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ACL Reconstruction Surgery

ACL Reconstruction Surgery. W.J.Leach Consultant Orthopaedic Surgeon Western Infirmary Glasgow. The Holy Grail. Reconstruct ligament Repair meniscus injury Prevent meniscus injury Return to full function No OA!. ACL Reconstruction. Major advances in last 15-20 years Restores stability

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ACL Reconstruction Surgery

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  1. ACL Reconstruction Surgery W.J.Leach Consultant Orthopaedic Surgeon Western Infirmary Glasgow

  2. The Holy Grail • Reconstruct ligament • Repair meniscus injury • Prevent meniscus injury • Return to full function • No OA!

  3. ACL Reconstruction • Major advances in last 15-20 years • Restores stability • Return to function • Reduces risk of meniscal tears • 90% normal or near normal in short to medium term

  4. Reconstructing the ACL?

  5. “Anatomical “ placement of the ACL on femur

  6. Surgical Placement of Femoral ACL Insertion 1990s • Somebody moved the ACL! • Isometry

  7. Femoral placement • Advent of arthroscopy • Placement to suit surgical jigs

  8. Femoral tunnel placement • Transtibial – may be too vertical ( 1 or 11 o’clock) with OTT guide • AM portal – beware MFC when drilling, flex to 120

  9. Femoral Tunnel Placement • Single bundle – mid-point more akin to AM bundle • Outside in - retrodrilling

  10. Tibial Tunnel Placement • Just anterior to MCL distally • Exit through stump of ACL • 7mm anterior to PCL • 40% A-P on lateral

  11. Two bundles better than one! • Attempt to recreate normal anatomy • Hypothesis that less OA changes develop • Technically demanding • Time consuming

  12. Lubowitz et al. Am J Sports Med 2008Meta-analysis (single bundle v. double bundle) • NO DIFFERENCE!

  13. ACL Graft types • Hamstring (4-strand) • BTB • Allograft

  14. RCTs Hamstring v. BTB Grafts in ACL Reconstruction

  15. Carey, Spindler et al JBJS 2009. Systematic review – allograft v.autograft • NO DIFFERENCE!

  16. Foster, Ryan et al. Am J Sports Med 2010. Systematic review allograft v. autograft • NO DIFFERENCE!

  17. What I do…. • BTB - hypermobile, pro footballer, rugby • HT – majority, anterior knee pain, kneelers

  18. Tibial Insertion • Through stump of ACL remnant • 7mm anterior to PCL • Elbow or PCL aimer 50-55 degrees • Start tibial tunnel just anterior to MCL fibres

  19. Femoral tunnel • Transtibial – OTT aimer 10 o’clock • Outside in – retroreamer

  20. Fixation • Hamstring – Closed loop endobutton proximally, bioabsorbable screw distally • BTB – metal interference screws

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