Abstract
Technique Video
Video demonstrating arthroscopic technique for staged bone grafting of tunnels for first stage of staged revision ACL reconstruction. Causes of ACL failure can be traumatic, technical, and biological in nature, and are frequently multifactorial. Infection represents <1 % of failure etiology. Factors to consider when planning for two stage revision include tunnel size, tunnel convergence, tunnel position, bone loss, and infection. The goal of the first stage bone grafting is to debride prior tunnels while preserving as much native bone stock as possible, and to use a bone graft matrix that results in reliable osseous integration. The arthroscopic video shows a right knee viewed through anterolateral portal looking at the notch with the lateral femoral wall on left of the screen. The prior ACL graft has largely been debrided and all hardware has been removed. An arthroscopic biter is used to debride graft from notch and tunnel. Debridement is performed by alternating between biter and a motorized shaver. The shaver is also used to debride lateral wall to better visualize femoral tunnel placement. A small straight curette is used to continue debridement in the femoral tunnel. The goal of debridement is to remove all prior graft material to reach healthy native bleeding bone. One should observe small punctate bleeding in tunnel once adequate debridement is performed. Next, an accessory medial portal is established with needle localization to confirm the trajectory to access femoral tunnel for graft placement. A 3 cc syringe is modified to delivery graft by cutting off the tip while retaining the plunger and hub. The syringe is then packed with cancellous chips, cortical fibers, whole blood, platelet rich plasma to backfill tunnels. This substrate is then introduced via accessory medial portal directly into the femoral tunnel using the modified syringe. The bone graft is deployed, and plunger can be used to gently pack graft into tunnel. A tamp is used to further compress the graft. This process is repeated until there is full fill of femoral tunnel. The prior skin incision is typically used to expose the distal portion of the tibial tunnel. This tunnel is then reestablished with a straight curette to enter the joint under arthroscopic visualization from outside in. Debridement of the tibial tunnel is started with the curette, then continued with the motorized shaver. Again, debridement is considered adequate when all prior graft has been removed and small punctate bleeding is observed in tunnel walls. The same modified 3 cc syringe used to introduce graft in outside in fashion and arthroscope is used to confirm there is no extravasation of graft material into joint. A key elevator placed intraarticularly can be used to prevent graft from being impacted into the joint.

Technique (With Video Illustration)
Patient Evaluation
Indications for Two-Stage Reconstruction
Associated Procedures
Surgical Technique






Postoperative Management
Criteria to Proceed With Stage 2 (Revision ACLR)

Discussion
Cancellous Bone Chip Allograft | Iliac Crest Dowel, OATS Technique | |
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Advantages |
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Disadvantages |
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Pearls | Pitfalls |
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Perform single-stage revision when possible | Revision tunnel placement malpositioning |
Consider 1- stage revision in the setting of: | Debride remnant ACL to visualize lateral notch wall and tibial footprint |
Concern for infection | Normal landmarks may be significantly altered from index procedure |
Tunnel malposition and/or enlargement that compromises revision graft position or fixation | Remove hardware interfering with ideal revision tunnel placement |
Need for advanced cartilage procedures, meniscal transplantation, osteotomy | Inadequate femoral tunnel debridement and grafting |
Preoperative planning includes: | Use accessory medial portal placed with needle localization (Fig 2) to ensure appropriate working angle |
Assessment of location of tunnels, cysts, hardware | Debride to healthy bleeding cancellous bone |
Quantification of bone loss | Insufficient tibial tunnel grafting |
Specific equipment required for prior hardware removal | Often requires more graft material (8-20 cc) |
Retain hardware if no concern for infection and no interference with tunnel positioning | Use key elevator placed intraarticularly to prevent graft from being impacted into joint |
Supplementary Data
- ICMJE author disclosure forms
- Video 1
Video demonstrating arthroscopic technique for staged bone grafting of tunnels for first stage of staged revision ACL reconstruction. Causes of ACL failure can be traumatic, technical, and biological in nature, and are frequently multifactorial. Infection represents <1 % of failure etiology. Factors to consider when planning for two stage revision include tunnel size, tunnel convergence, tunnel position, bone loss, and infection. The goal of the first stage bone grafting is to debride prior tunnels while preserving as much native bone stock as possible, and to use a bone graft matrix that results in reliable osseous integration. The arthroscopic video shows a right knee viewed through anterolateral portal looking at the notch with the lateral femoral wall on left of the screen. The prior ACL graft has largely been debrided and all hardware has been removed. An arthroscopic biter is used to debride graft from notch and tunnel. Debridement is performed by alternating between biter and a motorized shaver. The shaver is also used to debride lateral wall to better visualize femoral tunnel placement. A small straight curette is used to continue debridement in the femoral tunnel. The goal of debridement is to remove all prior graft material to reach healthy native bleeding bone. One should observe small punctate bleeding in tunnel once adequate debridement is performed. Next, an accessory medial portal is established with needle localization to confirm the trajectory to access femoral tunnel for graft placement. A 3 cc syringe is modified to delivery graft by cutting off the tip while retaining the plunger and hub. The syringe is then packed with cancellous chips, cortical fibers, whole blood, platelet rich plasma to backfill tunnels. This substrate is then introduced via accessory medial portal directly into the femoral tunnel using the modified syringe. The bone graft is deployed, and plunger can be used to gently pack graft into tunnel. A tamp is used to further compress the graft. This process is repeated until there is full fill of femoral tunnel. The prior skin incision is typically used to expose the distal portion of the tibial tunnel. This tunnel is then reestablished with a straight curette to enter the joint under arthroscopic visualization from outside in. Debridement of the tibial tunnel is started with the curette, then continued with the motorized shaver. Again, debridement is considered adequate when all prior graft has been removed and small punctate bleeding is observed in tunnel walls. The same modified 3 cc syringe used to introduce graft in outside in fashion and arthroscope is used to confirm there is no extravasation of graft material into joint. A key elevator placed intraarticularly can be used to prevent graft from being impacted into the joint.
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Footnotes
The authors report the following potential conflicts of interest or sources of funding: D.C.F. reports grants and other from Smith & Nephew, other from Depuy Mitek, grants and other from Zimmer Biomet, grants and other from Vericel, other from MTF, other from KCRN, other from Hyalex, grants and other from CartiHeal, grants and other from Anika Therapeutics, grants and other from Aesculap, and grants and other from Moximed, outside the submitted work. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
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