5 Femoral and Tibial Insertions AM BundlePL BundleFlexionExtensionPLAMAn important concept to understand is the relative change of the ACL insertion sites throughout flexion and extension:Extension: two bundles are parallelFlexion: femoral insertion site of the PLB comes forward and the two bundles cross each otherPLAMAMPL
6 AM and PL bundle have different length and diameter 7.0 mm6.4 mmPLAMPLStudies of intraarticular lengthAMB significantly longer intraarticular lengthHowever, cross-sectional diameter not too differentAM38.5 (+/-3)19.7 (+/-2)AM and PL bundle have different length and diameter
7 Natural History True natural history will probably never be known Most studies look at symptomatic patientsNumerous studies have implicated the ACL deficient knee in accelerated osteoarthritis40-70% patients have x-ray evidence of DJD at 8-10 yrsJones, Injury Clinic, 2003
8 PathogenesisMost commonly via non-contact mechanism (70-80% of ACL injuries)Sports: football, basketball, soccerClassic mechanismValgus, ER, twisting injury during decelerationEpidemiology150,000 new injuries per yearIn given sport, females have 4-8 higher risk
9 Associated Injuries Meniscus tears common Acute, lateral: 75%Chronic, medial: 91%Noyes, JBJS, 1980Removal of as little as 15-30%→ ↑ contact forces up to 350%Baratz, Am J Sports Med, 1986Meniscus is a secondary stabilizer to anterior translation in ACL deficient knee
10 Bone BruisesMiddle portion of LFC; posterior portion of lateral plateauGraf, Am J Sports Med, 1993Significance unknownResult of rotatory motionSecond look arthroscopy at 6 years shows cartilage thinning in areas of bruisingClatworthy, Clin Sports Med, 1999
11 Pathophysiology Four categories: Environmental Anatomical Hormonal Dry playing surfacesIncreased fricition between shoes and surfaceAnatomicalLarger X-sect area of ACL in malesNarrower notch in females (? Significance?)HormonalConflicting data on estrogen and progesteroneBiomechanicalDiffering patterns of knee motion may be associated with differences in neuromuscular control (i.e., females decrease hamstring firing, higher ant. Tibial shear force, greater knee valgus moment, smaller knee flexion angle have been noted in some studies)
12 Diagnosis History Exam Very important! Mechanism Effusion Effusion, joint line tenderness, ROMLigamentous exam (Lachman’s)KT 1000 (quantify laxity)
18 Goals of ACL surgery Provide stable joint** Delay osteoarthrosisAvoid further internal derangementReturn to sport, work, recreational activities**
19 Success of the ACL surgery Clinical success rates range from 69-95%Yunes, Arthroscopy, 2001Freedman, Am J Sports Med, 2003Studies include data from experienced, fellowship trained ACL surgeons85% of surgeons performing ACL reconstruction do fewer than 10 per yearHarner, Arthroscopy, 2004
20 Success??Degenerative radiographic changes in 90% of patients 7 years after ACL single-bundle reconstruction47% of patients returned to previous activity level after ACL single-bundle reconstructionFithian et al, Am J Sports Med, 2005
21 In Vivo: Abnormal Rotational Knee Motion During Running After ACL Reconstruction Tashman, AJSM, 2004Using high speed stereoradiographic systemAP stability restored in ACL reconstructionRotatory instability persistedMay contribute to long-term degeneration
22 Biomechanical analysis of anatomic ACL reconstruction. AJSM 2003 Fu and co-workersDemonstrated that a non-anatomic single-bundle reconstruction is biomechanically and kinematically inferior to an anatomic reconstruction (whether it is double- or single-bundle)
23 Femoral Tunnel Knee flexed 110- 120° Femoral drilling guide through anteromedial accessory portal10 or 2 o’clock position (right or left knee)Tunnel drilled over guide wire
24 Loh, et al, Arthroscopy, 20031212Femoral Tunnel99
25 SO NOW WHAT???? WHICH GRAFT SHOULD I CHOOSE?? IS ONE GRAFT BETTER??? Your patient has already researched it on the INTERNET!!!!
