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

Concept Anterior Cruciate Ligament Reconstruction Revision

Concept Computed Tomography

Concept Tibial Tunnel

Concept Tunnel Widening

Concept Tunnel Malposition

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

Anterior Cruciate Ligament Reconstruction Revision

Computed Tomography

Tibial Tunnel

Tunnel Widening

Tunnel Malposition