Principles for optimizing anterior cruciate ligament reconstruction outcomes in elite athletes: a review of current techniques

Abstract

Anterior cruciate ligament (ACL) tears are one of the most common sport-related injuries and occur in greater than 3% of athletes in a four-year window of sports participation. Non-contact injuries are the most common mechanism for ACL injury in elite-level athletes, especially with increased valgus and external rotation of the knee when loading eccentrically in flexion. Because of the immense toll these injuries and their recovery take on athletes especially, optimal treatment has been a subject of great interest for some time. Many ACL reconstruction (ACLR) and repair techniques have been implemented and improved in the last two decades, leading to many surgical options for this type of injury. The surgical approach to high-level athletes in particular requires additional attention that may not be necessary in the general population. Important considerations for optimizing ACL treatment in high-level athletes include choosing repair vs. reconstruction, surgical techniques, choice of auto- or allograft, and associated concomitant procedures including other injuries or reinforcing techniques as well as attention to rehabilitation. Here, we discuss a range of surgical techniques from repair to reconstruction, and compare and contrast various reconstructive and reinforcing techniques as well as associated surgical pearls and pitfalls. Good outcomes for athletes suffering from ACL injury are attainable with proper treatment including the principles discussed herein.

Keywords: Anterior cruciate ligament (ACL); graft; reconstruction; repair.

Figure 1

Harvest of BTB autograft. The senior author’s preferred sizing is 10 mm tendon width, with 20 mm × 10 mm × 10 mm patellar and 25 mm × 10 mm × 10 mm tibial bone block. (A) Image depicting use of an oscillating saw to cut the patellar bone block. (B) Image depicting removal of BTB autograft. BTB, bone-patellar tendon-bone.

Figure 2

Image depicting hamstring autograft harvest. The senior author prefers to use an open graft harvester when using hamstring autograft.

Figure 3

Image depicting quadriceps graft harvest using double scalpel handle.

Figure 4

Illustration demonstrating the tibial attachment of the ACL and its proximity to the anterior root of the lateral meniscus. Used with kind permission of the American Journal of Sports Medicine, LaPrade CM et al. (40). PCL, posterior cruciate ligament; PL, posterolateral; PM, posteromedial; LTE, lateral tibial eminence; MTE, medial tibial eminence; AC, articular cartilage; AL, anterior lateral; AM, anterior medial; ACL, anterior cruciate ligament; SFs, supplemental fibers.

Figure 5

Illustration demonstrating the orientating of the femoral attachments of the two bundles of the anterior cruciate ligament and their proximity to bony landmarks. Used with kind permission of the American Journal of Sports Medicine, Ziegler CG et al. (41). AMB, anterior medial bundle; PLB, posterolateral bundle.

Figure 6

MRI demonstrating graft with impingement. MRI, magnetic resonance imaging.