APEX Knee Navigating Pearls and Pitfalls-Optimizing Your ACL (Tunnel Placements, Graft Options, Fixation Choices, and More!)

Optimizing Your ACL (Tunnel Placements, Graft Options, Fixation Choices, and More!)

Video Transcription

Video Summary

The transcript covers a teaching-focused discussion of complex ACL reconstruction failures, emphasizing evaluation and revision strategy. A 23-year-old airplane mechanic with two prior failed ACL surgeries (BTB autograft, then allograft) presents with instability and a high-grade pivot shift. Imaging shows widened tunnels, markedly increased posterior tibial slope (~18°), and suspected meniscal pathology. The panel debates when to bone graft enlarged tunnels (often >12 mm), whether to stage revision, and how to measure slope. Most agree excessive slope is a major contributor to failure and should be corrected, typically targeting ~6–7° without overcorrection that could cause hyperextension.<br /><br />The surgeon performs a staged approach: first-stage arthroscopy with meniscal repair, tunnel bone grafting using large allograft dowels (soaked in bone marrow concentrate), and a supratubercle slope-reducing osteotomy while preserving a posterior hinge. At ~3 months, hardware is removed and revision ACL reconstruction is completed using an all–soft tissue quadriceps graft with suture-tape augmentation plus an anterolateral tenodesis. A lateral meniscal root tear is repaired with modern knotless aperture fixation, highlighting the importance of identifying and repairing root/radial tears (“Elmore lesion”) to reduce pivot shift and protect the ACL.<br /><br />A second case (17-year-old) demonstrates combined medial and lateral meniscal root tears with acute ACL rupture, focusing on tunnel-planning and operative sequence to avoid tunnel convergence.

Asset Caption

Moderator: Patrick A. Smith, M.D.

Meta Tag

ACL 1

Fixation Choices 1

Graft Options 1

Tunnel Placements 1

Keywords

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revision ACL reconstruction

posterior tibial slope reduction osteotomy

widened tunnel bone grafting

quadriceps tendon autograft

anterolateral tenodesis

meniscal root tear repair

tunnel convergence planning