Hi, my name is Matt Sosler. I work at Tufts Medical Center in Boston, Massachusetts. I'd like to thank Anna for the opportunity to present today. I'm going to be talking about tips for getting out if you have trouble with ACL reconstructions. I have no financial disclosures. I do have a non-financial disclosure. I've given many talks on revision ACL reconstructions and multiligament knee injuries. I think this is actually one of the more difficult talks I've had to give. One of the reasons why is there are many surgeons doing ACLs. There are many different techniques. The vast majority of people are doing a great job. So coming up with some tips to try to get people out of trouble is a lot more challenging than I thought it was going to be. In terms of the structure of the talk, I'm going to start off with getting started with ACL reconstructions, some issues that can arise with the graft, and finally some issues with perspective fixation and how to address those issues. The best advice I have overall, this is going to be a recurring theme throughout this talk, is that the best way to get out of trouble is to avoid to get it in the first place. The best place to start this is before we even get to the skin incision. A good examination under anesthesia is key to ensuring that you don't miss important injuries. This involves a full assessment of all ligament instability, range of motion, and a dial test. Missed post-traumatic coronary injuries are a common cause for failure of ACL reconstructions. In terms of positioning, there's no one right way to position, I just recommend you find a way that works for you and that you're consistent with it and you practice that. My preference is to have a patient supine on a flat table with a feet at the end of the bed. I like to have a foot bump and a thigh post and then I keep the thigh post at the level of the tourniquet. The goal is to have the foot bump and the thigh post such that when the patient's knee is flexed 90 degrees, you don't need any additional help to hold the leg in that position. I also put on a tourniquet that I say is for good luck. I use a tourniquet for BTV harvest, but other than that I don't use the tourniquet for the rest of the ACL reconstruction portion of the procedure. The key to any successful surgery is good exposure. In an arthroscopy, that means good portal position. Bad portal position can doom you and doom your entire ACL reconstruction. In terms of the anterolateral portal, I like to keep it high and tight like a military haircut. What I mean by that is I like to have the incision at the inferior border of the patella and then just off the patellar tendon. If you're any more lateral, it can make it difficult to see the femoral attachment of the ACL from within the notch. With respect to the anterior medial portal, that depends a little bit on what type of drilling technique you're going to be using. If you're going to be drilling from an anterior medial or a far anterior medial portal, you want to make sure that you make your initial anterior medial portal just off the patellar tendon. That way when you use your spinal needle to localize your more medial portal, you'll still have room between them. And finally, don't forget about the transpatellar portal. It's very rarely needed. If you're having issues confirming or localizing your femoral tunnel location, it's better to have a transpatellar portal than a misplaced femoral tunnel. Now that your portals are established, it's good to ensure that you have good visualization. That involves ensuring that your pump and suction are working appropriately, that you don't have a venous tourniquet, and that the patient's blood pressure is appropriate. Though I'll note that high blood pressure is typically not a problem for ACL reconstructions. If a patient has a hematoma, I usually aspirate that preoperatively. For all of my patients, I inject 20 to 30 cc's of lidocaine with epinephrine prior to prepping and draping. This gives the epinephrine plenty of time to achieve hemostasis prior to the start of the procedure. If your simple fixes haven't worked to fix your visualization, you can temporarily elevate your pump pressure. You can add epinephrine to your arthroscopy fluid. And finally, when there's a high risk time, whether you're to bring a fat pad, the ACL, or doing a synovectomy, those would be the times to have your electrocautery ready. Moving on to graft problems, one of the issues that we have is the incorrect size or an improper size of a graft. With a bone tendon, bone and quad tendons, you can usually choose the size of your own graft, and I'd encourage you to enlarge your incision as needed, as a larger incision is better than a smaller incision with a poor graft. With respect to hamstrings, one thing that we know that increases the risk of hamstring failure is going to be a graft that's smaller than a diameter of eight to eight and a half millimeters. The best way to avoid this happening is with good patient selection. The best predictor of a hamstring size is patient height. I typically don't use hamstring autografts in patients under five foot eight. If you do end up with a hamstring graft that's smaller than you expected, there are many bailout options. It's important to know and to practice one of them to be comfortable with it. One easy one would be allograft augmentation, though there is some mixed data on the retail rates. For me, I like to use a six-stranded all-inside graft. This requires a different fixation technique than I normally use. Again, it doesn't really matter what you do, whether it's different, you just need to know how to do it and ensure that you're prepared to do that. Now that we have our grafts and we're happy with the graft size and the graft preparation, it's time to talk about graft passage. Graft passage is one of the most difficult parts of the ACL reconstruction for people who are learning their career. One of the most common reasons why passage is difficult is that soft tissue will block your tibial opening. On a typical retrograde style where you're passing it through the tibial cortex, some of the soft tissue, especially with a small incision, can get entrapped inside of the tunnel. Though it sounds it's important on both