Graft selection begins with an open discussion between the surgeon and the patient concerning the advantages and disadvantages of both allograft and autograft use for ACL reconstruction. Patient demands, activity, age, and comfort with the potential risk for disease transmission and immunologic reaction to the allograft are factors that must be considered and contribute to the ultimate choice in graft. Allografts, however, eliminate donor site morbidity, allow for faster short-term recovery, and provide the increased volume of graft often necessary for double-bundle reconstruction (11). More recently, studies have reported up to a three times greater failure rate with allograft in the use of single-bundle constructs among younger and more athletic populations; therefore, graft demands must be factored into the selection process (9,12). Our practice appreciates the concerns of allograft in the young, athletic population and has actively pursued autograft sources such as the hamstrings and quadriceps tendon for reconstruction. In patients with considerable growth remaining, single-bundle hamstring autograft sources and occasionally soft tissue allograft such as the tibialis anterior are chosen to minimize the risk of growth arrest. Multiligamentous injuries are often addressed with allograft as well, given the volume of graft needed for the reconstruction. For older, more sedentary patients with symptomatic instability related to low-demand recreational or functional activities, allograft is almost universally chosen. Occasionally, patients will require only single AM or PL bundle augmentation and graft volume becomes less of an issue, allowing allograft or traditional autograft sources such as the hamstring tendons to be easily implemented. When allograft is chosen, our practice favors the use of tibialis anterior as a graft source. However, posterior tibialis, Achilles tendon, quadriceps tendon, bone-patellar tendon-bone (BPTB), and hamstring tendons may also be used. The long-term outcome of double-bundle reconstruction is unknown, but early results are encouraging (3,13). For this reason, as well as the absence of chronic anterior knee pain related to the harvest of BPTB autograft and biomechanical deficiencies related to hamstring harvest, allograft tissue is typically chosen. If a patient chooses to pursue double-bundle reconstruction but prefers to use autologous tissue only, then the quadriceps muscle is the only graft choice with enough predictable volume to satisfy this need.

An anesthetic regimen is determined after a discussion between the patient, the orthopaedic surgeon, and the anesthesiologist. Typically, ultrasound-guided peripheral nerve blocks involving the femoral and sciatic nerves are employed with a “light” sedation by experienced staff. This provides satisfactory intraoperative pain control as well as decreased postoperative narcotic use, decreased nausea, and ten times less likely hospital admission (16). The operative extremity is identified in the holding area, marked “yes,” and initialed.