et al19 com-
pared a horizontal incision and a vertical incision
and reported a infrapatellar numbness of 43%
resulting from a horizontal incision and 59%
resulting from a horizontal incision.
HAMSTRING AUTOGRAFT
The donor site morbidity associated with harvest-
ing a hamstring tendon graft is well recognized

to be less common than that associated with harvesting a
BPTB autograft.20 However, sensory disturbance is frequently
observed in regions on the anterior lower leg after ACL recon-
struction using medial hamstring tendons.21,22
CLINICAL EXAMINATION
We clinically examined 103 patients who had arthroscopi-
cally assisted ACL reconstructions using medial hamstring
tendons to investigate the frequencies and areas of sensory
disturbance.23 As an operative procedure, we made two hor-
izontal incisions for the arthroscopy portal and one longitu-
dinal incision (2.5–3 cm) at the pes anserinus for the tendon
harvest and the tibial drill holes. We performed an inside-
out technique and used Endobutton (Smith & Nephew
Endoscopy, Andover, MA) for femoral fixation. The clini-
cal examination was performed for an average of 13 months
(range 6–18 months) after the operation. We detected sen-
sory disturbance on the anterior surface of the lower leg in
60 of 103 (58%) patients. We randomly selected 13 patients
with sensory disturbance and neurologically examined in
detail the regions of sensory disturbance. The regions of
sensory disturbance were of various sizes and shapes
(Fig. 75-1). These regions were generally quadrilateral and
located lateral to the longitudinal incision for tendon harvest
and distal to the horizontal incisions for the arthroscopy
portal. In the detailed neurological examination, in 8 of 13
legs (62%) the region was very close to the longitudinal inci-
sion (see Fig. 75-1, A to C), and in the other 5 legs (38%) it
was relatively far away from the longitudinal incision (see
Fig. 75-1, D). The region was lower than the superior end
of the longitudinal incisions in 12 of 13 legs (92%); how-
ever, in one leg (8%), the region was close to the horizontal
P P
4 (31%) 3 (23%)
A B
FIG. 75-1 Examples of cases of sensory disturbance in 13 legs. A, 4 legs (31%); B, 3 legs (23 %); C, 1 leg (8%); D, 5
legs (38%). P, Skin incision for arthroscopy portal; H, skin incision for tendon harvest.
Numbness/Saphenous Nerve 75
incisions (see Fig. 75-1, C). The region was located in the
upper half of the lower leg in 10 legs (77%); however, in
three legs (23%), the region was wider than others (see
Fig. 75-1, B).
ANATOMICAL INVESTIGATIONS
In our anatomical study, 51 lower limbs of 26 adult cadavers
were used.24 In the mediodistal region of the patella, the nerve
branches pierced the fascia cruris in various patterns and
ran on the outer surface of the fascia to supply the skin
(Fig. 75-2). On the outer surface of the fascia, the nerve
branches often were connected to each other. In the regions
near the horizontal and longitudinal skin incision lines, the
nerve branches ran on the outer surface of the fascia cruris in
all legs.
After complete removal of the fasciae lata and cruris,
the origin of the nerve branches was examined. The anterior
surface of the lower leg was innervated by branches of the
medial femoral cutaneous nerve proximally and by branches
of the saphenous nerve distally. In addition, the patellar
region was innervated by branches of the intermediate fem-
oral cutaneous nerve superiorly and by branches of the
medial femoral cutaneous nerve medially and inferiorly.
Compared with our clinical examinations, the sensory dis-
turbance regions were considered to correspond with the
regions supplied by the branches of the medial femoral cuta-
neous and saphenous nerves.
In 33 of 51 legs (65%; Fig. 75-3, A, B), the infrapatellar
branch of the saphenous nerve ran along the inferoposterior
border of the sartorius muscle. The infrapatellar branch of
the saphenous nerve pierced the distal part of the sartorius
muscle in 16 of 51 legs (31%; see Fig. 75-3, C). In two legs
1 (8%) 5 (38%)
C D
581
 Anterior Cruciate Ligament Reconstruction

(4%; see Fig. 75-3, D), the branch of the saphenous nerve
emerged from the anterosuperior border of the sartorius mus-
cle and ran lateralward horizontally. The infrapatellar region
and the anterior region of the lower leg were generally sup-
plied by branches of both the medial femoral cutaneous nerve
and the saphenous nerve in various patterns. Branches of the
medial femoral cutaneous nerve were also distributed to the
anterior surface of the leg in eight legs (16%; see Fig. 75-3, A),
and branches of the saphenous nerve were also observed
P P to supply the infrapatellar region in two legs (4%; see
Fig. 75-3, D). Branches of these nerves and their connections
were distributed to the region around the insertion of the sar-
torius muscle. At least, therefore, the branches of these two
nerves showed a complementary distribution and a broad
Sa
transitional zone. One or more branches of the nerve ran
across the line of the longitudinal incision in 88% of the cases.
Sv

H DISCUSSION
FIG. 75-2 Examples of the distribution of the nerve branches on the
fasciae lata and cruris. The nerve branches connect in various manners in
the medial infrapatellar region. Some nerve branches pass through the
longitudinal skin incision line. H, Skin incision for harvest; P, horizontal skin
incision for portal for arthroscopy; Sa, sartorius muscle; Sv, saphenous vein.
In numerous clinical anatomical studies, nerve distribu-
tion patterns of the infrapatellar region have been
discussed.2,4–8,10,25 The nerve branches supplying the
skin of the medioinferior region of the patella are recog-
nized as the infrapatellar branch of the saphenous nerve
in most studies. However, according to our study and stan-
dard anatomy textbooks,13,16 branches of the saphenous
nerve and the medial femoral cutaneous nerve, which origi-
nate from the anterior cutaneous branches of the femoral
nerve, are distributed to this region. In addition, the
branches of the medial femoral cutaneous nerve sometimes
extend to the anterior lower leg region. Interestingly,

In Mn In Mn In Mn In Mn

Sn
Sn
Sn
Sn

8 (16%) 25 (49%) 16 (31%) 2 (4%)

A B C D
FIG. 75-3 Four patterns of the distribution of the nerve branches based on findings of 51 legs. A, Branches of the
medial femoral cutaneous nerve are distributed to the anterior leg region (8 legs; 16%). B, Branches of the medial femoral
cutaneous nerve are distributed to the infrapatellar region, and branches of the saphenous nerve are distributed to the
anterior leg region (25 legs; 49%). C, The infrapatellar branch of the saphenous nerve pierces the sartorius muscle and is
distributed to the infrapatellar region (16 legs; 31%). D, The infrapatellar branch of the saphenous nerve emerges from
the anterior border of the sartorius muscle and is distributed to the infrapatellar region (2 legs; 4%). In, Intermediate
femoral cutaneous nerve; Mn, medial femoral cutaneous nerve; Sn, saphenous nerve.

582
 Numbness/Saphenous Nerve 75
although both nerves are clearly distinguishable in origin, it
is very difficult to identify the border between their distribu-
tion territories due to their numerous connections because
of their complementary distribution.
On the basis of the detailed clinical and anatomical
investigations, the sensory disturbance is considered to be
closely related to the skin incisions. Nerve injury due to the
incisions used for the arthroscopy portal as well as the related P P
anatomical findings have been reported.2,11 In the present
clinical findings, the sensory disturbance region was located
in close proximity to the arthroscopy portals in only one case
(see Fig. 75-1, C). The branch of the medial femoral cutaneous
nerve might have been injured by the incisions for the arthros-
X
copy portal. There have been few reports on nerve injuries
Sa
related to the skin incision for tendon harvest.13 The line of
skin incision for tendon harvest at the pes anserinus runs across
the nerve branches originating from the medial femoral cutane-
ous nerve and the saphenous nerve. In some patients, the region H
of the sensory disturbance is not adjacent to the longitudinal
skin incision (see Fig. 75-1, D). These cases might be explained
by the various patterns of the connections and the overlapping Y
distribution territories of the saphenous nerve and the medial
femoral cutaneous nerve.
The possibility of nerve injury during harvesting of the
semitendinosus tendon with a tendon stripper cannot be
overlooked. The main trunk of the saphenous nerve runs Z
distally on the medial (outer) surfaces of the tendons of the
gracilis and semitendinosus muscles along the medial collat-
eral ligament. Because the sensory disturbance region was FIG. 75-4 Schematic drawings of the nervous distribution zone in the
infrapatellar region and the anterior leg region. The infrapatellar region and
located lateral to the longitudinal incision line in all patients, the anterior lower leg region are divided into three areas based on the
the tendon harvest using a tendon stripper cannot be the main distribution of the nervous branches: X, the region distributed by the
reason for the sensory disturbance. Injury or entrapment of medial femoral cutaneous nerve; Y, the transitional zone between the
regions X and Z; Z, the region distributed by the saphenous nerve. H, Skin
the main trunk of the saphenous nerve has been reported,26,27 incision for tendon harvest; Mn, branches of the medial femoral cutaneous
but the sensory disturbance region due to such injury is much nerve; P, horizontal skin incision for portal for arthroscopy; Sa, sartorius
wider than that found in our study. If the tendon stripper muscle; Sn, branches of the saphenous nerve.
caused the nerve injury, the main trunk of the saphenous
the sensory disturbance to avoid cutting the courses of the
nerve could be damaged as well as the branches of the nerve,
various branches of the nerves, based on our findings of
as previously pointed out by Pagnani.3 Therefore it is very
the nerve courses and distribution.
important to be careful of the main trunk of the saphenous
nerve due to its close positional relationship to the tendons References
to avoid sensory disturbance after ACL reconstruction.
The complicated anatomical variations of the nerve 1. Graf B, Uhr F. Complications of intra-articular anterior cruciate
branches in the infrapatellar region and the anterior lower reconstruction. Clin Sports Med 1988;7:835–848.
2. Mochida H, Kikuchi S. Injury to infrapatellar branch of saphenous
leg region preclude absolute avoidance in any surgical knee nerve in arthroscopic knee surgery. Clin Orthop Relat Res
incision (Fig. 75-4). Ebrahein and Mekhail6 described a 1995;320:88–94.
safety zone to avoid injury of the infrapatellar branch of 3. Pagnani MJ, Warner JJP, O’Brien SJ, et al. Anatomic considerations
in harvesting the semitendinosus and gracilis tendons and a technique
the saphenous nerve. However, their zone must be supplied of harvest. Am J Sports Med 1993;21:565–571.
by the branches of the medial femoral cutaneous nerve. 4. Arthornthurasook A, Gaew-Im K. Study of the infrapatellar nerve.
Therefore it might be very difficult to find a completely safe Am J Sports Med 1988;16:57–59.
5. Arthornthurasook A, Gaew-Im K. The sartorial nerve: its relationship
zone based on the findings of the present anatomical
to the medial aspect of the knee. Am J Sports Med 1990;18:41–42.
study.24 Nevertheless, an oblique incision for the tendon 6. Ebrahein NA, Mekhail AO. The infrapatellar branch of the saphe-
harvest would be a good candidate to minimize the area of nous nerve: an anatomic study. J Orthop Trauma 1997;11:195–199.

583
 Anterior Cruciate Ligament Reconstruction
7. Ganzoni N, Wieland K. The ramus infrapatellaris of the saphenous
nerve and its importance for medial parapatellar arthrotomies of the
knee. Reconstr Surg Traumat 1978;16:95–100.
8. Kartus J, Ejerhed L, Eriksson BI, et al. The localization of the infra-
patellar nerves in the anterior knee region with special emphasis on
central third patellar tendon harvest: a dissection study on cadaver
and amputated specimens. Arthroscopy 1999;15:577–586.
9. Pürner J. [Peripheral course of saphenous nerve.] Anat Anz
1971;129:114–132.
10. Sirang H. [Saphenous nerve: origin, course, and branches.] Anat Anz
1972;130:158–169.
11. Tifford CD, Spero L, Luke T, et al. The relationship of the infrapa-
tellar branches of the saphenous nerve to arthroscopy portals and inci-
sions for ACL surgery: an anatomic study. Am J Sports Med
2000;28:562–567.
12. Von Lanz T, Wachsmuth W. Praktische Anatomie. Band I, Teil 4. Bein
und Statik, Berlin, 1972, Springer-Verlag, pp 73–89, 292–300.
13. Berry MM, Starding SM, Bannister LH. Nervous system. In Wil-
liams PL, Bannister LH, Berry MM, et al (eds). Gray’s anatomy.
The anatomical basis of medicine and surgery, ed 38 (Brit). New York,
1995, Churchill Livingstone, pp 1280–1282.
14. Bach BR Jr, Jones GT, Sweet FA, et al. Arthroscopy-assisted anterior
cruciate ligament reconstruction using patellar tendon substitution:
two to four-year follow-up results. Am J Sports Med 1994;22:758–767.
15. Shelboune KD, Trumper RV. Preventing anterior knee pain after ante-
rior cruciate ligament reconstruction. Am J Sports Med 1997;25:41–47.
16. Mishra AK, Fanton GS, Dillingham MF, et al. Patellar tendon graft
harvesting using horizontal incisions for anterior cruciate ligament
reconstruction. Arthroscopy 1995;11:749–752.
17. Kartus J, Ejerhed L, Sernert N, et al. Comparison of traditional and
subcutaneous patellar tendon harvest: a prospective study of donor
site-related problems after ACL reconstruction using different graft
harvesting techniques. Am J Sports Med 2000;28:328–335.
584
18. Tsuda E, Okamura Y, Ishibashi Y, et al. Techniques for reducing
anterior knee symptoms after ACL reconstruction using a bone-
patellar tendon-bone autograft. Am J Sports Med 2001;29:450–456.
19. Portland GH, Martin D, Keene G, et al. Injury to the infrapatellar
branch of the saphenous nerve in anterior cruciate ligament recon-
struction: comparison of horizontal versus vertical harvest site inci-
sions. Arthroscopy 2005;3:281–285.
20. Corry IS, Webb JM, Clingeleffer AJ, et al. Arthroscopic reconstruc-
tion of the anterior cruciate ligament: a comparison of patellar tendon
autograft and four-strand hamstring tendon autograft. Am J Sports
Med 1999;27:444–454.
21. Bertnam C, Porsche M, Hackenbroch MH, et al. Saphenous neuralgia
after arthroscopically assisted ACL reconstruction with a semiten-
dinosus and gracilis tendon graft. Arthroscopy 2000;16:763–766.
22. Mochizuki T, Muneta T, Yagishita K, et al. Skin sensory change after
arthroscopically-assisted anterior cruciate ligament reconstruction
using medial hamstring tendons with a vertical incision. Knee Surg
Sports Traumatol Arthrosc 2004;12:198–202.
23. Mochizuki T, Akita K, Muneta T, et al. Anatomical bases for mini-
mizing sensory disturbance after arthroscopically-assisted anterior cru-
ciate ligament reconstruction using medial hamstring tendons. Surg
Radiol Anat 2003;25:192–199.
24. Clemente CD (ed). Anatomy of the human body, ed 30 (Am). Phila-
delphia, 1985, Lea & Febiger, pp 1231–1234.
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Topographie der Organsysteme, Systematik der peripheren Leitungsbahnen.
Stuttgart, 1988, Georg Thieme Verlag, pp 448–449.
26. Abram LJ, Froimson AI. Saphenous nerve injury. An unusual arthro-
scopic complication. Am J Sports Med 1991;19:668–669.
27. Kopell HP, Thompson WAL. Knee pain due to saphenous-nerve
entrapment. N Engl J Med 1960;263:351–353.
 Hardware Complications After Anterior
Cruciate Ligament Reconstruction
INTRODUCTION
A variety of autograft and allograft tissues can be
used for reconstruction of the anterior cruciate lig-
ament (ACL), and a number of different tools and
techniques can be used to achieve graft fixation,
whether bone to bone or tendon to bone. Com-
monly used fixation devices include interference
screws (metallic and bioabsorbable), the Endobut-
ton (Acufex Microsurgical, Mansfield, MA), and
cross-pins. Complications related to graft fixation
are often specific to the type of fixation used,
although a number of recurring themes occur.
We will review each type of fixation and the related
intraoperative and postoperative complications, as
well as methods for managing both types of com-
plication. Obviously, the ideal management is
avoidance of the complication in the first place.
Skeletally immature patients are susceptible to a
unique set of complications regardless of the
method of fixation, and we will review this compli-
cation separately.
INTERFERENCE SCREWS
Interference screws are a widely used method of
fixation during ACL reconstruction, both for
bone–bone fixation and tendon–bone fixation.
A number of complications related to inter-
ference screws may be encountered, and these
can occur intraoperatively or postoperatively.
Intraoperative complications include intra-
articular placement of the hardware, which
ideally will be recognized during the procedure
76
CHAPTER
and adjusted accordingly (Fig. 76-1). During Robert H. Brophy
insertion of the screw, possible complications
Robert G. Marx
include laceration of the graft-passing suture,1
advancement of the graft within the bone tunnel,1
graft laceration1 and even rupture,2 fracture of the
graft bone plug,3 and screw breakage.4–6 To mini-
mize the risk of lacerating the passing suture, at
least one suture can be passed through the tendon
at the base of the bone plug.1 To minimize the risk
of graft rupture, methylene blue can be used to
mark the bone–tendon junction of the graft, the
anterior portion of the bone tunnel can be notched
to ease the initial engagement of the screw, the
cancellous edge of the bone plug can be placed fac-
ing anterior flush with the intraarticular edge of
the femoral tunnel, and a protective sheath or can-
nula can be used to protect the graft during screw
placement.2 Another helpful technique to protect
the graft is to insert the femoral screw over a guide-
wire drilled through a cannulated screwdriver.
If the graft ruptures during screw place-
ment, a number of salvage options may be used.
If a patellar tendon graft is cut at the bone–
tendon junction, the graft can be reversed, plac-
ing the intact bone plug in the femoral tunnel
and fixing the tendinous portion of the graft
through the tibial tunnel with a post or button.2,7
If the remaining graft length is insufficient, an
alternative autograft or allograft should be used.
To minimize the chance of graft advancement,
it is important to maintain constant tension on
the passing sutures during screw insertion.1 Screw
breakage during insertion has been reported
with bioabsorbable screws in as many as 10% of
cases.4,5 Steps to minimize such a complication
585
 Anterior Cruciate Ligament Reconstruction

FIG. 76-1 A, Anteroposterior and, B, lateral X-rays and C, axial, D, coronal, and, E, sagittal computed tomography
scans demonstrating a malplaced, intraarticular femoral screw.
(Continued)
586
 Hardware Complications After Anterior Cruciate Ligament Reconstruction 76

FIG. 76-1—Cont’d

include use of a dilator device to create a pilot hole for screw

insertion, maintenance of continuous pressure on the screw-
driver to keep it fully seated, and use of a screw 1 mm smaller
than the diameter of the tunnel.6
Postoperative complications include intraarticular
placement of hardware, which may not be recognized at the
time of surgery and can present clinically after the index pro-
cedure. A second procedure may be necessary to reposition or
remove the misplaced hardware. Late screw breakage8–12 and
delayed intraarticular migration of interference screws13–16
have also been described in the literature. Late migration of
interference screws is rare but should be considered in the
case of sudden pain in the late postoperative period after
ACL reconstruction and, in the case of a metallic screw,
can easily be evaluated with plain films. If such a complication
is encountered, removal is mandated to minimize
mechanical problems and cartilage damage.9,14,17 An arthro-
scopic approach is preferred,17 even if the screw is in the
notch or popliteal fossa, although an arthrotomy may be
required.15

ENDOBUTTON
The Endobutton is another widely used fixation device
that has been associated with specific complications. The
Endobutton may remain in the femoral tunnel rather than
flipping outside of the tunnel to rest on the lateral femoral cor-
FIG. 76-2 A, Lateral and, B, anteroposterior X-rays show the Endobutton is
tex18 (Fig. 76-2). Conversely, the Endobutton may be pulled in the femur and is not extracortical, indicating it has not flipped outside of
too far off the femoral cortex into the overlying soft tissue19 the bone and is not supporting the graft.
587
 Anterior Cruciate Ligament Reconstruction
(Fig. 76-3). To ensure that the Endobutton has flipped and is
in the correct position, the femoral tunnel length should be
overdrilled by 6 mm and the graft should be marked at a loca-
tion 6 mm distal to the desired insertion level.18 Once the
Endobutton has flipped, the surgeon should feel for the but-
ton flipped on the lateral side of the femur against the cortex
by pulling on the sutures. The surgeon can then pull back
on the graft from below and pull both Endobutton sutures
to make sure the button is not flipping with tension on the
graft from the tibial side. If there is any doubt as to the posi-
tion of the Endobutton, intraoperative fluoroscopy or x-rays
should be used to confirm proper placement.19
Postoperatively, Muneta et al20 described late detach-
ment and intraarticular migration of an Endobutton that
had been fixed in the suprapatellar pouch, most likely due
to impingement between the patella and femoral groove.
To avoid this impingement and possible inflammatory reac-
tion, it is preferable not to affix the Endobutton in the joint,
particularly near the patellofemoral joint.20
FIG. 76-3 The Endobutton is free in the soft tissues and is not providing
support to the graft.
588
CROSS-PIN FIXATION
Cross pin fixation is a relatively new method used for tendon–
bone fixation with the hope of improving on the problems
with interference screw and Endobutton fixation methods.
As with all new surgical methods and devices, a learning curve
exists, with the potential for new problems as the technology
becomes more widely adapted. Intraoperative complications
with cross-pin fixation include lack of pin convergence and
pin breakage.
A number of postoperative complications associated
with cross-pin fixation have recently been described in the
literature. Incorrect placement, including leaving the pin
proud on the lateral side of the femur as well as advancing
the pin too far to penetrate the medial cortex of the femur,
should be avoided as it may require reoperation for hardware
removal21 (Fig. 76-4). The pin can break even after graft
incorporation.22 The case of late breakage reported by Han
et al22 using the Rigidfix system (Mitek Products, Norwood,
MA) was attributed to an improper femoral tunnel with
posterior wall blowout and posterior direction of the cross-
pins, potentially leading to abnormally high stress on the
pins. Iliotibial band syndrome has also been described, either
from direct irritation23 or in association with breakage of the
femoral bioabsorbable cross-pin, specifically BioTransfix
(Arthrex, Naples, FL).24
TIBIA FIXATION
A number of options can be used for cortical fixation in the
tibia, including interference screws and staples. Although
early studies indicated a high incidence of hardware removal
from the tibia due to pain when using interference
screws,23,25,26 low-profile interference screws are usually well
tolerated.27 Another option for tibial fixation when using
hamstring grafts or Achilles allografts is a cortical screw with
a spiked washer. Although one series using a higher-profile,
round-headed screw reported a 70% incidence of hardware
removal due to pain,28 other studies reviewing lower-profile
screws suggest a very low, almost negligible, rate of hardware
removal with this type of fixation.27,29 Staples are another
method of fixation, used for supplementary fixation more
often than primary fixation. The major concern with staples
is their high profile and the resulting incidence (as high as
29%) of kneeling pain leading to hardware removal.30
SKELETALLY IMMATURE PATIENTS
Graft fixation in skeletally immature patients has its own
potential for complication regardless of the type of fixation
device used. The primary concern is disruption of the
 Hardware Complications After Anterior Cruciate Ligament Reconstruction 76

FIG. 76-4 Case 1: A, Coronal and, B, axial magnetic resonance imaging (MRI) demonstrates proud cross-pin laterally.
Case 2: C, Axial MRI demonstrates proud cross-pin medially. In both cases the soft tissues were irritated, causing
symptoms and requiring reoperation. (Reprinted from Marx R, Spock CR. Complications following hamstring anterior
cruciate ligament reconstruction with femoral cross-pin fixation. Arthroscopy 2005;21:762.)

growth plates, which can manifest itself in a number of dif-
ferent ways including limb length discrepancy,31,32 tibial
recurvatum,33 and valgus deformity of the distal femur.33,34
Specific recommendations with regard to fixation include
avoidance of fixation hardware across the lateral distal
femoral epiphysis and tibial tubercle apophysis.33 Although
this complication reflects the surgical approach and tech-
nique as much as the type of graft fixation, it is important
to attempt to avoid or at least minimize disruption of the
growth plate(s) whenever possible.

