ACL Reconstruction SurgeryACL Reconstruction Surgery

W.J.Leach

Consultant Orthopaedic Surgeon

Western Infirmary

Glasgow

The Holy GrailThe Holy Grail

Reconstruct ligamentRepair meniscus injuryPrevent meniscus injuryReturn to full functionNo OA!

ACL ReconstructionACL 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

Reconstructing the ACL?Reconstructing the ACL?

““Anatomical “ placement of the Anatomical “ placement of the ACL on femurACL on femur

Surgical Placement of Surgical Placement of Femoral ACL Insertion 1990sFemoral ACL Insertion 1990s

Somebody moved the ACL!Isometry

Femoral placementFemoral placement

Advent of arthroscopyPlacement to suit surgical jigs

Femoral tunnel placementFemoral tunnel placement

Transtibial – may be too vertical ( 1 or 11 o’clock) with OTT guide

AM portal – beware MFC when drilling, flex to 120

Femoral Tunnel PlacementFemoral Tunnel Placement

Single bundle – mid-point more akin to AM bundle Outside in - retrodrilling

Tibial Tunnel PlacementTibial Tunnel Placement

Just anterior to MCL distallyExit through stump of ACL7mm anterior to PCL40% A-P on lateral

Two bundles better than one!Two bundles better than one!

Attempt to recreate normal anatomy

Hypothesis that less OA changes develop

Technically demanding Time consuming

Lubowitz et al. Lubowitz et al. Am J Sports Med 2008 Am J Sports Med 2008

Meta-analysisMeta-analysis (single bundle v. double bundle) (single bundle v. double bundle)

NO DIFFERENCE!

ACL Graft typesACL Graft types

Hamstring (4-strand)BTBAllograft

RCTs Hamstring v. BTB Grafts in RCTs Hamstring v. BTB Grafts in ACL ReconstructionACL Reconstruction

Feller and Webster 2003 NO DIFFERENCE

Laxdal et al 2005 NO DIFFERENCE

Maletis et al 2007 NO DIFFERENCE

Ejerhed et al 2003 NO DIFFERENCE

Carey, Spindler et al JBJS 2009. Carey, Spindler et al JBJS 2009. Systematic review – allograft Systematic review – allograft

v.autograftv.autograft

NO DIFFERENCE!

Foster, Ryan et al.Foster, Ryan et al. Am J Sports Med 2010. Am J Sports Med 2010.

Systematic review allograft v. Systematic review allograft v. autograftautograft

NO DIFFERENCE!

What I do….What I do….

BTB - hypermobile, pro footballer, rugby HT – majority, anterior knee pain, kneelers

Tibial Insertion 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

Femoral tunnelFemoral tunnel

Transtibial – OTT aimer 10 o’clock Outside in – retroreamer

FixationFixation

Hamstring – Closed loop endobutton proximally, bioabsorbable screw distally

BTB – metal interference screws