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ACL reconstruction with preservation of remnant of ACL H. Makhmalbaf MD Consultant Orth & Knee Surgeon Mashhad University, Iran 22.2.2012, Kish.

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Presentation on theme: "ACL reconstruction with preservation of remnant of ACL H. Makhmalbaf MD Consultant Orth & Knee Surgeon Mashhad University, Iran 22.2.2012, Kish."— Presentation transcript:

1 ACL reconstruction with preservation of remnant of ACL H. Makhmalbaf MD Consultant Orth & Knee Surgeon Mashhad University, Iran , Kish

2 Arthroscopy: The Journal of Arthroscopic & Related Surgery Volume 22, Issue 3Arthroscopy: 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

3 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

4 Acutely torn ACL remnant

5 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

6 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

7 Femoral socket preparation

8 Femoral socket along the guide pins

9 Guide pin for tibial tunnel

10 The guide pins switched to looped wires

11 The loop sutures pulled out

12 The remnant tissue is compacted

13 Sutures are tied

14 Belt-buckle fashion suture

15 No loop impingement in extension

16 Second look surgery

17 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

18 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

19 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

20 Best reconstructive procedure ? The role of mechanoreceptors in ACL Good results depend on : Mechanical stability & Quality of recovery of proprioception

21 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

22 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

23 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

24 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

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28 Tibial Guide Wire Placement & Tunnel Creation

29 Tibial Tunnel Creation

30 Femoral Tunnel Creation

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43 Thank you

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