589
 Anterior Cruciate Ligament Reconstruction

4. McGuire DA, Barber FA, Elrod BF, et al. Bioabsorbable interference

TABLE 76-1 Potential Complications of Graft Fixation Devices
screws for graft fixation in anterior cruciate ligament reconstruction.
Device Site Timing Potential Complications Arthroscopy 1999;15:463–473.
5. Pena F, Grontveldt T, Brown GA, et al. Comparison of failure
Interference Femur Intraoperative Laceration of passing suture strength between metallic and absorbable interference screws. Influ-
ence of insertion torque, tunnel-bone block gap, bone mineral density,
screw Advancement of graft within the
and interference. Am J Sports Med 1996;24:329–334.
tunnel 6. Smith CA, Tennent TD, Pearson SE, et al. Fracture of Bilok interfer-
Graft laceration/rupture ence screws on insertion during anterior cruciate ligament reconstruc-
Fracture of graft–bone plug tion. Arthroscopy 2003;19:E4–6.
7. Cain EL Jr, Gillogly SD, Andrews JR. Management of intraoperative
Screw breakage complications associated with autogenous patellar tendon graft
anterior cruciate ligament reconstruction. Instr Course Lect
Delayed Screw breakage
2003;52:359–367.
Intraarticular migration 8. Bottoni CR, Deberardino TM, Fester EW, et al. An intra-articular
bioabsorbable interference screw mimicking an acute meniscal tear
Tibia Intraoperative Screw breakage
8 months after an anterior cruciate ligament reconstruction. Arthros-
Delayed Painful hardware copy 2000;16:395–398.
9. Lembeck B, Wulker N. Severe cartilage damage by broken poly-L-
Endobutton Femur Intraoperative Remains within femoral tunnel lactic acid (PLLA) interference screw after ACL reconstruction. Knee
Surg Sports Traumatol Arthrosc 2005;13:283–286.
Advanced too far off femoral
10. Macdonald P, Arneja S. Biodegradable screw presents as a loose intra-
cortex in soft tissue articular body after anterior cruciate ligament reconstruction. Arthros-
copy 2003;19:E22–24.
Delayed Detachment and intraarticular
11. Shafer BL, Simonian PT. Broken poly-L-lactic acid interference screw
migration after ligament reconstruction. Arthroscopy 2002;18:E35.
12. Werner A, Wild A, Ilg A, et al. Secondary intra-articular dislocation
Cross-pin Femur Intraoperative Lack of pin convergence of a broken bioabsorbable interference screw after anterior cruciate
Pin breakage ligament reconstruction. Knee Surg Sports Traumatol Arthrosc
2002;10:30–32.
Delayed Improper placement (proud 13. Bush-Joseph CA, Bach BR Jr. Migration of femoral interference screw
lateral or medial) after anterior cruciate ligament reconstruction. Am J Knee Surg
Pin breakage 1998;11:32–34.
14. Hallet A, Mohammed A. Displaced femoral interference screw caus-
Iliotibial band syndrome ing locked knee. Injury 2003;34:797–798.
15. Karlakki SL, Downes ME. Intra-articular migration of a femoral
Staple Tibia Intraoperative Insufficient bite
interference screw: open or arthroscopic removal. Arthroscopy
Delayed Painful hardware 2003;19:E19.
16. Sidhu DS, Wroble RR. Intra-articular migration of a femoral interfer-
ence fit screw. A complication of an anterior cruciate ligament recon-
struction. Am J Sports Med 1997;25:269–271.
CONCLUSION 17. Resinger C, Vecsei V, Heinz T, et al. The removal of a dislocated
femoral interference screw through a posteromedial portal. Arthroscopy
In summary, each method of graft fixation presents its own 2005;21:1398.
18. Karaoglu S, Halici M, Baktir A. An unidentified pitfall of Endobutton
potential complications both at the time of surgery and in use: case report. Knee Surg Sports Traumatol Arthrosc 2002;10:247–249.
the short- and long-term postoperative period (Table 76-1). 19. Simonian PT, Behr CT, Stechschulte DJ Jr, et al. Potential pitfall of
Surgeons should be aware of the potential complications the EndoButton. Arthroscopy 1998;14:66–69.
20. Muneta T, Yagishita K, Kurihara Y, et al. Intra-articular detachment
with the methods of fixation they use, how to avoid them, of the Endobutton more than 18 months after anterior cruciate liga-
and how to treat them if they occur. Special considerations ment reconstruction. Arthroscopy 1999;15:775–778.
should be made in skeletally immature patients to minimize 21. Marx RG, Spock CR. Complications following hamstring anterior
cruciate ligament reconstruction with femoral cross-pin fixation.
disruption of the growth place, with graft harvest, tunnel
Arthroscopy 2005;21:762.
placement and drilling, and graft fixation. 22. Han I, Kim YH, Yoo JH, et al. Broken bioabsorbable femoral cross-
pin after anterior cruciate ligament reconstruction with hamstring ten-
References don graft: a case report. Am J Sports Med 2005;33:1742–1745.
23. Clark R, Olsen RE, Larson BJ, et al. Cross-pin femoral fixation: a
1. Matthews LS, Soffer SR. Pitfalls in the use of interference screws for new technique for hamstring anterior cruciate ligament reconstruction
anterior cruciate ligament reconstruction: brief report. Arthroscopy of the knee. Arthroscopy 1998;14:258–267.
1989;5:225–226. 24. Pelfort X, Monllau JC, Puig L. Iliotibial band friction syndrome after
2. Arciero RA. Endoscopic anterior cruciate ligament reconstruction: anterior cruciate ligament reconstruction using the transfix device:
complication of graft rupture and a method of salvage. Am J Knee Surg report of two cases and review of the literature. Knee Surg Sports Trau-
1996;9:27–31. matol Arthrosc 2006;14:586–589.
3. Malek MM, Kunkle KL, Knable KR. Intraoperative complications of 25. Howell SM, Deutsch ML. Comparison of endoscopic and two-inci-
arthroscopically assisted ACL reconstruction using patellar tendon sion techniques for reconstructing a torn anterior cruciate ligament
autograft. Instr Course Lect 1996;45:297–302. using hamstring tendons. Arthroscopy 1999;15:594–606.

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26. Siegel MG, Barber-Westin SD. Arthroscopic-assisted outpatient
anterior cruciate ligament reconstruction using the semitendinosus
and gracilis tendons. Arthroscopy 1998;14:268–277.
27. Prodromos CC, Han YS, Keller BL, et al. Stability results of
hamstring anterior cruciate ligament reconstruction at 2- to 8-year
follow-up. Arthroscopy 2005;21:138–146.
28. Jansson KA, Linko E, Sandelin J, et al. A prospective randomized study
of patellar versus hamstring tendon autografts for anterior cruciate
ligament reconstruction. Am J Sports Med 2003;31:12–18.
29. Prodromos CC, Joyce BT, Shi K, et al. A meta-analysis of stability after
anterior cruciate ligament reconstruction as a function of hamstring
versus patellar tendon graft and fixation type. Arthroscopy 2005;21:1202.
30. Hill PF, Russell VJ, Salmon LJ, et al. The influence of supplementary
tibial fixation on laxity measurements after anterior cruciate ligament
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reconstruction with hamstring tendons in female patients. Am J Sports
Med 2005;33:94–101.
31. Andrews M, Noyes FR, Barber-Westin SD. Anterior cruciate liga-
ment allograft reconstruction in the skeletally immature athlete.
Am J Sports Med 1994;22:48–54.
32. Lipscomb AB, Anderson AF. Tears of the anterior cruciate ligament
in adolescents. J Bone Joint Surg 1986;68A:19–28.
33. Kocher MS, Saxon HS, Hovis WD, et al. Management and compli-
cations of anterior cruciate ligament injuries in skeletally immature
patients: survey of the Herodicus Society and The ACL Study Group.
J Pediatr Orthop 2002;22:452–457.
34. Koman JD, Sanders JO. Valgus deformity after reconstruction of the
anterior cruciate ligament in a skeletally immature patient. A case
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591
77
CHAPTER
Vascular Complications After Anterior
Cruciate Ligament Reconstruction
R.P.A. Janssen* Vascular complications after anterior cruciate
ligament (ACL) reconstructions cause serious
morbidity and potential mortality. Fortunately,
their incidence is low. Only a few peer-reviewed
case reports provide information,1–5 and even
a specific review article on complications after
ACL surgery does not mention these rare
complications.6
This chapter will be subdivided into dis-
cussions of arterial and venous complications
after arthroscopic ACL reconstruction.
ARTERIAL COMPLICATIONS
Knee arthroscopy is generally a safe procedure
with a low incidence of complications. The two
largest studies to date report complication rates
of 0.54% and 0.8%.7,8 Penetrating popliteal artery
injuries were described by DeLee in 6 of 118,540
arthroscopies.7 Small noted 9 cases (of 375,000
arthroscopic procedures) of penetrating trauma to
the popliteal artery.8 A subsequent study of 8741
cases done by experienced arthroscopists showed
no vascular complications.9 Pseudoaneurysm is
the most frequently published popliteal artery
lesion after arthroscopy of the knee. It is associated
with direct violation of the posterior capsule or
previous (open) knee surgery. However, it is still
rare and published in case reports only.10–23
The incidence of arterial lesions after
arthroscopic ACL reconstruction is unknown.
* mal femoral, popliteal, and distal pulses. Diagno-
The author would like to thank J.B.A. van Mourik, MD, PhD, for
his critical review in preparing this chapter.
592
Five case reports have been published on various
techniques of ACL reconstruction.
Roth and Bray1 described an occlusion of
the popliteal artery 7 cm proximal to the knee
joint line. A composite graft, consisting of a poly-
propylene ligament augmentation and the mid-
dle third of the quadriceps patellar tendon, was
used as ACL reconstruction and fixed to the lat-
eral femur with a single staple in an over-the-top
position. The patient had a burning pain in the
foot 6 hours after surgery. Doppler signals of
the pedal arteries were intact. The symptoms
subsided. Dull aching at the posterior calf
occurred at 3 weeks. Pain and dysesthesia in the
foot recurred at 6 weeks. Angiography revealed
the occlusion. The artery was trapped between
the composite graft and the femur at surgical
exploration. A saphenous bypass was performed.
Spalding et al2 reported a case of unilateral
claudication 8 years after ACL reconstruction
with use of a GoreTex polytetrafluoroethylene
braided ligament. Computed tomography (CT)
analysis demonstrated a cyst had formed around
the femoral insertion of the ruptured GoreTex
ligament. The cyst was excised without the need
for vascular repair.
Evans et al3 reported a pseudoaneurysm of
the medial inferior genicular artery following
ACL reconstruction with a central third patellar
tendon graft fixed with interference screws into
the tibia and femur. It was detected at 5 weeks
postsurgery with a 10-day history of pulsating
swelling on the medial side of the knee with nor-
sis was made by contrast angiography. Ligation
 Vascular Complications After Anterior Cruciate Ligament Reconstruction 77
of the artery and removal of the thrombus from the pseudo-
aneurysm led to an excellent recovery. The cause of the lesion
was elevation of the periosteum on the medial side of the tibia
for tibial tunnel preparation.
Aldridge et al4 described an avulsion of the middle
genicular artery after arthroscopic ACL reconstruction with
a bone–patellar tendon–bone (BPTB) autograft fixed with
interference screws in both the tibia and femur. After tour-
niquet release, serious hemorrhage was detected with absent
dorsal pedal pulse and a cold foot. The patient had a history
of intravenous contrast dye allergy; therefore a CO2 arterio-
gram was performed with no evidence of vascular injury.
The symptoms resolved overnight. At 2 weeks, the patient
experienced difficulty with knee extension and felt a mass
in the popliteal fossa. No mass was felt at examination,
and pedal pulses were normal. Ultrasound examination
showed no sign of venous thrombosis. At 4 weeks, a palpa-
ble mass in the fossa with 30-degree flexion contracture of
the knee led to hospital readmission. Contrast angiography
showed the vascular lesion. Surgical exploration revealed a
tear in the popliteal artery, which was repaired with a short
running stitch after removal of the hematoma. There was no
rupture of the posterior capsule, and the avulsion of the
middle genicular artery was hypothesized to have occurred
during débridement of the femoral ACL stump.
In our own consecutive series of 625 hamstring graft
arthroscopic ACL reconstructions (1998–2005), three arte-
rial complications occurred. In this series, the quadruple
hamstring graft is fixed with a Bone Mulch Screw on the
femoral side and a WasherLoc device in the tibia (rationale FIG. 77-1 Angiography of the right knee showing subtotal occlusion of
the popliteal artery at the level of the superior genicular artery.
and surgical technique according to S.M. Howell; fixation
devices by Arthrotek). The latter is a spiked washer with suggestive of small distal occlusions. Anticoagulant therapy
bicortical screw fixation. with intravenous heparin as well an epidural analgesia were
Our first case was a 44-year-old male with a previous administered until complete recovery of peripheral circula-
history of open medial and lateral ligament repair of the tion was attained. The patient developed a superficial infec-
same knee 15 years previously (motor vehicle accident). tion of the groin wound, which was treated by antibiotics.
The hospital recovery was uneventful after ACL reconstruc- He was mobilized and discharged after 8 days. Sensory loss
tion. On day 17 postsurgery, he experienced pain and of the foot slowly recovered after 4 months. Vascular analy-
swelling in the popliteal fossa of the knee. The complaints sis in rest and strenuous activity was performed at 4 months.
partially resolved with physiotherapy. Two days later, the He had no more complaints, a symmetrical ankle-brachial
fossa pain returned with alterations of skin color, sensory index in both legs, and intact pulses at the foot and ankle.
loss, and an increasingly cold foot. Adequate dorsal pedal Our hypothesis of the cause was the traumatic knee disloca-
and posterior tibial pulses were noted. Duplex ultrasound tion 15 years previously. Precursors could have been preexis-
examination showed no sign of venous thrombosis. Angiog- tent intimal vascular damage or adhesions of the artery at
raphy revealed a subtotal occlusion of the popliteal artery at the level of the superior genicular artery in combination with
the level of the superior genicular artery (Fig. 77-1). An the use of the tourniquet.
embolectomy was performed using a Fogarty catheter We have previously published our second case of pseu-
inserted in the femoral artery. The pedal pulses were dimin- doaneurysm of the popliteal artery due to damage by the
ished after embolectomy, and a second angiography was bicortical tibial drill.5 A 24-year-old man had an ACL recon-
performed. The occlusion at the level of the popliteal artery struction using a quadruple hamstring graft. The patient was
was no longer detected. No further emboli were noted; allowed full weight bearing, and an aggressive rehabilitation
however, the peripheral flow qualified as too slow and was started the day after surgery. The hospital stay was

593
 Anterior Cruciate Ligament Reconstruction

FIG. 77-3 Three-dimensional CT (3D-CT) angiography reconstruction of

the right knee (posteromedial view) showing pseudoaneurysm of the
FIG. 77-2 Sagittal computed tomography (CT) angiography of the right popliteal artery near the tip of the bicortical screw.
knee showing pseudoaneurysm of the popliteal artery near the tip of the
bicortical tibial screw. (Reproduced with permission from Janssen RPA,
Scheltinga MRM, Sala HAGM: Pseudoaneurysm of the popliteal artery after
anterior cruciate ligament reconstruction with bicortical tibial screw
fixation. Arthroscopy 2004;20:E4–E6.)

uneventful. Twelve days after surgery, the patient complained

of progressive pain in the popliteal fossa that had started on
day 5 postsurgery. On physical examination, a pulsating mass
was felt in the popliteal fossa and there was a sensory loss of
the medial foot as well as the plantar heel. The dorsal pedal
and posterior tibial pulses were intact. Duplex analysis and
CT angiography demonstrated a pseudoaneurysm of the
infragenicular popliteal artery near the site of the bicortical
tibial screw (Fig. 77-2). The pseudoaneurysm measured
3.5  1.5 cm on the sagittal view and 3.5  4 cm in the frontal
aspect (Figs. 77–3 and 77–4). Surgical exploration was imme-
diately performed. A vascular defect (3 mm) of the infrageni-
cular popliteal artery was found just proximal to the origin of
the anterior tibial artery (Fig. 77-5). However, the tip of the
bicortical screw was not in direct contact with the arterial
lesion. Apparently the 3.2-mm drill used for the bicortical
screw had caused perforation of the popliteal artery. An arter-
FIG. 77-4 3D-CT reconstruction of the right knee (dorsal view) with
iotomy was performed, and an intimal lesion was repaired. subtraction of popliteal artery and pseudoaneurysm demonstrating exit
A venous patch was used to close the arterial defect. A Fogarty point of femoral Bone Mulch Screw and tibial bicortical screw.
catheter was inserted to remove small clots present in the
tibioperoneal trunk. Aspirin was prescribed for 3 months. the knee. Lachman and anterior drawer test were 0 to 2 mm
No complications occurred after the vascular repair. Func- (according to International Knee Documentation Committee
tional treatment using continuous passive motion (CPM) was [IKDC]) with an absent pivot-shift test. Neurological evalua-
started the day after surgery. The muscular and proprioceptive tion by a neurologist showed a sensory loss of the saphenous
rehabilitation was initiated after wound healing occurred. and medial plantar nerves and, to a lesser degree, sensory loss
At 4-month follow-up, there was full range of motion of of the superficial peroneal nerve of the right leg. There was no

594

FIG. 77-5 Posteromedial view of the right knee at surgery showing a
3-mm vascular defect of the popliteal artery at the origin of the
pseudoaneurysm. (Reproduced with permission from Janssen RPA,
Scheltinga MRM, Sala HAGM: Pseudoaneurysm of the popliteal artery after
anterior cruciate ligament reconstruction with bicortical tibial screw
fixation. Arthroscopy 2004;20:E4–E6.)
loss of motor function. The dorsal pedal and posterior tibial
pulses were intact.
Our most recent case was a 50-year-old woman with a
pseudoaneurysm of the popliteal artery after ACL recon-
struction. She was seen 1 week postsurgery with pain in the
popliteal fossa, absent foot pulses and sensory loss in the foot.
Doppler examination showed weak signals in the foot. MRI
angiography revealed a pseudoaneurysm of the supragenicular
popliteal artery and a 4-cm occlusion proximal to the tibioper-
oneal trunk (Fig. 77-6). Surgical exploration on postsurgery
day 9 showed damage to the artery in line with the tibial
bicortical screw. Just as in our previous case, the tip of the
bicortical screw was not in direct contact with the artery.
The drill used for the bicortical screw had caused perforation
of the popliteal artery. There was no hematoma around the
pseudoaneurysm, nor was it in line with the Bone Mulch
Screw fixation of the femur. The vascular surgeon thought
this lesion to be preexistent and not related to the ACL
surgery. The pseudoaneurysm was ligated and a saphe-
nous bypass performed. A 5-day course of intravenous
heparin was administered in combination with aspirin.
Aspirin was continued after discharge. Follow-up is now
3 months; sensory loss of the plantar foot and decreased
motor function of the flexor hallucis longus muscle are still
present.
Post et al24 studied the relative position of the neuro-
vascular structures at risk when drilling bicortical screws for
tibial fixation in ACL reconstruction. Arthroscopic tibial
tunnels were placed in cadaver human knees using lateral
roentgen graphs for accurate positioning. A 4.5-mm bicorti-
cal drill hole was placed perpendicular to the tibial surface,
1 cm distal to the tibial tunnel. The distances from the pos-
terior tibial drill exit point to the nearby neurovascular
Vascular Complications After Anterior Cruciate Ligament Reconstruction 77
FIG. 77-6 Magnetic resonance imaging (MRI) angiography of the right leg
showing pseudoaneurysm of the supragenicular popliteal artery and a
4-cm occlusion of the distal popliteal artery.
structures were measured with a caliper. The closest struc-
ture to the exit point was the bifurcation of the popliteal
artery/vein (11.4  0.6 mm). The next closest was the ante-
rior tibial vein (11.7  1.6 mm). The closest any individual
hole came to a neurovascular structure was 3.5 mm from the
anterior tibial vein. The researchers concluded that bicortical
screw and spiked washer fixation of soft tissue ACL grafts
appears to be relatively safe.24 Variations in anatomy and
surgical technique are possible, and care should be taken
in drilling through the posterior cortex.
Possible recommendations to prevent neurovascular
damage in drilling bicortical tibia screws are the use of a drill
stop5 or directing the screw toward the fibular head instead
of the posterior cortex.25 A single cortex fixation on the tibia
is another possible safeguard without compromising stability
of fixation.26
All cases show a certain delay in diagnosis (2–6 weeks
postsurgery to 8 years). Damage to the popliteal artery can
occur even with an all-inside technique of arthroscopic ACL
reconstruction and fixation as well as with any type of graft.
Other than the GoreTex rupture ligament case,2 all patients
maintained adequate ACL stability after vascular surgery.
The neurological deficits, however, may be permanent.
Conclusion
The incidence of arterial complications after arthroscopic
ACL reconstruction is 0.5% in our own consecutive series.
A high level of suspicion, with clinical symptoms of painful
595
 Anterior Cruciate Ligament Reconstruction
pulsating mass and sensory deficits in the lower leg and foot,
is mandatory in detecting these potentially devastating
lesions. The differential diagnosis should include compart-
ment syndrome and deep venous thrombosis. Doppler
examination and intact dorsal pedal and posterior tibial
pulses are unreliable in diagnosing arterial lesions after ACL
reconstruction. Contrast CT and MRI angiography are the
diagnostic tools of choice. Surgical exploration and vascular
repair (or ligation/embolization of the feeding vessel) remain
standard management. An immediate surgical exploration is
imperative in limiting neurological damage.
VENOUS COMPLICATIONS
The incidence of deep vein thrombosis (DVT) in orthopaedic
surgery is amongst the highest in clinical practice. DVT is
complicated by pulmonary embolism (PE) and the post-
thrombotic syndrome. The former may be fatal in its imme-
diate course and may result in pulmonary hypertension in
the long term. The latter affects 23% of limbs 2 years after
DVT, 35% to 69% at 3 years, and 49% to 100% at 5 to 10
years.27 A recent meta-analysis of DVT after knee arthros-
copy without thromboprophylaxis showed an overall DVT
rate of 9.9% (3.1% to 17.9%) when routine screening using
ultrasound or contrast venography is used. The proximal
DVT rate is 2.1% (0% to 4.9%).28 The range of incidence
among different studies is mainly related to two factors: (1)
heterogenous groups of variable age, risk factors, and types
of surgery and (2) variable experience of ultrasound technolo-
gists in detecting DVT in comparable populations.27
Delis et al27 found 50% of the DVT patients to be
completely asymptomatic. Lohman sign and thigh circum-
ference measurements were unreliable. They also examined
the history of DVT if treated (aspirin in calf DVT, heparin-
warfarin in proximal DVT). Following early diagnosis, total
clot lysis was documented in 50% and partial clot lysis in the
remaining 50% within 118 days median follow-up. Segmen-
tal venous reflux developed in at least 75% of the legs sustain-
ing thrombosis. A previous thrombosis or the presence of two
or more risk factors for thromboembolism significantly
increased the incidence of DVT. No symptoms or signs of
PE were documented.27 Geerts et al reviewed the evidence-
based literature for thromboprophylaxis. They suggest not
using thromboprophylaxis in knee arthroscopy, other than
early mobilization. For patients undergoing arthroscopic knee
surgery who are at higher than usual risk based on preexisting
venous thromboembolic risk factors or following a prolonged
or complicated procedure, they suggest thromboprophylaxis
with low-molecular-weight heparin (Grade 2B level of evi-
dence).29 The authors do not present further definitions of
596
their suggestions or specific guidelines for thromboprophy-
laxis after ACL reconstructions.
The incidence of DVT in ACL reconstruction has
been prospectively analyzed with duplex ultrasound by Cul-
lison et al.30 They found an incidence of DVT of 1.5%
without thromboprophylaxis. However, one must note their
selected population: all male (no previous surgery) with an
average age of 26.5 years (the oldest patient is 39 years
old). Their data cannot be extrapolated to a female popula-
tion or patients with DVT risk factors or previous surgery.
Hirota et al31 quantified pulmonary emboli after tour-
niquet release in patients undergoing ACL reconstruction
(extramedullary procedure) versus total knee arthroplasty
(intramedullary procedure). They chose these two groups to
have more than 60 minutes of tourniquet time. This period
was found to significantly increase the risk for DVT according
to Demers et al.32 Hirota et al detected pulmonary emboli in
all patients after release of the tourniquet using transesopha-
geal echocardiography with a peak at 30 to 40 seconds postre-
lease. The amount of emboli formed was defined as %Ae
(percentage of total emboli formed to the right atrial area).
The atrial emboli percentage returned to baseline levels 2 min-
utes after tourniquet release in the ACL group. They found a
significant linear correlation between the atrial emboli per-
centage and the duration of tourniquet inflation in the ACL
group. In comparison, the total knee arthroplasty group had
a significant larger atrial emboli percentage (four- to fivefold)
with no return to baseline levels during the assessment period.
No patient in either group showed signs of PE.31
Pulmonary emboli occur in all patients with ACL
reconstructions after tourniquet release. In addition, PE
may occur as a result of proximal DVT.33 No incidence is
known for PE after ACL reconstruction.
In our own consecutive series of 625 hamstring graft
arthroscopic ACL reconstructions (1998–2005), one fatal
PE is documented (incidence 0.2%). The patient was a 19-
year-old woman who used oral anticontraceptives. She suf-
fered an ACL rupture 8 month previously in a soccer match.
Arthroscopy had been performed 6 months previously at
another institution. No complication occurred at the time.
A conservative therapy for the knee instability was initiated.
She was referred to our clinic due to persistent instability in
daily activities. An ACL reconstruction was performed.
There were no other intraarticular lesions. The patient was
allowed full weight bearing, and an aggressive rehabilitation
was started the day after surgery. During the 3-day hospital
stay, thromboprophylaxis was given by means of low-molecu-
lar-weight heparin. The prophylaxis was discontinued at the
time of discharge. The hospital recovery was uneventful.
Eleven days postsurgery, she complained of increasing
pain in the left medial upper leg. She was seen by a family

