Anatomic Anatomic Anterior Cruciate Ligament Reconstruction Research Articles

Prevention of graft-tunnel mismatch during anatomical anterior cruciate ligament reconstruction using a bone-patellar tendon-bone graft.

Graft-tunnel mismatch of the bone-patellar tendon-bone (BPTB) graft is a major concern during anatomical anterior cruciate ligament (ACL) reconstruction if the femoral tunnel is positioned using a far medial portal technique, as the femoral tunnel tends to be shorter compared with that positioned using a transtibial portal technique. This study describes an accurate method of calculating the ideal length of bone plugs of a BPTB graft required to avoid graft-tunnel mismatch during anatomical ACL reconstruction using a far medial portal technique of femoral tunnel positioning. Based on data obtained intra-operatively from 60 anatomical ACL reconstruction procedures, we calculated the length of bone plugs required in the BPTB graft to avoid graft-tunnel mismatch. When this was prevented in all the 60 cases, we found that the mean length of femoral bone plug that remained in contact with the interference screw within the femoral tunnel was 14 mm (12 to 22) and the mean length of tibial bone plug that remained in contact with the interference screw within the tibial tunnel was 23 mm (18 to 28). These results were used to validate theoretical formulae developed to predict the required length of bone plugs in BPTB graft during anatomical ACL reconstruction using a far medial portal technique.

Analysis of Femoral Tunnel Position Targeted at Bifurcate Ridge Using Anteromedial Portal Technique in Anatomic Anterior Cruciate Ligament Reconstruction

Purpose: The purpose of this study is to analyze the position of the 10-mm-sized femur tunnel drilled aiming for the bifurcate ridge using anteromedial portal technique with ‘Figure of 4 position’ by 3-dimensional computed tomography (3D-CT) reconstruction images after anatomic anterior cruciate ligament (ACL) reconstruction and to evaluate it’s propriety. Materials and Methods: Out of 35 patients who underwent anatomic ACL reconstruction from March 2012 to February 2013, 32 patients who undergone postoperative 3D-CT scans were included in this study retrospectively. Medial surface of the lateral femoral condyle was reconstructed using Mimics, and then the position of the femoral tunnel was evaluated using the Bernard quadrant method and the results were compared with those of published literatures. The mean age of the patients was 32.6 years old. There were 25 cases of doublebundle ACL reconstruction with one femoral-two tibial tunnel. There were 7 cases of single bundle ACL reconstruction with one femoralone tibial tunnel. Results: The mean distance of the femoral tunnel center was 32.2%±2.9% (range, 27.4%-37.6%) along the line parallel to the Blumensaat’s line from the posterior condylar surface and 46.7%±2.3% (range, 43.5%-51.1%) along the line perpendicular to the Blumensaat’s line from the roof of the notch. In comparison with the results of published literature, although the center of the femoral tunnel was presented in the femoral footprint, it was located slightly more shallow and inferior than the center of the ACL footprints. Conclusion: The bifurcate ridge may be a good anatomic landmark when making a 10-mm-sized single femoral tunnel in ‘Figure of 4 position’ using the anteromedial portal technique.

Tibia Rotational Technique to Drill Femoral Bone Tunnel in Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction

In anatomic anterior cruciate ligament (ACL) reconstruction, several pitfalls in creating the femoral bone tunnels at the correct position are of great concern. Our new method, the tibia rotational (TR) technique, may contribute to resolving these. The purpose of this study is to describe further details about the TR technique in anatomic double-bundle ACL reconstruction. Both anteromedial and posterolateral femoral bone tunnels were drilled through a posterolateral tibial bone tunnel using tibial rotation without deep knee flexion. When it is difficult to reach the mark with the rigid guide pin, the narrow curved TR technique guide and the flexible drill system allow drilling femoral bone tunnels in the correct position. The TR technique offers the technical ease required for widespread acceptance while prioritizing the fundamental goals of an anatomic double-bundle ACL reconstruction.

Does flexible tunnel drilling affect the femoral tunnel angle measurement after anterior cruciate ligament reconstruction?

