Arthroscopic Acl Reconstruction By Dr Shekhar Shrivastav. HOW NORMAL KNEE WORKS ? The knee is the largest joint in the body, and one of the most easily injured. It is made up of the lower end of the thigh bone(femur), the upper end of the shin bone (tibia), and the knee cap (patella), which slides in a groove on the end of the femur. Four bands of tissue, the anterior and posterior cruciate ligaments, and the medial and lateral collateral ligaments connect the femur and the tibia and provide joint stability. The surfaces where the femur, tibia and patella touch are covered with articular cartilage, a smooth substance that cushions the bones and enables them to glide freely. Semicircular rings of tough fibrous-cartilage tissue called the lateral and medial menisci act as shock absorbers and stabilizers. WHAT IS THE ROLE OF ACL ? ACL along with other ligaments of the knee joint and meniscus provides stability to the knee joint. WHAT IS LIGAMENT RECONSTRUCTION ( ACL ) ? Ligament reconstruction involves replacing the torn ligament with a tendon (graft) from your knee and fixing the graft in place with screws. This procedure is performed with the use of the arthroscope. The anterior cruciate ligament (ACL) is the most common ligament requiring reconstruction procedures. The torn ligament is excised arthroscopically and new ligament is prepared by ligament grafts taken from your own body. Bony tunnels are prepared in femur and tibia using specialized instruments through which the new ligament is passed and fixed with special screws. This procedure requires relative rest or leave from your work or studies for about 2-3 weeks after which you will be allowed normal day to day activities. WHEN CAN THE PATIENT BE AMBULATED AFTER SURGERY ? The patient can walk from the same evening of the surgery. Initially the patient is advised to walk with a brace and a walking cane. Strengthening and range of motion exercises for the knee are started from the next day. The patient is discharged from the hospital 2nd or 3rd day after surgery. The patient can walk without support by 10-14 days depending on muscle strengthening. Slow Jogging and other strenuous activities are permitted after 3 months and the patient can return to active sports only 8-9 months after surgery. Torn ACL Reconstructed ACL For Further Queries contact your Orthopedic Surgeon at + 91 9971192233

1. Dr. SHEKHAR SRIVASTAV
Sr.Consultant – Knee & Shoulder Arthroscopy
Delhi Institute of Trauma & Orthopaedics
Sant Parmanand Hospital DELHI
www.delhiarthroscopy.com
ACL RECONSTRUCTION

2. Ligamentous Anatomy of the Knee

3. Cruciate Ligaments
• Anterior (ACL) – resists
anterior translation
• Posterior (PCL) – resists
posterior translation
Collateral Ligaments
• Medial (MCL) – resists
medially directed force
• Lateral (LCL) – resists
laterally directed force
Ligaments of the Knee

4. Mechanism of Injury
ACL injury mechanism
of injury
• Twisting on fixed foot
• Blow to the knee
• Hyperextension
• 78% are non- contact
injuries (Noyes et al)

5. Examining the Patient
• History
• Examination
– Motion of knee and degree
of swelling
– Ligament specific tests of the
knee
• Lachman test
• Anterior and Posterior Drawer
– Look for associated injuries
Have you heard of the
unhappy triad?

6. MRI KNEE

7. MANAGEMENT
1/3 - No symptoms, Normal life
1/3 - Occasional instability,no strenuos activity
1/3 - Constant instability and pain
• ACL deficient- little higher rate of future medial
meniscus tearing and arthritis.

8. Indications for surgery
Factors to consider
•Degree of ACL injury
•Presence of associated ligamentous,
chondral and meniscal conditions
•Age/activity level/occupation
•Sports participation
•Patient compliance with post-op
rehab

9. ACL Surgery
ACL Tear-
No repair
Only Recontruction
Graft -
Autograft - common
Allograft

10. Graft Options
• Allograft – Rarely
• Autograft – BPTB
Hamstring grafts
Quadriceps Tendon graft
Hamstrings WHY
- Graft site morbidity- minimal
- Hamstrings regain their strength-95%
- Better Technique & fixation options
- Cosmetically appealing

11. Bony Tunnels are very precisely drilled in the tibia and femur to recreat
the normal anatomic position of the ACL . The graft is passed and
secured in plate.