physician on call. She was encouraged to continue her phys-
iotherapy sessions. Massage of the leg was additionally
undertaken.
On day 12 postsurgery, she dropped to the ground at
her front door and complained of serious shortness of breath.
She was transported by ambulance to the nearest hospital. She
was resuscitated during transport. A massive pulmonary
embolus was diagnosed and streptokinase therapy initiated.
She died the next day. Postmortem analysis showed a
proximal DVT as well as a probable protein S deficiency.
This was concluded after analysis of her relatives; a protein
S deficiency was diagnosed in her sister. In this case, the fatal
PE was due to a combination of factors: a preexistent
coagulopathy, oral contraceptive medication, surgery, and
failure to recognize DVT.
Conclusion
DVT and PE are the only reported venous complications
after ACL reconstruction. The incidence of fatal PE in our
series is 0.2%. Despite the scientific effort to date, no recom-
mendations for thromboprophylaxis in ACL reconstruction
can be provided. Further investigation is required to analyze
actual incidence and severity of venous thromboembolism as
well as the efficacy-to-bleeding tradeoff for thrombopro-
phylaxis after ACL reconstruction.
References
1. Roth JH, Bray RC. Popliteal artery injury during anterior cruciate lig-
ament reconstruction: brief report. J Bone Joint Surg 1988;70B:840.
2. Spalding TJW, Botsford DJ, Ford M, et al. Popliteal artery compres-
sion: a complication of Gore-tex anterior cruciate ligament reconstruc-
tion. J Bone Joint Surg 1996;78B:151–152.
3. Evans JD, Boer de MT, Mayor P, et al. Pseudoaneurysm of the
medial inferior genicular artery following anterior cruciate ligament
reconstruction. Ann R Coll Surg Engl 2000;82:182–184.
4. Aldridge JM III, Weaver JP, Mallon WJ. Avulsion of the middle geni-
cular artery: a previously unreported complication of anterior cruciate
ligament repair. A case report. Am J Sports Med 2002;30:748–750.
5. Janssen RPA, Scheltinga MRM, Sala HAGM. Pseudoaneurysm of
the popliteal artery after anterior cruciate ligament reconstruction with
bicortical tibial screw fixation. Arthroscopy 2004;20:E4–E6.
6. Allum R. Aspects of current management. Complications of arthro-
scopic reconstruction of the anterior cruciate ligament. J Bone Joint
Surg 2003;85B:12–16.
7. DeLee JC. Complications of arthroscopy and arthroscopic surgery:
results of a national survey. Arthroscopy 1985;1:214–220.
8. Small NC. Complications in arthroscopic surgery: the knee and other
joints. Arthroscopy 1986;2:253–258.
9. Small NC. Complication in arthroscopic surgery performed by experi-
enced arthroscopists. Arthroscopy 1988;4:216–221.
Vascular Complications After Anterior Cruciate Ligament Reconstruction 77
10. Beck DE, Robinson JG, Hallet JW. Popliteal artery pseudoaneurysm
following arthroscopy. J Trauma 1986;26:87–89.
11. Manning MP, Marshall JH. Aneurysm after arthroscopy. J Bone Joint
Surg 1987;69:151.
12. Vincent GM, Stanish WD. False aneurysm after arthroscopic menis-
cectomy. A report of two cases. J Bone Joint Surg 1990;72:770–772.
13. Armato DP, Czamecki D. Geniculate artery pseudoaneurysm: a rare
complication of arthroscopic surgery. Am J Roentgenol 1990;155:659
(letter).
14. Guy RJ, Spalding TJ, Jarvis LJ. Pseudoaneurysm after arthroscopy of
the knee. A case report. Clin Orthop Rel Res 1993;295:214–217.
15. Ritt MJ, Te Slaa RL, Koning J, et al. Popliteal pseudoaneurysm after
arthroscopic meniscectomy. A report of two cases. Clin Orthop Relat
Res 1993;295:198–200.
16. Hilborn M, Munk PL, Miniaci A, et al. Pseudoaneurysm after thera-
peutic knee arthroscopy: imaging findings. Am J Roentgenol
1994;163:637–639.
17. Aldrich D, Anschuetz R, Lopresti C, et al. Pseudoaneurysm compli-
cating knee arthroscopy. Arthroscopy 1995;11:229–230.
18. Potter D, Morris-Jones W. Popliteal artery injury complicating arthro-
scopic meniscectomy. Arthroscopy 1995;11:123–126.
19. Sarrosa EA, Ogilvie-Harris DJ. Pseudoaneurysm as complication of
knee arthroscopy. Arthroscopy 1997;13:644–645.
20. Carlin RE, Papenhausen M, Farber MA, et al. Sural artery pseudo-
aneurysms after knee arthroscopy: treatment with transcatheter embo-
lization. J Vasc Surg 2001;33:170–173.
21. Mullen DJ, Jabaji GJ. Popliteal pseudoaneurysm and arteriovenous fis-
tula after arthroscopic meniscectomy. Arthroscopy 2001;17:E1.
22. Kiss H, Drekonja T, Grethen C, et al. Postoperative aneurysm of the pop-
liteal artery after arthroscopic meniscectomy. Arthroscopy 2001;17:203–205.
23. Audenaert E, Vuylsteke M, Lissens P, et al. Pseudoaneurysm complicat-
ing knee arthroscopy. A case report. Acta Orthop Belg 2003;69:382–384.
24. Post WR, King SS. Neurovascular risk of bicortical drilling for screw
and spiked washer fixation of soft-tissue anterior cruciate ligament
graft. Arthroscopy 2001;17:244–247.
25. Howell SM. Personal correspondence, 2005.
26. Prodromos CC, Han YS, Keller BL, et al. Stability results of ham-
string anterior cruciate ligament reconstruction at 2- to 8-year fol-
low-up. Arthroscopy 2005;21:138–146.
27. Delis KT, Hunt N, Strachan RK, et al. Incidence, natural history and
risk factors of deep vein thrombosis in elective knee arthroscopy.
Thromb Haemost 2001;86:817–821.
28. Ilahi OA, Reddy J, Ahmad I. Deep venous thrombosis after arthros-
copy: a meta-analysis. Arthroscopy 2005;21:727–730.
29. Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thrombo-
embolism. The seventh ACCP conference on antithrombotic and
thrombolytic therapy. Chest 2004;126:338S–400S.
30. Cullison TR, Muldoon MP, Gorman JD, et al. The incidence of deep
venous thrombosis in anterior cruciate ligament reconstruction.
Arthroscopy 1996;12:657–659.
31. Hirota K, Hashimoto H, Tsubo T, et al. Quantification and compari-
son of pulmonary emboli formation after pneumatic tourniquet release
in patients undergoing reconstruction of anterior cruciate ligament and
total knee arthroplasty. Anest Analg 2002;94:1633–1638.
32. Demers C, Marcoux S, Ginsberg JS, et al. Incidence of venographi-
cally proved deep vein thrombosis after knee arthroscopy. Arch Intern
Med 1998;158:47–50.
33. Williams JS, Hulstyn MJ, Fadale PD, et al. Incidence of deep vein
thrombosis after arthroscopic knee surgery: a prospective study.
Arthroscopy 1995;11:701–705.
597
78
CHAPTER
Fracture Complications After Anterior
Cruciate Ligament Reconstruction
Kai Mithoefer Anterior cruciate ligament (ACL) reconstruc-
tion is one of the most frequently performed
Thomas J. Gill
operative procedures with more than 100,000
reconstructions performed annually in the
United States alone.1 Autogenous bone–patellar
tendon–bone (BPTB) presents the most fre-
quently used graft choice by orthopaedic sur-
geons in the United States, Canada, and
Europe.2 This procedure includes creation of
large bony defects in the tibia, femur, and
patella for graft harvesting and fixation.2,3 The
effects of bony defects on bone strength have
become a major concern in orthopaedic trauma
surgery, and their relevance in the development
of postoperative fracture after ACL reconstruc-
tion is increasingly recognized.4,5 Complica-
tions have been reported to occur in 1.8% to
24% of ACL reconstructions.6–8 Serious com-
plications after ACL reconstruction include
arthrofibrosis, donor site pain, patella tendinitis,
patella tendon rupture, and avascular necrosis of
the femoral condyles. Fracture following ACL
reconstruction presents a devastating complica-
tion that may involve the tibia, patella, or femur.
FEMUR FRACTURE
Femur fracture following ACL reconstruction
has been reported in isolated cases as a result of
distal femoral bone defects created for extraarti-
cular fixation of a GoreTex prosthetic graft,9 a
ligament augmentation device,10 iliotibial band
tenodesis,11 or femoral post fixation.12 Supracon-
dylar femur fracture after arthroscopic ACL
598
reconstruction without intraoperative complica-
tions or use of supplemental fixation has also been
reported.13,14 Fracture of the femoral diaphysis
has also been described after ACL reconstruction
and was caused by multiple perforations of
the Beath pin trough’s femoral metaphyseal–
diaphyseal junction.15 Although femur fractures
are reported with increasing frequency after
ACL reconstruction, this complication is likely
underreported and its exact incidence is not
known.
Physical examination in patients with this
complication always produces marked tender-
ness, muscular guarding, bony crepitation, and
a large effusion. Plain radiographs and com-
puted tomography (CT) scans are helpful to
identify the fracture pattern and will often show
that the fracture occurred through the intraoss-
eous tunnel created in the posterior distal femur.
CT scans may demonstrate increased bone tun-
nel diameter (Fig. 78-1).
Several factors predispose the anatomical
area of the femoral tunnel to developing a distal
femur fracture after arthroscopic ACL reconstruc-
tion. The presence of the large femoral tunnel
likely acts as a predisposing factor due to the loca-
lized stress-rising effect of the bony defect.16–20
This effect results from a concentration of local
stresses around the femoral defect and reduced
energy-absorbing capacity from the decreased
amount of bone available to withstand the applied
load.17 Because bone with stress concentration
behaves in a more brittle fashion, the increased
local stresses can reach the ultimate stress of the
bone at much lower applied loads.19 Depending
 Fracture Complications After Anterior Cruciate Ligament Reconstruction 78

FIG. 78-1 A and B, Plain radiographs of the distal left femur

demonstrating supracondylar femur fracture after anterior cruciate ligament
reconstruction. C, Computed tomography demonstrating fracture through
the intraosseous femoral tunnel. D and E, Postoperative radiographs 12
months after open reduction internal fixation with a locking condylar plate.
(From Mithoefer K, Gill TJ, Vrahas MS. Supracondylar femoral fracture
after arthroscopic reconstruction of the anterior cruciate ligament.
J Bone Joint Surg 2005;87A:1591–1596.)

(Continued) 599
 Anterior Cruciate Ligament Reconstruction
FIG. 78-1—Cont’d
on the geometry of the defect, strength reductions of 20% to
90% may occur.18,19 Insertion of allogenic or autogenous bone
graft into the defect, such as in BPTB ligament reconstruction,
has not been shown to significantly change the mechanical
weakening of the bone.19 The combination of greater localized
stresses and decreased load-absorbing capacity predisposes
the area of the defect to failure. Aside from the bony defect,
additional stress concentration in the distal femur results from
the change in the bony moment of inertia due to the acute
change of sagittal, axial, and coronal geometry of the posterior
condylar flare and intercondylar notch.18,19 The bony geometry
of the distal femur has been found to play a critical role in the
structural properties and prediction of fracture load.21,22
Geometric analysis of the distal femur has shown the thinnest
cortical shell to be in the posterior aspect of the distal femur,23
therefore predicting the lowest fracture load in the anatomical
region of the femoral tunnel.
Decreased bone mineral density of up to 20% has
been observed after knee ligament injury and may also
600
contribute to the increased fracture risk after ACL recon-
struction due to decreased bending strength in the distal
femur.22,24 Bone bruising of the lateral femoral condyle,
which is frequently associated with ACL rupture, may also
compromise the biomechanical properties in the lateral
femoral condyle and predispose to earlier failure of the
bruised bone.25 When the area of the bony defect is sub-
jected to tensile stress, as with extension trauma to the knee,
the load strength of the already vulnerable posterior distal
femur is even further reduced.17,18 However, because the
bone in this anatomical region is predominantly under
compression, the likelihood of fracture development and
crack propagation is decreased. This may explain why femur
fracture does not occur more frequently after arthroscopic
ACL reconstruction.
Because bony remodeling has been shown to decrease
stress concentration around bony defects after 8 to 12
weeks,18 this would be expected to decrease the predisposition
for femur fracture after ACL reconstruction. However, bone

tunnel healing of the femoral tunnel has been shown to be
delayed by the exposure to biological factors from the joint.26
A previous report demonstrating fracture through the femoral
tunnel 2 years after ACL reconstruction27 suggests that the
stress concentration effect of the femoral tunnel continues
for a prolonged period after surgery.
Bone tunnel enlargement after ACL reconstruction is
well documented and occurs in as many as 68% of cases after
ACL reconstruction. The etiology of this clinical phenomenon
is not completely understood, but it is thought to be related to
a combination of multiple biological and mechanical factors.
A better understanding of the clinical relevance of bone tunnel
enlargement is still evolving.28 Previous experimental studies
have shown that the breaking strength of bone decreases in
direct proportion to the size of a bony defect.16 Based on these
findings, enlargement of the femoral tunnel may have clinical
relevance for the development of supracondylar femur fracture
after ACL reconstruction by further decreasing the mechanical
fracture resistance. Bone tunnel enlargement has also been
suggested to increase the risk for tibial plateau fracture after
ACL reconstruction.5,29 Given the frequency of ACL recon-
struction and high incidence of bone tunnel enlargement, the
potential predisposing effect of this phenomenon for fracture
of the distal femur needs to be further examined.
During ACL reconstruction, a tunnel is drilled into the
distal femur for subsequent graft fixation. Femoral tunnel
placement is performed arthroscopically in accordance with
recent technique recommendations.2,3 To optimize graft posi-
tioning, the femoral tunnel is placed as far posterior as possible
while carefully avoiding disruption of the posterior cortex. This
is commonly achieved by the use of a femoral tunnel placement
guide with built-in offset that maintains a 1- to 2-mm-thick
posterior cortical rim. Disruption of the posterior cortex can
result from posterior placement of the femoral tunnel.7 This
complication is different than fracture through the femoral
tunnel. However, it should be carefully avoided because it
may facilitate development of a fracture of the lateral femoral
condyle12 (Fig. 78-2). ACL reconstruction using computer-
assisted navigation systems for tunnel placement or using a
two-incision technique for ACL reconstruction may be able
to reduce the risk for this complication.30
Anatomical open reduction is critical to avoid premature
arthritis and may also be able to maintain the graft in the iso-
metric position. Fracture fixation by interfragmentary screws,
supracondylar blade plate, dynamic compression plate, and
intramedullary nail has all been described9–12 after femur frac-
ture following ACL reconstruction. Permanent loss of knee
motion has been described in some cases after distal femoral
fracture fixation.10,12,15 Early open reduction and internal fixa-
tion using condylar locking plates provide effective fracture fix-
ation with limited soft tissue dissection and reduced
postoperative morbidity and may allow for graft retention.13
Fracture Complications After Anterior Cruciate Ligament Reconstruction 78
FIG. 78-2 Computed tomography (CT) image showing lateral femoral
condyle fracture through the osseous tunnel following intraoperative
posterior wall disruption. (From Manktelow AR, Haddad FS, Goddard NJ.
Late femoral condyle fracture after anterior cruciate ligament
reconstruction. Am J Sports Med 1998;26:587–590.)
A proactive treatment approach facilitates early recovery, full
range of motion, excellent subjective knee rating, high func-
tional outcome scores, and return to pivoting sports.13 Follow-
ing anatomical fracture fixation, intraoperative stability testing
may reveal a functional ACL graft without the need for revision
ACL reconstruction. If anatomical fracture fixation does not
maintain graft function, revision ACL reconstruction may be
performed at the time of fracture fixation or at a later time.
PATELLA FRACTURE
Patella fracture represents a devastating complication follow-
ing ACL reconstruction using BPTB autograft and has been
reported with an incidence of 0.2 to 0.8%.5,31,32 Patella frac-
tures after ACL reconstruction are more frequently observed
in women and older patients.33 These fractures can occur
intraoperatively or postoperatively. Intraoperative fractures
are very rare and most often result from technical errors such
as harvesting too large a bone block. More frequently, injuries
occur between 5 and 12 weeks postoperatively.31,32,34 These
fractures in the early postoperative period are considered a
major complication because they may interfere with graft
remodeling and produce significant chondral damage and
persistent anterior knee pain. Most fractures are transverse
and occur at the proximal margin of the defect created during
bone block harvesting35 (Fig. 78-3). The transverse fracture
pattern usually results from indirect injuries to the patella,
such as rapid eccentric contractions of the quadriceps muscle.
Stellate and Y-type fracture patterns have been described
601
 Anterior Cruciate Ligament Reconstruction

FIG. 78-3 Lateral radiographic views (before [A] and after [B] fracture fixation) of a displaced transverse fracture
of the patella after anterior cruciate ligament reconstruction. (From Stein DA, Hunt SA, Rosen JE, et al. The
incidence and outcome of patella fractures after anterior cruciate ligament reconstruction. Arthroscopy
2002;18:578–583.)

after direct-impact injuries to the weakened patella.36 Longi-
tudinal patella fractures may also occur from vertical troughs
created by past-pointing with the saw blade. Patella fractures
can be displaced or nondisplaced and may or may not be
symptomatic.36,37 Most fractures cause a disturbance of the
extensor mechanism and are easily diagnosed. However,
silent nondisplaced patella fractures have been reported after
ACL reconstruction as a cause of chronic anterior knee pain
and long-term functional limitation.37
Multiple factors have been suggested to contribute to
the development of this complication. Decreased vascularity
to the central portion of the patella after graft harvest has
been suggested to contribute to the risk for postoperative
patellar fracture. The intraosseous blood supply of the
patella is composed of the midpatellar, polar, and quadriceps
tendon system.38 The disruption of these vessels during
graft harvest can impair healing of the harvest site and
may even affect the remaining normal bone.
In knee flexion, the patella is subject to posterior
forces along the superior and inferior poles and an opposing
anterior force when the posterior surface of the patella
contacts the femur. This three-point bending force on the
patella has been hypothesized to be the force that acts on
the weakened patella, resulting in many of the indirect
patella fractures that occur when the knee is flexed.39
Biomechanical studies have shown that the anterior
cortex of the patella has the highest load resistance and that
superior transverse cuts during graft harvest can reduce patel-
lar resistance by 30% to 40%.31 The transverse bone cut has
been shown to average more than 13 mm in width because
of subtle motion of both the patella and the cutting instru-
ment. Attention to surgical technique with smaller transverse
bone cuts can help minimize the weakening effect on the
anterior patellar cortex. Drill holes at the corners of the
planned osteotomy can also be helpful to prevent past-point-
ing and undesired propagation of the bone defect beyond the
outline of the osteotomy. Several authors have pointed out
that the dimensions of the grafted bone plug should not
exceed 9 to 10 mm in width. Using a 7-mm-wide sagittal
blade and angling the blade can reduce the width of the true
traversal cut. In addition to the width of the bone defect, its
length and depth are important. Graft length of less than

602

50% to 66% of the patellar length is recommended with
minimum graft length of 20 mm.40 Similarly, depth of the
graft should not exceed one-third of the measured depth of
the patella.41
Harvesting the BPTB graft acts as a significant stress
riser on the patellar bone.42 This stress-rising effect is directly
correlated with the size of the bone defect. Tapered bone
defects cause less patellar stress concentration compared with
square or trapezoidal defects but are still associated with
significantly higher stress concentration than in the normal
patella. Taking the larger trapezoidal bone plug from the tibia
and a triangular plug from the patella has been suggested as a
technique to reduce the patellar defect size and stress concen-
tration.40,43 Packing the patella defect with cancellous bone
grafts has been recommended by many authors.38,40–42,44–47
Bone grafting has been shown to decrease the stress-rising
effect and can help to normalize the strength and resistance
of the harvest site.44 Grafting the bony defect is particularly
recommended for graft sites wider than 10 to 12 mm or deep-
er than 6 mm.38 In addition to graft size and shape, the graft-
ing technique is also important. Use of a circular oscillating
saw can create lower stresses on the corners, removes smaller
grafts, and creates a rounded bottom of the trough.48
It has been theorized that some patella fractures after
ACL reconstruction result from a weakened patella and abnor-
mal patellar tracking due to a deconditioned quadriceps, which
in turn increases the patellofemoral contact stresses. Early
quadriceps conditioning and proprioceptive exercises decrease
abnormal patellar positioning and tracking.5,31 Improved
quadriceps strength and function may also help restore normal
gait pattern and thereby prevent direct fractures from falls or
from sudden uncoordinated muscle contraction.
Nondisplaced fractures can be treated nonoperatively
with rigid knee bracing. However, some authors advocate sur-
gical fixation for all fractures because it restores the extensor
mechanism and allows for immediate motion and rapid return
to knee rehabilitation.31 We have successfully used cannu-
lated screw fixation with figure-eight Fiberwire augmentation
through the cannulated screws for these nondisplaced frac-
tures. With appropriate treatment, minimal residual long-
term consequences have been observed after patella fractures
following ACL reconstruction with functional outcomes,
comparable to patients without fracture complications.12,40
TIBIA FRACTURE
Tibial Plateau Fracture
To date, six reports have described tibial plateau fracture
complicating ACL reconstruction4,29,49–52 (Fig. 78-4). The
fractures occur between 7 and 18 months postoperatively
Fracture Complications After Anterior Cruciate Ligament Reconstruction 78
and are frequently induced by torsional trauma. Examination
typically reveals a significant effusion and notable crepitation.
Plain radiographs and CT scans are diagnostic. In all
described cases, the fracture of the tibial plateau occurred
through the transosseous tibial tunnel. Although no bio-
mechanical studies have specifically addressed the mechanical
effect of tibial bone tunnels, the presence of the tibial tunnel
likely acts as a predisposing factor because the cortical defect
acts as a stress riser.17,20 It has been well documented that cor-
tical defects can decrease resistance to torsional forces by as
much as 90%.19,20 Stress concentration is known to occur in
the region of the anterior starting point of the tibial tunnel
from the sudden change of the anatomical geometry of the
metaphyseal–diaphyseal junction of the tibia.17 Screw holes
used for post and washer fixation of the tibial graft may further
increase the stress concentration. Bone tunnel enlargement
has also been suggested to increase the risk for tibial fracture
after ACL reconstruction.5,51
Treatment of tibial plateau fractures after ACL recon-
struction has been successfully achieved by nonoperative
treatment for nondisplaced fractures50 or by open reduction
and internal fixation.4,5,49 Less invasive fracture fixation
(LISS) (Synthes, Paoli, PA) (see Fig. 78-4) has been
described with minimal postoperative morbidity and early
functional recovery.51 Depending on the ability of the fracture
fixation to maintain the graft in the isometric position,
revision ACL reconstruction may5 or may not be necessary.51
Tibial Tubercle Fracture
Tibial tuberosity avulsion fractures have been described in
rare cases of autograft BTB reconstructions.53–55 Tibial
tubercle avulsion may occur ipsilaterally with primary ACL
reconstruction or in the contralateral leg when using the
contralateral patellar tendon autograft in revision cases.
These injuries usually occur in the early postoperative period
and have been described between the first postoperative day
and 6 weeks postoperatively. The early occurrence of these
injuries has been related to technical errors, early mechanical
overload from aggressive postoperative weight bearing, and
the combined stress-riser effect of the tibial bone plug har-
vest site and the tibial tunnel. Fractures may involve the
entire tubercle or only a part of the tibial tuberosity. Patients
commonly report a popping sensation with acute pain and
associated inability or difficulty to extend the involved
extremity. Radiographs are necessary to differentiate a tibial
tubercle fracture from a patellar tendon avulsion, which can
present with the same clinical findings (Fig. 78-5).
Harvesting of the central part of the tibial tubercle
graft creates a thin cancellous bone bridge between the graft
site and tibial tunnel. The tibial cortical defects result in a
significant stress concentration, particularly on the medial
603
 Anterior Cruciate Ligament Reconstruction

FIG. 78-4 Plain radiographs (A and B) and computed tomography (C) demonstrating tibial plateau fracture
through the transosseous tibial tunnel after anterior cruciate ligament reconstruction. Plain radiograph (D) of the
tibia at 6 months after fixation with limited invasive stabilization system (LISS). (From Mithoefer K, Gill TJ, Vrahas MS.
Tibial plateau fracture following anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc
2004;12:325–328.)