To quantify the mean difference in femoral tunnel angle (FTA) as measured on knee radiographs between rigid and flexible tunnel drilling after anatomic anterior cruciate ligament (ACL) reconstruction. Fifty consecutive patients that underwent primary anatomic ACL reconstruction with a single femoral tunnel drilled with a flexible reamer were included in this study. The control group was comprised of 50 patients all of who underwent primary anatomic ACL reconstruction with a single femoral tunnel drilled with a rigid reamer. All femoral tunnels were drilled through a medial portal to ensure anatomic tunnel placement. The FTA was determined from post-operative anterior-to-posterior (AP) radiographs by two independent observers. A 5° difference between the two mean FTA was considered clinically significant. The average FTA, when drilled with a rigid reamer, was 42.0° ± 7.2°. Drilling with a flexible reamer resulted in a mean FTA of 44.7° ± 7.0°. The mean difference of 2.7° was not statistically significant. The intraclass correlation coefficient for inter-tester reliability was 0.895. The FTA can be reliably determined from post-operative AP radiographs and provides a useful and reproducible metric for characterizing femoral tunnel position after both rigid and flexible femoral tunnel drilling. This has implications for post-operative evaluation and preoperative treatment planning for ACL revision surgery. IV.

Is the native ACL insertion site "completely restored" using an individualized approach to single-bundle ACL-R?

The goal of individualized anatomic anterior cruciate ligament reconstruction (ACL-R) is to reproduce each patient's native insertion site as closely as possible. The amount of the native insertion site that is recreated by the tunnel aperture area is currently unknown, as are the implications of the degree of coverage. As such, the goals of this study are to determine whether individualized anatomic ACL-R techniques can maximally fill the native insertion site and to attempt to establish a crude measure to evaluate the percentage of reconstructed area as a first step towards elucidating the implications of complete footprint restoration. This is a prospective pilot study of 45 patients who underwent primary single-bundle anatomic ACL-R from May 2011 to April 2012. Length and width of the native insertion site were measured intraoperatively. Using published guidelines, reconstruction technique and graft choice were determined to maximize the percentage of reconstructed area. Native femoral and tibial insertion site area and femoral tunnel aperture area were calculated using the formula for area of an ellipse. On the tibial side, tunnel aperture area was calculated with respect to drill diameter and drill guide angle. Percentage of reconstructed area was calculated by dividing total tunnel aperture area by the native insertion site area. The mean areas for the native femoral and tibial insertion sites were 83±20 and 125±20mm(2), respectively. The mean tunnel aperture area for the femoral side was 65±17, and 86±17mm(2) for the tibial tunnel aperture area. On average, percentage of reconstructed area was 79±13% for the femoral side, and 70±12% for the tibial side. Anatomic ACL-R does not restore the native insertion site in its entirety. Percentage of reconstructed area serves as a rudimentary tool for evaluating the degree of native insertion site coverage using current individualized anatomic techniques and provides a starting point from which to evaluate the clinical significance of complete footprint restoration. IV.

Anatomic Single-Bundle ACL Reconstruction Is Possible with Use of the Modified Transtibial Technique

Anatomic anterior cruciate ligament (ACL) reconstruction is essential to the restoration of normal knee kinematics and to achieving successful results after ACL surgery. The purpose of this study was to evaluate whether anatomic single-bundle ACL reconstruction can be performed with use of the modified transtibial technique such that the tunnel characteristics are not substantially different from those of the anteromedial transportal technique, with comparable clinical results. One hundred and four patients underwent single-bundle ACL reconstruction performed with use of either the modified transtibial technique or the anteromedial transportal technique. Each group included fifty-two patients retrospectively matched on the basis of age, sex, and body mass index. All patients had postoperative computed tomography (CT) and a minimum duration of follow-up of twenty-four-months. CT parameters, including tunnel position, tunnel length and shape, and graft obliquity, were evaluated. Clinical assessments were based on manual laxity tests, arthrometric analysis, and clinical scores recorded preoperatively and at the time of follow-up. The femoral tunnel was placed at a slightly inferior and anterior position with use of the modified transtibial technique compared with the anteromedial transportal technique, but the difference was not significant (superior-inferior mean [and standard deviation], 35.7% ± 3.1% versus 33.9% ± 4.1%, p > 0.05, and anterior-posterior mean, 31.6 ± 6.8% versus 35.1 ± 6.9%, p > 0.05, as assessed with use of the quadrant method). The femoral tunnel length was significantly longer (p < 0.05) and the tibial tunnel length was significantly shorter (p < 0.05) with use of the modified transtibial technique compared with the anteromedial transportal technique (mean femoral tunnel length, 40.5 ± 4.2 mm versus 34.4 ± 2.6 mm and mean tibial tunnel length, 32.3 ± 3.1 mm versus 35.5 ± 2.7 mm); however, tunnel length was sufficient to allow for adequate fixation. There were no significant differences between the two groups in terms of tibial tunnel position, graft obliquity, tibial tunnel widening, and clinical results. Tunnel characteristics including anatomic position, graft obliquity, and tunnel widening after single-bundle ACL reconstruction performed with use of the modified transtibial technique were not significantly different from those of the anteromedial transportal technique, and clinical results were comparable.

