Anterior Cruciate Ligament Reconstruction: Bone Tunnel Placement, Graft Choice, and Graft Fixation

Anterior cruciate ligament (ACL) injury is an increasingly common knee injury. Due to the limited healing potential of the native ACL, surgical treatment most often consists of replacing the ACL with a new graft, fixed into bone tunnels in the tibia and femur. This technique is known as ACL reconstruction (ACL-R). Over the years, reconstruction techniques have evolved in a quest to obtain more consistent results and to replicate the native ACL more closely. Three key aspects of successful ACL-R are bone tunnel placement, graft choice, and graft fixation. Bone tunnel placement has changed throughout the years from open surgical approaches resulting in nearly anatomic tunnel placement, then many transitioned to arthroscopic techniques favoring surgical efficiency over anatomic placement, and more recently newer techniques that have allowed a return to more anatomic placement. Graft choice has also evolved, and commonly utilized options include autograft (bone-patellar tendon-bone, hamstring tendon, and quadriceps tendon) and cadaveric allografts. Graft fixation in ACL-R can be performed through a variety of techniques that can be categorized depending on where the ACL graft is fixed (i.e., intratunnel, cortical button, or extratunnel fixation) or based upon their underlying mechanisms (i.e., compression, suspension, expansion, and transverse femoral). The aim of this review is to understand current concepts and evidence-based recommendations for bone tunnel placement, graft choice, and graft fixation.