Dr.Subodh Pathak

ACL :Decision Making and Current Concepts

Common Questions………..

When to Check ACL injury??

How to Check??

When to Operate??

Fixation Methods???

Patient Presents with H/O fall

• In Acute Swollen Knee----Anterior Drawer Difficult because cant flex till 90 degree

• Do Lachman Test--------------POSITIVE

• Varus /Valgus Test in Knee Extension----POSITIVE

• MRI to be done if injury is severe with Positive Findings

Lachman test Anterior Drawer test

•If None of test POSITIVE

•Wait for 3 weeks for Acute Event to Subside

•Test Again for Lachman and Anterior Drawer Test

•If test Positive -----Confirm with MRI

If in ACUTE stage ACL tear is confirmed

If OPERATED Immediately then Surgeon will face lot of blood oozing and haziness in the background of the Scopy Field.

BRACE the KNEE for 1-3 weeks for the Soft tissue to

HEAL

SURGERY IN ACUTE PHASE• May also cause Extravasation of fluid into the Extra articular

Compartment and may cause Compartment Syndrome.

• Some Literature states Fibrosis if OPERATED IMMEDIATELY????

Patients whose ligaments were reconstructed within the 1st week after injury (Group I) had a statistically significant increased incidence of arthrofibrosis (limited extension, scar tissue) over patients who had ACL reconstruction delayed 21 days or more. 

Partial Tear of ACL

• AM Bundle attached at 10 Clock Position

• PL Bundle attached at 9.30 Position

HOW MUCH???

• The ACL is composed of two separate bundles, the AM and the PL. • The intra-articular length of the ligament is between 28 and 31mm.

• The attachment sites on the tibia and femur have a fairly small isometric center.

• The ACL and PCL are closely intertwined and are called the “central pivot.

Femoral Foot Prints of ACL

A: Intercondylar RidgeB:Bifurcate Ridge

In Knee Arthroscopy• In Arthroscopy in 90 degree of Flexion…

The AM Bundle is more Vertical, (Deep & high) and fill the Hollow space of the Notch.

The PL Bundle curve Horizontally (Shallow & Low)near the articular surface of Femoral Condyle. It is Lax to some extent in 90 Knee Flexion.

Recent Advancement ----Replace only torn part BUT anatomical point should be well Visualized

HOW DO WE FIX THE TORN LIGAMENT???

WHOLE LIGAMENT?? OR TORN BUNDLE

REMEMBER: AM Bundle Controls Anterior Stability PL bundle Controls Rotational Knee Stability to some extent

Anteromedial portal VS TransTibial Portal

• Anteromedial portal approach makes it easier to access the femoral footprint of the AM and PL bundles.  

• ACL position is lower and more horizontal in Anteromedial procedure than that achieved when performing the transtibial procedure.

• A femoral tunnel placed too far anteriorly in Transtibial could result in a vertically oriented graft, which is different from the oblique orientation of the native ACL.

A: TransTibialB:AnteroMedial

• RESULTS:There were no differences in the center of the femoral tunnels on the Blumensaat's line between the two groups (mean 23.5% (4.2) for the transtibial technique and 26.0% (4.3) for the AM portal technique (P = n.s.). In the height of the femoral condyle, the center of the tunnels was significantly lower in the AM portal technique group [mean 34.7% (3.8) vs. 24.0% (7.9) (P < 0.001)]. In the tibia, the center of the tunnel in the sagittal plane was significantly posterior in the transtibial technique (mean 55.4% (4.9) vs. 44.4% (3.7) (P < 0.001).

• CONCLUSIONS: The AM portal technique places the femoral and tibial tunnels more centrally in the ACL footprint when compared with the transtibial technique (More Anatomical)

Mayer and Mc Keevers Tibial Spine # Classification

• Type I fracture is an undisplaced fracture of tibial eminence

• Type II fracture is partially displaced fracture, in which the anterior part of the avulsed fragment is displaced superiorly from the bone bed and gives a beak like appearance on the lateral x-rays.

• Type III fracture is completely displaced fracture and there is no contact of avulsed fragment to the bone bed.

• Type III A involves only ACL insertion and• Type III B involves entire Intercondylar eminence.

• Type IV include comminuted fractures of tibial spine.

Tibial Spine Fracture• ACL may be torn at femoral attachment ,Midsubstance,

or Tibial end or with Tibial Spine Fracture

• If Big chunk of Tibial Spine fix with SS wire Endobutton or Cannulated Cancellous screw.

