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, 51 (4), 385-95

Anterior Cruciate Ligament - Updating Article


Anterior Cruciate Ligament - Updating Article

Marcus Vinicius Malheiros Luzo et al. Rev Bras Ortop.


This updating article on the anterior cruciate ligament (ACL) has the aim of addressing some of the most interesting current topics in this field. Within this stratified approach, it contains the following sections: ACL remnant; anterolateral ligament and combined intra and extra-articular reconstruction; fixation devices; and ACL femoral tunnel creation techniques.

Keywords: Anterior cruciate ligament; Joint instability; Knee; Patellar ligament; Reconstructive surgical procedures.


Fig. 1
Fig. 1
Arthroscopic classification of the ACL remnant.
Fig. 2
Fig. 2
Recommended ACLR type that preserves the remnant.
Fig. 3
Fig. 3
ACLR involving current concepts of remnant tissue preservation and extra-articular reinforcement with iliotibial tract band (monoloop) and reconstruction of the anterolateral ligament. (A) ACL injury with presence of remnant tissue. Morphological type: scarring at the intercondylar roof (III). Remnant functionality (assessed with probe): functional. No. 5 Ethbond wire passed from the femoral tunnel to the tibial tunnel, showing tissue preservation with tibial tunnel made in the periphery of the footprint and preserving the remnant. The graft will be passed alongside it, thus maintaining the remnant functional fibers and its tibial and femoral inserts. (B) AG ACLR that preserves the remnant. AG-augmentation: ACLR in a partial lesion involving one or both bundles with functional remnant tissue. Estimated percentage of graft coverage by the remnant tissue: 30%. The line separates the graft in the inferior region and the remainder in the superior portion. (C) ACL injury with presence of remnant tissue. Morphological type: unidentifiable pattern, scarred at the lateral femoral condyle (IV). Remnant functionality (assessed with probe): nonfunctional. A path was created within the remnant shell with the shaver, which opens it proximally (the tip of the shaver can be seen protruding through the remainder of the enclosure). All tissue in the periphery is maintained, and only a central path is created, to pass the graft. (D) ACL Remnant-preserving reconstruction type NFRP. NFRP – nonfunctional remnant preservation: ACLR in a complete lesion involving both bundles with non-functional remnant tissue. The graft was passed through the center of the tibial footprint and encased by the remnant tissue, which will act as a biological sleeve, whether by the remnant synovial sheath, remnant ligament tissue, or both. Estimated percentage of graft coverage by the remnant tissue: 60%. Arrow shows graft exit within the remnant. (E) Extra-articular ACL reinforcement with isolated iliotibial band (derivative monoloop, similar to the extra-articular techniques by MacIntosh and Lemaire). The central one-third of the iliotibial tract is dissected with 1–1.5 cm thicknesses, maintaining its distal insertion and releasing its proximal insertion. This is prepared with Krackow suture with No. 5 Ethbond wire. A Kelly clamp is passed deeply into the lateral collateral ligament (arrow) to allow for central iliotibial tract band passage after proximal release and preparation. The central third of the iliotibial tract with 1–1.5 cm thicknesses is already made. (F) Center band of the iliotibial tract already deeply passed by the lateral collateral ligament (arrowhead) and inserted into the distal insertion of the lateral intermuscular septum of the femur, as shown by the arrow (one of the recommended points for insertion of extra-articular reinforcements in ACLR) after satisfactory isometric test. The reinforcement is fixed with an interference screw or anchor with knee at 90° flexion and neutral rotation after ACLR and fixation. In this case it was made with quintuple flexor grafts, outside-in femoral tunnel (aiming to avoid conflict with the femoral tunnel for the fixation of extra-articular reinforcement) and fixation with absorbable interference screw in the femur and tibia. This case demonstrates primary ACLR and extra-articular reinforcement was indicated due to the presence of explosive pivot. (G) Open reconstruction of the anterolateral ligament with gracilis graft combined with ACLR with triple semitendinosus graft. The arrow shows the femoral insertion of the anterolateral ligament. (H) Percutaneous reconstruction of the anterolateral ligament with gracilis graft combined with ACLR with triple semitendinosus graft. The arrow shows the femoral origin and the wire demonstrates the bone tunnels used for tibial insertion of the anterolateral ligament. In this type of reconstruction, the graft is passed superficially to the lateral collateral ligament.

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