604

FIG. 78-5 Lateral radiograph showing a minimally displaced tibial
tuberosity fracture after tibial tubercle graft harvesting osteotomy. (From
Busfield BT, Safran MR, Cannon WD. Extensor mechanism disruption after
contralateral middle third patellar tendon harvest for anterior cruciate
ligament revision reconstruction. Arthroscopy 2005;21:1268.)
aspect of the tibial tubercle. Undermining the medial or lat-
eral insertion sites of the patellar tendon with the osteotome
or oscillating saw causes further thinning of the bone bridge,
which in some cases may lead to avulsion fractures. Under-
mining may result from a failure to account for the anatomi-
cal slope of the tibial tuberosity when making the bone cuts.
Bone cuts perpendicular to the extremity axis lead to under-
mining, particularly of the lateral tibial tuberosity with its
posterolateral slope. Sawing perpendicular to the tuberosity
reduces the tendency to undermine the lateral tuberosity.53
Harvesting triangular bone blocks has also been proposed
to minimize undermining and stress concentration.53 The
use of round-cornered or trapezoidal bone cuts also helps
minimize the stress-riser effect at the graft site. Lack of
active knee extension and displacement of the fragment
are indications for surgical fixation. The combination of
interfragmentary screw fixation and tension band techniques
provides rigid fixation that allows for immediate passive
range-of-motion postoperatively and return of unrestricted
knee function.53–55
In summary, fracture after ACL reconstruction is an
infrequent but serious complication. Knowledge of the
pathogenesis, risk factors, and specific anatomical and
technical aspects that can lead to fracture complications
after ACL reconstruction are important for the surgeon
performing ACL reconstruction and can help prevent these
devastating complications. Patients should be routinely
counseled regarding these potential complications, particu-
larly when BTB autograft is harvested.
Fracture Complications After Anterior Cruciate Ligament Reconstruction 78
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25. Johnson DL, Bealle DP, Brand JC, et al. The effect of geographic
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cruciate ligament reconstruction. Am J Sports Med 2004;32:543–549.
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32. Papageorgiou CD, Kostopoulos VK, Moebius UG, et al. Patellar frac-
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33. Sharkey NA, Donahue SW, Smith TS, et al. Patellar strain and patello-
femoral contact after bone-patellar tendon-bone harvest for anterior cru-
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41. Malek MM, Kunkle KL, Knable KR. Intraoperative complications of
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anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol
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disruption after contralateral middle third patellar tendon harvest
for anterior cruciate ligament revision reconstruction. Arthroscopy
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54. Acton KJ, Dowd GS. Fracture of the tibial tubercle following anterior
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J Orthop 1998;27:629–630.
 Anterior Knee Problems After Anterior
Cruciate Ligament Reconstruction
INTRODUCTION
Anterior knee problems such as anterior knee
pain, tenderness, crepitus, disturbed sensitivity,
and inability to kneel or knee-walk after anterior
cruciate ligament (ACL) reconstruction are
common and, although they occur more often
when patellar tendon autograft is used, they
can be seen with other graft options as well.
Anterior knee pain is multifactorial in origin
and yet not clearly understood. The patellofe-
moral joint is a very vulnerable joint. It can be
the source of pain after almost any surgery to
the knee, even if it is not directly involved.
The patellar tendon and peripatellar soft tissues
are similarly vulnerable. Damage to the infrapa-
tellar branch of the saphenous nerve with
neuroma formation during graft harvesting,
shortening of the patellar tendon after ACL
reconstruction (patella baja) due to fibrosis
of the infrapatellar fat pad, flexion and/or
extension deficit due to poor surgical technique
or inadequate rehabilitation, and pain stem-
ming from tibial tunnel creation have all been
implicated as possible causes. Pain during
kneeling is bothersome, especially if interferes
with certain recreational or occupational
activities (e.g., masons, plumbers) and with
religious (e.g., Islamic) or cultural habits (e.g.,
Asian peoples).
In general, anterior knee problems can be
due to factors related to the graft, the procedure,
79
CHAPTER
or the rehabilitation. Of these, the most impor- Michael E. Hantes
tant factors are those related to the graft.
Apostolos P. Dimitroulias
ANTERIOR KNEE PROBLEMS RELATED
TO THE GRAFT
Patellar Tendon and Hamstring
Tendon Autografts
The impact of patellar tendon graft harvesting
on knee symptoms is well documented. An
increased incidence of anterior knee problems
such as pain and loss of sensitivity was found
in patients in whom a patellar tendon autograft
was harvested from the “healthy” contralateral
knee, and therefore this procedure should be
avoided because additional problems and mor-
bidity are transferred onto the healthy contralat-
eral knee.1
The gold standard thus far for ACL
reconstruction is the mid-third bone–patellar
tendon–bone (BPTB) autograft. However, it
has been associated with significant (in 40% to
60% of patients) anterior knee symptoms,2–7
and therefore the use of four-strand hamstring
tendon graft is increasing in popularity because
these problems seem to be less frequent.
In the literature, results are conflicting in
the comparison of the two most popular grafts
(patellar and hamstring tendon) regarding the
incidence of anterior knee pain.8–10
607
 Anterior Cruciate Ligament Reconstruction
This variability in results is mostly due to inherent dif-
ficulties in achieving homogeneity in different studies owing
to technical issues (method of graft harvest, preparation of
the graft, cycling of the graft, degree of knee flexion and graft
tension when securing the graft, fixation method, rehabilita-
tion protocol, and outcome measures). The ideal way to com-
pare the incidence of anterior knee symptoms between
different types of grafts would be a large multicenter rando-
mized trial, but such a large-scale trial has not yet been done.
However, three meta-analyses concluded that ACL
reconstructed knees with patellar tendon are more prone
to developing anterior knee symptoms and extension deficit
than the hamstring tendon group.11–13
In a study with a long-term follow-up,7 kneeling pain
was found to persist even at 7 years postoperatively and was
more common and more severe in the patellar tendon group
(54%) than the hamstring tendon group (20%). Similarly,
the incidence of donor site symptoms in any form was more
than doubled in the patellar tendon group compared with
the hamstring tendon group, and the incidence of extension
deficit increased over time in the patellar tendon group, prob-
ably secondary to development of osteoarthritic changes.7
FIG. 79-1 A, Measurement of the patellar tendon length in a sagittal magnetic resonance image (MRI) of a knee
16 months after anterior cruciate ligament (ACL) reconstruction with bone–patellar tendon–bone graft. B, Sagittal
MRI of the contralateral healthy knee (3-mm difference, or 6.6%).
608
But what causes anterior knee problems after patellar
tendon harvest?
Harvesting trauma, patellar tendonitis, tendon changes
during the repair process of the tendon gap, vascular damage
of the retropatellar fat pad, and proprioceptive loss of the exten-
sion mechanism are all possible causes.14 Patellar tendon
shortening is another important factor for development of
anterior knee pain. It has been demonstrated with a magnetic
resonance imaging (MRI) study15 that significant patellar
tendon shortening (with a mean of 9.7%) occurs after harvest-
ing BPTB graft compared with the contralateral nonoperated
control knee 1 year after ACL reconstruction (Fig. 79-1).
A possible explanation for this is the retropatellar fat pad
fibrosis secondary to the surgical trauma, contraction of the scar
that develops in the gap created after patellar tendon harvesting
due to diminished elastic components, and the decreased
strength of quadriceps contributing to patella baja, which stres-
ses patellofemoral joint. Moreover, quadriceps inhibition/
weakness causes delayed rehabilitation with subsequent exten-
sion deficit and abnormal patellofemoral joint forces.
In contrast, harvesting of hamstring tendons resulted in
a nonsignificant shortening of the patellar tendon of 2.6%

(Fig. 79-2). Using an Insall-Salvati ratio less than 0.74 as
the MRI criterion for patella baja diagnosis,16 12.5% of the
patients in the BPTB group and 3% in the hamstring group
were found to develop patella baja after surgery. This
shortening was not of clinical importance, as it was not asso-
ciated with anterior knee pain in the short-term follow-up.
However, one other study with longer follow-up (average 7
years) has clearly shown that severity of patellofemoral joint
arthritis and anterior knee symptoms correlate with the
amount of patellar tendon shortening17 (Fig. 79-3).
Central patellar tendon harvesting has been found to
cause a slight medial displacement of the patella,18 and this
alteration in position causes high contact forces in the
medial patellofemoral joint.14 A solution to this may be
the use of the medial third of the patellar tendon, which
does not influence the patellofemoral angle and causes an
insignificant lateral patellar displacement.18
Anterior knee pain does occur after hamstring ACL
reconstruction, despite the fact that the anterior structures
of the knee remain intact. The reason for this is not clear,
but it is known that the patellofemoral joint can be the
FIG. 79-2 A, Measurement of the patellar tendon length in a sagittal magnetic resonance image (MRI) of a knee
14 months after anterior cruciate ligament (ACL) reconstruction with hamstring (HS) graft. B, Sagittal MRI of the
contralateral healthy knee (1-mm difference, or 2.6%).
Anterior Knee Problems After Anterior Cruciate Ligament Reconstruction 79
source of pain after almost any surgery to the knee, even if
the patellofemoral extension mechanism is not directly
involved. The incidence of anterior knee pain after ham-
string graft for ACL reconstruction in the literature is less
than 23%.19–22 Evaluation of the pain with diagrams has
shown that it is more diffuse and is not related to the skin
incision for tendon harvesting or tibial tunnel drilling.19 In
contrast, anterior knee pain after patellar tendon harvesting
is more well localized, and palpation reveals trigger points
that are usually over the inferior pole of the patella or the
tibial tuberosity or above the patellar tendon donor site.14,23
There are conflicting reports in the literature on
whether grafting the patella and tibial tunnel bone defects
after BPTB harvesting reduces23,24 or does not reduce25 the
incidence of anterior knee symptoms. There is also a report
that patella grafting increases the incidence of painful spurs
at the inferior pole of the patella.26 Similar arguments exist
regarding whether suturing the patellar tendon gap facilitates
tendon healing or is a cause of patellar tendon shortening.27
Patellar fracture is another important issue unique in BPTB
grafts, and its incidence varies from 0.2%28 to 2.3%.29
609
 Anterior Cruciate Ligament Reconstruction
FIG. 79-3 A, Symptomatic patellofemoral arthritis in a young patient 4 years after anterior cruciate ligament (ACL)
reconstruction with bone–patellar tendon–bone graft. B, Management with anteromedial tibial tubercle transfer
(Fulkerson osteotomy).
Patellar tendon rupture is another rare complication
that may occur after patellar tendon harvest. Devasculariza-
tion and an alteration in tendon healing and remodeling are
possible causes of this complication.30
Central Quadriceps Tendon
Use of quadriceps tendon autograft has been introduced to
overcome disadvantages of patellar tendon and hamstring
grafts. Literature is limited on the use of this graft, but initial
experience has been promising with regard to anterior knee
problems.
In a recent study, less than 10% of patients with quad-
riceps tendon graft suffered anterior knee pain in various
activities, and only 6% complained of kneeling pain.31
Donor site irritation over the proximal patellar border was
observed in several patients but did not last more than 6
months, and quadriceps strength 1 year postoperatively
was comparable with that of other autografts in the litera-
ture.31 The risk of patellar fracture must be lower than that
of patellar tendon graft because the bone in the proximal
patellar pole is more dense.32 Injury of infrapatellar branches
610
of the saphenous nerve is not a problem because the incision
does not cross them.
Allografts
During the past 30 years, allografts have been used com-
monly to reconstruct the ACL as an alternative to reduce
donor site morbidity. Allograft choices consist of patellar
tendon, quadriceps, hamstrings, Achilles, and anterior and
posterior tibialis tendons and fascia lata. The most com-
monly used at present is BPTB allograft. The improved
sterilization techniques with cryopreservation, which does
not interfere with the mechanical properties of the graft,
contributed to a rise of allograft use during recent years.
Some studies comparing patellar tendon autograft
versus allograft in ACL reconstruction failed to show any
difference in the incidence of anterior knee pain between the
two groups.33,34 Others found a significant reduction in
anterior knee pain with allografts, such as 14% versus 46%35
and 14.4% versus 55.8%.36
In a study comparing patellar tendon autograft versus
allograft with long-term follow-up (5 years), it was found
 Anterior Knee Problems After Anterior Cruciate Ligament Reconstruction 79
that the autograft group experienced more pain during the
first 3 postoperative months, which relates to the larger inci-
sion required and the resulting bony defect.37 At 2 and 5
years there was no difference in the pain. Moreover, both
in the short and long terms, there was no difference in the
range of motion and quadriceps strength.
However, incision site complaints (tenderness, irrita-
tion, numbness) are less common in the allograft group
when compared with the autologous BPTB group.33

ANTERIOR KNEE PROBLEMS RELATED TO THE

PROCEDURE
The infrapatellar branch of the saphenous nerve has two
main trunks, superior and inferior,38 coursing laterally and
slightly distally, respectively (Fig. 79-4). Incisions close to
the tibial tubercle and over the patellar tendon may damage
these branches with consequent anesthesia, dysesthesia, or
painful neuroma formation.39 A significant correlation exists
between disturbed anterior knee sensitivity and subjective
anterior knee pain as well as discomfort during knee walk-
ing.40,41 Moreover, there is an association between injury
of these sensory branches and development of reflex sympa-
thetic dystrophy.37 The importance of infrapatellar branches
can be appreciated by reports of prepatellar neuralgia after
direct blows to the anterior knee.42,43
Patients should be informed of these potential compli-
cations. The area of anesthesia is variable but always lateral to
the incision. It is not only the incision for graft harvesting that FIG. 79-4 The infrapatellar branch of the saphenous nerve with the two
puts in danger these sensory branches; the incision for the main trunks, superior and inferior, coursing laterally and distally. (Reprinted
medial portal can damage them as well.38,39 Therefore some with permission from Kartus J, Ejerhed L, Sernert N, et al. Comparison of
traditional and subcutaneous patellar tendon harvest. A prospective study
propose a horizontal rather than vertical incision for the of donor site-related problems after anterior cruciate ligament
portals to minimize the risk of nerve damage.38 Another reconstruction using different graft harvesting techniques. Am J Sports Med
maneuver to avoid damage of these nerves is placing the 2000;28:328–335.)
anterior midline skin incision with the knee held in 90 degrees
of flexion. In this way the inferior branch moves farther skin incision, the dissection for the tendons, tendon strip-
distally and the risk of inadvertent damage is lessened.38 ping (as the saphenous nerve courses superficial to gracilis),
When harvesting patellar tendon autograft with a small and tibial tunnel drilling.19 However, it seems that the more
midline incision, every effort should be made to identify and distal the location of the area of disturbed sensitivity (as
protect these sensory nerve branches. Alternative techniques occurs after hamstring tendon harvesting), the less discom-
have been described for subcutaneous patellar tendon harvest- fort will result.45 In contrast with patellar tendon harvesting,
ing using two horizontal incisions,44 one horizontal incision the area of sensory changes is more proximal and thus more
at the midlevel of the patellar tendon,23 and two vertical41 bothersome.
incisions. This way the infrapatellar branches are avoided, Concomitant meniscal surgery during ACL recon-
making these incisions less likely to become a source of pain. struction may result in range of motion problems during
Injury to these branches can occur not only during rehabilitation, which will influence the incidence of anterior
patellar tendon harvesting but with hamstring tendon as knee problems.
well. Anterior knee sensory changes were found to be as Residual anterior instability after surgery can cause
high as 50% (at a minimum of 24 months postoperatively) anterior knee problems secondary to the altered patello-
following hamstring ACL reconstruction.19 The inadvertent femoral kinematics (lateral patellar tilt and shift) present in
injury of the sensory nerve branches may occur during the ACL deficient knees.

611
 Anterior Cruciate Ligament Reconstruction
Proper placement of the drill holes at the isometric
point is a prerequisite to achieve full range of motion post-
operatively.40 It has been found in a study that after BPTB
ACL reconstruction, patients with patellofemoral joint
arthritis tended to have more anterior placement of the fem-
oral tunnel and more posterior placement of the tibial tunnel
than those without patellofemoral joint arthritis.17
Arthrofibrosis after ACL reconstruction may result
from an exaggerated inflammatory response, synovitis, or a
sympathetic algodystrophy and will cause range-of-motion
deficit.10
Formation of a “Cyclops” lesion is another reason for
extension deficit and anterior knee pain.46 This lesion is
usually formed anterolaterally to the tibial tunnel placement
of the graft. Arthroscopic débridement of the nodule can
improve extension.
ANTERIOR KNEE PROBLEMS RELATED TO
REHABILITATION
An operation performed too early (i.e., before regaining full
range of motion) is a well-known cause of postoperative
range of motion deficit. For this reason we support a rather
delayed reconstruction, not less than 2 months after the
injury, to allow for posttraumatic synovitis to settle or the
knee to regain full range of motion without effusion.47,48
Reduced strength and loss of range of motion are
correlated with anterior knee pain after ACL reconstruction
using all kinds of grafts.49 Thereby every effort should be
made postoperatively to achieve full range of motion and
regain quadriceps and hamstrings muscle strength. Loss of
hyperextension can be a significant cause of anterior knee
discomfort after ACL reconstruction.50–53 The reason for
Arthrofibrosis
All Cyclops lesion
grafts Inappropriate drill holes
Delayed rehabilitation
Poor quads strength
Retropatellar fat fibrosis
BPTB
PT scar contraction
Medial displacement of patella
BPTB
Injury to the infrapatellar
and
branches of saphenous nerve
HS
FIG. 79-5 Causes of anterior knee pain after anterior cruciate ligament (ACL) reconstruction. BPTB, Bone–patellar
tendon–bone; HS, hamstring; PFJ, patellotemoral joint.
612
anterior knee symptoms in loss of extension is the resultant
increase of patellofemoral joint reaction forces. It is not only
loss of extension that can cause anterior knee symptoms but
loss of flexion as well, although this has been more controver-
sial.52,54 Patients with both flexion and extension deficits have
more anterior knee pain than patients with an extension defi-
cit alone.40 The reason for anterior knee symptoms in loss of
flexion is the decreased muscle strength in both flexor and
extensor mechanisms40 (Fig. 79-5).
HOW TO REDUCE ANTERIOR KNEE SYMPTOMS
AFTER ANTERIOR CRUCIATE LIGAMENT
RECONSTRUCTION
Although the results in terms of restored laxity and a return
to sports have been good after ACL reconstruction, anterior
knee symptoms can be a problem after this procedure.
Therefore efforts should be made to minimize the presence
of anterior knee symptoms after ACL reconstruction in
order to increase patient satisfaction.
The donor site morbidity associated with harvesting a
hamstring tendon graft is less common than that associated
with harvesting a BPTB autograft. Therefore fewer pro-
blems should be expected when harvesting a hamstring ten-
don graft. Probably this type of graft is a better choice than
patellar tendon graft for patients whose activities require
kneeling. Quadriceps tendon autograft seems to be an alter-
native choice for ACL reconstruction, although further
studies are needed to support this hypothesis. When patellar
tendon is used, the technique involving two transverse inci-
sions significantly reduces anterior knee symptoms.
A horizontal incision may be a useful option for ham-
string graft harvesting to provide a more satisfactory scar
Extension deficit
Abnormal
PFJ forces
PT shortening
Anterior
knee pain
Anesthesia,
dysesthesia or
painful neuroma

with less risk of damage to the infrapatellar branch of the
saphenous nerve. However, regardless of the incision used,
damage to the infrapatellar branch of the saphenous nerve
is a potential complication (for patellar tendon and ham-
string autografts), and patients should be counseled about
this preoperatively. Postoperative rehabilitation with control
of pain, soft tissue swelling, and hemarthrosis and the insti-
tution of immediate motion, patellar mobilization, and
quadriceps exercises are of paramount importance in the
prevention of knee motion complication and anterior knee
problems. In addition, all patients should be instructed to
achieve early knee extension.
Finally, surgical technique is probably the most
important factor to prevent anterior knee symptoms. Metic-
ulous technique during soft tissue dissection and graft har-
vesting, accurate placement of the graft, and stable graft
fixation to allow early rehabilitation are essential factors for
a good result.
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1993;9:143–148.
22. Corry IS, Webb JM, Clingeleffer AJ, et al. Arthroscopic reconstruc-
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23. Tsuda E, Okamura Y, Ishibashi Y, et al. Techniques for reducing
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24. Muellner T, Kaltenbrunner W, Nikolic A, et al. Shortening of the
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25. Boszotta H, Prunner K. Refilling of removal defects: impact on
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graft for anterior cruciate ligament reconstruction. Arthroscopy
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26. Kohn D, Sander-Beuermann A. Donor-site morbidity after harvest of
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27. Brandsson S, Faxen E, Eriksson BI, et al. Closing patellar tendon
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28. Viola R, Vianello R. Three cases of patella fracture in 1,320 anterior
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30. Marumoto JM, Mitsunaga MM, Richardson AB, et al. Late patellar
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31. Lee S, Seong SC, Jo H, et al. Outcome of anterior cruciate liga-
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32. West RV, Harner CD. Graft selection in anterior cruciate ligament
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33. Peterson RK, Shelton WR, Bomboy AL. Allograft versus autograft
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34. Shelton WR, Papendick L, Dukes AD. Autograft versus allograft
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36. Gorschewsky O, Klakow A, Riechert K, et al. Clinical comparison of
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40. Kartus J, Magnusson L, Stener S, et al. Complications following
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Knee Surg Sports Traumatol Arthrosc 1999;7:2–8.
41. Kartus J, Ejerhed L, Sernert N, et al. Comparison of traditional and
subcutaneous patellar tendon harvest. A prospective study of donor site-
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different graft harvesting techniques. Am J Sports Med 2000;28:328–335.
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reconstructive surgery. Stockholm, Sweden, 2001, Karolinska Institutet
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51. Irrgang JJ, Harner CD. Loss of motion following knee ligament
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 PART R GAIT ANALYSIS AND TISSUE ENGINEERING
Gait Analysis in Anterior Cruciate
Ligament Deficient and Reconstructed
Knees
INTRODUCTION
Anterior cruciate ligament (ACL) rupture is a
common injury of the knee joint that usually
results in surgical reconstruction.1,2 The goal
of ACL reconstruction and subsequent rehabil-
itation is to restore the knee to an acceptable
muscular strength and joint stability.3,4 The sta-
bility of the knee thought to have an ACL
injury is traditionally evaluated with an arth-
rometer (i.e., KT-1000) while the patient is in
a standard static position. The arthrometer pro-
vides the clinician with a quantitative measure
of the amount of passive movement between
the femur and the tibia. A minimal amount of
joint laxity during the test is considered to be
clinically and functionally acceptable. However,
such an evaluation is a measure of passive joint
stability and does not provide a measure of the
joint’s stability during daily physical activ-
ities.5–7 Dynamic functional joint stability is
defined as the condition in which the joint is
stable during daily physical activities.5 Previous
research has indicated that there is lack of a
relationship between passive and dynamic func-
tional joint stability.5,8–10
Recently, gait analysis has been used to
quantify the dynamic functional knee stability
after ACL reconstruction.11–14 Gait analysis
can be defined as an advanced laboratory pro-
cess by which present day electronics (i.e., video
*
Dr. Stergiou is supported by the National Institutes of Health
(K25HD047194), the National Institute on Disability and
Rehabilitation Research (H133G040118), and the Nebraska
Research Initiative.
80
CHAPTER
cameras) are used to integrate information from Nicholas Stergiou*
a variety of inputs in order to demonstrate
Stavros Ristanis
and analyze the dynamics of gait (Fig. 80-1).
For example, gait analysis can offer a more in- Constantina Moraiti
depth evaluation of movement patterns by Anastasios Georgoulis
providing information on each joint. Such
information has also become common practice
in many other orthopaedic areas where the
effects of surgical procedures (i.e., joint arthro-
plasty, cerebral palsy) are evaluated to identify
gains in mobility.15–19
The use of this technology allows the
development of normal joint movement profiles
that can be used to identify abnormalities, help-
ing in this way to improve diagnosis, treatment,
design, and performance of reconstructive sur-
gery and rehabilitation programs. Gait analysis,
using advanced computerized systems in con-
junction with multiple high-speed (i.e., 200
frames per second) video cameras, can document
three-dimensional (3D) knee joint movement
profiles.20 Thus all six degrees of freedom of the
knee joint can now be discerned, and the dynamic
functional levels of individuals performing every-
day activities can be objectively measured and
evaluated. This is accomplished by obtaining data
from surface markers that are placed on specific
anatomical bony landmarks. The position of the
markers in space is recorded, and then joint
movement profiles can be acquired.
A possible limitation of gait analysis is that
surface markers may not accurately represent the
underlying bone motion during highly dynamic
activities,21 as the markers are attached on the skin
and not directly on the bone. As skin movement
615
 Anterior Cruciate Ligament Reconstruction

Jumping

Landing

Pivoting

3
FIG. 80-1 A stick figure demonstrating the landing activity: the subject jumps off the platform and lands with
both feet on the ground. Following foot contact, the subject pivots (externally rotates) on the right or left
(ipsilateral) leg at 90 degrees and walks away from the platform. While pivoting, the contralateral leg is swinging
around the body and the trunk is oriented perpendicularly to the platform.

increases, the location of the marker and of the underlying bone
differs. As a result, error is introduced.21–26 One way to avoid
these limitations is to directly measure skeletal motion with
intracortical pins.25 However, the applicability of this method
is limited because the implantation of intracortical pins is a
highly invasive procedure that may cause discomfort or pain
to the patient and result in restriction of movements. In addi-
tion, implantation of intracortical pins is a method that is lim-
ited by the sample size, as an effective number of volunteers
cannot be found.

