Anatomic Arthroscopic Anterior Cruciate Ligament Reconstruction Using Bone–Patellar Tendon–Bone Autograft

Summary: Recent studies have shown that the tibial endoscopic technique for anterior cruciate ligament (ACL) reconstruction, in which the graft is placed nonanatomically through the tibial spine, creates a more “central cruciate” ligament that does not control rotation. Furthermore, this nonanatomic reconstruction may lead to increased loads on the joint surfaces leading to accelerated degenerative joint disease. Although there are many graft options available for ACL reconstruction, anatomic tunnel placement is the most important factor in achieving a successful outcome. The obliquity of the reamers used in creating the bone tunnels for reconstruction cause an oval entrance on the femur and exit tunnel on the tibial plateau. These factors must be considered when trying to achieve anatomic reconstruction. Although the double-bundle, anatomic reconstruction techniques are receiving much attention, a bone–patellar tendon–bone or triple/quadruple semitendinosus and gracilis graft will fill the necessary portions of the insertional sites on the tibia and femur. Graft regeneration follows Wolff's law such that it will reproduce the function of both bundles as the graft matures. New research strongly suggests that both ACL bundles work at relatively low flexion angles together rather than in a reciprocal fashion. The necessity and efficacy of a double-bundle reconstruction, with its technical challenges, have yet to be elucidated.