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ACL RECONSTRUCTION- GRAFT OPTIONS, TUNNEL PLACEMENT & FIXATION DR SHEKHAR SRIVASTAV SR. CONSULTANT- Knee & Shoulder Arthroscopy Delhi Institute of Trauma & Orthopedics, Sant Parmanand Hospital, Delhi

ACL Surgery ACL TearNo repair Only Recontruction Graft Autograft - common Allograft

ACL RECONSTRUCTION SUCCESS Quality of the Graft Appropriate Tunnel Placement Strong Graft Fixation

Graft Options Autograft  BPTB  Hamstring  Quadriceps Allograft

Bone-Patellar Tendon Graft  Considered GOLD standard  Middle third of patellar

tendon harvested(1011mm)  Incision -Medial Vertical -Transverse  10 mm wide graft harvested  2.5 mm bone plug from patella & Tibial tuberosity

Skin incision

Take the central slip of 10 mm

Mark bone tendon junction

BPTB Graft AdvantagesEase of harvest Consistent size & shape Strong bone-tendon interface Strong Bone to Bone fixaton Good healing

BPTB Graft Dis-advantagesRisk of patellar # Patellar tendonitis Patello-femoral pain Donor site tenderness on kneeling Bigger incision scar Loss of sensation scar

Hamstring Grafts  Quadrupled Semi-T / Doubled STG graft  4 strands of Hamstrings = 250% strength of

native ACL Advantages  Stronger graft  Smaller Incision- Cosmesis  Can be used in skeletally immature







Hamstring Grafts Disadvantages Soft tissue to bone

healing  Tunnel widening  Technically difficult than BPTB  Loss of Hamstring strength( apprx 10%)

Quadriceps Tendon Graft  Bony end on one side

and soft tissue strip on other  Cross-sectional area thicker than BPTB

Disadvantages Donor site risks


tendon graft

INCISION: Anterior midline

Tendon exposure: central third

Harvested with a bone plug

Quadriceps tendon  Advantage  Comparatively less harvest site morbidity  Larger cross sectional area of graft

 Disadvantage  Bone block at only one end of graft

Allografts Advantages No graft site mobidity  Available off the shelf  Boon- Multiligamentous Injuries Disadvantages Risk of disease transmission  Weak graft  Delayed incorporation  Not universally available,Expensive

Which Graft Better?  Both grafts give excellent results

- Clinically - Functionally - Instrumented Examinations  Choose Graft

- Experience & Training - Comfort level



TIBIAL TUNNEL ENTRY POINT Tibial jig- set at an angle of 45-550 300 medial to mid sagital axis Apprx. 4 cms below joint line

Anatomic Tibial Tunnel EXIT (INTRA ARTICULAR) LANDMARKS(A) ACL Footprint Center of ACL footprint (B) LATERAL Meniscus Post. Border of Ant. Horn


Access for tunnel placement -Through the Tibial Tunnel - Through medial instrument portal ANATOMICAL POSITION -Over the top position - Right Knee-9 10pm - Left Knee- 2 - 3 am


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Anatomic Femoral Tunnel

Anatomic Tibial Tunnel

Graft Passage

Graft Fixation

Graft fixation  Secure graft fixation is paramount to a successful

reconstruction  ACL rehab emphasizes on immediate movement and weight bearing  High demand on initial graft fixation  Ultimate long term success of an ACL reconstruction depends on healing of the graft fixation sites and biological healing

Ideal fixation  Strong enough to avoid failure  Stiff enough to restore knee stabilty  Secure enough to avoid slippage

Ideal Graft fixation  Anatomic  Biocompatible  Safe and reproducible

 MRI compatible  Allow easy revision

Graft Fixation  Choice of graft fixation depends on

-Surgeon preference -Choice of graft -Surgical technique  Fixation Options Femoral Interference screws/Intrafix - Cross pin fixation- Rigidfix/ Tranfix - Endobutton Fixation Tibial - Intererference Screws/ Intrafix - Suture discs, Post with washer

Types of Fixation  Aperture Fixation: at the level of joint  Interference screws

 Suspensory Fixation:  Cortical: Endobutton, Staples, Screw posts  Cancellous: Transfixation pins

