Anterior Cruciate Ligament (ACL) Tears: ACL Reconstruction Using a Bone-Tendon-Bone Graft

Anterior Cruciate Ligament (ACL) Tears: ACL Reconstruction Using a Bone-Tendon-Bone Graft

In this surgical demonstration on a left cadaver knee, a full tunnel has already been drilled from the outside into the shin bone or tibia, and a socket drilled in the thigh bone, or femur. The looped passing suture is also in place, ready to bring the graft through the tunnel in the front of the shin bone into the joint. The sutures that are attached to the first bone plug are passed through the joint into the tunnel in the thigh.

Here, the metal button is being passed up through the tunnel, which will eventually sit against the outside of the thigh bone. By moving the camera to the other side of the knee, the button can be seen going all the way up the tunnel to the outside of the bone. Once the button is settled on the outside of the femur, the tensioning sutures are pulled to bring the first bone plug into the socket. The surgeon will use an instrument to help guide the bone plug into the socket.

Here, the bone plug is fully seated in the socket. Only the soft tissue of the patellar tendon graft can be seen. This will act as the new ACL. Since the graft was pulled into the knee through the tunnel in the tibia, the second bone plug is already in place in the tunnel. This large blue suture will be used to help support the ligament during the early phases of healing. The surgeon will use an anchor to fix it to the front of the shin bone.

First, a small hole is drilled and then the anchor is used to secure the suture to the bone. The other set of sutures still attached to the bone plug in the tibia are pulled tight, and a screw that will absorb into the bone over time is inserted to hold the second bone plug in place. Here is the final graft. If needed, the surgeon can pull the tensioning sutures from the femur to make the graft tighter. You can see the graft tighten up just a little bit.

The surgeon does one final check to make sure the graft is under the appropriate tension and the surgery is complete.