12. ACL RECONSTRUCTION
SUCCESS
Quality of the
Graft
Appropriate
Tunnel Placement
Strong Graft
Fixation

13. GRAFT HARVEST

14. GRAFT HARVEST

15. GRAFT HARVEST

16. GRAFT PREPARATION

17. GRAFT PREPARATION

18. FAILURE OF ACL
Single Most Common
Cause
INCORRECT TUNNEL
PLACEMENT

19. TUNNELS FOR
ACL
LENGTH
DIAMETER
POSITION

20. TIBIAL TUNNEL
ENTRY POINT
Tibial jig- set at an
angle of 45-550
300 medial to mid
sagital axis
Apprx. 4 cms
below joint line

21. TIBIAL JIG
EXIT (INTRA ARTICULAR)
LANDMARKS-
(A) ACL Footprint
3 mm post. to center of
ACL footprint
(B) LATERAL Meniscus
Post. Border of Ant.
Horn
(C) PCL
7 mm ant. to ant. Border
of PCL in 90 flexion

22. TIBIAL GUIDE WIRE

23. IMPINGEMENT TEST

24. TIBIAL TUNNEL DRILL

25. FEMORAL TUNNEL
ISOMETRIC POSITION-
Distance between tibial and femoral tunnel
Changes < 2mm on flexion and extension.
FEMUR - Over the top position(Beware of
Resident’s Ridge)

26. OVER THE TOP

27. FEMORAL TUNNEL
Access for tunnel placement
-Through the Tibial Tunnel
- Through medial
instrument portal
ANATOMICAL POSITION
-Over the top position
- Right Knee-9 – 10pm
- Left Knee- 2 - 3 am
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28. FEMORAL TUNNEL

29. FEMORAL TUNNEL(OFFSET DRILL
GUIDE)

30. FEMORAL GUIDE WIRE

31. FEMORAL TUNNEL DRILL

32. FEMORAL TUNNEL

33. PASSAGE OF GRAFT

34. ACL GRAFT

35. Graft fixation
• Secure graft fixation is paramount to a
successful reconstruction
• ACL rehab emphasizes on immediate
movement and weight bearing
• High demand on initial graft fixation
• Ultimate long term success of an ACL
reconstruction depends on healing of the
graft fixation sites and biological healing

36. Graft Fixation
• Choice of graft fixation depends on
-Surgeon preference
-Choice of graft
-Surgical technique
• Fixation Options
Femoral – Interference screws
- Cross pin fixation
- Endobutton Fixation
Tibial - Intererference Screws
- Suture discs, Post with washer

37. Bio-Interference Screw Fixation
• Aperture Fixation
• Compaction drilling
• Dependent upon
cancellous bone
• Post wall blowout
• Concern -Graft maceration
& failure at physiological
loading

38. Cross pin fixation
• Impacted transversely into
lateral cortex
• Implant passed under
looped graft
• Implant perpendicular to
graft
• Highest ultimate load
failure and stiffness
• Concern- tunnel widening
and windshield wiper
effect

39. Endobuttton Fixation
• Fixation at lateral femoral
cortex
• No wear or abration of
graft
• Advantages-
Osteoporotic bones &
femoral tunnel blowout
• Problems- fixation away
from aperture- tunnel
widening & bungee effect

40. POST-OP

41. Rehab following ACL reconstruction
Rehab depends on:
-graft selection
-graft quality
-graft fixation
-associated procedure-meniscal repair,
Chondral debridement, associted ligament
reconstruction
Emphasis on immediate movement & weight
bearing
MOVE IT OR LOSE IT

42. Rehab following ACL reconstruction
IMMEDIATE POST-OP
Ice Packs
ROM exer- CPM
Isometric Hams & Quads Exer
Weight bearing with a Brace & Stick
2-3 WEEKS
Walk without stick but brace on( 6-8 wks)
Knee ROM- upto 900
Closed chain Quads & Hams Strength Exer

43. Rehab following ACL reconstruction
6-8 WEEKS
Open Chain Exer- Quads & Hams
ROM- Full
Straight running,Jogging- 2-3 mnths
Cutting – 5-6 mnths
Return to Sports- 9 mnths

44. Complications
Pre-op consideration
• Patient selection- Non compliant/
Apprehensive
• Timing of the operation
• Immature Athlete
• Med. Comp OA with ACL insufficiency

45. Complication- Graft
Graft harvest
• Graft cut short
• Small size
Prevent
• careful harvest technique
• Cut all band attached
before using stripper
Dropped graft
• Careful passing of graft
• Another graft harvest

46. Complications
femoral tunnel
Improper tunnel
placement-Anterior
femoral tunnel
• Residents ridge
• Use femoral tunnel
guides
Solution
• Notchplasty
Posterior wall blow-out
• Endobutton or transfix

47. Complications
Tibial Tunnel
Improper tibial tunnel-
anterior tunnel placement
• Intra-articular landmarks
• Check guide wire
impingement before drilling
Solution
• Notchplasty
• Chamfering of the tunnel

48. Complications
Neurovascular – most
serious complication
• Vessel behind Post.
Horn Lat. meniscus
• Early recognition and
prompt repair
• Careful handling of
shaver and burr in
posterior compartment

49. Complication
• Recurrent Effusions
-Debris during surgery
-Reaction to bioabsorbable implants
-Vigourous physio
Management- Repeated aspirations
• Infection - < 1%
Management- antibiotics & arthroscopic deb.
• Stiffness –
- Improper tunnels
- Post-op arthrofibrosis
- Cyclops lesion
- Inadequate physio/ non-compliant patient
Management- Gentle MUA / Arthr. Adesiolysis

50. THANK YOU