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Monday 30 April 2018



ACL reconstruction using B-PT-B graft
Modified Clancy technique
  • open or arthroscopic
  • single or small double incisions
  • single incision – 8cm superolateral to patella – distally to cross tibial tuberosity to anteromedial tibia
  • double incisions
    • anteromedial incision – beginning just medial to superomedial border of patella and paralleling the patellar tendon – to 2 cm distal tuberosity
    • lateral incision – 8-10cm - beginning at lateral epicondyle of femur - proximally over mid lateral iliotibial band
  • graft taken by 2 parallel incisions – full thickness of tendon10mm apart from inf pole of patella to attachment of tibial tuberosity
  • this free non vascularised b-pt-b graft – 5x10mm patellar bone 2cm long – 10mm wide full thickness patellar tendon – 8x10mm piece of tibial tuberosity 2cmlong
  • femoral tunnel - intercondylar notch of femur – pilot hole created – exit site for tunnel is 3-4cm proximal to lateral femoral condyle
  • tibial tunnel – drilling a guide wire through medial tibial condyle – 300 angle with tibia just medial to tibial tuberosity – 25-30mm below joint surface – enter the joint at posterior half of tibial attachment of ACL
  • n+7 rule
    • determining the tibial guide angle
    • length of the tendinous portion of graft +7
  • guide wire
    • should pierce the tibial cortex in middle of foot print
    • or posterior edge of anterior horn of lateral meniscus at the posterior edge of midpoint of notch
    • or just lateral to medial tibial spine
    • or 7mm anterior to PCL
  • graft positioned in tunnel by cannulated interference screw
    • cortical surface of femoral plug positioned posteriorly – femoral screw against cancellous surface
    • tibial plug rotate 1800 – cortical surface face anteriorly
  • screw length = length of bone plug
Macintosh technique
  • distal attachment to tibial tuberosity left intact
  • in most knees – pt-b graft has insufficient length – to allow patellar bone to be placed in femoral tunnel
Tomato stick procedure
  • in skeletally immature knees
  • trough in proximal tibial epiphysis – extends to tibial attachment of ACL
  • trough eliminates the need for tunnel (which pass through the physis and cause growth arrest)
  • graft passes over the lateral femoral condyle- anchored to bone – avoids the distal femoral physis
Lipscomb's procedure
  • uses hamstrings for reconstruction
  • medial para patellar incision – just above the superior pole of patella – extends 8cm distal to joint line near the tibial insertion of pes anserinus tendon
  • proximal semitendinosus and gracilis tendons released from surrounding fascia at musculo tendinous junction – gracilis more proximal than semitendinosus – insertion of semitendinosus identified by Y shaped incision to tibial crest and anteromedial tibia
  • tibial tunnel – by guide wire – in anteromedial tibia 3.5-4 cm below joint line – directing proximally and medially – to enter joint area at normal tibial attachment of ACL
  • free tendon graft – femoral fixation via another lateral skin incision and rear entry OR single incision trans tibial femoral guide system
  • graft secured with interference screws
  • post op – controlled knee motion brace
Synthetic materials for ligament reconstruction
  • simpler and easier reconstruction – arthroscopic – more rapid rehab – as do not become weak during tissue vascularization and reorganization
  • can be
    • prosthetic ligament – permanent replacement for the normal ligament
    • stent temporarily protecting or augmenting an autogenous graft
    • scaffold providing support and nutrition for ingrowth of collagen
  • used in salvage procedures when all other procedures fail
  • Prosthetic ligaments used are
    • GoreTex ligament
      • high failure rate
      • effusions, inguinal lymph node enlargement
    • Compact diameter cruciate ligt
      • II gen GoreTex – cross sectional diameter reduced by 40% - reduce abrasion in bony canals
    • stryker dacron ligt
      • core of 4 strands of dacron tape surrounded by dacron tube
      • high failure in 2nd and 3rd year
    • Leeds – keio prosthesis
      • polyester act as scaffolds – promotes ingrowth of fibrous tissues
      • before implantation strength of 840-870N – after fibrous tissue invades 2000N
      • synovitis reaction to polyester particles
Synthetic augmentation for ACL repair or reconstruction
  • braided polypropylene ribbon inserted along with biological graft tissue – composite biological – synthetic graft
  • one end of augmentation device is anchored to bone – other end sutured to graft itself
  • stress shield the biological part of graft – allowing it to revascularise and remodel
Allograft ligament replacement
  • allografts and autografts go through 4 stages
    • necrosis
    • revascularisation
    • cellular proliferation
    • remodelling
  • allograft cells gradually replaced by host cells – after revascularisation – no allograft cells remain after 3 wks of revascularisation
  • sterile procurement- careful donor screening – secondary sterilization with gaseous ethylene oxide (residual ethylene glycol in tissues – sterile effusions later) or gamma radiation
  • risk of HIV, Hepatitis
Rehabilitation after ACL reconstruction
  • goals are
  • restoration of joint anatomy
  • provision of static and dynamic stability
  • maintenance of aerobic conditioning and psychological well being
  • early return to work and sports
  • intensive rehab – prevent early arthrofibrosis – restore strength and function earlier
  • immediate post op – knee immobilization in extended knee brace – supports weakened quadriceps and prevent flexion contracture
  • strengthening hamstrings – which functions with ACL to prevent anterior translation of tibia
  • partial weight bearing with crutches allowed immediately
  • crutches discontinued after 3-4 weeks
  • returns to sports after 6 months
Complications of ACL surgery
  • Pre op criterias
    • timing of surgery
    • pre op conditioning and strengthening
    • graft and fixation choice
    • minimal/ no swelling
    • leg control
    • full range of motion
  • Intra operative
    • patellar #
    • inadequate graft length
    • bone plug and tunnel size mismatch
    • graft #
    • suture laceration
    • posterior femoral cortex violation
    • incorrect tunnel placement
  • Post op
    • persistent anterior knee pain (MC)
    • motion deficits
      • pre op factor
        • effusion – limited ROM – concomitant knee ligt injuries
      • intra op
        • incorrect tunnel placement – inadequate notch plasty
      • post op
        • prolonged immobilization – inadequate rehab
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