616
 Gait Analysis in Anterior Cruciate Ligament Deficient and Reconstructed Knees
These limitations can also be addressed with careful
experimentation procedures. The following are a few of
the procedures commonly used:
1 Minimize interoperator error by having the same clinician
place all markers and acquire all anthropometric
measurements.
2 Incorporate a standing calibration procedure to correct for
subtle misalignment of the markers that define the local
coordinate system and to provide a definition of zero
degrees for all movements in all planes.
3 Maximize your control conditions to “tease” out true
differences. For example, in our research work,14,27 we
used as control conditions both the intact leg of the ACL
reconstructed or deficient group and a completely healthy
group of individuals.
4 Always use the same instrumentation for all individuals to
maintain the same level of measurement noise across all
individuals. Thus any differences can be attributed to
changes within the system itself.
5 Increase statistical power by using an adequate sample
size and selecting the proper alpha level.
These suggestions can solidify conclusions drawn from
gait analysis. Thus gait analysis is widely accepted at the pres-
ent time and is considered a well-established and reliable
method.28,29 This methodology allows the in vivo evaluation
of the ACL deficient and reconstructed knee during dynamic
activities (i.e., walking, pivoting), something that static
measures (i.e., arthrometer) are unable to do.
IMPORTANCE OF IN VIVO BIOMECHANICAL
RESEARCH TO QUANTIFY SUCCESS OF
SURGICAL TECHNIQUES
Example 1: Tibial Rotation
In this section, we will present our first example of how gait
analysis and in vivo biomechanics can help quantify success
in the operating room. For this example, we will focus on knee
joint rotational movement patterns for which in vivo research
work is scanty.
Our investigations have examined knee joint rotational
movement patterns during high- and low-demand activities
in both ACL deficient and reconstructed individuals. In our
first study, we evaluated ACL deficient and reconstructed
individuals during a low-demand activity such as walking.14
We examined 13 individuals with unilateral ACL deficiency,
21 individuals who had undergone ACL reconstruction,
and 10 healthy controls. ACL reconstruction was done
80
arthroscopically using a bone–patellar tendon–bone (BPTB)
autograft. We found that the ACL deficient group exhibited
significantly increased tibial rotation range of motion during
the initial swing phase of the gait cycle when compared with
the ACL reconstructed and control groups. Thus our results
demonstrated that ACL deficiency produced rotational
differences at the knee during walking. These differences
did not exist when we compared the ACL reconstructed
group with the control. Thus, in this low-demand activity,
the surgical reconstruction restored tibial rotation to
normal levels.
Next, we wanted to identify whether this is also the case
in a higher-demand activity that can apply increased rota-
tional loading at the knee. Therefore we examined 18 ACL
reconstructed individuals and 15 controls during a high-
demand activity (descending stairs and subsequent pivot-
ing).27 The ACL reconstruction was done arthroscopically,
again using a BPTB autograft. The evaluation was performed
at an average of 12 months after reconstruction. The indivi-
duals were asked to descend three steps and then immediately
pivot on the landing leg at 90 degrees and walk away from the
stairway while kinematic data were collected. The tibial rota-
tion range of motion during the pivoting period was found to
be significantly larger in the ACL reconstructed leg compared
with the contralateral intact leg and the healthy control. No
significant differences were found between the healthy con-
trol leg and the intact leg of the ACL reconstructed group.
Therefore our results demonstrated that tibial rotation
remained abnormal and significantly increased 1 year after
ACL reconstruction during high-demand activities such as
pivoting after descending from stairs.
To verify our findings, we performed an additional
experiment in which we evaluated another high-demand
activity.30 Data were collected while the subjects jumped
off a 40-cm platform and landed on the ground; following
foot contact, they immediately pivoted at 90 degrees and
walked away from the platform. We chose this activity
because landing from a jump is a task that places higher
demands on the knee than walking or even stepping
down.31,32 We combined landing with a subsequent pivot-
ing to create rotational loads on the knee. The subjects were
11 patients, all ACL reconstructed with the same arthro-
scopic technique using a BPTB autograft, 1 year after the
surgery; 11 ACL deficient subjects who had sustained
the injury more than 1 year prior to testing; and 11 controls.
The same dependent variable was evaluated as in the previ-
ous study.27 Both the reconstructed leg of the ACL group
and the deficient leg of the ACL deficient group had signi-
ficantly larger tibial rotation values than in the healthy con-
trol group. We also found no significant differences between
the deficient leg of the ACL deficient group and the recon-
structed leg of the ACL reconstructed group. It was
617
 Anterior Cruciate Ligament Reconstruction
concluded that current ACL reconstruction using the
BPTB autograft is inadequate to restore excessive tibial
rotation during an activity such as landing and subsequent
pivoting, which practically simulates sport activities.
Next, we wanted to identify whether tibial rotation
remains excessive for a longer period: 2 years following the
reconstruction. We speculated that it is possible adaptations
will set in and the patients will compensate. Thus we per-
formed a follow-up evaluation33 in nine ACL reconstructed
subjects who had participated in our previous study.30 We
examined them with the same methodology and for both
activities that we used in our previous work.27,30We also
incorporated a control group of 10 individuals. We found
that tibial rotation remained significantly excessive even
2 years after the reconstruction. This result was verified with
comparisons conducted with both the intact contralateral
knees of our patient group and with the healthy controls.
Furthermore, we found that tibial rotation of the intact knee
of our patient group was similar to those recorded from the
healthy control group.
In all of our previous work, ACL reconstruction was
performed with a BPTB autograft. Thus it was logical to
question whether tibial rotation will remain excessive if an
alternative autograft is used. Such an autograft is the qua-
drupled hamstring tendon (semitendinous and gracilis
[ST/Gr]). Originally we hypothesized that the ST/Gr auto-
graft would be able to restore tibial rotation during our
experimental protocols due to its superiority in strength
and linear stiffness34–37 and because it is closer morphologi-
cally to the anatomy of the natural ACL.34–36 We examined
11 individuals who were ACL reconstructed with an ST/Gr
autograft, 11 individuals who were ACL reconstructed with
a BPTB autograft, and 11 healthy controls.38,39 The exper-
imental protocol was identical to our previous studies. Tibial
rotation was found to be significantly larger in both ACL
reconstructed groups when compared with the healthy con-
trols. Therefore our hypothesis was refuted, and we con-
cluded that ACL reconstruction using the ST/Gr
autograft is as inadequate as the one using the BPTB auto-
graft in terms of restoring excessive tibial rotation.
The results of our studies were also supported by in vitro
research work in which the biomechanical efficiency of the
ACL reconstruction has also been questioned.40–43 These
studies showed that ACL reconstruction was successful in lim-
iting anterior tibial translation in response to an anterior tibial
load but was insufficient to control a combined rotatory load
of internal and valgus torque. Furthermore, our tibial rotational
values were in close agreement with the in vitro work.40
In summary, our research work showed how gait analy-
sis and in vivo biomechanics can help quantify success in the
operating room. We found that ACL deficiency results in
abnormal movement patterns such as excessive tibial rotation.
618
ACL reconstruction seems to restore ACL function regard-
ing tibial rotation in low-demand activities such as walking.
However, this is not the case in higher-loading activities
such as during pivoting, immediately following step-down,
or in a landing from a jump. These types of activities can reveal
differences that are masked during low-demand activities.
Example 2: Dynamic Functional Knee
Stability Using Nonlinear Analysis
In this section we present our second example of how gait
analysis and in vivo biomechanics can help measure dynamic
functional knee stability. For this example, we will focus on
our research work in which we used nonlinear tools to
examine whether an injured joint is functionally stable dur-
ing daily physical activities.
Biomechanists have recently proposed that the use of
stride-to-stride variability, defined as fluctuations on the wal-
king movement patterns from one stride to the next, provides
a quantitative measure of functional joint stability.44–47 This
proposal is based on scientific evidence that neuromuscular
pathology is related to an increased amount of stride-to-stride
variability.44–47 Hence a “biomechanical” hypothesis has been
formed in which neuromuscular pathology is related to an
increased amount of variability and deterioration of functional
stability. However, this biomechanical hypothesis lacks
support in other medical domains. Numerous studies in diverse
medical areas have shown that a decreased amount of variability
is related to pathology. These investigations include medical
domains such as heart rate irregularities, sudden cardiac death
syndrome, blood pressure control, brain ischemia, and epileptic
seizures.48–55 Hence a contradictory hypothesis has been pro-
posed in which variability is described as “healthy flexibil-
ity.”56–58 These investigations indicate that variations in the
behavior of the biological system may be necessary to provide
flexible adaptations to everyday stresses placed on the human
body. Alternatively, a lack of healthy flexibility is associated
with rigidity and inability to adapt to stresses. Based on this
logic, it is possible that injury or pathology can result in a loss
of healthy flexibility that may not be regained despite surgical
treatment (loss of complexity hypothesis).
This contradiction in the literature may be due to the
usage of linear tools (i.e., standard deviation) to assess
stride-to-stride variability.44–47 Linear tools only provide a
measure of the amount of variability that is present in the
gait pattern and may mask the true structure of motor
variability. Masking occurs when strides are averaged to
generate a “mean” picture of the subject’s gait. This averag-
ing procedure may lose the temporal variations of the gait
pattern. Additionally, the statistical processing of linear
measures requires random and independent variations
between subsequent strides.
 Gait Analysis in Anterior Cruciate Ligament Deficient and Reconstructed Knees 80
Recent studies have overcome the problems of linear
measures by using nonlinear tools such as the Approximate
Entropy.59–62 These studies have determined that variations
in the gait pattern are distinguishable from noise and have a
deterministic origin. A deterministic origin indicates that
stride-to-stride variations are neither random nor indepen-
dent. Rather, these variations have a meaningful pattern that
characterizes the behavior of the locomotive system. Linear
tools are not able to provide such information. Thus the
A ability to quantify the characteristic features of these varia-
tions has been the strength of using nonlinear tools to sup-
port the “loss of complexity” hypothesis.
65
In our research work, we wanted to quantify knee
Flexion-Extension

55
45 joint stride-to-stride variability in ACL deficient and recon-
35
25
structed individuals during a common daily activity such as
15 walking. We used nonlinear analysis to explore whether
5
−5
the “loss of complexity” hypothesis can also be generalized
0 5 10 15
Time
to orthopaedic-related problems. In our first study62 we
examined ten subjects with unilateral ACL deficiency who
B
walked on a treadmill at different speeds while kinematic
data were collected for 80 consecutive strides for each speed.
65
The Approximate Entropy of the resultant knee joint flex-
Flexion-Extension

55
45 ion–extension kinematic data was calculated (Fig. 80-2).
35
The ACL deficient knee had significantly smaller values
25
15 than the intact contralateral knee. This indicated more reg-
5
ular and repeatable movement patterns for the injured knee
−5
0 5 10 15
Time
and a decrease in healthy flexibility, as mentioned previ-
ously. Therefore nonlinear measures such as Approximate
C
Entropy could prove to be of great importance in orthopae-
dics, providing the clinician with a mean of dynamical assess-
ment of the effect of the pathology on movement and of the
results of various therapeutic interventions. In addition, we
believe that the “loss of complexity” hypothesis may be more
universal than its proponents suggested. Pathologies of bior-
hythms are similar no matter whether one deals with the car-
diovascular, nervous, or musculoskeletal system.

FIG. 80-2 Approximate Entropy (ApEn) is a nonlinear measure that

quantifies the regularity (predictability) of a time series. The smaller the ApEn,
the more regular and predictable the system. ApEn values range from 0 to 2.
D A value of 0 corresponds to a periodic behavior, whereas a value of
2 describes a completely random time series. The examples of these five time
series illustrate this issue. A, The time series from a simple periodic function
sin(t/10). Periodic behavior always repeats itself and is highly predictable. The
ApEn value of this time series is 0. B, Representative knee flexion–extension
time series from an anterior cruciate ligament (ACL) deficient knee. The ApEn
value of this time series is 0.2236. C, Representative knee flexion–extension
time series of the contralateral intact knee. The ApEn value of this time series
is 0.2646. It is evident that the subtle differences detected with the use of
ApEn between these two latter time series cannot be discerned with the
naked eye. D, A time series from a known chaotic system (the Lorenz
attractor). The ApEn value of this time series is 0.3552. E, A time series from
random numbers with a Gaussian noise centered on 0 and a standard
deviation of 1.0. The ApEn value of this time series is 2.
E

619
 Anterior Cruciate Ligament Reconstruction
Next, we wanted to examine the effect of an ACL
reconstruction on knee joint stride-to-stride variability.63
Again, we used the same nonlinear analysis, the Approximate
Entropy. We examined six individuals who were ACL recon-
structed with an ST/Gr autograft, seven individuals who were
ACL reconstructed with a BPTB autograft, and 12 healthy
controls. All subjects walked on a treadmill at a self-selected
pace while kinematic data were collected from 120 consecu-
tive strides. The control group had the smallest Approximate
Entropy values, whereas the ST/Gr group had the largest.
Significant differences were found only between the control
and the ST/Gr reconstructed knees. We concluded that the
ST/Gr reconstructed knee flexion/extension movement pat-
terns during walking are less regular and repeatable than in
the healthy control knee. However, the BPTB reconstructed
knee seems to exhibit properties similar to the control. In
addition, the results are also quite intriguing because
they showed that the ACL reconstruction led to increased
“flexibility” in the system. In the next section, we will present
a theoretical explanation for this research outcome.
In summary, our research work demonstrated how
knee stride-to-stride variability, which can be measured with
gait analysis and analyzed with nonlinear measures, can help
quantify functional knee stability during activities of daily
living. We found that ACL deficiency results in a “loss of
complexity,” which is in agreement with the general medical
literature that pathology will decrease variability. However,
we found that ACL reconstruction increased variability,
and thus complexity, as compared with healthy controls.
ADVANCED THEORETICAL CONSIDERATIONS
Development of Osteoarthritis Due to
Excessive Tibial Rotation
Degeneration of the knee joint and eventual development of
osteoarthritis have been associated with ACL deficiency.
Longitudinal follow-up studies have shown that ACL defi-
ciency leads to the development of chondral injuries, meniscal
tears, degeneration of the articular cartilage, and eventually
posttraumatic arthritis.64–68 However, similar problems have
also been found longitudinally in the ACL reconstructed
knee.69 Even more disturbingly, such findings have been seen
shortly after the reconstruction as well.70 Therefore ACL
reconstruction cannot protect the knee from progressing to
degenerative change.
Based on our research results presented earlier, we
would like to propose that excessive tibial rotation may be
an abnormal movement mechanism that degenerates soft
tissues (i.e., cartilage), resulting in osteoarthritis. We hypoth-
esize that because current ACL reconstruction procedures
620
cannot exactly replicate normal ACL anatomical complexity,
they cannot restore normal tibiofemoral kinematics at the
knee joint, thus leading to pathological movement patterns.
These patterns also exist in ACL deficient knees. The abnor-
mal rotational movements of the articulating bones at the
knee could result in the applications of loads at areas of the
cartilage that are not commonly loaded in a healthy knee. It
has been shown that normal functional loading results in
increased resistance of the cartilage by improving the mecha-
nical stiffness and the proteoglycan content of the tissue.71–74
Furthermore, in joints that are prone to arthrosis, it has been
found that the best-preserved cartilage areas are those of
higher loading.75 Therefore in a healthy knee there are areas
that are commonly loaded and others that are not. These latter
areas, due to lack of sufficient cartilage, may not be able to
withstand the newly introduced loading that is the result of
the abnormal rotational movements of the articulating bones.
Over time this could lead to knee osteoarthritis.
A Modified Complexity Hypothesis Model
Changes in the system’s variability have been associated
with pathology in several medical areas. Using few examples
from cardiology, Kleiger et al (1987)76 showed a correlation
between decreased heart rate variability (greater rigidity) and
increased mortality in subjects who had suffered an acute
myocardial infarction. Kaplan et al (1991)77 showed
decreases in cardiovascular variability with age and con-
cluded that variability as measured with nonlinear tools
may be a useful physiological marker. Similarly, decreases
in variability have been reported in electroencephalographic
(EEG) tracings during seizures when compared with resting
EEG recordings.78 Our research work explored another
physiological biorhythm, stride-to-stride variability, which
can be mapped to heart rate variability. We showed that
musculoskeletal pathology (i.e., ACL rupture) can also lead
to similar results as in other medical areas where the “loss of
complexity” hypothesis has been proposed.
Our previously discussed results supported the “loss of
complexity” hypothesis in the ACL deficient knee. However,
they also provide ground for an even more interesting hypoth-
esis regarding musculoskeletal variability. It is possible that
changes in knee stride-to-stride variability may in fact be the
consequence of modifications, not only in the deterministic
operation of the adaptive complex control systems, but also
in intrinsic stochasticity (noise). It is possible that musculo-
skeletal variability can actually be represented by a continuum.
The two ends of the continuum are complete periodicity and
complete randomness (see also Fig. 80-2). A “healthy” opti-
mal variability or “complexity” by a motor system is some-
where between the two ends. Decreases or losses can make
the system more rigid/periodic and less adaptable, as in the
 Gait Analysis in Anterior Cruciate Ligament Deficient and Reconstructed Knees 80
ACL deficient knee. Thus an individual with ACL deficiency
is more cautious in the way that he or she walks, trying to
eliminate any extra movements, and thus is more rigid. On
the other hand, increases can make the system more noisy,
as in the ACL reconstructed knee with the ST/Gr autograft.
Thus an individual, knowing that now the ACL is
reconstructed, feels secure in increasing and adding extra
movements. However, because the proper proprioceptive
channels are not exactly present, more noise enters in the
system, resulting in excess movements. These deviations from
the healthy optimal variability may result in a knee more sus-
ceptible to acute and chronic injury. If the knee is more rigid
as in ACL deficiency or noisier as in ACL reconstruction, it
may reduce the capability of the joint to respond to different
perturbations and adapt to the changing environment. This
may in turn increase susceptibility to injury and future pathol-
ogy, such as the development of degenerative knee arthritis.
One of our future goals is to further test this model
and verify the just-presented hypothesis. We also believe
that the examination of the knee stride-to-stride variability
will become a routine examination among orthopaedists to
examine dynamic functional knee stability.

RECOMMENDATIONS FOR FUTURE WORK: HOW

GAIT ANALYSIS CAN GUIDE THE DEVELOPMENT
OF SURGICAL TECHNIQUES
Double Bundle
In the past few years, the rotational role of the ACL has been
studied more thoroughly. Recent cadaveric studies of the
ACL have shown that it consists of two major components,
the anteromedial (AM) bundle and the posterolateral (PL)
bundle (Fig. 80-3). The two-bundle description of the ACL
has been accepted as a basis for understanding the function
of the ACL. The ACL does not function as a simple band
of fibers with constant tension as the knee moves; the two
bundles seem to exhibit different tension patterns, and they
seem to be susceptible to different forces. When the knee is
extended, the PL bundle is tight and the AM bundle is mod-
erately lax. As the knee is flexed, the femoral attachment of
the ACL takes a more horizontal orientation, causing the
AM bundle to tighten and the PM bundle to loosen.79 How-
ever, it seems that this structural morphology of the ACL can-
not be restored with the common ACL reconstruction
techniques. Therefore recent techniques have been developed
to better approximate the actual anatomy and physiology of
the ACL. One very promising technique is the two-bundle
ACL reconstruction.
The advantage of two-bundle reconstruction is that it
can better replicate the function of the ACL. This is
FIG. 80-3 The posterolateral (PL) and anteromedial (AM) bundles of the
anterior cruciate ligament (ACL).
accomplished due to the reinstatement of the two-bundle
anatomy of the ligament.80 It is generally agreed that cur-
rent ACL reconstruction techniques using BPTB or ST/
Gr grafts, anchored in one femoral and one tibial tunnel,
achieve this goal partially because they replicate mostly the
AM bundle of the ACL. The role of this bundle has been
well documented as resisting anterior translational loads.41
However, the PL bundle has received limited attention.
A recent in vitro study81 has revealed that the PL bundle
is important for the stabilization of the knee against rota-
tional loads. Thus it is possible that the lack of restoration
of tibial rotation after an ACL reconstruction is related to
the lack of proper replication of the two ACL bundles and
specifically of the PL bundle. Recent studies in both human
and animals have demonstrated similar results with the two-
bundle reconstruction technique.80,82–86 However, this con-
clusion needs to be verified in vivo using gait analysis, as
described earlier in our research work. Our experimental
protocols can determine whether the double-bundle tech-
nique is truly superior in restoring tibial rotation during
physical activities.

621
 Anterior Cruciate Ligament Reconstruction
Tunnel Positioning
Another very promising technique that has been developed
recently to better approximate the actual anatomy and phys-
iology of the ACL is the more oblique femoral tunnel place-
ment. A more oblique placement of the femoral tunnel can
also affect rotational stability.40,87,88 The basic advantages of
this technique are: (1) it is not as surgically demanding as
others (i.e., a two-bundle reconstruction) and (2) the only
difference from the current techniques is in the setting of
the femoral tunnel in a more oblique location (between 9
and 10 o’clock for a right knee). Current techniques use a
vertical orientation approximately at the 11-o’clock position
(Fig. 80-4). Several studies used in vitro methodology to
examine the more oblique placement of the femoral tunnel
using either the BPTB40,87 or the ST/Gr autograft.88 They
found that the more oblique placement of the femoral tun-
nel more effectively resisted rotational loads. This can be
attributed to the fact that the PL bundle of the ACL is
located more horizontally and toward the 9-o’clock position
of the femur (for the right leg) and is important for the
stabilization of the knee against rotational loads. Thus a
more oblique placement can better replicate the PL bundle
and result in increased resistive ability to rotational forces.
In our studies, the femoral tunnel was placed at the
11-o’clock position.
However, we are currently examining the effect of a
more horizontal placement of the femoral tunnel on tibial
11 12
10
9 3
FIG. 80-4 A schematic of the placement of the femoral tunnel with the
“hours” identified for the right knee.
622
rotation. We perform reconstructions with both BPTB and
the ST/Gr autografts in which the femoral tunnel is placed
in a more oblique location and at 9 o’clock. Then we use gait
analysis and our experimental protocols to identify whether a
more horizontal placement of the femoral tunnel is superior in
restoring tibial rotation during physical activities.
SUMMARY
In this chapter, we presented how gait analysis and in vivo
biomechanics revealed excessive tibial rotation in ACL defi-
ciency. Our experimental work showed that ACL reconstruc-
tion with the currently used autografts (BPTB and ST/Gr)
cannot restore tibial rotation, as has also been found in activ-
ities that are more demanding than walking and involve both
anterior and rotational loading of the knee. Based on this
research work, we presented a hypothesis for the development
of osteoarthritis in both ACL deficient and ACL recon-
structed knees. Specifically, we proposed that excessive tibial
rotation will lead to abnormal loading of cartilage areas that
are not commonly loaded in the healthy knee. Over time, this
abnormal loading will lead to osteoarthritis.
We also presented how the evaluation of knee stride-to-
stride variability using nonlinear analysis can be used to
quantify dynamic functional knee stability. We proposed an
alternative complexity hypothesis model. In this model
we hypothesized that there is an optimal healthy amount of
knee variability, and decreases or increases due to ACL
pathology can result in future knee pathology. We based this
proposition on our experimental work that revealed that
ACL deficiency results in a more rigid knee, whereas ACL
reconstruction results in a noisier knee.
In addition, we demonstrated how gait analysis can
assist in the improvement and development of new surgical
procedures and grafts that could restore not only the patho-
logical anterior drawer, but also the increased tibial rotation.
Attempts to achieve this include a more horizontally ori-
ented femoral tunnel or a double-bundle ACL reconstruc-
tion. Experimental methodology such as that presented in
this chapter can examine the advantages and disadvantages
of these different surgical procedures, whether it be the graft
material or the tunnel positioning, keeping always in mind
the importance of reproducing the actual ACL anatomy
during the reconstruction.
Finally, additional studies are also needed to verify or
refute our theoretical propositions regarding the development
of osteoarthritis due to excessive tibial rotation and the gener-
alization of the complexity hypothesis to musculoskeletal
pathologies.
 Gait Analysis in Anterior Cruciate Ligament Deficient and Reconstructed Knees
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 Growth Factors and Other New Methods
for Graft-Healing Enhancement
Anterior cruciate ligament (ACL) reconstruction
using tendon autograft has been greatly improved
over the last 2 decades.1 In ACL reconstruction,
however, the strength of the grafted tendon is
reduced in the early phase after surgery, and then
it gradually increases.2–4 A problem is that this graft
remodeling occurs very slowly.5 The slow graft
maturation may result in graft failure or elongation
during the postoperative rehabilitation period due
to unknown causes. In addition, a firm attachment
of a tendon graft to the bone is a significant factor
for success in ACL reconstruction. In procedures
using a hamstring tendon graft, however, the
anchoring strength of the soft tissue in a bone tun-
nel is the weakest in the femur–graft–tibia complex
in the early phase after surgery.6 To improve these
problems after ACL reconstruction in the near
future, we should try to develop a new strategy to
accelerate the intraarticular and intraosseous remo-
deling of the tendon graft. This may enable more
aggressive rehabilitation and an earlier return to rig-
orous sports for patients with ACL reconstruction.
In this chapter, the authors will review recent
experimental studies that are intended to enhance
intraarticular and intraosseous graft healing after
ACL reconstruction using growth factors, gene
therapy, and cell-based therapy.
BASIC KNOWLEDGE TO ENHANCE THE
GRAFT REMODELING IN ANTERIOR
CRUCIATE LIGAMENT RECONSTRUCTION
In ACL reconstruction, intrinsic fibroblasts of
the tendon graft are necrotized immediately after
81
CHAPTER
transplantation, and then numerous extrinsic Harukazu Tohyama
fibroblasts infiltrate the graft with revasculari-
Kazunori Yasuda
zation.7,8 However, it is possible that the cell
infiltration into a core portion of the graft occa-
sionally occurs very slowly. Delay et al5 reported
a clinical case in which the core portion of the
patellar tendon graft still remained necrotic even
at the 18-month period after ligament reconstruc-
tion. On the other hand, biomechanically, the
mechanical properties of the graft deteriorate in
the early phase after transplantation and then are
very gradually restored over a long period.2–4
Concerning the graft deterioration mech-
anism, the fibroblast necrosis itself does not
deteriorate the mechanical properties of the ten-
don matrix, but extrinsic fibroblasts proliferat-
ing after the necrosis reduce the strength
properties.9 In the extrinsic fibroblasts, type III
collagen is overexpressed even under physiolog-
ical stress in areas where extrinsic fibroblasts
infiltrate.10 In the matrix of the autograft after
transplantation, ultrastructurally, fibrils having
a diameter less than 90 nm predominantly
increase in the graft matrix, and these fibrils
with small diameters still remain predominant
at the 4-year period after surgery.11 Such ultra-
structural changes due to type III collagen pro-
duction are considered to be one of the causes
of mechanical deterioration of autografts.
What molecular mechanisms control the
autograft remodeling? In a rabbit ACL recon-
struction model, vascular endothelial growth
factor (VEGF) is overexpressed in the extrinsic
fibroblasts at 2 weeks after graft implantation,
followed by vascular formation at 3 weeks.12
625
 Anterior Cruciate Ligament Reconstruction
This fact shows that revascularization in the graft is induced
by VEGF produced in the fibroblasts. On the other hand,
basic fibroblast growth factor, transforming growth factor
(TGF)-b, and platelet-derived growth factor (PDGF) are
overexpressed in the autogenous patellar tendon graft used
to reconstruct the ACL in the canine model, reaching their
greatest expression 3 weeks after implantation.13 This fact
suggests that a complex growth factor network controls the
fibroblasts, resulting in remodeling of the graft matrix,14,15
and implies that control of the fibroblasts using growth fac-
tors is a potential strategy to accelerate the graft remodeling
after ACL reconstruction.
ENHANCEMENT OF GRAFT HEALING WITH
GROWTH FACTORS
Intraarticular Healing
PDGF-BB
It has been known that PDGF-BB enhances proliferation
and migration of ligament fibroblasts in vitro.16,17 In addi-
tion, an in vivo rabbit study showed that the strong expression
of PDGF correlates with the observed increased cellularity
around the wound site in the medial collateral ligament
(MCL), suggesting potent mitogenic and chemotactic prop-
erties of PDGF in vivo.18 Concerning the in vivo effect of
application of PDGF-BB on ligamentous tissues, Woo
et al19 and Hildebrand et al20 described that 20-mg PDGF-
BB alone is the most effective agent to enhance the extraarti-
cular MCL healing in the rabbit. Regarding intraarticular
ACL reconstruction, Weiler et al21 applied PDGF-BB of
approximately 60 mg using coated sutures as a vehicle on the
flexor tendon autograft in a sheep ACL reconstruction model.
They showed that the PDGF-BB application significantly
increased the load to failure and vascular density of the graft
at 6 weeks after ACL reconstruction, although they found
no significant effects at 24 weeks. However, Nagumo et al22
investigated the effect of PDGF-BB using fibrin sealant as a
carrier on the in situ frozen-thawed rabbit ACL, an idealized
intraarticular autograft model.23–25 They reported that an
application of 4-mg PDGF-BB did not significantly affect
the mechanical properties of the frozen-thawed ACL at 12
weeks. Hildebrand et al20 suggested that the dose is critical
to evaluate the effect of growth factors on ligament healing.
Application of a high dose of PDGF-BB appears to be effec-
tive for MCL healing. However, the effect of PDGF-BB in
ACL reconstruction is controversial.
VEGF
VEGF is a potent mediator of angiogenesis, which involves
activation, migration, and proliferation of endothelial cells,
626
in various pathological conditions.26 A rabbit study showed
that extrinsic cells newly proliferating in the necrotized ten-
don graft express VEGF at 3 weeks after surgery, when the
revascularization does not occur.12 This finding suggests the
high possibility that an application of VEGF to the necro-
tized tendon graft enhances angiogenesis in the graft and
accelerates remodeling of the graft. Ju et al27 histologically
and mechanically examined the effect of an application of
30-mg VEGF to the in situ frozen-thawed rabbit ACL.
The application of VEGF significantly enhanced vascular
endothelial cell infiltration and revascularization in the
ACL at 3 and 12 weeks, respectively (Fig. 81-1). On
the other hand, the application provided no significant
effect on the mechanical properties of the ACL at 12 weeks,
although the mechanical properties of the in situ frozen-
thawed rabbit ACL were significantly weaker than
those of the normal ACL at 12 weeks. Thus VEGF has a
potential to be used as a treatment to enhance only revas-
cularization of the autograft after ACL reconstruction
surgery.
TGF-b and EGF
A number of in vitro studies have shown that TGF-b
enhances collagen and noncollagenous protein synthesis in
fibroblasts.28–30 EGF also stimulates fibroblast proliferation
in vitro.31 A combined application of these two growth fac-
tors enhances these effects.32 Sakai et al25 examined in vivo
effects of an application of TGF-b and EGF on the in situ
frozen-thawed ACL, using fibrin sealant as a vehicle. They
found that a combined application of 4-ng TGF-b and
100-ng EGF significantly inhibited the natural deteriora-
tion that occurred in this autograft model with significant
reduction of the water content and significant changes of
the ultrastructural profile. Azuma et al33 investigated the
effect of the timing of this combined application on the
same rabbit model. They reported that the effect was signif-
icantly greater when 4-ng TGF-b and 100-ng EGF were
applied at 3 weeks than when they were applied at 0 and
6 weeks. This study suggested that the timing is critical in
application of these growth factors. Recently, Nagumo
et al22 distinguished between the effect of 4-ng TGF-b
and the effect of 100-ng EGF on the autograft model.
According to them, the effect of 100-ng EGF was not sig-
nificant, but the effect of 4-ng TGF-b was significant.
Concerning an intraarticular application of TGF-b and
EGF on the bone–patellar tendon–bone (BPTB) autograft
in a canine ACL reconstruction model, Yasuda et al34 eval-
uated the effect on the structural properties of the graft.
They stated that a combined application of 4-ng TGF-b
and 100-ng EGF significantly inhibited the natural reduc-
tion of the structural properties of the autograft at 12 weeks
after ACL reconstruction.
 Growth Factors and Other New Methods for Graft-Healing Enhancement 81

