Courtesy Dr Patric W Joyuner, Dr Ashok Shyam, Ortho TV

 

ACL Reconstruction: Adjustable Loop Buttons & Soft Tissue Grafts

Introduction

• Focus on:
  • Soft tissue grafts
  • Femoral fixation
  • Adjustable loop devices
  • Practical surgical technique

ACL reconstruction can be simplified into:

1. Graft preparation
2. Femoral tunnel creation
3. Tibial tunnel creation
4. Tunnel drilling technique
5. Fixation method

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Graft Choice

Hamstring vs Bone–Patellar Tendon–Bone (BTB)

Similarities

No major difference in:

• Functional outcomes
• Clinical results
• Long-term osteoarthritis risk

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Patellar Tendon (BTB)

Advantages:

• Better static stability
• Lower graft failure in young athletes

Disadvantages:

• Increased anterior knee pain
• Higher donor site morbidity

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Hamstring Graft

Advantages:

• Less anterior knee pain
• Less kneeling pain

Disadvantages:

• Slightly increased laxity in some studies
• Mild reduction in knee flexion strength

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Meta-analysis Findings

• Four-strand hamstring grafts provide:
  • Comparable stability
  • Comparable function
  • Lower anterior knee pain compared with BTB grafts

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Osteoarthritis Risk

• ACL injury itself initiates degenerative change
• No major long-term difference between:
  • Hamstring graft
  • BTB graft
  • Likely quadriceps tendon graft as well

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Age-Based Outcomes

Patients <20–25 Years

• BTB graft shows lower failure rate
• Hamstring graft may have:
  • 3–3.6× higher failure rate

Reason:

• Higher activity level in younger patients

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Patients >25 Years

• No significant difference between graft types

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Graft Size: Critical Concept

Most Important Technical Factor

Graft Diameter >8 mm

• Failure rate <2%

Graft Diameter <8 mm

• Failure rate may rise to 7–14%

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Surgical Pearl

• If graft is small:
  • Fold graft to increase diameter

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Graft Preparation Technique (SpeedTrap)

Advantages:

• Fast preparation
• Strong fixation
• No tendon holes required
• Less graft damage

Evidence:

• Comparable strength to FiberLoop
• Faster than traditional techniques

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Important Caution

• Suture material matters
• FiberWire may damage tendon before suture failure

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Tunnel Drilling System (Twister)

Features

• Adjustable reamer:
  • 6–12 mm
  • Half-size increments

Advantages:

• Cost-effective
• Single instrument for multiple tunnel sizes

Applications:

• ACL reconstruction
• PCL reconstruction
• Meniscal root repair

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Tibial Tunnel Technique

Circle Guide

Advantages:

• High reproducibility
• Central tunnel placement
• Reduces anterior/posterior malposition

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Femoral Fixation Devices

Fixed Loop vs Adjustable Loop

Fixed Loop Devices

• Approximately 1.3 mm displacement

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Traditional Adjustable Loop Devices

• Up to 4 mm displacement
• Potential biomechanical concern

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Rigid Adjustable Loop Devices

Advantages:

• Lower displacement (~1.7 mm)
• Comparable to fixed loop devices
• Better stability
• Less stretching

Considered superior to traditional adjustable systems.

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Surgical Pearls

Notch and Tunnel Preparation

Avoid Routine Notchplasty

Reasons:

• Preserves anatomy
• Prevents unnecessary bone removal

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Preserve PCL Fibers

Benefits:

• Better orientation
• Anatomical reference

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Preserve Small Tibial Stump

Benefits:

• Helps proprioception

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Femoral Tunnel Placement

Preferred Position

• Posterior placement preferred

Important principle:

• Posterior error is safer than anterior error

Reason:

Posterior Blowout

• Salvageable with suspensory fixation

Anterior Tunnel Placement

• Poor biomechanics
• Higher failure risk

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Intraoperative Positioning

Figure-of-4 Position

Advantages:

• Better visualization
• Protects lateral meniscus during debridement

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Final Recommendations

Hamstring Graft

Good option if:

• Diameter >8 mm

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Patients >20 Years

• Hamstring graft equivalent to BTB in most cases

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Younger Athletes

Consider:

• BTB graft
• Quadriceps tendon graft

Reason:

• Larger graft size
• Lower failure risk

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Key Takeaways

• Graft size is one of the strongest predictors of success
• Aim for graft diameter >8 mm
• Younger age increases graft failure risk
• Rigid adjustable loops provide:
  • Better stability
  • Less displacement
  • Reliable fixation
• Posterior femoral tunnel positioning is safer than anterior malposition

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Reported Outcome