Table 2.

Technical Pearls and Pitfalls

Pearls

1. Careful assessment of the ACL for suitability for repair determines outcome. Proximal avulsions with excellent tissue quality only are suitable for repair. In case of doubt, perform a standard anatomic ACL reconstruction with remnant preservation.

2. A central portal greatly improves visualization of the femoral insertion site of ACL.

3. Only high-strength suture material must be used, preferably with a self-retrieving suture passing instrument.

4. A low accessory medial portal provides a straight trajectory for insertion of the suture anchor.

5. Augmentation with high-strength suture tape provides initial stability, protects the repair, and allows early range of motion.

Pitfalls

1. Strict selection of patients who are amenable for an ACL repair makes or breaks this surgery and its outcome.

2. Visualizing the femoral insertion site through the anterolateral portal, as is usually done during ACL reconstruction, can compromise precise suture anchor placement at the femur.

3. Passage of sutures through the ACL stump must be through the bulk of the tissue to improve grasp and purchase. This precision is possible by using a device, which allows simultaneous grasping of the stump and suture passage at the desired site. Also, sutures must be passed in the anteroposterior and mediolateral direction to improve purchase, and the slack in the suture must be removed after each pass.

4. There is only one attempt possible for fixing the ACL stump with the suture anchor, and retensioning is not possible. Hence, utmost care has to be taken to maintain adequate tension and not leave the ACL slack after fixation.

5. The awl and suture anchor are introduced through the accessory medial portal to maintain a straight trajectory, with the knee in 90° of flexion.

ACL, anterior cruciate ligament.