Anatomic anterior cruciate ligament (ACL) reconstruction: a global perspective. Part 1

In August 2011, orthopaedic surgeons from more than 20 countries attended a summit on anatomic anterior cruciate ligament (ACL) reconstruction. The summit offered a unique opportunity to discuss current concepts, approaches, and techniques in the field of ACL reconstruction among leading surgeons in the field. Five panels (with 36 panellists) were conducted on key issues in ACL surgery: anatomic ACL reconstruction, rehabilitation and return to activity following anatomic ACL reconstruction, failure after ACL reconstruction, revision anatomic ACL reconstruction, and partial ACL injuries and ACL augmentation. Panellists' responses were secondarily collected using an online survey. Thirty-six panellists (35 surgeons and 1 physical therapist) sat on at least one panel. Of the 35 surgeons surveyed, 22 reported performing "anatomic" ACL reconstructions. The preferred graft choice was hamstring tendon autograft (53.1 %) followed by bone-patellar tendon-bone autograft (22.8 %), allograft (13.5 %), and quadriceps tendon autograft (10.6 %). Patients generally returned to play after an average of 6 months, with return to full competition after an average of 8 months. ACL reconstruction "failure" was defined by 12 surgeons as instability and pathological laxity on examination, a need for revision, and/or evidence of tear on magnetic resonance imaging. The average percentage of patients meeting the criteria for "failure" was 8.2 %. These data summarize the results of five panels on anatomic ACL reconstruction. The most popular graft choice among surgeons for primary ACL reconstructions is hamstring tendon autograft, with allograft being used most frequently employed in revision cases. Nearly half of the surgeons surveyed performed both single- and double-bundle ACL reconstructions depending on certain criteria. Regardless of the technique regularly employed, there was unanimous support among surgeons for the use of "anatomic" reconstructions using bony and soft tissue remnant landmarks.

Comparison of transportal inside-out and outside-in femoral drilling techniques in anatomic ACL reconstruction

The purpose of this study was to examine tunnel length and incidence of posterior wall breakage during drilling of the femoral anteromedial (AM) tunnel in anatomic anterior cruciate ligament (ACL) reconstruction and compare those results between inside-out (transportal) and outside-in techniques. The study population comprised 68 patients (30 females and 38 males) with a mean age at surgery of 24.1 years (range, 14–45 years). In the reconstructive procedure, the femoral AM bone tunnel was drilled inside-out through the anteromedial portal in 32 knees, while the outside-in technique was employed in the remaining 36 knees. The intra-articular aperture of the femoral AM tunnel was located behind the resident's ridge in all knees as assessed by the postoperative computed tomography (CT) image. Length of the bony tunnel was measured with the depth gauge intraoperatively, while incidence of the posterior bony wall breakage (blowout) was assessed on the postoperative CT image. Thereafter, the obtained results were compared between the groups (transportal inside-out drilling vs. outside-in drilling). Knee stability was assessed at 12 months using a KT arthrometer. The mean length of the femoral AM tunnel in the inside-out group (32.2 ± 4.7 mm) was significantly shorter than that in the outside-in group (36.3 ± 4.6 mm). In the inside-out groups, posterior wall breakage was encountered in one patient (3.6%), and a lack of the tunnel length precluded the use of the EndoButton CL in three patients (10.7%). By contrast, no such complication was encountered in the outside-in group. No significant difference in knee stability was detected between the groups. During the femoral AM tunnel drilling in the current anatomic ACL reconstruction, the potential risks for the problems such as short tunnel length and posterior wall breakage were higher in the transportal inside-out drilling than the outside-in procedure. Adoption of the outside-in technique can reduce the risk of complications associated with femoral drilling. Level of evidenceLevel IV, case series.

