ACL reconstruction: Surgical approaches and anatomic considerations in 2014

An anterior cruciate ligament (ACL) tear is one of the most common injuries seen by orthopaedic surgeons and is the most common complete ligamentous injury in the knee. Recent reports indicate that over 250,000 ACL reconstructions are performed each year in United States. Recent studies have emphasized the importance of anatomic tunnel placement during ACL reconstruction in an effort to restore normal knee kinematics, stability, and improve outcomes. ACL reconstruction was first described as an open technique, followed shortly by the outside-in, two-incision techniques, both of which provided relatively anatomic reconstruction methods. The transtibial technique became popular with the advent of offset guides early in the 1990s. The current trend appears to be shifting back towards anatomic reconstruction of the ACL through outside-in drilling or anteromedial-portal drilling. The objective of anatomic single- or double-bundle reconstruction is to restore a maximal percentage of the native ACL footprint attachment on the femur and tibia and thereby stability of the knee. This article discusses the most up-to-date literature on the anatomic considerations in ACL reconstruction, with a primary emphasis on restoring the anatomic footprint.