FIG. 81-1 Immunohistochemistry for CD31 to identify vascular endothelial cells in the anterior cruciate ligament
(ACL) after the in situ freeze-thaw treatment without vascular endothelial growth factor (VEGF) application (A, 3
weeks; B, 6 weeks; C, 12 weeks) and with VEGF application (D, 3 weeks; E, 6 weeks; F, 12 weeks). A, In the ACL
after in situ freeze-thaw treatment, few vascular endothelial cells were found at 3 weeks. B, At 6 weeks, several
vascular endothelial cells formed vessels in the superficial portion of the ACL. C, The number of the vessels with
endothelial cells decreased in the ACLs from 6 weeks to 12 weeks. D, Several vessels formed by endothelial cells
were observed in the superficial portion of the ACL with VEGF application at 3 weeks after the in situ freeze-thaw
treatment. E and F, The vessels with endothelial cells in the ACL with VEGF application were more abundant than
those in the ACL without VEGF application until 12 weeks. (From Ju YJ, Tohyama H, Kondo E, et al. Effects of local
administration of vascular endothelial growth factor on properties of the in situ frozen-thawed anterior cruciate
ligament in rabbits. Am J Sports Med 2006;34:84–91.)

Intraosseous Healing interface and that it biomechanically increased the anchoring

Bone Morphogenetic Proteins
The process of tendon–bone healing involves bone ingrowth
into the interface tissue between the tendon and bone.35 Bone
morphogenetic proteins (BMPs) are members of the TGF-b
superfamily and are factors that have a strong osteoinductive
and osteogenic capacity.36 They induce endochondral bone
formation at extraskeletal sites. They are mostly expressed at
sites of epithelial–mesenchymal interaction and serve as sig-
naling molecules during mammalian embryogenesis and
morphogenesis, suggesting their capability for differentiation
of mesenchymal cells into chondrocytes and osteoblasts. The
BMPs have been successfully used to regenerate bone defects,
to stimulate bone ingrowth into soft tissues and metal
implants, and to regenerate articular cartilage defects in large
animals.36 Concerning intraosseous healing of the tendon,
Rodeo et al37 showed that tendon healing in a bone tunnel
was enhanced by BMP-2 in the canine. Their histological
analysis showed that the BMP-2 treatment resulted in earlier
and more abundant bone ingrowth into the tendon–bone
strength. Anderson et al38 described that a bone-derived
extract (Bone Protein, Sulzer Biologics, Wheat Ridge, CO)
was effective in augmenting healing of a tendon graft within
a bone tunnel in a rabbit ACL reconstruction model.
Recently, Mihelic et al39 reported that BMP-7 (osteogenic
protein-1) induced the new bone formation at the bone–
tendon interface, creating a dense trabecular network in a
sheep ACL reconstruction model. Their mechanical testing
showed greater strength in the knees treated with BMP-7
than in control specimens. Thus BMPs have potential growth
factors to enhance intraosseous graft healing.
TGF-b
TGF-b is a multifunctional growth factor that induces new
matrix synthesis in numerous types of cells. It has been shown
that TGF-b can enhance bone ingrowth into biomaterial
implants.40,41 Recently, Yamazaki et al42 found that adminis-
tration of exogenous TGF-b1 significantly increased the
bonding strength of the flexor tendon graft to the tunnel wall
at 3 weeks in a canine ACL replacement model. This result

627
 Anterior Cruciate Ligament Reconstruction

A B
FIG. 81-2 The new bone formation at the anterior wall of the bone tunnel at 3 weeks after anterior cruciate
ligament (ACL) reconstruction using flexor tendon graft. The rectangle (500  1000 mm) was drawn in the adjacent
trabecular area to the tunnel wall. The newly formed bone was generated more richly in the interface with
transforming growth factor (TGF)-b application (A) than in that without TGF-b application (B). (B, Bone; G,
granulation tissue in tendon–bone gap) (hematoxylin and eosin, original magnification 20). (From Yamazaki S,
Yasuda K, Tomita F, et al. The effect of transforming growth factor-beta1 on intraosseous healing of flexor tendon
autograft replacement of anterior cruciate ligament in dogs. Arthroscopy 2005;21:1034–1041.)

was accompanied by the histological findings that the
administration appeared to enhance not only synthesis or
maturation of the perpendicular collagen fibers connecting
the graft to the bone, but also new bone formation from the
tunnel wall (Fig. 81-2). Thus, TGF-b1 also has the potential
to enhance intraosseous graft healing.
ENHANCEMENT OF GRAFT HEALING WITH
GENE THERAPY
Gene therapy approaches may represent a new alternative in
delivering these specific growth factors to the grafted tendon
after ACL reconstruction.43 Martinek et al44 examined the
capacity of BMP-2 gene transfer to improve the integration
of semitendinosus tendon grafts at the tendon–bone inter-
face after reconstruction of the ACL in rabbits. They found
that in the intraosseous portion of the grafts, the number of
infected cells did not decrease until 8 weeks after surgery.
Moreover, a number of transduced cells were found in the
deeper layers of the tendon in the bone tunnel. In the
AdBMP-2–infected ACL graft, the tendon–bone interface
in the osseous tunnel was similar to that of a normal ACL
insertion. The pullout load and the stiffness were signifi-
cantly greater in the AdBMP-2–transduced graft than the
control graft.
Concerning gene therapy for the intraarticular portion
of the graft healing after ACL reconstruction, however,
Gerich et al45 evaluated methods for gene delivery to patel-
lar tendons in the rabbits using the lacZ marker gene. They
found that after injection of the adenovirus, high-level
expression of lacZ was observed only in the portion adjacent
to the injection site. Martinek et al44 reported that in the
intraarticular portion of the AdLacZ-infected grafts,
infected cells were observed only in the surface portion,
and the number of the cells decreased between 2 and 8 weeks

628
 Growth Factors and Other New Methods for Graft-Healing Enhancement 81
after ACL reconstruction with the autologous semitendi-
nosus tendon graft in the rabbit. Therefore it seems diffi-
cult to directly transfer genes for specific proteins to the Synovial tissues harvested
core portion of the intraarticular graft and to maintain from the left suprapatellar bursa

the number of the cells for a long period. Thus it may be

difficult to successfully perform gene therapy by itself to
enhance the graft healing of the intraarticular portion in
ACL reconstruction. In 1999, Menetrey et al46 reported
a myoblast-mediated gene transfer method for a persistent
expression of selected growth factors to enhance ACL Day 10–14 1st passage
healing following injury.

ENHANCEMENT OF GRAFT HEALING WITH

CELL-BASED THERAPY Day 21 Embedding in the fibrin glue

TGF-b1 and EGF significantly inhibited the deterioration of

the mechanical properties of the BPTB autograft in ACL
reconstruction.34 Nagumo et al22 suggested that only TGF-
b1 is a key in this effect on the intraarticular graft. However,
Mi et al47 reported that gene transfer of TGF-b induced
arthritic changes of the articular cartilage in the knee joint.
Thus intraarticular administration of TGF-b is considered
to be unsuitable for clinical application with an ACL recon-
struction procedure. Therefore Okuizumi et al48 conducted
the rabbit study to clarify the effect of cell therapy with autolo-
gous synovial tissue–derived fibroblasts activated by TGF-b1
on the necrotized ACL (Fig. 81-3). They wrapped the fibrin
glue with autologous synovial tissue–derived fibroblasts after
TGF-b stimulation around the necrotized ACL following
the freeze-thaw treatment. Histological observation found
that implantation of fibroblasts after TGF-b stimulation
accelerated cellular infiltration into the ACL following
fibroblast necrosis (Fig. 81-4). Biomechanically, the trans-
plantation of synovial tissue–derived autologous fibroblasts
activated by TGF-b inhibited deterioration in the tangent
modulus of the ACL after the freeze-thaw treatment.
Therefore this cell-based therapy using fibroblasts activated
by TGF-b may be a potential solution against this problem
in order to inhibit the deterioration of the mechanical prop-
erties of the graft after ACL reconstruction.
Mesenchymal progenitor cells (MPCs) or mesenchy-
mal stem cells (MSCs) also have a potential for cell therapy.
For example, an autologous MSC–collagen graft could
improve the quality as well as accelerate the rate of healing
after the defect of the patellar tendon in rabbits.49 Recently,
Ouyang et al50 reported the efficacy of using a large number
of MSCs to enhance tendon–bone healing in a rabbit
model. They found that introduction of a large number of
MSCs to the bone tunnel improves the insertion healing
of tendon to bone in a rabbit model through formation of
Day 26 Application of rhTGF-beta1
Day 28 Implantation to the frozen-thawed ACL
FIG. 81-3 The experimental protocol of the cell-based therapy with
autologous synovial tissue–derived fibroblasts with transforming growth
factor (TGF)-b application. ACL, Anterior cruciate ligament. (From Okuizumi T,
Tohyama H, Kondo E, et al. The effect of cell-based therapy with autologous
synovial fibroblasts activated by exogenous TGF-beta1 on the in situ frozen-
thawed anterior cruciate ligament. J Orthop Sci 2004;9:488–494.)
fibrocartilaginous attachment at early time points. However,
there are no reports on application of the cell-based therapy
with MPCs or MSCs for ACL reconstruction at present.
SUMMARY
Recent experimental studies have suggested that application
of growth factors, in particular TGF-b, is a possible strategy
to prevent graft deterioration in ACL reconstruction and
that several types of BMPs and TGF-b enhances tendon–
bone healing in animal models. Gene therapy and cell-based
approaches may represent new alternatives in delivering
these specific growth factors to the grafted tendon and the
interface between the graft and the bone after ACL recon-
struction. The recent advancements in ACL graft biology
may bring new strategies and additional therapeutic options
to accelerate the remodeling of the graft after ACL
reconstruction.

629
 Anterior Cruciate Ligament Reconstruction
FIG. 81-4 Histology of the anterior cruciate ligament (ACL) at 12 weeks after the in situ freeze-thaw treatment and cell
therapy with transforming growth factor (TGF)-b application (A) and without TGF-b application (B). (From Okuizumi T,
Tohyama H, Kondo E, et al. The effect of cell-based therapy with autologous synovial fibroblasts activated by exogenous
TGF-beta1 on the in situ frozen-thawed anterior cruciate ligament. J Orthop Sci 2004;9:488–494.)
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32. Assoian RK, Frolik CA, Roberts AB, et al. Transforming growth fac-
tor-beta controls receptor levels for epidermal growth factor in NRK
fibroblasts. Cell 1984;36:35–41.
33. Azuma H, Yasuda K, Tohyama H, et al. Timing of administration of
transforming growth factor-beta and epidermal growth factor influ-
ences the effect on material properties of the in situ frozen-thawed
anterior cruciate ligament. J Biomech 2003;6:373–381.
34. Yasuda K, Tomita F, Yamazaki S, et al. The effect of growth factors
on biomechanical properties of the bone-patellar tendon-bone graft
after anterior cruciate ligament reconstruction: a canine model study.
Am J Sports Med 2004;32:870–880.
35. Rodeo SA, Arnoczky SP, Torzilli PA, et al. Tendon-healing in a bone
tunnel. A biomechanical and histological study in the dog. J Bone Joint
Surg 1993;75:1795–1803.
36. Termaat MF, Den Boer FC, Bakker FC, et al. Bone morphogenetic
proteins. Development and clinical efficacy in the treatment of
fractures and bone defects. J Bone Joint Surg 2005;87:1367–1378.
37. Rodeo SA, Suzuki K, Deng XH, et al. Use of recombinant human
bone morphogenetic protein-2 to enhance tendon healing in a bone
tunnel. Am J Sports Med 1999;27:476–488.
38. Anderson K, Seneviratne AM, Izawa K, et al. Augmentation of ten-
don healing in an intraarticular bone tunnel with use of a bone growth
factor. Am J Sports Med 2001;29:689–698.
Growth Factors and Other New Methods for Graft-Healing Enhancement 81
39. Mihelic R, Pecina M, Jelic M, et al. Bone morphogenetic protein-7
(osteogenic protein-1) promotes tendon graft integration in anterior
cruciate ligament reconstruction in sheep. Am J Sports Med
2004;32:1619–1625.
40. Lind M, Overgaard S, Soballe K, et al. Transforming growth factor-
beta 1 enhances bone healing to unloaded tricalcium phosphate
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41. Sumner DR, Turner TM, Purchio AF, et al. Enhancement of bone
ingrowth by transforming growth factor-beta. J Bone Joint Surg
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42. Yamazaki S, Yasuda K, Tomita F, et al. The effect of transforming
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2005;21:1034–1041.
43. Evans CH, Robbins PD. Genetically augmented tissue engineering
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S410–S418.
44. Martinek V, Latterman C, Usas A, et al. Enhancement of tendon-
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45. Gerich TG, Kang R, Fu FH, et al. Gene transfer to the rabbit patellar
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46. Menetrey J, Kasemkijwattana C, Day CS, et al. Direct-, fibroblast-
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49. Awad HA, Butler DL, Boivin GP, et al. Autologous mesen-
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631
 Index
Page numbers followed by f, t, or b indicate figures, tables, or boxed material, respectively.

A Allografts (Continued )
graft sleeve with, 335
AATB. See American Association of Tissue Banks preparation of, 340
ABC graft, 88 in tunnel widening, 577
Abductor strengthening, 524 Alpine skiing, 24, 32
ACL. See Anterior cruciate ligament AM bundle. See Anteromedial bundle
Active heel-lift exercise, 515 American Association of Tissue Banks (AATB), 454
Adductor strengthening, 524 AMRI. See Anterolateral rotatory instability; Anteromedial
Allografts, 80 rotatory instability
anterior knee problems and, 610 Anatomical fixation, 284
BPTB, Anatomical risk factors, 19
complications, 561–563 notch width of, 19
hamstring, surgical preparation, 236 studies evaluating, 21
increased laxity and, 562–563 Q angle and, 19
chemical treatments, 562 Anesthesia, 472
donor age, 562 Angiography, 593f
freezing, 562 CT, 594
immunological response, 563 MRI, 595
increased shelf time, 563 Animal studies, graft tunnel healing, 418
radiation sterilization, 562 authors’ experience, 421
infection and, 557 bone quality in, 420
bacterial, 557 fixation technique, 420
viral, 557 gap size, 420
IntraFix with, 343 graft types, 419
meniscal, 493–499 mechanical stresses, 421
methods, 84 Anterior cruciate ligament (ACL), 3
morbidity, 561–562 anatomy, 3, 141f
delayed graft failure, 561 AM bundle, 4
disease transmission, 562 crossing pattern, 6
graft failure, 561 development of, 4
graft laxity, 561 historical descriptions of, 3
infection, 562 insertion site, 4
osteochondral, 496 PL bundle, 4
peroneus, 313 tensioning pattern, 6
for posterolateral augmentation, 473 attachment points, 143, 145
rehabilitation, 525 biomechanics, 7, 15
in revisions, 447 anterior-posterior translation control, 9
stability, 548 historical studies on, 7
strength comparisons, 84 rotational stability, 9
tendo-Achilles, 313 in surgery, 9
tibial, 208 complete tears,
surgical preparation, 236 deficiency, 60
tibialis, 313 bracing in, 64

633
 Index

Anterior cruciate ligament (ACL) (Continued ) Anterior cruciate ligament (ACL) (Continued )
hamstrings in, 63 with meniscal allograft transplantation, 493–499
natural history of, 70 meniscus tears, 486–492
quadriceps in, 63 with microfracture, 493–499
rehabilitation, 64 mid-third patella tendon graft harvesting for, 101–105
fetal, 4f, 5 Milagro, 381–384
graft tensioning, 399–404 mini-arthrotomy technique, 364–372
hamstring grafts with osteochondral allograft transplantation, 493–499
postoperative rehabilitation protocol, 339 osteoporosis after, 572–574
tibial fixation for, 211–216 partial tears, 470–475
healing, 477 patient expectations, 493
histology of, 630 physeal-sparing, 465
injury postoperative, 514
LCL combined, 477–483 proprioception and, 535–539
MCL combined, 477–483 purpose of, 79
osteoarthritis following, 69–74 radiographs of, 71f
PCL combined, 477–483 restoration of motion, 493
prevention studies, 43 retrodrill technique, 134–137
ligament tears retroscrew fixation, 299–302
acute, 53 revisions, 443
chronic, 53, 54 semitendinosus tendon graft, 110–113
partial, 53 in skeletally immature patients, 457–468
PCL tears v., 54 stability results after, 540–548
physical exam, 54 success rates, 493, 494
loading, 13–15 surgeon factors, 493
knee flexion and, 14 tension after, 327
noncontact injuries, 12–15 third-party payor payments, 80
anatomical risk factors, 19 tissue-engineering, 82
environmental risk factors, 18 transepiphyseal, 462
familial tendency to, 25 transphyseal, 467
hormonal risk factors, 20 tunnel widening after, 576–578
neuromuscular, 23 vascular complications, 585–588
normal, whipstitch-post tibial fixation, 310–315
reconstructions, 79 rehabilitation principles, 509–520
additive costs, 80 stability conservative, 521–526
all-inside, 300f strain
anatomical double-bundle, 144, 168–177 during rehabilitation, 501–506
anatomical double-bundle, double-stranded hamstring autografts, weight bearing and tibia external loading, 13
155–159 tear rates, 29t, 35
anatomical double-bundle with semitendinosus hamstring tendon female to male, 38, 39
graft, 161–166 prevention programs, 40
anatomical single-bundle, 144 risks, 39
anterior knee problems after, 598, Anterior knee problems, 598,
anteromedial portal for, 129–131 allografts, 610
arthroscopic, 111, 163 causes of, 612
arthrosis following, 71, 72 central quadriceps tendon, 610
with autologous chondrocyte implantation, 493–499 graft-related, 607–610
autologous hamstring tendon, 427–440 pain, 609
background on, 79 procedure-related, 611
BPTB, 354–361, 373–380 reducing, 612
computer-assisted navigation for, 186–, rehabilitation, 612
costs of, 79, 80 Anterior laxity, high-stiffness, slippage-resistant cortical fixation, 204
CQFT for, 106–108 Anterior shear force
double-bundle, 82, 147–152 knee flexion angle and, 13
double-bundle, double-stranded hamstring autografts, 155–159 at tibia, 13
economics of, 81t Anterior-posterior translation control, 9
endobuttons in, 218–224 Anterolateral rotatory instability (AMRI), 429, 432, 433
failed, 496 Anteromedial (AM) bundle, 3, 12, 147, 153, 155, 168, 621
femoral tunnel placement in, 140–145 anatomy of, 4, 473
fracture complications of, 598–603 arthroscopic view of, 5, 8
gait analysis in, 615–622 crossing patterns, 7, 176
graft remodeling, 408–412 arthroscopic view of, 8
graft tensioning in, 392–396 femoral guide, 175
hamstring harvest technique for, 91–94, 95–100 femoral insertion points, 6
with high tibial osteotomy, 493–499 footprints, 172
IntraFix, 351 insertion landmarks, 174
ligamentization, 408–412 sockets for, 150

634
 Index

Anteromedial (AM) bundle (Continued ) Autografts (Continued )

tibial tunnels, 174 in tunnel widening, 577
Anteromedial portal, 129–131 Autologous chondrocyte implantation, 493–499
advantages of, 129 Autologous hamstring grafts, 427–440
possible complications of, 131 failure analysis, 427
technique, 129 concomitant pathology, 429
Anteromedial rotatory instability (AMRI), 429 radiographic evaluation, 428, 428f
Anteromedial tibial drill guide, 158 graft fixation, 440
Anteroposterior (AP) instability, 71 graft selection, 440
Anteroposterior (AP) laxity, 53 hardware management, 432
Antibiotic administration, 554 removal, 433, 435
AP instability. See Anteroposterior instability tunnel management, 434–440
AP laxity. See Anteroposterior laxity classification of positions, 435
Aperture fixation, 547 enlargement, 439
Approximate Entropy, 619, 619 malplacement, 434
Arterial complications, 585 surgical, 436
Arthrex, 262f, 299
Arthro-Care Coblation device, 172 B
Arthrofibrosis, 509
Arthroplasty, 499 Bacterial infections, 557
Arthroscopy, 188 Basic fibroblast growth factor (bFGF), 565
Beath pin, 175, 280
in Stryker Biosteon Cross-Pin System, 268
Arthrosis, following reconstruction, 71 Betadine, 365
studies on, 72 Beta-tricalcium phosphate copolymers, 382
Arthrotek, 233 bFGF. See Basic fibroblast growth factor
Autogenous patellar tendon grafts, 364–372 Bicycling, 505, 524
button fixation, 370 Bioabsorbable materials, in tibial fixation, 216
closure Biofeedback, 568
Biofilm formation, 552
contralateral graft, 371
ipsilateral graft, 370 Biological scaffolds, 424
graft harvest, 369 Biomechanics, 7
contralateral, 369 in surgery, 9
BioScrew XtraLok
ipsilateral, 369
lateral incisions in, 366 applying tension with, 329
preoperative planning, 364 tibial fixation, 328–329
radiographs, 364 results, 328
in tibial tunnel, 328
rehabilitation, 364
surgical management, 436 troubleshooting, 329
technique, 365, 371 BMD. See Bone mineral density
BMPs. See Bone morphogenetic proteins
arthroscopic evaluation, 365
exposure, 365 Bone dowel
femoral exposure, 366 CT scan of, 322
femoral tunnel, 369 harvesters, 318, 321
tibial fixation, 316–322
graft fixation, 369
graft passage, 369 compacting, 318
graft tensioning, 369 harvesting, 316
medial arthrotomy, 366 surgical technique, 316–319
tendon-tunnel healing, 318–319
notchplasty, 367
postoperative care, 371 tunnel widening, 320
preparation, 365 Bone mineral density (BMD), 194, 195, 200, 204
tibial exposure, 365 decreased, 600
tibial tunnel, 367 in interference screw fixation, 361
tunnel placement, 367–368 osteoporosis and, 572
Autografts schematic, 573f, 574
Bone morphogenetic proteins (BMPs), 423, 627
BPTB, 278
BTB, numbness saphenous nerve and, 580 Bone Mulch Screw, 595
double-bundle, double-stranded hamstring, 155–159 Bone plugs, 103, 308
surgical procedure, 155–159 tibial, 360
Bone proteins, 423
hamstring, 246, 547, 607
double-bundle, double-stranded, 155–159 Bone wedge technique, 292, 293
numbness saphenous nerve and, 580 chisel for, 294
methods, 84 Bone-patellar tendon-bone (BPTB), 80, 84, 194, 567
patellar tendon, 607 allograft,
in revisions, 447 autograft, 278
semitendinosus, tripled or quadrupled, 305–308 endobutton continuous loop, 373–380
fixation, 195
stability, 548
strength comparisons, 84 fixation options, 449t

