General Technical Consideration in Arthroscopic Anterior Cruciate Ligament Reconstruction

Abstract

An essential step in successful ACL reconstruction is achieving appropriate tunnels or sockets for graft placement and fixation. Several drilling techniques have been described, all of which have their justification in respect to different operation and fixation strategies [6]. For single-bundle ACL reconstruction, one bone tunnel is needed in the femur and one in the tibia. There are four primary techniques for femoral drilling: inside-out anteromedial portal (AMP) technique, outside-in (OI) technique, outside-in retrograde-drilling (RD) technique, and endoscopic transtibial (TT) technique [15]. Basically two possibilities for tibial drilling exist, also: outside-in technique and outside-in retrograde drilling. Combinations are possible and commonly applied (i.e., outside-in tibial and inside-out femoral drilling). Whether the femoral or tibial tunnel is placed first is up to the surgeon since transtibial femoral drilling is on the decline due to less anatomical tunnel positioning [1, 10]. Primary femoral drilling can facilitate arthroscopy. Fluid loss through tibial tunnel can be controlled with a plug after primary tibial tunnel placement. In general, anatomic tunnel placement is more important than the actual drilling technique [4, 13]. The surgeon must adapt drilling to chosen graft, available instruments, desired fixation method, and individual skills.