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ACL Tear
Updated: Oct 4 2016

Physeal sparing ACL reconstruction

Preoperative Patient Care
Operative Techniques

Preoperative Plan


Physical Exam and Imaging Analysis

  • Evaluate patient for concomitant injuries and lower extremity alignment. An AP hip to ankle x-ray can be obtained pre-op to confirm neutral alignment. If there is valgus present, if may need to be addressed with guided growth.
  • Review MRI for meniscal and chondral pathology

Room Preparation and Patient Positioning


Surgical instrumentation

  • Iliotibial band harvester. Options include open tendon stripper or curved meniscal knife.
  • The meniscal knife should have an angled neck to allow for proximal detachment
  • Long, broad Cobb elevator to free subQ tissue off of IT band.
  • Reinforcing suture for graft. #2 nonabsorbable or larger
  • Long curved clamp to retrieve IT band
  • Curved rasp to create groove in tibial ACL footprint
  • Burr to decorticate tibia.
  • Heavy nonabsorbable suture for femoral fixation. #2 or larger.
  • Heavy nonabsorbable suture (#2 or larger) or sturdy suture anchor for tibial fixation


OR Table

  • Radiolucent table in case C-arm is needed



  • Optional


Patient positioning

  • Supine at end of bed
  • Lateral thigh post
  • Consider placing tourniquet sterile after IT band harvest as it may impede proximal harvest.
  • Prep up to groin to have access to entire thigh for IT band harvest.


Perform appropriate physical exam under anesthesia

  • Lachmann test
  • Pivot Shift Test

Iliotibial Band Harvest and Preparation



  • 4-6 cm oblique incision on lateral knee from lateral joint line up to anterior IT band border


Isolate IT band

  • Will be immediately deep to subQ fat
  • Clear subQ tissue with Cobb elevator distally and proximally.
  • Can use a "windshield wiper technique to ensure all adhesions are freed.
  • Free adhesions a little more proximal than you intend to harvest. May need to be as much as 20 cm.


Harvest IT Band

  • Identify anterior and posterior borders of IT band and incise 2-3 mm away from each border.
  • Initial length of incisions in IT band should be 4-5 cm.
  • If using open tendon stripper, load incised part of IT band onto stripper and push tendon stripper proximal to desired length and truncate with cutting mechanism specific to stripper.
  • If using meniscal knife, use knife to extend anterior and posterior incisions proximal to desired length.
  • Make sure knife cuts do not converge proximally as this will lead to a small graft. If anything, err on having knife cuts diverge a bit to create a more fan shaped proximal harvest. This will create a thicker graft.
  • To connect the incisions proximally with meniscal knife and detach graft, have the knife positioned at the proximal extent of one of the cuts and angle the knife toward the other cut. Push across proximal IT band to connect the longitudinal cuts and detach graft.
  • If needed, a proximal counter incision can be made on thigh to expose and detach proximal IT band.
  • Release IT band distally from knee capsule but make sure to leave attached to Gerdy's tubercle.
  • Reinforce free end with heavy suture and place graft back into wound for later retrieval.

Diagnostic Arthroscopy


Perform Diagnostic Arthroscopy

  • This can be done before or after graft harvest based on surgeon preference/comfort with diagnosis.
  • Evaluate knee in standard fashion for any meniscal and/or chondral pathology
  • Address any pathology as appropriate prior to commencing ACL reconstruction.
  • Debride ACL stump enough to visualize over the top position.

Graft Passage into Knee


Clamp Placement

  • Widen anteromedial portal
  • Insert clamp through anteromedial portal and place into over the top position
  • Push clamp through posterolateral aspect of knee joint and advance until it emerges laterally in the IT band defect.
  • Open and close clamp periodically during passage to dilate soft tissues.
  • Palpate where the clamp is going to emerge laterally. Adjust direction as needed to make sure it emerges with IT band defect.


IT Band Passage into Knee

  • Open clamp and place reinforcing sutures from graft in teeth of clamp.
  • Pull clamp back through knee and bring sutures out anteromedial portal.
  • Pull sutures to bring graft to the over the top position and park it there.

