Human ACL reconstruction
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1 Human ACL reconstruction current state of the art Rudolph Geesink MD PhD Maastricht The Netherlands
2 Human or canine ACL repair...!?
3 ACL anatomy... right knees!
4 ACL double bundles...
5 ACL double or triple bundles...?
6 ACL double bundle footprints...
7 ACL double bundle functionality...
8 ACL imaging on MRI... Normal ACL and PCL ligaments on MRI
9 Knee kinematics...
10 Knee kinematics...
11 Knee epicondylar axis...
12 Knee rollback and medial pivot... Li! Freeman!
13 Forces in the ACL... McLean s setup to measure knee forces...
14 Forces in the ACL... 14
15 Native laxity in the ACL... Females have somewhat larger rotation potential in the knee and are therefore more prone to ACL injuries (Park).!
16 Epidemiology of ACL injuries... ACL injuries USA > per year ACL reconstructions USA per year ACL injuries Europe > per year ACL reconstructions Europe > per year
17 Injury mechanisms of the ACL...
18 Injury mechanisms of the ACL...
19 Damage and overstretch of the ACL...
20 Diagnosis of ACL injuries... - trauma history - symptoms - physical examination - imaging studies - arthroscopy
21 Clinical diagnosis of ACL injuries... Anterior drawer sign for ACL injury
22 Clinical diagnosis of ACL injuries... Lachman test for ACL injury - AM bundle if isolated
23 Clinical diagnosis of ACL injuries... Pivot shift test
24 Quantification of ACL laxity... MEDmetric arthrometer KT1000
25 MRI diagnosis of ACL injuries... ACL rupture on MRI
26 MRI diagnosis of complex injuries... Unhappy triad: - ACL rupture - MCL rupture - meniscal rupture - cartilage damage
27 Arthroscopic diagnosis of ACL injuries...
28 Arthroscopic diagnosis of ACL injuries...
29 Treatment of ACL injuries... A typical ACL tear does not heal...
30 Conservative treatment of ACL injuries... physical therapy - exercises
31 Conservative treatment of ACL injuries... Braces in use for treatment of ACL injuries or after ACL reconstruction
32 Surgical procedures for ACL injuries... persistent instability with giving way symptoms...
33 Treatment rationale for ACL injuries...
34 Restore stability and prevent osteoarthritis... (Lohmander)
35 Surgical procedures for ACL injuries... Jones procedure...
36 ACL arthroscopic surgery...
37 Relevant factors for good surgical outcome...
38 Graft choice... Patellar tendon or hamstring tendon as used for graft in ACL repair
39 Doubling (or 4-8x) of hamstring grafts... Semitendinosus tendon used for ACL reconstruction, difference in size and geometry between patellar tendon and hamstring tendon grafts.
40 Graft fixation... Fu!
41 Graft slippage & elongation... Graft slippage (fixation problem) versus graft elongation (graft problem) resulting in late instability (Kahn)
42 Synthetic ligaments...?
43 Synthetic ligaments...? (Mascarenas)!
44 Goretex and Leeds-Keyo... Gore-Tex ligament and micro-structure! Leeds-Keio ligament and micro-structure after 6 years in vivo.!
45 LARS ligament augmentation... PCL
46 Back to autografts...! new opportunities with new materials..?
47 New opportunities..?
48 ACL arthroscopic surgery...
49 Do we really need ACL bundles..?
50 Advantages of double bundle ACL repair... - Total contact area between tendon and bone is larger by about 40%. - Usually sufficient to harvest one tendon (semitendinosus). - Less surgical injury is done. - Allows for anatomica restoration of the oval shape of the ACL insertions. - Tension is shared between two bundles. - Four points of fixation provide better graft stabilisation. - Thinner grafts decrease risk on impingement with PCL. - Small tunnel diameter provides better anatomical conditions in case of later revision. - Possible to reconstruct a single bundle of a partially torn ACL.
51 Single femoral tunnel -bundle technique... Graft preparation for single femoral tunnel - double bundle ACL repair!
52 Double bundle ACL surgical technique... AM PL AM PL Orientation of future drill holes.
53 Double bundle ACL surgical technique... Preparation of femoral AM graft tunnel - thicker drill tibia - thinner canal in femur
54 Double bundle ACL surgical technique... second PL tunnel is drilled, again tibial thicker than femur a pull-through wire is brought through the PL tunnel
55 Double bundle ACL surgical technique......by which the graft is pulled through the tunnel similar procedure for AM tunnel. Graft fixation at femoral end.
56 Double bundle ACL surgical technique... tensioning and fixation of both grafts at tibial side.
57 Arthroscopic techniques... Arthroscopic placement of interference screw Final result of DB-ACL repair with skin incisions.
58 Aiming devices... Drill guides to improve the accuracy of bone tunnel drilling & pull-through wires for DB-ACL graft.
59 Aiming devices... Drill guide and hamstring grafts for DB-ACL repair
60 Tensioning devices & laxity testers... Graft tensioner and laxity tester during surgery
61 ACL computer navigation...
62 ACL computer navigation... femoral & tibial tunnel navigation... Optimization: - isometric stability - range of motion
63 Surgical tips and tricks... - tunnel osteophyte removal - widen tunnel in PCL dominant knee > 1-mm of graft diameter - avoid PCL impingement - avoid overstuffing narrow space with graft - avoid too wide drill canals - experience... experience...
64 Relevant factors for good surgical outcome... - Reconstructing the ACL anatomy - Restoring the native insertion site anatomy of the ACL - Restoring the tension pattern of each bundle - Individualising the surgery for each patient - Bone morphology dictates the motion of the knee
65 Problems and complications...
66 Complications...
67 Problems...
68 Relevant factors for good surgical outcome...
69 Thank you
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