635
 Index

Bone-patellar tendon-bone (BPTB) (Continued ) Central quadriceps free tendon (CQFT) (Continued )
graft strengths, 86 troubleshooting, 107
hamstring v., 525 bottom view of, 108
in tunnel widening, 576 with PLLA screw, 109
harvesting, 603 reconstructions
interference screw fixation in, 354–361 exposure, 107f
BMD in, 361 fixation of, 108
bone blocks in, 358 release of, 107
bone tunnel preparation in, 356 sizing of, 108
divergence, 359 CG. See Control groups
graft preparation, 354 Chemical treatments, 562
graft protectors in, 355 Cincinnati Knee Rating System, 538
graft-tunnel mismatch, 360 Closed kinetic chain squatting exercises,
parallelism, 359 Clostridium, 557, 557
pin position in, 358 Cold compression device, 371
screw and graft position in, 357 Cold machines, 82
screw selection, 354 Collagen
tibial pin in, 356 crimp, 411
roof impingement in, 123 remodeling, 413
stability rates, 548 Computed tomography (CT) scan, 592
strain, 506 angiography, 594
suture configuration, 355f of bone dowel, 322
Bone-tendon-bone (BTB), 195, 397 sagittal, 594
autograft, numbness saphenous nerve and, 580 tibial fracture, 604
endobutton continuous loop, 373–380 Computer-assisted navigation, 186–192,
areas of, 376 postoperative screenshots, 191
femoral tunnel, 375 precision and, 186–192,
graft length, 374f, 375 rationale for, 186
measuring, 376 results of, 191
results, 380 techniques, 187
revision surgery, 377 Concomitant meniscal surgery, 611
technique in detail, 374 Contamination, 552, 563
technique overview, 373 Continuous passive motion (CPM), 82, 282, 466, 483, 513, 593
troubleshooting, 380 Contralateral graft, 518
Xtendobuttons in, 378 closure, 371
interference screw fixation, 197f harvest, 369
intratunnel fixation of, 199 postoperative rehabilitation, 512
femoral fixation, 199 special considerations, 372
tibial fixation, 199 Control groups (CG), 48
Borelli, 7 Corin anchor, 448
Bovine flexor tendon, double spike plate and, 324 Coring reamers, 214
BPTB. See Bone-patellar tendon-bone Coronal image
Bracing inversion recovery, 58
in ACL deficiency, 64 T1 weighted, 58
environmental risk factors and, 18 Cortical screw post femoral fixation, 227–232
functional, 82 biomechanics, 227
postoperative, 82 ease of, 232
strain and, 506 equipment for, 232
BTB. See Bone-tendon-bone EZLoc, 234
Bucket-handle tears, 489, 489–490 fixating single strands, 230
Bungee cord effect, 284 history, 227
morbidity in, 232
C radiographs, 231
stability of, 232
Calcanei, surgical technique, 228–231
Candida glabrata, 557 femoral post, 228–230
C-arm, 463 incision, 228
Cartilage restorative procedures, 499 insertion screw, 228
Cast immobilization, 481 materials, 228
CDC. See Centers for Disease Control and Prevention universal salvage, 232
Cell therapy, 424 uses of, 231
experimental protocol, 629 Cosmesis, 99–100
healing with, 629 Counter bores, 317, 319
Centers for Disease Control and Prevention (CDC), 557 CPM. See Continuous passive motion
Central quadriceps free tendon (CQFT) CQFT. See Central quadriceps free tendon
for ACL reconstruction, 106–108 C-reactive protein (CRP), 553, 553, 569
technique, 106 Crossing pattern, 6

636
 Index

Crossing pattern (Continued ) Elliptical trainers, 519, 524

AM and PL bundles, 7 Endobuttons, 109, 463, 585
arthroscopic view of, 8 CL length, 220, 224
Cross-pin guide frame, 281 continuous loop BTB fixation system, 373–380
hardware complications, 587, 589 areas of, 376
CRP. See C-reactive protein femoral tunnel, 375
Crutches, 511 graft length, 374f, 375
Cryo/Cuff, 511, 513, 514, 515 measuring, 376
CT scan. See Computed tomography results, 380
Cushing retractors, 367 revision surgery, 377
Cyclical loading, 523 technique in detail, 374
lower extremity, 524 troubleshooting, 380
Cyclops lesion, 569, 569f, 570, 612 Xtendobuttons in, 378
femoral fixation, 218–224
D biomechanics of, 218
clinical results of, 218
Data conversions, 32 passing sutures, 224
DaVinci, Leonardo, 7 pulling out, 224
DBST technique. See Double-bundle, single-tendon technique surgical technique, 219–222
Deep vein thrombosis (DVT), 596 troubleshooting, 222–224
Deficiency, 63 flattening, 222–224
bracing in, 64 graft construct, 220
hamstrings in, 63 hardware complications, 585
natural history of, 70 lateral cortex blowout and,
quadriceps in, 63 placement of, 465
rehabilitation, 64 retrograde tension and, 223
Differential Variable Reluctance Transducer (DVRT), 501–502 seating, 221
limitations of, 502 sutures, 475
schematic drawing of, 502f Xtendobutton and, 225
Direct fixation, 285 EndoPearl, 287, 293
indirect fixation v., 311 MRI, 295
Disposables, 81 Enterobacter, 554
DLET. See Doubled lateral extensor of toes Enterococcus faecalis, 558
Donor age, 562 Environmental risk factors, 18
Double spike plate (DSP), 324–327 bracing and, 18
basic concept, 324 Epidermal growth factor (EGF), 423, 626
biomechanical data, 324 Erysipelothrix rhusiopathiae, 554
graft fixation steps, 325 Erythrocyte sedimentation rate (ESR), 553, 569
impactor tip, 325 Escherichia coli, 558
under optional tension, 325f ESR. See Erythrocyte sedimentation rate
pullout graft fixation with, 326 EUA. See Examination under anesthesia
radiographs of, 326 Examination under anesthesia (EUA), 56
rationale for, 324 Exercise, 60
specifications, 324 Exposures, 28, 32
three-bundle graft fixation with, 326 Extension torque, 504
troubleshooting, 327 Extension-flexion motion, 505
two-bundle graft fixation with, 326 Extensor, deficit, 61f, 62
Double-bundle, single-tendon (DBST) technique, 161 EZLoc, 209
anatomy in, 161 as cortical femoral fixation device, 234
preliminary results of, 163, 165 fixation properties of, 235
scientific rationale for, 162 growth plates and, 239
special considerations in, 165 pa, 235
surgical technique, 162–163 radiographs of, 235
trouble shooting in, 166 removal of, 240
Doubled lateral extensor of toes (DLET), 421 on soft tissue grafts, 233–241
Drains, 516 design, 233
DSP. See Double spike plate diameter, 233
DVRT. See Differential Variable Reluctance Transducer femoral cortex and, 239
DVT. See Deep vein thrombosis mechanism, 233
Dynamic functional joint stability, 615 packaging, 233
revision surgery with, 239
E in skeletally immature patients, 238
troubleshooting, 240
EGF. See Epidermal growth factor surgical technique, 236–238
Egypt, 3 hamstring allograft preparation, 236
Electrical stimulation, 568 tibia allograft preparation, 236
Electron microscopy, 532 tibial fixation, 238

637
 Index
F Femoral fixation (Continued )
Fastlok device
staple positioning, 307
for tibial fixation, 305–308
graft fixation, 306
results, 306
scientific rationale for, 305
surgical technique for, 306
troubleshooting, 308
tunnel preparations, 306
Females, ACL tear rates in, 38, 39
Femoral blocks, 81
Femoral condyle lesions, 495f
Femoral cortex
blown out, 224
EZLoc and drilling through, 239
Femoral fixation
endobutton ACL reconstruction, 218–224
biomechanics of, 218
clinical results of, 218
flattening, 222–224
passing sutures, 224
principle of, 219
pulling out, 224
surgical technique, 219–222
troubleshooting, 222–224
EZLoc, on soft tissue grafts, 233–241
graft sleeve and tapered screw, 333
interference screw, 287–292
options, 450t
Pinn-ACL crosspin system, 253–259
cortical length measurement in, 255
cross-pin implant selection, 255
femoral tunnel in, 255
graft fixation, 257
graft harvesting, 254
graft passing, 256
implant design, 253
notchplasty, 254
surgical technique, 254–257
tibial tunnel in, 255
Rigidfix device for, 277–282
cruciform periosteal incision, 279
graft positioning, 280
graft preparation, 279
postsurgical care, 282
skin incision, 278f
surgical technique, 278
troubleshooting, 282
Stratis ST, 242–249, 250
advantages and disadvantages of, 250
aperture fixation, 244
arthroscopic preparation, 246
design rationale of, 243
femoral tunnel and, 244
femoral tunnel in, 246
graft block, 244f
graft block insertion, 248
graft integrity and, 244
graft limb orientation, 245
graft preparation, 246
graft-block-graft construct, 248
implant removal, 250
pullout strength, 244
system, 244, 245
technique, 245–249
638
tendon harvest, 245
tibial tunnel in, 246
transverse tunnel, 247
Stryker Biosteon Cross-Pin, 267–274
femoral tunnel location, 270
graft harvest, 270
potential pitfalls, 275
tibial tunnel location, 270
TransFix, 261–266
biomechanics, 261
clinical results, 261
surgical technique, 262
troubleshooting, 265
X-ray demonstrating, 358
Femoral guide, 136
Femoral post
endobutton tied to, 230
endobutton-CL fabric loop passed around, 228
fabric tape tied around, 229
whipstitch technique, 229
Femoral reamer, 237
Femoral tunnel, 140–145
ACL isometry and, 141
anterior edge notching, 291
arthroscopic view of, 127
in autogenous patellar tendon grafts, 369
channel length, 220
creation of, 149
divergence, 438
double, 145
drilling, 237, 240
formation, 219–222, 247
basic technique, 219
endobutton seating, 221
endobutton-CL length, 220
finishing, 219
graft construct, 220
graft passing, 221
notchplasty, 219
passing suture removal, 222
principles of, 219
redrilling, 219
tunnel length, 219
functional anatomy and, 140
graft harness in, 257
graft sleeve and tapered screw, 333
guidance, 191
incorrect, 437, 438
IntraFix, 344
Isometric graft attachment sites, 143
length of, 237
measuring, 237, 246, 334
pin placement for, 357
in Pinn-ACL crosspin system, 255
placement, 135, 621
preparation of, 156
rasps for smoothing, 357
reuse of, 437
Stratis ST and, 244
in Stratis ST femoral fixation, 246
Stryker Biosteon Cross-Pin System, 270
transition line between graft attachments, 143
transverse, 243
Femur
AM and PL bundle insertion points at, 6
exposure, 366
 Index

Femur (Continued ) Graft sleeve and tapered screw, 330–340

fixation devices on, 205f advantages of, 332
footprints, 172 application of, 333
fracture, 598 basic science, 329–330
tibia and, 188 biomechanical testing, 330
Fiber attachment length changes, 142 biocompatibility and histology of fixation site
Fiberstick Suture, 299 healing, 331, 332
Fixation implants, 80 femoral fixation, 333
breakage, 231 femoral tunnel, 333
Fixation pin future of, 340
advanced, 250 gracilis in, 334
loaded, 250 graft passage, 334
Flexion angles, 132 hamstring tendon graft preparation, 333
ACL loading and, 14 postoperative management, 335
anterior shear force and, 13 follow-up, 335
Flexor, deficit, 61f, 62 rehabilitation, 335
Flexwire, 271–272 problems with, 337
Fluoroscopic control, 131 radiographs, 338
Football, 34 rehabilitation protocol, 339
Australian rules, 39 results, 338
Foreign body reaction, 89, 90, 563 surgical technique, 332–335
4ST technique, 115–119, 313 tibial fixation, 335, 336
with bone block, 119 supplemental, 337
without bone block, 119 tibial tunnel, 333
Fracture complications, 598–603 with tibialis allografts, 335
femur, 598 Graft tensioning, 392–396, 399–404, 567
patella, 601 basic science, 400
tibial, 603 biomechanical studies on, 392
plateau, 603 clinical relevance, 395
tubercle, 603 high and low initial tension, 394
Fraudulent tissue procurement, 563 relaxation of, 393
Freezing, 562 tension-flexion curve, 392
Friction, 310 devices, 404
Full extension, 523 factors effecting, 400f
Full flexion, 523 high-tension, 402
histology, 400
G knee fixation angle, 404
low-tension, 402
Gait analysis, 615–622 physiological, 401
advanced theoretical considerations, 619–620
preconditioning, 403
modified complexity hypothesis model, 620 pretensioning, 403
biomechanical research on, 617 randomized trials, 396
tibial rotation, 617 specific, 401
future work on, 620–621
strategies, 404
double bundle, 620 stress relaxation, 403
tunnel positioning, 621 in vivo studies, 395
Gait training, 525 essential tension effects, 395
Galen, Claudius, 3
initial tension in, 395
Galileo, 7 Graft Tunnel Solution (GTS) System, 202
Gastrocnemius, 92, 524 Graft-block-graft construct, 248, 249
Gene therapy, 423 Graftmaster, 220
healing and, 628 Grafts. See Autografts; specific types
Glides, 568 Graft-tunnel mismatch, 360
GM-CSF. See Granulocyte-macrophage colony-stimulating factor Gram stain, 553
Gore-Tex, 88, 592
Granulocyte-macrophage colony-stimulating factor
ligament failure, 89f (GM-CSF), 70
tunnel enlargement after, 90 Growth factors, 423, 625–629
Gracilis, 96f, 465 Growth plates, EZLoc and, 239
arthroscopic appearance of, 337
GTS System, 331f. See Graft Tunnel Solution System
colored sutures on, 345, 346
graft, 93 H
in graft sleeve, 334
in hamstring harvesting, 116 Hall Effect Strain Transducer (HEST), 501
harvesting, 232 Hamstring, 60, 417
identifying, 97 in ACL deficiency, 63
Graft malpositioning, 566 allograft, surgical preparation, 236
Graft remodeling, 408–412 anti-shear vector of, 64

639
 Index

Hamstring (Continued ) Healing

autografts, 246, 547 ACL, 477
double-bundle, double-stranded, biocompatibility and histology of, 331, 332
155–159 cell-based therapy, 629
numbness saphenous nerve and, 580 early graft, 408
BPTB v., 525 gene therapy, 628
in tunnel widening, 576 graft tunnel, 417–424
co-contractions, 15 animal studies, 418–420
femoral graft fixation options, 450t biological scaffolds, 424
four bundle graft, 329f bone proteins in, 423
grafts, 115–119 cell therapy in, 424
advantages and disadvantages of, 116 future directions in, 422
double-bundle compatibility, 117 gene therapy in, 423
fifth limb in, 118f growth factors in, 423
gracilis, 116 human studies, 417
lengths of, 115 MMP inhibitors, 424
parameters for, 115–117 growth factors and, 625–629
postoperative rehabilitation protocol, 339 intraarticular healing and, 626–627
strength of, 86, 116 intraarticular, 626
tibial fixation in, 116, 211–216 intraosseous, 627
troubleshooting, 118 lateral-side structures, 479
harvest technique, 91, 95, 245 ligamentization phase, 412
anatomy, 95 ligaments, 477–479
clinical experience, 100 MCL, 479
complications, 94 PCL, 478
cosmesis in, 100 proliferation phase of, 409
graft preparation, 93, 98 promoting, 318–319
in large patients, 100 revascularization during, 410
oblique anteromedial incision for, 92f at six weeks, 410f
premature amputation in, 99 Hemarthrosis, 55, 371
problems with, 99 Hemostats, 107
saphenous nerve trauma, 99–100 Heparin, 593
skin incision, 91 HEST. See Hall Effect Strain Transducer
surgical, 96 High tibial osteotomy, 493–499
tendon exposure, 91 High-stiffness, slippage-resistant cortical fixation,
tendon freeing, 98 204–209
tendon identification in, 99 advantages of, 208
tendon release, 92 examples of, 205
tendon stripping, 92, 98, 99 preferred technique, 208
timing of, 98 in restoring anterior laxity, 204
interference screw fixation, 284–295 stiffness principle in, 207
biological boundary conditions, 285 High-tension grafts, 402
biomechanical considerations, 284–285 Hips, control, 65
boundary considerations, 284 History, ligament tears
graft preparation, 287 acute, 54
technical considerations, 287–295 chronic, 54
quadrupled tendon graft, 277 HIV. See Human immunodeficiency virus
regeneration, 528–533 HLA types, 565
animal models, 531 Hooke, 7
functional studies, 530 Hormonal risk factors, 20
future directions, 533 concerns and, 23
gross morphology, 530 laxity and, 20
histological studies, 531 ligament biology and, 23
radiographic studies, 528 monthly distribution of injuries and, 20
universality, 530 Human immunodeficiency virus (HIV),
in soccer, 61 Human studies, graft tunnel healing, 417
strengthening, 524 Humani Corporis Fabrica Libris Septum
tendon graft, 161–166 (Vesalius), 3
autologous, 427–440 Hybrid fixation, 290
preparation, 333 femoral, 292, 441
Handball, 39 possibilities for, 294
Hardware complications, 585–590 tibial, 295, 441
cross-pin fixation, 587, 589 Hybrid grafts, 152
endobuttons, 585 Hydroxyapatite, 268
interference complications, 585 osteoconductive properties of, 269
skeletally immature patients, 588 Hyperextension, 510f, 511
tibial fixation, 588 avoiding, 523

640
 Index

I Interference screw fixation (Continued )

bone tunnel preparation in, 356
IAT. See Intraarticular graft tension divergence, 359
IG. See Intervention groups graft preparation, 354
IKDC scoring system, 137, 176, 262, 461, 488, 593 graft protectors in, 355
mean scores, 453 graft-tunnel mismatch, 360
normal classifications, 159, 445 parallelism, 359
IL. See Interleukin pin position in, 358
Iliotibial band, 465 screw and graft position in, 357
grafts, 466 screw selection, 354
Immunological response, 563 tibial pin in, 356
Indirect fixation, direct fixation v., 311 cross-pin fixation, 215
Infections, 551–558 development of, 285
allografts and, 557 different types of, 286
bacterial, 557 dilation of site, 290
viral, 557 divergence of, 198
causes of, 563 femoral, 287–292
development times, 553 graft rotation in, 292
diagnosis of, 553–554 hybrid fixation, 292
clinical findings, 553 screw insertion problems, 292
imaging studies, 554 hamstring tendon, 284–295
laboratory findings, 553 biological boundary conditions, 285
microbiology, 554 biomechanical considerations, 284–285
intraoperative graft contamination, 558 boundary considerations, 284
management protocol, 554–556 graft preparation, 287
antibiotic administration, 554 technical considerations, 287–295
microbiology of, 554 hardware complications, 585
morbidity and, 562 intratunnel fixation with, 205, 207
pathogenesis, 551–552 metal, 198
biofilm formation, 552 rigid interosseous compression and, 215
contamination, 552 tibial, 294–295
local factors, 552 hybrid fixation, 295, 297
systemic factors, 551 intratunnel view, 295
prevalence, 551 screw diameter, 295
sterilization and, 563 screw insertion, 295
surgical management, 555 tunnel preparation, 294
debridement, 555 tunnel widening and, 578
graft removal, 555 Interleukin (IL), 408
graft retention, 555 Intervention groups (IG), 48
irrigation, 555 Intraarticular femoral screws, 586f
persistent cases, 554 Intraarticular graft tension (IAT), 206
persistent septic arthritis, 556 Intraarticular healing, 626
postoperative, 555 Intraarticular replacements, 460–461
tissue-handling and, 563 IntraFix, 204, 215, 282, 341–351
Infrapatellar contracture syndrome, 568 with allografts, 343
Infrared camera, 188f closure, 350
Initial tension, 396 design of, 341
effects of, 394 histology in, 342
increasing, 393f MRI of, 342f
tension-flexion curve, 392 postoperative dressings, 350
in vivo studies, 395 postoperative management, 351
Insall-Salvati ratio, results, 351
Insertion site, anatomy, 4 screw insertion, 349
Intercondylar notch, measuring, 367 sheath insertion, 348
Interference screw fixation, 197f sizing scheme for, 342f, 350
biodegradable, 286, 382f, 386–390, 441 surgical technique, 342–350
biomechanical, 387–388 device insertion, 344
clinical results, 388–389 femoral tunnel, 344
fixation strength, 387 graft fixation, 344
Inion Hexalon, 387f, 389 graft passage, 344
MRI, 389, 390 graft preparation, 342
randomized trials, 388 graft tensioning, 344
strength retention, 388 tibial fixation, 344
torsional strength, 388 tibial tunnel, 343
BPTB, 354–361 troubleshooting, 347–350
BMD in, 361 failure to advance, 350
bone blocks in, 358 low bone density, 350

641
 Index

IntraFix (Continued ) LCL. See Lateral collateral ligament

screw breakage, 349 Leeds-Keio graft, 88
sheath overinsertion, 347 Less invasive fracture fixation (LISS), 603
short grafts, 350 LFC. See Lateral femoral condyle
Intraoperative graft contamination, 558 Ligament augmentation device (LAD), 88
Intraosseous healing, 627 Ligament restraints, static, 24
Intratunnel ACL graft fixation Ligament tears
alternative, 201 acute, 53
biomechanics of, 194–202 history, 54
limitations of studies on, 195 chronic, 53
BMD in, 196 history, 54
bone-tendon-bone, 199 partial, 53
femoral fixation, 199 physical exam, 54
tibial fixation, 199 EUA, 56
BPTB fixation in, 196 hemarthrosis, 55
with interference screw, 205, 207 KT-1000 tests, 55
soft tissue, 199 Lachman test, 54, 55
Ipsilateral graft, postoperative rehabilitation, 512 locking, 55
Isokinetic torques, 537 MRI, 56
Isometric graft attachment sites, 143 patellofemoral injury, 55
pivot shift, 54
K radiographs, 56
valgus laxity, 55
K. pneumoniae, 558 Ligamentization, 84, 399–400
K wire, 132 phase, 412
Kelly clamps, 212 Ligastic graft, 88
Kennedy ligament augmentation device, 88 LISS. See Less invasive fracture fixation
Kinematic analysis, 10 Lizard tail phenomenon, 528
Kirschner wires, 149, 150, 188, 213
Load to failure (LTF), 84, 195, 201, 211, 341
trackers attached with, 189 data, 85t
Klebsiella, 554 tests, 422
Knee extension, 510 Longitudinal graft, 285
emphasis of, 516
Longitudinal studies, 536, 538
Knee fixation angle, 404 Loop, 310
Knee flexion, 510, 602 Low-stiffness cortical fixation, 205, 206
regaining, 511 Low-tension grafts, 402
Knee instability, 445
LTF. See Load to failure
Knee stability symmetry, 540 Lysholm score, 61
Knee stability Test-Pre, 190
Kocher clamp, 221 M
KT-1000 tests, 13, 274, 402, 454, 512
in ligament tear physical exams, 55 Magnetic resonance imaging (MRI), 9, 14, 54, 70, 121, 179, 471
KT-2000, 152 angiography, 595
biodegradable interference screw fixation, 389, 390
L EndoPearl, 295
follow-up, 300f
Lachman test, 54 of IntraFix, 342f
in ligament tear physical exam, 55 knee, 569
Lacrosse, 34 in ligament tears, 56
LAD. See Ligament augmentation device neotendons, 531
Landing activity, 616f of patellar tendon shortening, 608
Large patients, 100 of PCL, 478f
Lateral capsule of semitendinosus regeneration, 529, 529
repair, 483 Males, ACL tear rates, 38, 39
tear, 482 Marcaine, 268, 568
Lateral collateral ligament (LCL), 42, 477–483 Matrix metalloproteinases (MMPs), 424
clinical examination of, 479 MCL. See Medial collateral ligament
imaging, 480 Medial collateral ligament (MCL), 12, 15, 42, , 274, 429, 477–483
postoperative rehabilitation, 483 clinical examination of, 479
treatment principles, 481–483 healing, 479
Lateral cortex, 223 imaging, 480
blowout with endobutton fixation, postoperative rehabilitation, 483
Lateral femoral condyle (LFC), 4, –, , 180, 473 treatment principles, 481–483
Lateral-side structures Meniscal allograft implantation (MAT), 495
healing, 479 Meniscus tears, 486–492
repair, 482 lateral, 487
Law of functional adaptation, 407 superior surface of, 487