Tibial Passageway and Groove Preparation


Tibial Incision

  • Create 3-4 cm vertical incision on anteromedial tibia that is medial to tibial tubercle apophysis and distal to proximal tibial epiphysis. It should be fairly in-line with more proximal anteromedial arthroscopic portal.
  • Fluoroscopy can be used in this step to ensure appropriate placement away from both growth plates.
  • Incise down to, but not through, periosteum.
  • Bluntly dissect proximally to level of joint


Tibial Groove Creation

  • Bluntly insert curved clamp into knee under intermeniscal ligament.
  • The surgeon's hand will need to be parallel or nearly parallel with floor at this point to get clamp under ligament.
  • Can also place a suture around IM ligament and retract it up to facilitate clamp passage
  • Open clamp to dilate soft tissue passageway
  • Replace clamp with curved rasp
  • Place rasp in tibial ACL footprint and create groove that extends from footprint to anterior tibial border.
  • This will allow for early bony healing of graft in joint and will allow graft to sit a bit more posterior to minimize chance of graft impingement.

Final Graft Placement and Fixation


Graft Passage Through Knee

  • Remove rasp and place clamp back in knee under the IM ligament via the tibial incision.
  • Grasp the sutures attached the graft (a portion of them will have been intra-articular this whole time) and pull them under the IM ligament and out the knee via the tibial incision.
  • Pull sutures to advance graft under the IM ligament and out the knee to emerge in the tibial incision.


Femoral Fixation

  • Pull on free end of graft while inspecting the graft as it wraps around the lateral femoral condyle.
  • If there is a soft tissue bridge between the graft passageway and the lateral femoral condyle, this should be released with scissors to ensure the graft lies flush against the lateral femoral condyle.
  • Allow knee to hang at a relaxed 90 degrees of flexion
  • With firm tension on the free end of the graft, place 3 to 4 figure 8 sutures securing the graft to the periosteum of the lateral femoral condyle.
  • This will provide femoral fixation of the graft as well as restore rotational stability to the knee. The fixation point of the graft is very near the native femoral footprint of the anterolateral ligament (ALL).
  • DO NOT externally rotate the foot during femoral fixation. This can overconstrain the knee in flexion.


Tibial Fixation

  • Place knee in full extension.
  • Expose and incise periosteum in tibial incision.
  • Elevate periosteal flaps with a Cobb
  • Do a minimal elevation laterally as this can be close to tubercle apophysis.
  • Decorticate exposed tibia with burr
  • Pull firm tension on graft to determine final position on the tibia.
  • Place at least three heavy sutures through each periosteal flap and graft.
  • When placing, pass sutures through graft a couple millimeters proximal from where they pass through the periosteum. This will help pull a little more tension on the graft when the knots are tied.
  • Place all sutures prior to tying.
  • With one person pull tension on graft and making sure it is reduced in the incision, a second person will tie the knots. A second assistant can be useful here as well.
  • An alternative mode of fixation can be with an interference screw or knotless suture anchor construct.
  • If this mode of fixation is chosen, the periosteum should still be sutured to the graft for back up fixation and to ensure graft incorporation to periosteum.
  • After final fixation, perform Lachman exam to confirm appropriate tension.

Proximal and Distal Fixation


Proximal fixation

  • pass loop device
  • visualize the loop device from the proximal incision
  • expose the lateral femoral cortex
  • position it so you can retrieve from tibial tunnel
  • use a drill tip to palpate the anterior and posterior femoral cortices
  • insert screw
  • drill a hole at the center of the shaft
  • insert a screw with a soft tissue washer
  • do not fully tighten at this point
  • place the suture loop around the screw
  • apply slight tension to the graft
  • this allows the loop to sit in the correct position around the screw
  • tighten the screw


Distal fixation

  • tension graft
  • tension distally with flexion/extension maneuvers
  • place a soft tissue staple distal to the growth plate for graft fixation
  • trim the remnants of the graft and check range of motion

Identify and Address Intraoperative Complications and Wound Closure


Wound closure

  • use 3-0 and 4-0 biosyn for closure


Dressings and immobilization

  • tegaderm and occlusive dressings
  • steri-strips
  • place in bledsoe and cryocuff
Postoperative Patient Care
Private Note

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