Anatomic transtibial single-bundle anterior cruciate ligament reconstruction: a new surgical technique

Objective Many surgeons perform anatomic anterior cruciate ligament (ACL) reconstruction through the anteromedial portal due to the difficulty in reaching the anatomic femoral insertion through the transtibial technique. A number of authors have described technical modifications to the transtibial technique to improve and restore the native femoral tunnel obliquity. In this work we present a new technique to reach the native femoral footprint in anatomic single-bundle ACL reconstruction through the transtibial tunnel with the aid of new instruments. Materials and methods From September 2009 to October 2010, 80 consecutive ACL reconstruction surgeries were performed following a prospective study design. The mean patient age was 31 years (range, 18-45 years); there were 72 male patients and eight female patients. The guide pin was inserted in the femoral footprint through the tibial tunnel with a special arthroscopic manipulator and\or pusher. Radiographic evaluation was carried out by measuring the femoral tunnel orientation in anteroposterior view in plain radiographs. Using computed tomography, the angle of femoral tunnel was measured in coronal and sagittal cuts, and the distance of the tunnel from posterior wall was measured. Clinical evaluation was performed with the IKDC scores. Results The mean angle of the femoral tunnel orientation with reference to the bicondylar line was 52.1° (range, 40°-60°). The average clock position was that of 10 O'clock. In the computed tomographic evaluation the femoral entry point at the sagittal view was 1-2 mm. The mean distance of the tunnel from the articular surface in the coronal views was 4 mm. The mean IKDC scores had increased from 55.5±18.0 to 76.8±15.3 postoperatively. Conclusion With the aid of the arthroscopic manipulator and\or the pusher, the anatomic footprint of ACL insertion site could be reached through the transtibial tunnel drilling technique.

Evidence to Support the Interpretation and Use of the Anatomic Anterior Cruciate Ligament Reconstruction Checklist

Published papers on anatomic anterior cruciate ligament (ACL) reconstruction often lack details in the description of the surgical procedure, and there are large variations in anatomic ACL reconstruction techniques. We aimed to develop a validated checklist to be used for anatomic ACL reconstruction. First, a list of all potential items that could be used in the checklist was generated. Thirty-four ACL experts were selected to participate in an anonymous online survey to rate the importance of these items on a scale of 1 to 4 (with a score of 4 having the most importance). The results were verified by surveying a large sample of 959 orthopaedic specialists who are peer reviewers for four major orthopaedic journals. Items were included in the final checklist if they received an importance score of 3 or 4 from at least 75% of the survey takers. The survey response rate was 79% (twenty-seven of thirty-four) of the ACL experts and 40% (379 of 959) of the peer reviewers. The final Anatomic ACL Reconstruction Checklist includes seventeen items with a maximum score of 19 points. The final checklist underwent preliminary testing for internal consistency, intertester reliability, and validity. Cronbach's alpha for internal consistency was 0.82, and the intraclass correlation coefficient (ICC) for intertester reliability was 0.65. This large survey-based study on anatomic ACL reconstruction resulted in the development of the Anatomic ACL Reconstruction Checklist; preliminary evidence for interpretation of the scores is provided.

The concept of individualized anatomic anterior cruciate ligament (ACL) reconstruction

To describe the concept of individualized anatomic anterior cruciate ligament (ACL) reconstruction. The PubMed/Medline database was searched using keywords pertaining to ACL reconstruction. Relevant articles were reviewed in order to summarize important concepts of individualized surgery in ACL reconstruction. Surgical experiences with case examples are also highlighted. Individualized ACL surgery allows for the customization of surgery to each individual patient. Accounting for graft selection and other characteristics such as anatomy, lifestyle and activity preferences may provide the patient with the best potential for a successful outcome. The surgeon should be comfortable with a variety of graft harvests and surgical techniques when practicing individualized surgery. Individualized anatomic ACL reconstruction is founded on the objective evaluation of functional anatomy and individual characteristics, thereby restoring the ACL as closely as possible to the native anatomy and function. The adoption and subsequent use of individualized surgery may facilitate improved clinical as well as objective outcomes, particularly in the long term. V.