642

Meniscus tears (Continued )
leaving in situ, 487
medial, 488
inferior surface of, 488
repairing, 488
3 months after, 491
ACL surgery and,
unstable, 489
Menstrual cycle, 20f
Mersilene-Fastlok, 307
Micro particle dispersion (MPD), 383
Microfracture, 493–499
Mid-third patella tendon graft
harvesting for, 101–105
exposure, 101
fashioning, 104
skin incision in, 101, 102, 102f
taking, 101
length of,
tubularizing,
Milagro, 381–384
basic science of, 382
biochemical data, 381
biomechanical data, 381
clinical information, 383
pearls, 384
postimplantation, 383
uses of, 383
Mini-arthrotomy technique, 364–372
Mitrek Intra-Fix sheath, 273
Mitrogenic growth disturbance, 459
MMPs. See Matrix metalloproteinases
Morphine, 568
MPD. See Micro particle dispersion
MRI. See Magnetic resonance imaging
Muscle contraction, dynamic, 24
Muscular inhibition, 522
N
Navigation, 82
Neovascularization, 411
Nerve branch distribution, 587–588
in infrapatellar region, 589
Neuromuscular function tests, 535
Neuromuscular risk factors, 23
Neuromuscular training
comprehensive, 48
strengthening, 46
technique, 46
varied, 47
Neurovascular injury, 480, 595
Neurovascular safe zone, 263
Newton, Isaac, 7
Nitinol wire, 265
Non-anatomical fixation, 284
Nonaperture fixation, 547
Noncontact injuries, 12–15
occurrence of, 12–13
Notch length, 191
Notch width
anatomical risk factors and, 19
studies evaluating, 21
measuring, 180f
PCL impingement and, 123, 124
Notchplasty, 179–182
anatomy in, 179
Index
Notchplasty (Continued )
arthroscopic view of, 183
in autogenous patellar tendon grafts, 367
complications, 182
indications, 180
initiation of, 184
Pinn-ACL crosspin system and, 254
potential risks, 180
techniques, 182
bony, 183
debridement in, 183
Numbness saphenous nerve, 580–582
anatomical investigations, 581
BTB autografts, 580
clinical examination, 581
hamstring autografts, 580
O
OATS. See Osteochondral autograft transfer system
OCAl. See Osteochondral allograft
Orthopilot, 187–188
Orthotape-Fastlok, 307
Osteoarthritis, 443–444
pathophysiology of, 69
tibial rotation and, 619
Osteochondral allograft (OCAl), 496
Osteochondral autograft transfer system (OATS), 496
Osteoporosis, 572–574
bone loss and, 573
defining, 573
musculoskeletal injuries and, 573
peak bone mass and, 572
surgery and, 573
as risk factor, 574
Osteotomes, 102, 104
Outpatient surgery, 513
Overexertion, 518
P
P. aeruginosa, 558
Partial tears, 470–475
complications, 475
preoperative considerations, 470–472
history, 470
imaging, 471
indications, 472
physical examination, 471
rehabilitation, 475
results, 475
surgical technique, 472–473
anesthesia, 472
diagnostic arthroscopy, 472
graft preparation, 473
positioning, 472
reconstruction technique, 473
surgical landmarks, 472
Passive extension, 511
Passive movement test, 535
Patella fracture, 601
Patellar tendon graft, 277, 417
autografts, 607
measurement of, 608f, 609
Patellofemoral injury, 55
Patient information screens, 189
Patient Specific Functional Scale, 538
643
 Index

PCL. See Posterior cruciate ligament Posterior cruciate ligament (PCL), 42, 157, 213, 279, 429,
PDGF. See Platelet-derived growth factor 477–483, 567
PDS, 354 clinical examination of, 479
PE. See Pulmonary embolism combined injury, 477–483
Peak posterior ground reaction forces, 14 healing, 478
PEP Program, 48–49 imaging, 480
Peptostaphylococcus, 554 impingement, 121–127
Periosteum, 312, 366 complications, 121
Peroneus allograft, 313 definitions, 121
Pes anserinus, 212 diagnosis, 121
PGA. See Polyglycolic acid preventing, 123
Phantom foot mechanism, 24 principle for avoiding, 124
Physeal injury, basic science research on, 459 surgical technique for avoiding, 125
Physeal-sparing reconstructions, 465 knee injury, 480
postoperative rehabilitations, 466 ligament tears, ACL tears v., 54
Physical exam MRI of, 478f
in anatomical double-bundle reconstruction, 169 postoperative rehabilitation, 483
ligament tears, 54 treatment principles, 481–483
ACL v. PCL, 54 Posterior horn avulsion tear, 487f
EUA, 56 Posterior oblique ligament (POL), 429
KT-1000 tests, 55 Posterolateral (PL) bundle, 3, 147, 155, 164, 621
Lachman test, 54, 55 anatomy of, 4
locking, 55 arthroscopic view of, 5, 8
MRI, 56 crossing patterns, 7, 176
patellofemoral injury, 55 arthroscopic view of, 8
pivot shift, 54 femoral insertion points, 6
radiographs, 56 footprints, 172
valgus laxity, 55 graft, 175
partial tears, 471 guidewire insertion for, 151
Physical therapy, 82, 516, 538 insertion landmarks, 174
home v. clinic, 525 sockets for, 150
in tibial fixation for hamstring grafts, 216 tibial insertion, 6
timing strengthening, 523 tibial tunnels, 174
Pinn-ACL crosspin system Posterolateral femoral drill guide, 157
femoral fixation, graft fixation, 257 Posterolateral rotatory instability (PLRI), 429,
for femoral fixation, 253–259 431, 432
cortical length measurement in, 255 Posterolateral tibial drill guide, 158
cross-pin implant selection, 255 Posteromedial rotatory instability (PMRI),
femoral tunnel in, 255 429, 432
graft harvesting, 254 Post-screw construct, 164
graft passing, 256 Preconditioning, 403
implant design, 253 Pretensioning, 403
notchplasty, 254 Prevention studies, 43
surgical technique, 254–257 functioning of, 50
tibial tunnel in, 255 individual v. population-based, 50
tibial fixation, 257 intervention timing, 49
tips and tricks for, 257 performance effects of, 50
troubleshooting, 259 program specifics, 49
video technique, 259 results of, 44
PL bundle. See Posterolateral bundle education, 44
PLA pin, 215 isolated proprioceptive training, 46
Platelet-derived growth factor (PDGF), 423, isolated strengthening and conditioning, 44
565, 626 neuromuscular training, 46–48
PLGA. See Polylactide co-glycolide summary of, 45
PLLA screw. See Poly-L-lactic acid screw Proliferation phase, 409
PLRI. See Posterolateral rotatory instability Propionibacteriaceae, 554
PMN cells. See Polymorphonuclear cells Proprioception, 525, 535–539
PMRI. See Posteromedial rotatory instability comparing, 537t
POL. See Posterior oblique ligament defining, 535
Polyester tape, 306f evaluating, 536
Polyglycolic acid (PGA), , 386 training exercises, 535
Polylactide co-glycolide (PLGA), 383 Proximal tunnel
Poly-L-lactic acid (PLLA) screw, 109, 355–356, revision surgery and, 231
383, 386 wall blowout, 231
Polymers, combining, 386–390 Pseudomonas aeruginosa, 554
Polymorphonuclear (PMN) cells, 553 Pulmonary embolism (PE), 596
Porcine tibiae, double spike plate and, 324 Purse-strings, 338

644
 Index

Q Reconstructions (Continued )
graft tensioning in, 157
Q angle, anatomical risk factors and, 19 postoperative care, 159
Q-400 tests, 13 setup, 155
Quadriceps, 13, 60 surgical procedure, 155–159
in ACL deficiency, 63 tibial tunnels in, 157
central tendon, 610 anatomical double-bundle with semitendinosus hamstring tendon graft,
strengthening, 524 161–166
tendon allograft, 313 anatomy in, 161
tendon graft strength, 85 applications of, 165
checking grafts in, 164
R preliminary results of, 163
radiographs in, 165
Radiation sterilization, 562 scientific rationale for, 162
Radiographs, 489 special considerations in, 165
of ACL reconstruction, 71f surgical technique, 162–163
in anatomical double-bundle grafts, 165 troubleshooting, 166
anteroposterior, 121, 444, 461f, 462 anatomical single-bundle, 144
of autologous hamstring grafts, 428, 428f anterior knee problems after, 607–612
cortical screw post femoral fixation, 231 arthroscopic, 111
of distal left femur, 599 arthrosis following, 71
of DSP, 326 studies on, 72
EZLoc, 235 with autologous chondrocyte implantation, 493–499
graft sleeve and tapered screw, 338 autologous hamstring tendon, 427–440
of hamstring regeneration, 528 background on, 79
lateral, 181, 439, 461f, 462 BPTB, 354–361
ligament tear, 56 computer-assisted navigation, 186–,
posteroanterior weight-bearing, 429, 430 accuracy without, 186
post-revision, 447f postoperative screenshots, 191
stress, 430 precision in, 186
tibial fracture, 604, 605 rationale for, 186
of transverse fractures, 602 techniques, 187
of two-stage revision, 234f costs of, 79
Radiolucency, 312 additive, 80
Reconstructions information on, 79
additive costs, 80 institutional fixed, 80
all-inside, 300f postoperative, 81
anatomical double-bundle, 144, 147–152, 168–177 CQFT for, 106–108
anesthesia and positioning, 170 exposure, 107f
clinical results, 152, 154, 177 fixation of, 108
complications, 176 technique, 106
diagnostic examination, 171 troubleshooting, 107
graft fashioning in, 150 double-bundle, 82
graft placement in, 151 double-bundle, double-stranded hamstring autografts, 155–159
graft preparation, 170 economics of, 81t
graft tensioning and fixation, 152 endobuttons in, 218–224
history in, 169 failed, 496
hybrid grafts in, 152 femoral tunnel placement in, 140–145
imaging, 169 fracture complications of, 598–603
indications in, 169 gait analysis in, 615–622
landmarks in, 170 graft remodeling, 408–412
physical examination in, 169 graft tensioning in, 392–396
postoperative considerations, 175–176 hamstring harvest technique for, 91, 95
preoperative considerations, 169 anatomy, 95
preparation for, 147 clinical experience, 100
procedure, 147–152 complications, 94
results, 176 cosmesis in, 100
specific steps, 171 graft preparation, 93, 98
surgical technique, 170–171 in large patients, 100
tibial tunnels in, 147 premature amputation in, 99
anatomical double-bundle, double-stranded hamstring autografts, problems with, 99
155–159 saphenous nerve trauma, 99–100
arthroscopic reconstruction, 156 skin incision, 91
femoral tunnels in, 156 surgical, 96
graft fixation in, 157 tendon exposure, 91
graft harvesting, 155 tendon identification in, 99
graft positioning in, 157 tendon release, 92

645
 Index

Reconstructions (Continued ) Rehabilitation (Continued )

tendon stripping, 98, 99 aggressive v. conservative, 577
timing of, 98 allograft, 525
with high tibial osteotomy, 493–499 anatomical double-bundle, 175
IntraFix, 351 anterior knee problems, 612
ligamentization, 408–412 graft sleeve and tapered screw, 335, 339
with meniscal allograft transplantation, 493–499 hamstring graft, 339
meniscus tears, 486–492 LCL, 483
with microfracture, 493–499 MCL, 483
mid-third patella tendon graft, 101–105 partial tears, 475
exposure, 101 PCL, 483
fashioning, 104 physeal-sparing reconstructions, 466
skin incision in, 101, 102, 102f postoperative, 451
taking, 101 contralateral graft, 512
Milagro, 381–384 early, 514
mini-arthrotomy technique, 364–372 ipsilateral graft, 512
with osteochondral allograft transplantation, 493–499 operative considerations, 513
osteoporosis after, 572–574 outpatient surgery, 513
partial tears, 470–475 phase II, 517
complications, 475 phase III, 518
preoperative considerations, 470–472 phase IV, 519
rehabilitation, 475 premises of, 521
results, 475 preoperative planning for, 364, 510
surgical technique, 472–473 mental preparation for, 512
patient expectations, 493 principles of, 509–520
physeal-sparing, 465 protocol, 521
postoperative rehabilitations, 466 returning to competition after,
postoperative, 514 stability-conservative, 521–526
proprioception and, 535–539 abductor strengthening, 524
purpose of, 79 adductor strengthening, 524
radiographs of, 71f cyclical loading in, 523, 524
restoration of motion, 493 equipment, 525
retrodrill technique, 134–137 in first three months, 522
preliminary results, 137 fixation point healing, 522
surgical, 136 full extension in, 523
retroscrew fixation, 299–302 full flexion in, 523
revisions, 443 gait training, 525
allograft, 447 gastrocnemius in, 524
apertural fixation, 448 graft strength, 522
autograft, 447 hamstring strengthening, 524
cortical fixation, 448 history of, 521
failure, 444, 453f home v. clinic therapy, 525
knee instability, 445 hyperextension in, 523
literature on, 454 muscular inhibition after, 522
postoperative, 451 proprioception, 525
surgical procedure, 446 quadriceps strengthening, 524
treatment options, 444 results, 526
two-stage, 453 stairs in, 524
semitendinosus tendon graft, 110–113 strength testing, 526
in skeletally immature patients, 457–468 symmetric stability after, 522
stability results after, 540–548 timing strengthening, 523
success rates, 493 triceps surae, 524
surgeon factors, 493 stiffness, 568
tension after, 327 strain during, 501–506
third-party payor payments, 80 imaging techniques, 502–503
tissue-engineering, 82 measuring, 501
transepiphyseal, 462, 463–464 rank comparison of, 504
postoperative rehabilitation, 464 studies on, 503
surgical technique, 463 transepiphyseal reconstruction, 464
transphyseal, 467 transphyseal reconstruction, 468
rehabilitation, 468 RER. See Retroeminence ridge
tunnel widening after, 576–578 Resident’s ridge, 180, 182
vascular complications, 585–588 Retrodrill technique, 134–137
whipstitch-post tibial fixation, 310–315 assembly, 135
Reflex sympathetic dystrophy (RSD), 568 pin in, 135
Rehabilitation preliminary results, 137
in ACL deficiency, 64 surgical, 136

646
 Index

Retrodrill technique (Continued )

traditional method, 135
S
Retroeminence ridge (RER), 157 Sagittal CT, 594
Retroscrew fixation, 299–302 Sagittal graft, 285
insertion of, 299 Sagittal proton density image, 58
operative technique, 299, 302 Saphenous nerve
placement, 303 infrapatellar branch of, 611
tibial, 187–192, 300 trauma, 99–100
Revascularization, 410 Sartorius fascia, 212
Revision screwdrivers, 435 Secondary sexual characteristics, 459
Revisions, 443 Self-tapping, cancellous compression
allograft, 447 screws, 317
apertural fixation, 448 Semimembranosus, 528, 533
autograft, 447 Semitendinosus, 96f, 465, 528, 533, 537
cortical fixation, 448 in anterior incision, 97
failure, 444, 453f autograft, tripled or quadrupled, 305–308
knee instability, 445 colored sutures on, 345, 346
literature on, 454 double-bundle graft, preparation, 162
radiographs after, 447f finding, 96
surgical procedure, 446 graft, 93
stage I, 446 hamstring tendon graft, 161–166
stage II, 446 harvesting, 97, 212, 232
treatment options, 444 insertion, 96
tunnel widening and, 578 isolation of, 97
interference screw fixation and, 578 MRI of, 529
noninterference screw fixation tendon graft, 110–113
and, 578 clinical results of, 112
two-stage, 453 complications, 113
RICE, 568 diagram of, 112
Rigid fix device, 216 preparation for, 111
absorbable pins, 281 quadrupled, 111, 112
drill holes, 281 surgical technique, 111–113
for femoral sided fixation, 277–282 tripled, 111
cruciform periosteal incision, 279 Sensory disturbance, 581f
graft positioning, 280 Septic arthritis, 556
graft preparation, 279 Shuttle machine, 515
postsurgical care, 282 Side-to-side difference (SSD), 540
skin incision, 278f Single-socket, double-bundle graft, 302
surgical technique for, 278 final inspection of, 303
troubleshooting, 282 preparation, 303
Rigid interosseous compression, in tibial Single-socket, single-bundle graft, 299
fixation, 215 Skeletally immature patients, 457–468
Risk factors accessing, 458
anatomical, 19 complications in, 588
notch width of, 19, 21 EZLoc in, 238
Q angle and, 19 mitrogenic growth disturbance in, 459
environmental, 18 natural history, 457
bracing and, 18 normal growth and development, 458
hormonal, 20 physeal injury, 459
concerns and, 23 recommendations, 461
laxity and, 20 treatment options, 460, 461
ligament biology and, 23 Soccer, 32, 70
monthly distribution of injuries and, 20 hamstrings and, 61
neuromuscular, 23 indoor, 34
Rome, 3 Soft tissue grafts, 199
Roof impingement, 121–127, 236 EZLoc femoral fixation on, 233–241
in BPTB graft, 123 design, 233
complications, 122 diameter, 233
definition, 122 mechanism, 233
diagnosis, 122 packaging, 233
principle for avoiding, 124 fixing, 238
surgical technique for avoiding, 125 tibial fixation
Rotational stability, 9 bone dowel, 316–322
Roux, Wilhelm, 399 intratunnel, 330–340
RSD. See Reflex sympathetic dystrophy WasherLoc, 316–322
Rugby, 34 Sports.See also specific sports
Running, 524 tear rates in, 32

647
 Index

SSD. See Side-to-side difference Stryker Biosteon Cross-Pin System (Continued )

Stability femoral fixation, 267–270, 274
allograft, 548 femoral tunnel location, 270
aperture fixation, 547 graft harvest, 270
autograft, 548 potential pitfalls, 275
BPTB, 548 results, 274
by graft subgroups, 547 tibial tunnel location, 270
by graft types, 547 postoperative care, 273
nonaperture fixation, 547 surgical technique, 268–273
results, 540–548 initial arthroscopy, 268
symmetrical stability, 540 tibial fixation, 270
statistical methods, 540 Styker Dracon graft, 88
study criteria of, 540 Surgery, 626
divided by graft and function, biomechanics considerations in, 9
Stair climbing, 505 Sutures, 220, 221
Stair-stepping machine, 519 BPTB, 355f
Standing extension, 511 on gracilis, 345, 346
Standing habit, 516 passing, 224
Staphylococcus aureus, 554, 557, 558 pulling, 468
Staphylococcus caprae, 554 removing, 222
Staphylococcus epidermidis, 554 on semitendinosus, 345, 346
Static tensioners, 213 tangled, 223–224
Stationary bike, 519 tibial hybrid fixation using, 297
Sterilization, 563 Synovial fluid infiltration, 577
Stiffness, 565–570 Synthetic bone substitute, 439, 440
etiology of, 565–568 Synthetic grafts
genetic predisposition for, 565 failure of, 88
infrapatellar contracture syndrome, 568 future of, 89
surgical factors, 566 history of, 88
principle, 207 types of, 88
rehabilitation, 568
treatment, 569 T
Straight leg raise exercises, 515
Strain Tanner stages, 458, 459, 462
BPTB, 506 Tears
bracing and, 506 prevention programs, 40
imaging techniques, 502–503 rates, 29t, 35
measuring, 501 female to male, 38, 39
rank comparison of, 504 risks,
studies on, 503 in sports, 32
weight bearing and tibia external loading, 13 Tendo-Achilles allograft, 313
Stratis ST, femoral fixation, 242–249, 250 Tensile strength testing, 532
advantages and disadvantages of, 250 Tension-flexion curve, biomechanical studies on, 392
aperture fixation, 244 Tensioning pattern, 6
arthroscopic preparation, 246 TGFs. See Transforming growth factors
design rationale of, 243 Threaded cannulated drill pins, 135f, 137, 138
femoral tunnel and, 244 Threaded femoral cancellous screw and washer, 230f
femoral tunnel in, 246 3D kinematics, 24
graft block, 244f 3ST/2Gr technique, 115–119, 313
graft block insertion, 248 five strand, 118
graft integrity and, 244 morbidity, 118
graft limb orientation, 245 results, 118
graft preparation, 246 surgical technique, 118
graft-block-graft construct, 248 uses, 118
implant removal, 250 Tibia, 5
pullout strength, 244 allograft, surgical preparation, 236
system, 244, 245 allografts at, 208
technique, 245–249 anterior shear force at, 13
tendon harvest, 245 eminence avulsion,
tibial tunnel in, 246 exposure, 365
transverse tunnel, 247 femur and, 188
Stress relaxation, 403 footprints, 172
Stride-to-stride variability, 618 fracture, 603
Stryker Biosteon Cross-Pin System CT, 604
biomechanical performance of, 274 plateau, 603
bony healing, 269 radiographs, 604, 605
elasticity of, 269 tubercle, 603

648

Tibia (Continued )
insertion landmarks, 174
lateral capsule tear, 482
PL bundle insertion point at, 6
proximal, 454f
Tibial fixation, , 158, 384
backup, 296
BioScrew XtraLok, 328–329
results, 328
in tibial tunnel, 328
troubleshooting, 329
cancellous bone and, 320
devices, 205f
EZLoc, 238
Fastlok device for, 305–308
graft fixation, 306
results, 306
scientific rationale for, 305
surgical technique for, 306
troubleshooting, 308
tunnel preparations, 306
graft sleeve and tapered screw, 335
for hamstring grafts, 211–216
bioabsorbable materials in, 216
bone grafting, 214
cross-pin, 215
distal tunnel fixation in, 214
graft cycling, 212
graft preparation in, 211
limited debridement in, 214
modified physical therapy after, 216
pretension, 212
rigid interosseous compression in, 215
tibial tunnel length in, 213
hardware complications, 588
interference screw, 294–295
IntraFix, 344
in intratunnel graft fixation, 199
options, 452t
Pinn-ACL crosspin system, 257
retroscrew, 288–300, 301
screws for, 441
soft tissue graft
bone dowel, 316–322
intratunnel, 330–340
WasherLoc, 316–322
Stryker Biosteon Cross-Pin System, 273
tension after, 327
tension during, 324, 326
whipstitch-post, 310–315
bioabsorbable screws, 312
biomechanics of, 310–311
clinical results, 311
direct v. indirect fixation, 311
ease of, 315
elongation, 310
graft sizing, 314
graft techniques, 313
metallic screws, 315
morbidity, 315
principle behind, 311
radiolucency, 312
screw insertion, 314
screw tightening, 314
short graft, 315
stability, 315
stiffness, 310
Index
Tibial fixation (Continued )
surgical technique, 311–314
sutures, 311
tensioning, 313
tibial screws, 311
trimming tendon grafts, 314
troubleshooting, 315
tying, 314
unicortical screw placement, 315
X-ray demonstrating, 358
Tibial guide
65-degree Howell, 126
placement of, 189
validation of, 126
Tibial pin, 356
Tibial rotation, 617
osteoarthritis and, 619
Tibial tubercle, 162
Tibial tunnel, 137, 163, 264
AM, 174
in anatomical double-bundle ACL
reconstruction, 147
arthroscopic view of, 127, 343
in autogenous patellar tendon grafts, 367
BioScrew XtraLok in, 328
bone dowel harvesting from, 316
bone grafting of, 214
debridement of articular edge of, 214
dilating, 317
distal fixation, 214
graft sleeve and tapered screw, 333
guidance, 191, 279
IntraFix, 343
maximizing length of, 213
outlets, 149
in Pinn-ACL crosspin system, 255
PL, 174
placement for, 125, 236, 367, 368
straight-line, 368
preparation of, 157
screw diameter and, 295
in Stratis ST femoral fixation, 246
Stryker Biosteon Cross-Pin System, 270
walls in, 368
whipstitches in, 212f
Tibialis allograft, 313
graft sleeve with, 335
preparation of, 340
Tilts, 568
Tissue-handling, 563
TMC. See Trimethylene carbonate
TNF. See Tumor necrosis factor
Transepiphyseal reconstruction, 462
surgical technique, 463–464
TransFix, 417, 433
Arthrex, 262f, 299
femoral fixation, 261–266
biomechanics, 261
clinical results, 261
surgical technique, 262
troubleshooting, 265
tunnel hook, 264
Transforming growth factors (TGFs), 423, 565, 626, 627
Transphyseal reconstruction, 467
postoperative rehabilitation, 468
Transtibial technique, 122, 124
Transverse cannula, 256
649
 Index

Transverse drill, 251 WasherLoc (Continued )

guide, 271 impacting, 317
Transverse fractures, 602 self-tapping, cancellous compression screws, 317
Tray rentals, 81 surgical technique, 316–319
Trevira ligament, 88 tendon-tunnel healing, 318–319
Triceps surae, 524 WBC. See White blood cell
Trimethylene carbonate (TMC), 386 Weighted means, 33
Tumor necrosis factor (TNF), 408, 565 Whipstitch implantation, 227, 310
Tunnel widening, 576–578 direct v. indirect fixation, 311
adverse effects, 578 femoral post, 229
direct, 578 first, 117
revision surgery and, 578 second, 117
decreasing, 578 placement, 312
factors associated with, 576–577 post-tibial fixation, 310–315
aggressive v. conservative rehabilitation, 577 bioabsorbable screws, 312
allograft v. autograft, 577 biomechanics of, 310–311
fixation location, 577 clinical results, 311
hamstring v. BPTB, 576 ease of, 315
synovial fluid infiltration, 577 elongation, 310
by graft and fixation type, 577f, 578 graft sizing, 314
methods of, 576 graft techniques, 313
identifying, 576 metallic screws, 315
literature analysis, 576 morbidity, 315
Tunnels. See specific types principle behind, 311
Two bundle grafts, 302 radiolucency, 312
2ST/2Gr technique, 115–119, 229, 313 screw insertion, 314
graft preparation screw tightening, 314
optimal length, 117 short graft, 315
sizing, 117 stability, 315
whipstitch implantation, 117 stiffness, 310
surgical technique, 311–314
U sutures, 311
tensioning, 313
Uterine T clamp, 107 tibial screws, 311
trimming tendon grafts, 314
V troubleshooting, 315
Valgus, laxity, 55 tubularization, 312
Valgus movements, 24 tying, 314
Vascular complications, 585–588 unicortical screw placement, 315
arterial, 585 in tibial tunnel, 212f
defects, 595 White blood cell (WBC), 553
venous, 596 WHO. See World Health Organization
Vascular endothelial growth factor (VEGF), 565, Wire navigators, 147, 148
625, 626 navi-tip of, 149
VEGF. See Vascular endothelial growth factor World Health Organization (WHO), 573
Venous complications, 596 Wrestling, 34
Vesalius, Andreas, 3
Viral disease, 557 X
Volleyball, 34
Xtendobutton, 219, 224, 380
W in continuous loop BTB fixation systems, 378
endobuttons and, 225
WasherLoc, 206, 208, 215, 593 in revision cases, 225
orientation of, 317
schematic of, 317 Y
slippage resistance, 320
tibial fixation, 316–322 Yardsticks, 515

650