sides, it's actually even more important when you're dealing with an all-inside and you're trying to pass your graft retrograde from your articular surface down into your tibia. If you don't have it completely debrided your ACL, you'll end up getting some soft tissue caught and that'll be quite difficult. Additionally, for all grafts, I'd recommend using a pulley if needed. I don't need to do this very often, but it can be helpful, especially in BTPs. To do this, I put my scope in the anterior medial portal and put a switching stick in the anterior lateral portal. Then you can use that switching stick to ensure that you are pulling up your graft in line with your tibial tunnel as opposed to in line with your femoral tunnel. For bone-to-end and bone grafts, I usually recommend sizing about one millimeter over the size of your graft, whereas for soft tissue grafts, I recommend keeping it the same size. One of the most dreaded complications in ACL reconstruction would be a contaminated autograft intraoperatively. A recent survey of surgeons that I remember hearing about recently suggested about 50% of surgeons who perform ACL reconstructions have had this happen at one point in their career. Again, prevention is the best defense here, so make sure the harvesting surgeon brings the ACL graft back to the back table, keep it wrapped in saline, keep that saline-wrapped graft in a kidney basin in the back table, and ensure that everyone in the procedure knows that that's where it is and how to keep it protected. Finally, if it does happen, you've got to know what your plan is for dealing with it or where to find that plan if you don't know it. I just looked this up and I found a great article from arthroscopy in 2000 that showed with a 92nd chlorhexane wash, only 2% of the grafts still had a positive culture. Interviewing other literature, one other thing that's suggested as being helpful is mechanical irritation. So this is a level 6 evidence, that's a non-expert like me. I would recommend a chlorhexane wash for 90 seconds, mechanical irritation and saline, another 90 second chlorhexane wash. There are many different types of fixation. I'm going to do my best to talk about all of them. I will note that this is not my idea, but I thought this was a great slide and I wanted to reproduce it. In terms of suspensory fixation, one issue you could run into would be lateral wall blowout. Solutions for that would be having a larger button, interference group fixation, or the traditional old school lateral incision and hanging it over a post and screw it with a washer. It's important to be comfortable with these different options and to ensure that you have that equipment available in case this happens. One additional problem with suspensory fixation would be a tunnel that's too short. Though there's some debate on these lengths, I recommend 20 millimeters for your tunnel and a 6 millimeter cortical bridge. Looking at the radiograph in this slide, you can see that if you extend the length of your tunnel by the additional 6 millimeters for a cortical bridge, you can lengthen your tunnel by causing a lateral wall blowout. Then you can basically address that with the techniques previously discussed. If you're going to be using aperture fixation with an interference screw as opposed to suspensory fixation, a lateral wall blowout won't be a problem, but you will have to worry about potential posterior wall blowout. If this happens, you can switch over to suspensory fixation. Additional problems you can get would either be graft abrasion when you're putting your screw in or screw tunnel divergence. Both of these can be avoided by using the same portal for your screw placement that you use for your drilling and also placing the screw with the same flexion angle as you did when you did your drilling. In addition, you can also use a soft tissue protector. Moving on to the tibial side, one problem that you can run into is having a BTP graft that's too long. A couple of solutions would be to either twist the graft half a turn, any more than that, and you're going to lose some mechanical properties of the graft, but half a turn can fix a graft that's just slightly too long. If there's more significant tunnel, bone, tendon, and bone graft mismatch, you can create a bone trough in the tibia with a burr and secure it with screw fixation. One additional problem that you can run into on the tibial side would be poor fixation. That's going to occur with interference screw fixation because the tibial bone is a little bit weaker than the femoral bone. It's also important to have good fixation here because the ACL is pulling in line with your tunnel. So when do I use backup fixation with the belt and suspenders technique? Well, I don't have a great answer. I do always use it in revision situations like the x-rays you see down in the bottom right corner. I used to use it when it just doesn't feel right. If I'm just not happy with the bite that I'm getting. I don't know exactly if there's any benefit to using backup fixation here, but I know that I'd sleep better tonight using it. Two options that I'll use, you can see in the radiograph on the left, you can use a knotless anchor or in the radiograph on the right, you can use a more traditional post and washer. In summary, the best advice I have to get yourself out of trouble in ACL reconstruction is to avoid it in the first place. One of my mentors once told me that there are tigers everywhere and I hope this talk can help you either avoid some of those tigers or if you do encounter them, figure out what to do when you see them. I think the best way to do this is going to be develop and practice a technique that works very well for you. Be consistent so that you know where those tigers are going to be, how to avoid them and what to do when you see them. It's also important to know other techniques because sometimes the way to get yourself out of trouble is to switch techniques and know when to do that. Thanks everybody, good luck and I hope I get to see you in person next year.

ACL reconstructions

complication management

surgical techniques

preoperative assessment

intraoperative challenges

preoperative assessments

graft sizing

surgical technique

complication prevention