Anatomic Single-bundle ACL Reconstruction With Oval Tunnels

Aim of anatomic anterior cruciate ligament (ACL) reconstruction is to imitate the footprint anatomy of the ACL as closely as possible. The presented technique is a single-bundle technique using a semitendinosus graft. The femoral tunnel is prepared via the anteromedial portal. For guidewire placement a specific medial portal aimer is used. The position of the guidewire is always controlled with the arthroscope in the anteromedial portal (medial portal view). Landmarks are the interconylar line and the transition from cartilage to bone. The tunnel should be in the center of the femoral ACL footprint. After drilling with 4.5-mm drill, a blind tunnel with an oval aperture is created by stepwise dilation with oval-shaped dilators. The position of the femoral tunnel should always be controlled with the arthroscope in the medial portal. For the tibial tunnel also, a specific anatomic aimer was used. Landmark is the anterior horn of the lateral meniscus. The tibial tunnel should be located in the center of the tibial footprint. Remnants of the original ACL are left intact unless they interfere. Femoral fixation is achieved with a Flip tack. The graft is tensioned at 10 degrees of flexion with maximal manual force. Tibial fixation is achieved with a degradable interference screw and a button (Endotack).

The Importance of Tibial Tunnel Placement in Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction

The purposes of this study were to measure the anterior edge of the tibial tunnel after anatomic anterior cruciate ligament (ACL) reconstruction on lateral radiographs and to determine whether the difference in tibial tunnel placement affects postoperative outcomes. For 60 patients who underwent anatomic double-bundle ACL reconstruction with semitendinosus tendon, we evaluated the side-to-side difference in anterior tibial translation on stress radiographs, as well as rotational stability by the pivot-shift test, 2 years after surgery. Loss of extension (LOE) was evaluated on lateral radiographs of both knees in full extension, and graft integrity was assessed during second-look arthroscopy 1 to 2 years after surgery. On true lateral radiographs, we measured the anterior placement percentage of the tibial tunnel using the method described by Amis and Jakob. The cutoff value was set at 25% of the mean value of the anterior edge of the ACL that Amis and Jakob reported, and patients were divided into 2 groups (27 in the anterior group and 33 in the posterior group). Postoperative clinical results were compared between the groups. The mean anterior placement percentage was 26.0% ± 4.1%. The postoperative mean side-to-side difference was 1.4 ± 2.7 mm for the anterior group and 3.0 ± 2.7 mm for the posterior group, a significant difference (P < .05). The positive ratio of the pivot-shift test was not significantly different between groups (P > .05). Mean LOE in the anterior and posterior groups was 0.9° ± 3.0° and -0.8° ± 4.0°, respectively; the difference was not significant (P > .05). Five of 27 knees in the anterior group and 5 of 33 knees in the posterior group had superficial graft laceration or elongation, which was not significantly different (P > .05). Anterior placement of the tibial tunnel in anatomic double-bundle ACL reconstruction leads to better anterior knee stability than posterior placement does. Anterior tibial tunnel placement inside the footprint did not increase the incidence of LOE and graft failure. Level IV, therapeutic case series.

Evaluation of intraoperative anterior cruciate ligament laxity using a navigation system in the anatomical single bundle reconstruction

PurposeThe anatomical anterior cruciate ligament (ACL) reconstruction attempts to, by reproducing the natural orientation of its fibres, achieve a better rotational stability of the knee. The aim of this paper is to quantify the anteroposterior and rotational laxity of the knee before and after an anatomic ligamentoplasty using the Orthopilot® navigation system as a supporting tool. Material and methodWe describe the distinctive steps of Orthopilot® navigation as well as conducting a retrospective cross-sectional study on a cohort of 20 patients operated in our hospital for chronic primary ACL rupture from January 2010 to May 2011. The precise location of the tunnels was defined with the help of the navigator and the intra-articular landmarks and stability tests were performed in both the sagittal and axial planes. ResultsIn our technique for anatomical ACL reconstruction placed the tibial tunnel at a mean distance of 16.8±4.92mm from the posterior cruciate ligament in a position that represented 44.1±4.35% of the total width of the tibial plateau. The average distance from the centre of the femoral tunnel to the posterior cortex of the lateral condyle was 7.89±2.78mm. Intra-operatively and before ACL reconstruction, the mean (±SD) anteroposterior movement, internal rotation and external rotation of the tibia at 30° position were 15.5mm (±5.11), 19° (±3.62) and 19.65° (±3.26), respectively. After reconstruction these values decreased to 5.6mm (±1.72°), 12.17° (±3.76) and 16.9° (±4.42), respectively. ConclusionsThe use of navigation systems supporting the surgery allows the systematic positioning of bone tunnels and standardises the procedures for the desired reconstruction. ACL reconstruction using the technique described, improves the anteroposterior and rotational stability compared to preoperative status, to a stability state that could be considered physiological according to current scientific knowledge.

