Hi, my name is Dr. Amit Mamiya and I'm an orthopedic surgeon and chief of sports medicine at UAB. In this PowerPoint, we will talk about ACL preoperative planning. Complications can happen with any surgery, but ACL reconstruction is composed of multiple small steps that can compound if complications happen. Preoperative planning is essential for surgeons even if high volume. Knowledge and preparedness can help minimize any negative effects on these outcomes, allowing the surgeon to pivot to any alternative techniques when exposed to certain complications or issues in the operating room. When harvesting a hamstring tendon for ACL autograft, sometimes one can encounter too small of a diameter. If you were harvesting just the semitendinosus, you can harvest also the gracilis and double these over to make a larger diameter graft. You could also consider just quadrupling over the semitendinosus, which can often get you to a sufficient graft diameter, or you can augment with a contralateral hamstring autograft harvest. Traditionally, we've been taught that you need a diameter of at least 8mm to decrease failure rates. Other option is to augment with an allograft. However, a study out of San Diego taught us that augmenting with an allograft may make the graft behave more like an allograft, and sometimes it is better to leave the size as-is. We've also been taught that we need approximately 15-20mm minimum in each tunnel, so that's important to keep in mind when looking at the length of your graft. When harvesting a quadriceps tendon for autograft, sometimes you can encounter too short of a quad tendon that is unexpected. Some possible solutions to this involve taking a bone plug on the patella if the quad tendon is still attached distally, or you could switch to suspensory on both sides instead of doing a screw on the tibia, which some people rely on when trying to get a 75-80mm quad autograft harvest. Other times, people try to harvest a partial thickness quadriceps tendon and accidentally violate the joint capsule. This is not a big issue, and is okay just to repair the joint capsule if you encroach upon it. When harvesting a bone patella tendon bone graft, a complication that can be devastating includes patella fracture. It is important to immediately recognize this if this happens intraoperatively and fix the patella fracture with screws. One wants to limit early flexion to allow the patella to heal while balancing the need for some motion of the ACL and knee. Also, one may encounter a thin bone plug when harvesting the graft. In these cases, consider a loop suture around both the tendon and the bone to get a better grasp of both of them so suture doesn't simply pull out of the thin bone, and you can still fix it with a screw, or sometimes consider suspensory fixation. A rare but devastating complication involves dropping the graft on the ground. One must be very careful to move the graft from the patient's knee to the back table for preparation, but a graft can drop, and if it is dropped, one should be knowledgeable about how to cleanse the graft. Studies have shown that chlorhexidine solutions can reduce graft contamination, and it should be soaked in such a solution. Betadine solution can also help, but is found to be not as effective. Also, some systematic reviews have shown us that soaking the graft with a vacomycin solution may help reduce infection risk. When drilling tunnels, a complication that you can encounter is a back wall blowout on the femur side. If you are planning on screw fixation, you may want to avoid this, as a back wall blowout may result in poor fixation, and you can switch to suspensory fixation in these cases with a button on the cortex. On the opposite side, if you have a tibial wall blowout or poor bone quality with loose fixation with a screw, you may want to switch to suspensory fixation, or you can consider a trough in the tibia outside the actual tunnel and fix with a post-distally. Another complication you can have, especially when doing a suspensory fixation of the ACL, is a cortical wall blowout if you are drilling from inside out. In these cases, you don't want to use a normal-sized button, as it may enter into the tunnel when you're trying to fix the ACL, resulting in a lax graft. In order to fix this, you can use an extender button, so your normal button sits inside of this longer-diameter button to sit on the cortex, or switch to screw fixation. Another complication you can encounter during ACL reconstruction is having a graft length tunnel length mismatch. This most commonly occurs with bone patellar tendon bone grafts that are long. It's important to recognize this preoperatively on the MRI. Possible solutions involve drilling a full tunnel in the femur and doing a screw. You can do this with an outside-in screw fixation. If you have graft coming out of the tibial tunnel, you can create a trough in the tibia distal to the tunnel and fixation outside the tunnel with your choice of staple or post. You can also twist the graft to shorten it a little bit, or you can fold. If you have too much graft coming out, you can fold over the distal bone plug and stuff it back into the tibial tunnel to shorten your graft and have screw fixation there.

ACL preoperative planning

graft handling

fixation techniques

intraoperative challenges

sports medicine

ACL reconstruction

preoperative planning

graft management

orthopedic surgery