ACL reconstruction with preservation of remnant of ACL

1. ACL reconstruction with preservation of remnant of ACL H. Makhmalbaf MD Consultant Orth & Knee Surgeon Mashhad University, Iran 22.2.2012 , Kish

2. Arthroscopic Anterior Cruciate Ligament Reconstruction With the Tibial-Remnant Preserving Technique Using a Hamstring Graft Arthroscopy: The Journal of Arthroscopic & Related SurgeryVolume 22, Issue 3 , March 2006 Byung-III Lee, M.D. Kyung-Dae Min, M.D, et al.

3. We propose that • It enhances the revascularization & Cellular proliferation of the graft • It preserves proprioceptive function • To place the graft anatomically without impingement • Preserve as much as possible of the remnant as a source of reinnervation

4. Acutely torn ACL remnant

5. Surgical technique • Developed to maximize the preservation of the tibial remnant • Semitendinous & gracilis tendon harvest distally attached • Femoral & tibial tunnels created • Tibial tunnel at the ACL remnant • Preserve the tibial remnant

6. Surgical Technique • The grafts are pulled through tibial tunnel • And ACL remnant and the femoral socket • The ACL remnant is compacted • The graft is secured proximally by sutures in the lateral femoral condyle • And at the tibia with double staples by • A belt-buckle method

7. Femoral socket preparation

8. Femoral socket along the guide pins

9. Guide pin for tibial tunnel

10. The guide pins switched to looped wires

11. The loop sutures pulled out

12. The remnant tissue is compacted

13. Sutures are tied

14. Belt-buckle fashion suture

15. No loop impingement in extension

16. Second look surgery

17. Advantages of the technique • Maximal preservation of the tibial remnant • No roof impingement by • Intrasynovial anatomic placement of the graft • The simplicity of the procedure • The minimal need for hardware

18. Advantages • The economic benefit • Potential prevention of tibial tunnel enlargement by preventing leakage of SF • Optimal treatment of torn ACL is controversial • Difficult to reproduce natural biomechanical and anatomic function of ACL

19. Discussion • ACL functions as a sensory organ • Providing proprioceptive information & • Initiating protective & stabilizing muscular reflexes • In ACL recons. proprioception is correlated with both functional outcome & Patient’s satisfaction • Most of the MCRP’s are located distally

20. Best reconstructive procedure ? • The role of mechanoreceptors in ACL • Good results depend on : • Mechanical stability & • Quality of recovery of proprioception

21. Roles of tibial remnant • To enhance revascularization & Cellular proliferation of the graft • To preserve proprioceptive function & anatomic placement of the graft • Without roof impingement • Facilitate the vascular ingrowth and ligamentization of the grafted ACL

22. After treatment • Knee immobilized in extension brace • For 1 to 2 weeks • Quadriceps setting exercises then: • Active or ROM exercises • After 4 weeks, full ROM & • Closed chain exercises

23. Discussion • Usually we find a tibial remnant • Especially in acute cases • The remnant enhances revascularization & Cellular proliferation of the graft • Preserves some proprioceptive function • Thus the remnant should be preserved

24. Discussion • The weak link in recons. is point of graft fixation • In hamstring ACL graft the ideal suture must have a high ultimate tensile load & experience minimal plastic deformation when loaded • Ethibond sutures are used

28. Tibial Guide Wire Placement & Tunnel Creation

29. Tibial Tunnel Creation

30. Femoral Tunnel Creation

43. Thank you