Two-Stage Revision Anterior Cruciate Ligament Reconstruction: Bone Grafting Technique Using an Allograft Bone Matrix

Abstract

Outcomes of primary anterior cruciate ligament (ACL) reconstruction have been reported to be far superior to those of revision reconstruction. However, as the incidence of ACL reconstruction is rapidly increasing, so is the number of failures. The subsequent need for revision ACL reconstruction is estimated to occur in up to 13,000 patients each year in the United States. Revision ACL reconstruction can be performed in one or two stages. A two-stage approach is recommended in cases of improper placement of the original tunnels or in cases of unacceptable tunnel enlargement. The aim of this study was to describe the technique for allograft ACL tunnel bone grafting in patients requiring a two-stage revision ACL reconstruction.

Fig 1

Tunnel bone graft immediately postoperatively on (A) anteroposterior and (C) lateral radiographs and incorporation of graft at 6 months postoperatively on (B) anteroposterior and (D) lateral radiographs in a left knee.

Fig 2

Computed tomography scan of a right knee showing tunnel enlargement in both the tibia and femur including the corresponding measures in the (A) coronal, (B) sagittal, (C) tibial axial, and (D) femoral axial planes.

Fig 3

Optimal visualization of the anterior cruciate ligament femoral reconstruction tunnel can be obtained through an anteromedial arthroscopic portal.

Fig 4

Intraoperative photograph of a 9-mm reamer that is over-reaming a previously placed guide pin to remove the sclerotic walls of the tibial tunnel in a right knee while being visualized with an arthroscope inserted through the anterolateral portal. A Kocher clamp is holding the guide pin through the anteromedial portal to prevent advancement of the pin.

Fig 5

(A) Arthroscopic view of a bioabsorbable screw in the tibial tunnel after reaming. (B) A small curved curette or a surgical grasper can be used to remove bioabsorbable screw remnants.

Fig 6

Demineralized allograft bone matrix is packed into a large cannula to be inserted into the femoral tunnel through the anteromedial (AM) portal.

Fig 7

To address the tibial tunnel, the knee is flexed to approximately 90° and an arthroscope is inserted through the anterolateral portal while a large curette is inserted through the anteromedial portal (right leg). A cannula filled with heated allograft bone matrix is inserted into the tunnel and impacted.

Fig 8

Arthroscopic view through the anterolateral portal. Before insertion of the allograft bone into the tibial tunnel defect, a large curette is inserted through the anteromedial portal to provide a roof while the graft is impacted to prevent allograft from entering into the joint. (A) Proper covering of the proximal tibial tunnel during impaction. (B) Demonstration of how the curette prevented bone graft from spreading into the joint after impaction has been completed. (MFC, medial femoral condyle; PCL, posterior cruciate ligament.)