ACL RETRO RECONSTRUCTION

Abstract

Arthroscopic controlled retrograde drilling of femoral and tibial sockets and tunnels using a specially designed cannulated drill pin and retrocutter (Arthrex Inc, Naples FL.) provides greater flexibility for anatomical graft placement and in revision cases avoids previous tunnels and intra osseus hardware. Inside out drilling of femoral and tibial sockets minimises incisions and eliminates intra articular cortical bone fragmentation of tunnels rims common to conventional antegrade methods. This technique is also ideal for skeletally immature patients since drilling and graft fixation through growth plates may be avoided. Initial tunnel-referencing cannulated drill guide pin placement is carried out from outside-in. This technique (out-in/in-out) combines the advantages of the two-incision and the one-incision technique. In fact it permits us, as in the two-incision technique, to drill a pin guide from outside to inside in order to obtain the correct anatomical insertion of the ACL, otherwise not reproducible from inside-out.

Since November 2004 our preferred technique for hamstring (autogenous quadrupled semitendinosis/ gracilis) ACL reconstruction incorporates the above mentioned femoral socket creation. In recent years, arthroscopically assisted ACL reconstruction has become the procedure of choice. Initially, arthroscopic techniques required two incisions for outside-in drilling of bone tunnels, but there has been a trend toward using a single incision with inside-out of the femoral tunnel. Those who advocate the two-incision technique state that they do so primarily because they believe that the two-incision procedures makes accurate femoral tunnel placement easier. Harner found no difference in tunnel placement using the two techniques, while Schiavone found that the inside-out femoral tunnels were significantly more vertical in the one-incision procedure.

We have performed two-incision ACL reconstruction routinely since 1977, with very favourable results. The recent variation in our technique affords a reduction in morbidity, associated with improved cosmesis and quicker post-operative recovery. One factor related to our success appears to be a more anatomically positioned femoral tunnel, which in our hands, is difficult to accomplish with the single incision trans-tibial femoral socket creation. The retro-drill technique allows preparation of the correct anatomical femoral and tibial socket or tunnel, either with a very small lateral skin incision or without any skin incisions if the surgeon is using an allograft, and appears to represent a promising future technique in ACL reconstruction.