Stage I Revision ACL Reconstruction With Allograft Bone Dowels

When evaluating a patient with a failed anterior cruciate ligament (ACL) reconstruction, a detailed history and physical examination is paramount. The position and size of original femoral and tibial tunnels are critical in the surgical decision-making in the setting of revision ACL reconstruction. This video presents a case of stage I revision ACL reconstruction with the use of allograft bone dowels due to increased size and poor position of original fixation tunnels.

Indications for staging revision ACL reconstruction include significant tunnel osteolysis or dilation (>14 mm), or any situation in which the previous bone tunnels will interfere with anatomic graft placement and fixation.

The patient is placed in the supine position with a standard setup for knee arthroscopy, including lateral thigh post and foot stop for maintained knee flexion at 90°. After diagnostic arthroscopy, the ACL graft remnant is debrided. The femoral tunnel is then debrided and re-cannulated, followed by reaming with cannulated reamers until adequate cortical chatter is achieved, ensuring the presence of a bleeding rim of bone throughout the tunnel to confirm that the correct diameter reamer has been reached. The appropriately sized bone dowel is inserted along the guide pin until fully seated and flush with lateral wall of the notch. This process is then repeated for the tibial tunnel, accessing the tunnel from the previous incision along the medial tibia.

This video presents a technique to achieve adequate bone grafting of previously used tunnels that are not suitable for single-stage revision ACL reconstruction. Patients undergo second-stage revision ACL reconstruction at roughly 4 to 6 months following stage I, when bone graft has fully incorporated on radiographs.

Stage I revision ACL reconstruction with tunnel grafting using allograft bone dowels is a minimally invasive method of grafting previously used fixation tunnels to allow for anatomic second-stage graft placement and fixation.

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