Evaluación mediante navegación intraoperatoria de la laxitud del ligamento cruzado anterior en su reconstrucción anatómica monofascicular

PurposeThe anatomical anterior cruciate ligament (ACL) reconstruction attempts to, by reproducing the natural orientation of its fibres, achieve a better rotational stability of the knee. The aim of this paper is to quantify the anteroposterior and rotational laxity of the knee before and after an anatomic ligamentoplasty using the Orthopilot® navigation system as a supporting tool. Matherial and methodWe describe the distinctive steps of Orthopilot® navigation as well as conducting a retrospective cross-sectional study on a cohort of 20 patients operated in our hospital for chronic primary ACL rupture from january 2010 to may 2011. The precise location of the tunnels was defined with the help of the navigator and the intra-articular landmarks and stability tests were performed in both the sagittal and axial planes. ResultsIn our technique for anatomical ACL reconstruction placed the tibial tunnel at a mean distance of 16.8±4.92mm from the posterior cruciate ligament in a position that represented 44.1%±4.35 of the total width of the tibial plateau. The average distance from the centre of the femoral tunnel to the posterior cortex of the lateral condyle was 7.89±2.78mm. Intra-operatively and before ACL reconstruction, the mean (±SD) anteroposterior movement, internal rotation and external rotation of the tibia at 30° position were 15.5mm (±5.11), 19° (±3.62) and 19.65° (±3.26), respectively. After reconstruction these values decreased to 5.6mm (±1.72°), 12.17° (±3.76) and 16.9° (±4.42), respectively. ConclusionsThe use of navigation systems supporting the surgery allows the systematic positioning of bone tunnels and standardises the procedures for the desired reconstruction. ACL reconstruction using the technique described, improves the anteroposterior and rotational stability compared to preoperative status, to a stability state that could be considered physiological according to current scientific knowledge.

Surgical and biomechanical concepts of anatomic anterior cruciate ligament reconstruction

The purposes of this review are to explain surgical and biomechanical concepts of anatomic anatomic anterior cruciate ligament (ACL) reconstruction and to introduce our anatomic reconstruction procedure of the anteromedial (AM) and posterolateral (PL) bundles of the ACL using hamstring tendon autografts. According to common medical concept, anatomical ACL reconstruction is defined as the reconstruction in which all 4 ends of 2 tendon grafts are grafted at the center of the anatomical attachment of the AM bundles or the PL bundles, not only on the femur but also on the tibia, because only such a procedure allows for the reconstruction of 2 bundles having an anatomical orientation. On the basis of our anatomic studies on the normal attachments of the ACL, we developed an arthroscopy-assisted anatomic reconstruction procedure of the AM and PL bundles that involves a new method of creating the tibial and femoral tunnels for the posterolateral bundle. To insert a Kirschner wire as a guide into the tibia, we use an originally developed a Wire-navigator, which is a key device for the trans-tibial tunnel technique. To visualize the femoral attachment of the posterolateral bundle, the medial infra-patellar portal is more useful than the lateral one. Biomechanical studies have shown that anatomic double-bundle ACL reconstruction has some biomechanical advantages over a single-bundle reconstruction. In our clinical experience, results of the anatomic reconstruction were superior to those of the one-bundle reconstruction. We believe that the anatomic reconstruction of the AM and PL bundles using hamstring tendon autografts is clinically practical in the treatment for the ACL-deficient knee.

Anatomic anterior cruciate ligament reconstruction: The Japanese experience

Anatomical anterior cruciate ligament (ACL) reconstruction, which is designed to reproduce both anteromedial and posterolateral bundles of the ACL, has become very popular in Japan during the past decade. A number of basic studies have demonstrated the advantages of this procedure from both biomechanical and biological viewpoints. Although a statistically significant improvement in clinical outcome has not been attained, short-term clinical results are encouraging. This article focuses on the history and current trends in anatomical ACL reconstruction. We have also included the rationale for anatomical ACL reconstruction based on our experience.