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Check out Dr. Garcia’s technique for 2 stage ACL reconstruction with bone grafting
Dr. Garcia specializes in complex knee, shoulder and elbow sports surgeries. He has prepared a number of surgical videos below to help patients better understand their procedures. He is frequently updating his surgical video database so check back soon for further updates.
In this video, Dr. Grant H. Garcia demonstrates the first stage of a two-stage revision ACL reconstruction, focusing on bone grafting old tunnels that have widened or were malpositioned by a previous surgery. This step is necessary to rebuild a solid bone foundation before drilling new tunnels for a fresh ACL graft in six months.
The surgical procedure involves the following steps:
- Femoral Tunnel Clearing & Removal of Hardware: The surgeon visualizes the joint from the lateral portal and works through an anteromedial portal. He locates the old femoral tunnel and removes old hardware (remnants of a PEEK screw in this case). The tunnel is sequentially reamed to a depth of 20–25mm to clear out old scar tissue and ensure healthy, bleeding bone surrounds the area.
- Femoral Bone Dowel Insertion: Dr. Garcia shapes a dense bone dowel, cutting it to length (roughly 20mm) and "bulleting" the tip to smooth out its profile. He guides the dowel into the tunnel using a flexible guidewire, gently tapping it with a mallet and a Freer elevator until it sits completely flush with the bone wall.
- Tibial Tunnel Evaluation & Debridement: In this patient, the previous tibial tunnel was placed too far posteriorly (backward). To fix this, the surgeon reams out the old tibial tract to a standard wide size (11–13mm depending on the pre-operative CT scan) using a bone-cutting shaver and manual curettes to establish clean, raw bone edges.
- Tibial Grafting Paste Delivery: On the back table, a graft mixture consisting of cancellous bone chips, DBM (demineralized bone matrix) putty, and PRP (platelet-rich plasma) to boost cellular healing is loaded into a modified 5cc syringe with its tip cut off.
- Packing and Compacting: A Cobb elevator is held tightly over the intra-articular opening of the tibial tunnel to prevent the material from spilling into the joint. The surgeon injects the bone graft mixture straight into the tibial tunnel, using bone tamps and finger pressure to firmly compress and pack the graft until it is completely flush.
Once both tunnels are solidly packed, a follow-up CT scan will be scheduled in a few months to track bone density and integration before performing the final stage-two ACL reconstruction.
