Hi, my name is Dr. Amit Mamaya and I'm an orthopedic surgeon and serve as Chief of Sports Medicine at the University of Alabama at Birmingham. In this PowerPoint, we will discuss ACL preoperative planning. Preoperative planning for ACL reconstruction is paramount in achieving optimal outcomes. The plan should be individualized for the patient and surgeons should avoid a cookie cutter approach to all patients with an ACL tear. With regard to imaging, we often obtain standard AP, lateral, and sunrise views. Also consider obtaining standing full-length lateral tibial films to check tibial slope. There's been some studies that demonstrate that a posterior tibial slope greater than 12 degrees may be concerning in a risk factor for re-tearing of the ACL and poor outcomes. You may also want to consider full-length alignment films to check for any varus or valgus deformity of the patient. When examining a patient with concern for an ACL tear, there are a few different things you should examine in the physical exam. Some of these things include the ability to obtain full extension prior to surgery, the degrees of flexion, how much of an infusion the patient has in their knee, any varus or valgus laxity or a positive posterior drawer, which would let us know that this could be a possible multiligamentous knee injury. You also want to check for pathologic hyperextension. This video demonstrates someone who has significant hyperextension and one may want to choose to add in any extra articular procedures to account for this. You also want to examine for a pivot shift test. Sometimes this can be done on a chronic ACL in the clinic setting or sometimes on the table. And again, an explosive pivot shift test may lead you down the road of adding an extra articular procedure. There are multiple graft choices when considering for ACL reconstruction. The main choice at first needs to be autograft versus allograft. Studies have shown that allografts result in much higher failure rates than autografts, especially in younger, higher-demand patients. When choosing an allograft, consider using a non-irradiated and younger donor age allograft as they may have better mechanical properties. When looking at autograft choices, there are multiple choices including the batard tendon, quad tendon with or without bone plug, hamstring, or perineal tendon. We often involve the patient when choosing a graft choice, but it should be individualized to each patient. For example, in a sprinter, you may want to avoid hamstring harvest. In those who have to kneel a lot on their knees, you may want to avoid a BTB as almost 50% of patients with a BTB can experience some level of discomfort with anterior knee pain when kneeling. You also may want to consider preoperative measurements on MRI or ultrasound of the hamstring to check for diameter obtained, although studies are controversial on whether this is reliable. Check the MRI for quad thickness and length to make sure you have sufficient length. Some studies have shown that females under the height of 5'1 may not have sufficient length of their quad tendon. And then also check on the MRI the length of the batard tendon as you want to be prepared for any kind of graft length, tunnel length mismatch. The use of lateral extra-articular tenodesis procedures have been shown to reduce retail rates and improve outcomes in certain patient populations. The indications continue to remain controversial, but you may want to consider this in female gender patients, high-risk sports such as soccer or basketball, pathologic hyperextension, high-grade pivot shift tests, or revision procedures. You may also want to discuss the block and pain control for the patient with the anesthesia team. We often try to avoid femoral nerve blocks due to persistent motor blockade of the quadriceps. Consider an adductor canal nerve block in order to avoid these motor issues and largely decrease sensory pain on the front of the knee.

ACL reconstruction

individualized preoperative planning

autografts

tibial slope

lateral extra-articular tenodesis

ACL preoperative planning

individualized approach

graft choices

lateral extra-articular procedures

adductor canal nerve blocks