ANTERIOR CRUCIATE LIGAMENT - PART III

 

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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