Graft choice

There are 3 main graft choices for ACL reconstruction:
1. Hamstrings
2. Bone-patellar tendon-bone (BPTB) graft
3. Quadriceps

Hamstrings
The hamstring tendon autograft is a popular choice for ACL reconstruction due to several advantages it offers. This graft involves harvesting a portion of the semitendinosus and gracilis tendons from the hamstring muscles at the back of the thigh.

Compared to other autograft options like the bone-patellar tendon-bone (BPTB) graft, the hamstring graft is associated with less anterior knee pain and extensor mechanism complications. The harvest site morbidity is generally lower, leading to a more comfortable post-operative recovery.

The hamstring tendons provide a strong, flexible graft with excellent biomechanical properties for ACL reconstruction. They can be quadrupled or tripled to create a robust graft construct, mimicking the native ACL's strength and stiffness.

One advantage of the hamstring autograft is the ability to create anatomic graft placement, closely replicating the native ACL's footprint. This may lead to better rotational stability and more natural knee kinematics.

Overall, the hamstring tendon autograft is a versatile and widely-used option for ACL reconstruction, offering advantages in terms of reduced morbidity, anatomic graft placement, and good biomechanical properties.

Bone Patella Tendon Bone

Bone-patellar tendon-bone (BPTB) graft involves harvesting a central strip of the patellar tendon along with a bone plug from the patella (kneecap) and a bone plug from the tibial tubercle.

One of the key advantages of the BPTB autograft is its robust fixation and rapid incorporation into the bone tunnels, facilitated by the bone-to-bone healing. This graft construct is strong and can closely restore the native ACL's biomechanical properties.

Additionally, the BPTB autograft allows for precise graft placement, replicating the native ACL footprint and restoring knee kinematics.
However, the BPTB autograft is not without drawbacks. The graft harvest can lead to anterior knee pain, quadriceps weakness, and potential patellofemoral complications.

There is also a risk of patellar fracture, tendon rupture, and numbness around the incision site.

Quadriceps Tendon

The quadriceps tendon autograft involves harvesting a portion of the quadriceps tendon along with a bone block from the patella.
One of the main benefits of the quadriceps tendon autograft is the reduced harvest site morbidity compared to other autografts like the bone-patellar tendon-bone (BPTB) or hamstring tendons. The quadriceps tendon has a rich blood supply, facilitating rapid
graft integration and healing.

However, the quadriceps tendon autograft is not without drawbacks. There is a risk of quadriceps weakness, especially in the early post-operative period, which may impact rehabilitation progress. Furthermore, the graft size may be limited in smaller patients, potentially compromising graft strength and stiffness.

Overall, the quadriceps tendon autograft is a viable option for ACL reconstruction, offering advantages in terms of reduced morbidity, preservation of knee biomechanics, and potentially faster recovery. Proper surgical technique, graft sizing, and rehabilitation are crucial for optimizing outcomes with this graft choice.

Lateral extra-articular tenodesis

Lateral extra-articular tenodesis (LET) is a surgical technique that can be performed in conjunction with ACL reconstruction. The purpose of LET is to provide additional rotational stability to the knee joint.

During the ACL reconstruction procedure, a graft is used to replace the torn ACL. However, this intra-articular graft alone may not fully restore rotational control of the knee, especially in patients with hypermobility or chronic ACL deficiency.

LET involves taking a tendon graft (commonly the iliotibial band or a portion of the hamstring tendon) and creating an extra-articular restraint on the lateral side of the kneejoint. This tenodesis graft is passed through bone tunnels and anchored, acting as a
checkrein to limit excessive internal rotation of the tibia.

This is an additional procedure, performed at the same time as ACL reconstruction in selected patients. It involves taking a 1cm strip of iliotibial band on the outside of the knee, keeping it connected to the outside of the shinbone (tibia) and securing it to
the side of the thigh bone (femur). The latest high-level evidence shows that this additional procedure can dramatically reduce the failure rate of ACL reconstruction in selected patients.

Rehabilitation
Rehabilitation plays a crucial role in recovering from ACL reconstruction surgery, aiming to restore knee function, strength, and stability. The rehabilitation process is typically divided into several phases, with specific goals and exercises for each
phase.

The initial phase, lasting 2-4 weeks, focuses on reducing swelling, regaining knee range of motion, and activating the quadriceps muscle. Exercises may include quadriceps sets, ankle pumps, and gentle knee flexion/extension movements.

The next phase, lasting around 6-12 weeks, emphasizes progressive strengthening and neuromuscular control. Exercises may include closed-chain exercises like leg presses, step-ups, and balance/proprioception training. Stationary cycling and pool
exercises are often incorporated.

The advanced phase, typically from 3-10 months post-op, focuses on sport-specific training, agility drills, and plyometric exercises. The goal is to prepare the patient for a safe return to their desired activities.

Throughout the rehabilitation process, adherence to the prescribed exercises and progression protocols is crucial. Factors such as graft type, concomitant injuries, and individual progress may influence the rehabilitation timeline.

Regular follow-up with the physiotherapy team and Tom Kurien is essential to monitor progress, address any setbacks or complications, and ensure a successful recovery. Proper rehabilitation can help optimize outcomes, reduce the risk of re- injury, and facilitate a safe return to sports or other activities.

Tom Kurien has developed protocols with several physiotherapists in order to ensure the best physiotherapy is delivered.