title: Anterior cruciate ligament revision: double-bundle augmentation of primary vertical graft.
abstract: A variety of factors contribute to the failure of primary anterior cruciate ligament (ACL) reconstruction; most commonly, it is technical error related to tunnel placement. Recently, the increasing popularity of the all-endoscopic ACL reconstruction and concern about graft impingement may have led to more posterior placement of the tibial tunnel by surgeons. Working through a tibial tunnel placed too posterior makes it more difficult to recognize the correct starting position on the femur, and more likely to start the femoral tunnel in a central 12 o'clock position. The combination of subtle posterior placement of the tibial tunnel and central placement of the femoral tunnel results in a graft that is malpositioned in both the sagittal and coronal planes--a "vertical graft." We present a novel method of ACL revision surgery applicable to a specific subset of ACL revision patients with an intact "vertical graft" and instability that is rotational more than translational. In these patients, a double-bundle revision ACL augmentation technique can be used, leaving the original graft in place. A new tibial tunnel is placed anterior to the original and a new femoral tunnel lateral to the original. Reconstruction is performed with allograft and the combined ACL construct provides robust translational and rotational stability to the tibiofemoral joint.
authors.affiliation: Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, New York 10021, USA. brophyr@hss.edu
authors.forename: Robert H
authors.initials: RH
authors.lastname: Brophy
authors.forename: Ronald M
authors.initials: RM
authors.lastname: Selby
authors.forename: David W
authors.initials: DW
authors.lastname: Altchek
mesh_terms: D016118:Anterior Cruciate Ligament / Q000601:surgery*; D050376:Bone-Patellar Tendon-Bone Grafting / Q000379:methods*; D004724:Endoscopy / Q000009:adverse effects*; D006801:Humans; D019651:Plastic Surgery Procedures / Q000009:adverse effects*; D012086:Reoperation; D017211:Treatment Failure