Femoral Fixation

Graft properties- Strength Stiffness Slippage

Graft Tunnel MotionBungee Effect Windshield Wiper Effect

Bio-Interference Screw Fixation  Aperture Fixation

 Compaction drilling  Dependent upon cancellous bone  Post wall blowout  - Concern- Graft maceration & failure at physiological loading

Cross pin fixation  Impacted transversely into lateral cortex  Implant passed under looped graft  Implant perpendicular to

graft  Highest ultimate load failure and stiffness

 Concern- tunnel widening and windshield wiper effect

Endobuttton Fixation  Fixation at lateral femoral

cortex  No wear or abration of graft  Advantages- Osteoporotic bones & femoral tunnel blowout  Problems- fixation away from aperture- tunnel widening & bungee effect

Tibial Fixation  Interference screw/

Intrafix  Suture post  Dual fixation


Complications Pre-op consideration  Patient selection- Non compliant/ Apprehensive  Timing of the operation  Immature Athlete  Med. Comp OA with ACL insufficiency

Complication- Graft Graft harvest  Graft cut short  Small size Prevent  careful harvest technique  Cut all band attached before using stripper Dropped graft  Careful passing of graft  Another graft harvest

Complications femoral tunnel Improper tunnel placementAnterior femoral tunnel  Residents ridge  Use femoral tunnel guides Solution  Notchplasty Posterior wall blow-out  Endobutton or transfix

Complications Tibial Tunnel Improper tibial tunnel- anterior tunnel placement  Intra-articular landmarks  Check guide wire impingement before drilling Solution  Notchplasty  Chamfering of the tunnel


Complications Neurovascular most serious complication  Vessel behind Post. Horn Lat. meniscus  Early recognition and prompt repair  Careful handling of shaver and burr in posterior compartment

Complication  Recurrent Effusions

-Debris during surgery -Reaction to bioabsorbable implants -Vigourous physio Management- Repeated aspirations  Infection - < 1% Management- antibiotics & arthroscopic deb.  Stiffness - Improper tunnels - Post-op arthrofibrosis - Cyclops lesion - Inadequate physio/ non-compliant patient Management- Gentle MUA / Arthr. Adesiolysis

To Summarise  Autografts are better option than allograft  Both BPTB & Hamstring grafts work equally

well  Appropriate tunnel placement is essential to prevent failure  Fixation method should be biological, reproducible & should have sufficient strength to allow early mobilisation & rehab



www.delhiarthroscopy. com

ARTHROSCOPY KNEE  Commonest surgery

performed in UK  Treatment Ligamentous and soft tissue injury of knee  > precise and accurate than open method  Less morbidity and early rehab


Ligaments of the Knee Cruciate Ligaments  Anterior (ACL) resists

anterior translation  Posterior (PCL) resists

posterior translation Collateral Ligaments  Medial (MCL) resists

medially directed force  Lateral (LCL) resists

laterally directed force

Mechanism of Injury ACL injury mechanism of injury  Twisting on fixed foot  Blow to the knee  Hyperextension  78% are non- contact injuries (Noyes et al)

Examining the Patient  History

Pain & Instability  Examination  Motion of knee and degree of

swelling  Ligament specific tests of the knee  Lachman test  Anterior and Posterior Drawer

MANAGEMENT 1/3 - No symptoms, Normal life 1/3 - Occasional instability,no strenuos activity 1/3 - Constant instability and pain ď&#x201A;§ ACL deficient- little higher rate of future medial

meniscus tearing and arthritis.

ACL Reconstruction We’ll walk through an ACL reconstruction

using the patient’s own grafts

Bony Tunnels are very precisely drilled in the tibia and femur to recreat the normal anatomic position of the ACL . The graft is passed and secured in bones.

SCORECARD ENDOSCOPIC Small incision Less pain Less morbidity Accuracy Early function Cosmesis

OPEN x x x x x x

Acl reconstruction surgery call 09971192233  
Acl reconstruction surgery call 09971192233  

Acl reconstruction surgery by Dr Shekhar Shrivastav call 09971192233