If we try to do a Primary ACL repair then shattered Tibial Bed will not allow ISOMETRIC POINT

• If the Tibial Spine Fragment is Shattered then gives a small Contact & Poor Hold.

• If all there is associated ACL partial Tear ,which is partially shredded

Immobilize for 6 weeks &WAIT FOR

Fracture to UNITE ie Around 3 Months and then do Primary ACL

Repair

ASSOCIATED INJURIES

• Posterior Cruciate Ligament

• Medial Collateral Ligament

• Posterio Lateral Corner

• Both Ligaments Reconstructed in One Sitting

• Easy to See for PCL Tibial Attachment in absence of ACL

• Drill PCL tibial hole first as it will be difficult to see after leakage of fluid due to other Holes.

•WATCH FOR TOURNIQUET TIME

PCL +ACL Injury

ACL WITH MCL INJURY

ACL repair in next sitting

MCL requires IMMOBILIZATION in plaster for 4-6 weeks

Remove the Plaster and get the Knee ROM with Physiotherapy

• Surgery to be done in 2 Sittings

LCL+POSTERIOLATERAL CORNER+ACL+PCL

1st LCL + PLC and IMMOBILSE THE KNEE FOR 4-6 WEEKS

2ND ACL +PCL AFTER GETTING Free ROM

PHYSIOTHERAPY

CURRENT CONCEPTS IN RECONSTRUCTION

• STRONG Enough to avoid Failure

• STIFF Enough to restore Knee Stability

• SECURE enough to avoid Slippage

IDEAL FIXATION

Important Factors in Surgeons HandsGraft Selection

Graft Positioning

Graft Fixation

Rehabilitation

How to Fix??

ENDOBUTTONBONE MULCH SCREW RIGID FIX

BIOSCREWRCI SCREW

SMARTSCREW

• APERTURE FIXATION: At joint Level Interference Screws

• SUSPENSORY FIXATION:Far Cortex Cortical: Endobuttons,Tightrope,Staples,Screw &washers. Cancellous:Transfixation Pins

Types of Fixation

Interference Screws• Interference is defined as the amount by which diameter of the screw

exceeds the gap between graft and the tunnel.

Length of Screw

Size & Geometry of Screw

Divergence of Screw

Torque of Insertion

Screw material

BMD

Divergence > 15 Compromises Stability Screw Size

• 1 Size more than tunnel diameter in Soft tissue Graft

• Same Size in Bone plug Graft

INTRAFIX WasherLoc tibial fixation EZLoc femoral fixation device

3 Types of Graft Motion

• Longitudinal Motion called BUNGEE CORD EFFECT

• Horizontal motion called WIND WIPER EFFECT

• Creep of graft tissue leading to ELONGATION.

Endobutton• First Generation Suspensory Fixation.

• Femoral tunnel had 2 parts :Insertion part and Connection part

• Insertion part drilled to diameter of graft

• Connection part is of 4.5mm

• Femoral tunnel Length – Desired graft Insertion length= Loop length.

• Insertional Tunnel Length should be 10mm more than desired graft Insertion Length.

• If the Tunnel Length is 60mm, Desired insertion length is 40mm then the loop length should be 20mm and insertion tunnel should be 50mm long

• Second Generation Suspensory Fixation

• Loop Length reduced after flipping by Tightening the rope

• Allows full Length filling of Graft part of Femoral Tunnel

TightRope

TightRope

TightRope RT

Advantages of TightRope• Dramatic reduction in Tunnel widening and the bungy effect of the graft• No loop length calculations are required• Fill the entire socket with the graft, promoting advanced healing Socket• Less instrumentation required• One size fits all thus removing the need to stock a variety of sizes.• The ability to redeploy the implant if it is caught in soft tissue• 980N (Load to Failure)• Easy to deploy

Double Bundle Technique

• The positions of the two femoral tunnels were at 11:00 and 9:30 o’clock (right) and 1:00 and 2:30 o’clock (left) with the same diameter as that of the proximal diameter of each graft for the AM and PL bundles.

• Care has to be taken to leave a distance of at least 1 mm between the two tunnels to avoid overlapping.

Parallel guide K-wire inserted with the parallel guide

Two femoral sockets in the double-bundle reconstruction Grafts for the PL and AM bundles

THANK YOU