Anterior cruciate ligament graft placement recommendations and bone-patellar tendon-bone graft indications to restore knee stability.

The anterior cruciate ligament (ACL) resists the combined abnormal motions of anterior tibial translation and internal tibial rotation that occur in the pivot-shift phenomenon. The placement of a single ACL graft high and proximal at the femoral attachment and posterior at the tibial attachment results in a vertical graft orientation. This graft position has a limited ability to provide rotational stability. A more oblique ACL graft orientation in the sagittal and coronal planes achieved from a central anatomic femoral and tibial location provides an orientation that is better in resisting the pivot-shift phenomenon. Tibial and femoral tunnels are drilled independently; transtibial drilling of the femoral tunnel is not recommended. The meticulous surgical technique for ACL reconstruction includes identifying the appropriate landmarks to achieve correct graft placement. There are insufficient experimental and clinical data to recommend the more complex double-bundle ACL graft technique over a central anatomic single graft in terms of restoring knee rotational stability. Allografts are used only in select knees for which autograft tissue is not available. The postoperative rehabilitation program takes into account the condition of the menisci and articular cartilage and associated reconstructive procedures.