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So let's first talk about anterior cruciate

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ligament reconstructions.

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What is the main goal?

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Well, we're basically trying to stabilize the joint in terms

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of translational and to a less degree rotatory instability,

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um, by restoring that native ACL anatomy and function.

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Now, the prevalence of recurrent instability

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after ars pretty low, quoted about one

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to 8% in the literature,

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and most of the failures occur in the first six months.

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And that could be related to failure

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or graft incorporation, surgical net technique,

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or even errors in the rehabilitation stage.

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As many, many of you probably are aware if you fall

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any professional sports.

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Um, professional athletes

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who suffer an ACL tear are usually out, uh,

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for the better part of a year, um, meaning that, uh,

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they have to undergo extensive rehabilitation

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before they can return to sport.

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So in terms of graft options, uh, there are two main graphs.

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Um, these are either autograph,

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meaning they come from the patient themselves

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or allograft, meaning usually a cadaveric donor.

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And so some of the popular autographs,

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what is considered main, the main kind of gold standard

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to this day is the bo the patella tendon autograph,

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or more correctly referred to

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as the bone patella tendon bone autograph.

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And, uh, the reason why I refer to it as such is

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because when you harvest the patella tendon, you, uh,

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the surgeon will take small, uh,

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bone plugs from both the patella

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and the tibial tuberosity

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to implant into the femoral and tibial tunnels.

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Uh, another popular graph is quadriceps, uh,

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distal quadriceps tendon,

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often harvesting a small bone plug from the, uh,

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superior pole of the patella.

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And then, uh, what my wife had was hamstring autograph,

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usually comprised of two tendons that are harvest.

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So the semi tendinosis and gracilis.

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These are often looped on each other.

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So from two, you move to four tendon, uh, fibers,

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uh, or tendon, uh, loops within your graft.

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So you have a quadruple, uh, tendon graft.

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Others that are less commonly seen are iliotibial band,

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and these, uh, sometimes are used in those lateral extra

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articular 10 dcs.

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So again, when you, um, are confronted with a patient, uh,

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who have o obviously had previous surgery,

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but you don't have access to surgical notes,

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you can always do a little bit of your own detective work.

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Looking at the scan,

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this is a patient had a previous hamstring autograph.

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Remember, uh, the, the, um, pla tendons, which is Latin

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for gooses foot, so your sartorious, gracilis,

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and semi tendinosis.

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It is these latter two tendons that are harvested for,

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um, hamstring autographs.

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And here in this patient after harvesting, you can see

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that the tendons are thickened in irregular

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appearance, especially the

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Semi tendinosis, which has a substantially thicker

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appearance than a native tendon.

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Here's the same patient just on carotal images.

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You can see the thickened appearance of the semi tendinosis,

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uh, tendon falling hamstring harvesting.

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Now it's important to realize that these hamstrings, uh,

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tendons are harvested in their entirety.

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So they're basically stripped with at tend stripper,

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and they do, uh, to some degree reconstitute.

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And it's not entirely understood how they reconstitute,

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but probably the tunnels that are left behind

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where the tend used to be, uh, form sort of a conduit

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for fibrosis and collagen deposition along the course

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of those harvested tendons.

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But it's been found in the literature that, uh,

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these neo tendons are structurally inferiorly

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and should not be used, um, again,

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for another harvesting, uh, procedure.

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The other graph that I spoke about with the,

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which is considered, uh, to this day, uh, more

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or less the gold standard, is the patella bone patella

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tenon autograph.

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Now, you may be able to even parse this out on radiographs.

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Look for this, uh, uh,

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defect within the central third of the patella.

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You can sometimes also see it on your frontal radiographs,

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but much better seen on your merchant

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or, um, uh, sunrise views.

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And sometimes when you on your sunrise views,

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you may even get a little bit

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of the tibial tuberosity poking through,

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and you can see a bony defect corresponding

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to the distal portion of the graft that was harvested.

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This is the MRI of the same patient.

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Again, you can show,

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see the bony changes in the central third of the patella.

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And as you look more inferiorly, um,

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you can often see a central cleft in the middle third of

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that patella tendon.

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On sagal images, you may see slight thickening

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and irregularity of that patella tendon, not to be confused

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with some underlying patellar tendinosis or tendon tearing.

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This is just a normal postoperative appearance

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of a patellar tendon that's been harvested.

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So patellar tendon harvest is a relatively benign procedure.

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Um, there may be some issues with donor site pain,

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particularly when patients kneel.

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Um, rarely with over aggressive harvesting

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of the bone plugs, you can have patellar fracture.

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And here's just an example from the literature.

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Luckily I've not seen a case at our institution,

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but you can see you kind of, sort

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of a over aggressive harvesting of bone, uh, leading

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to a fracture through the lateral patellar facet,

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which you can see also here on radiographs.

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Here's what a quadriceps, uh, harvest site might look like.

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Similar to the patella tendon,

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you may see a defect in a central third

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of the patella tendon, as well

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as some osseous changes from bone plug harvesting from

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the superior pole, the patella.

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But note that the patella tendon more inferiorly is normal,

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so this is a quadriceps autograph.

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And finally, this is, uh, an unusual case

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of an iliotibial band.

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Uh, autograph. Uh, portions

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of the iliotibial band will be harvested

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to create a split thickness graft that is rerouted

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through the distal femur to, uh, create the, um,

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an reconstructed anterior cruise ship ligament.