ACL reconstruction with preservation of remnant of ACL

H. Makhmalbaf MD

Consultant Orth & Knee Surgeon

Mashhad University, Iran

22.2.2012 , Kish

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 22, Issue 3 , March 2006

Byung-III Lee, M.D. Kyung-Dae Min, M.D, et al.

Arthroscopic Anterior Cruciate Ligament Reconstruction With the

Tibial-Remnant Preserving Technique Using a Hamstring Graft

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

Acutely torn ACL remnant

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

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

Femoral socket preparation

Femoral socket along the guide pins

Guide pin for tibial tunnel

The guide pins switched to looped wires

The loop sutures pulled out

The remnant tissue is compacted

Sutures are tied

Belt-buckle fashion suture

No loop impingement in extension

Second look surgery

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

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

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

• Best reconstructive procedure ?

• The role of mechanoreceptors in ACL

• Good results depend on :

• Mechanical stability &

• Quality of recovery of proprioception

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

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

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

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

Tibial Guide Wire Placement & Tunnel Creation

Tibial Tunnel Creation

Femoral Tunnel Creation

Thank you