30 Hamstrings INFERIOR Hamstring reconstructions: 1. Longer time to graft incorportation2. Grafts loosen/Tibial fixation3. Residual flexion weakness
31 Graft HealingAnterior Cruciate Ligament Replacement using Patellar Tendon. An evaluation of graft revascularization in the dog. Arnoczky JBJS 1982.16 weeks showed near-completion of revascularization of the graft.Tendon-healing in a bone tunnel: a Biomechanical and histological study in the dog. Rodeo et al. JBJS 1993.Tendon healing to bone: 12 weeksBone-tendon-Bone healing: 6 weeks
32 Failure of Osteointegration of Hamstring Tendon Autograft After Anterior Cruciate Ligament ReconstructionEun Kyoo Song, M.D., et al ArthroscopyReport on 2 cases of failed osteointegration between the hamstring tendon and boneConcluded failed fixation methods
33 Graft FixationInadequate fixation is the most common cause of ACL failure in the first 2 months post-opStudies have indicated tibial fixation the weakest point in early post-op period (due to cancellous bone and screw divergence)Most common is Interference screw fixationParallel fixation is crucialArea of screw compressing bone plug or soft tissue graft important
34 Graft loosening? BTB grafts heal faster BTB fixation better construct than SMT [Adam AJSM 2004]BTB had lower side to side difference [Freeman AJSM 2003]BTB have less tunnel widening [Aglietti JBJS 2004]
35 Restoration of function 2003JOURNAL“…Patellar tendon autografts had significantly lower rate of failure and resulted in better knee stability and increased patient satisfaction…”
36 Flexion weakness Theoretical in most activities > 90% strength of contralateral knee [Spindler AJSM 2004]Weakness most significant at higher degrees of flexion (>90 degrees) [Nakamura Arthroscopy 2002]@ 18 months, 69-83% decrease in strength with 110 degrees of flexion [Tashiro AJSM 2003]
37 Hamstring Regeneration Knee Surg Sports Traumatol Arthrosc Jun;14(6):542-5Knee Surg Sports Traumatol Arthrosc Feb;15(2): (Review)Show regeneration of hamstrings both grossly and macroscopically (“closely resembles” normal tendon)……just like “hyaline-like” cartilage!!!!
38 Hamstrings Regenerate??? Really!?! With Seth and Amy on ACL graft selection
39 Hamstring use in ACL surgery Burks et al. Arthroscopy 2005 Hamstring strength testing revealed a 26% deficit at 6 months, 21% at 12 monthsConclusions: At 1 year, the S.T.and gracilis muscles showed significant and persistent atrophy and frequent retraction of the S.T. muscle belly.Hamstring strength deficits persisting at 1 year after the use of the tendons for ACL reconstruction.
40 More WEAKness…Evaluation of Active Knee Flexion and Hamstring Strength After Anterior Cruciate Ligament Reconstruction Using Hamstring TendonsNorimasa Nakamura, M.D., et al ArthroscopyIsokinetic testing showed decreased strength at 90 deg flexion angle on operative sideThe side-to-side ratio in mean maximum standing knee flexion angle was significantly lower in the ST/G group than in the ST group.Conclusions: This study suggests that the loss of knee flexor strength following the harvest of the hamstring tendons may be more significant than has been previously estimated. Furthermore, multiple tendon harvest may affect the range of active knee flexion
42 Hamstrings B-T-B Easier to harvest As strong or stronger than B-T-B No anterior knee painMore difficult harvestAnterior knee painPatella fractures
43 Prevalence of Saphenous Nerve Injury After Autogenous Hamstring Harvest Brett Sanders, M.D., et al. Arthroscopy 2007Results: Postoperative sensory disturbance was present in 74% of patients surveyed.Conclusions: The SBSN is at higher risk of injury during hamstring ACL reconstruction than has been previously reported.
44 Hamstrings B-T-B Easier to harvest As strong or stronger than B-T-B No anterior knee painMore difficult harvestAnterior knee painPatella fractures
45 Treatment of Anterior Cruciate Ligament Injuries With Special Reference to Graft Type and Surgical Technique: An Assessment of Randomized Controlled Trials (A systematic review)Kristian Samuelsson, M.D., et al. Arthroscopy 2009The BPTB graft produces more anterior knee pain and kneeling pain than the HT graft, but the difference disappears with time.
46 How often do you kneel on a daily basis??? PlumberWrestlerConstruction……….
47 Hamstrings B-T-B Easier to harvest As strong or stronger than B-T-B No anterior knee painMore difficult harvestAnterior knee painPatella fractures
48 3 fellowship-trained sports medicine surgeons The Incidence of Acute Patellar Tendon Harvest Complications for ACL ReconstructionBach et al. Arthrscopy 2008September 1986 to April 20061,725 consecutive patients primary ACL reconstruction using BPTB autograft3 fellowship-trained sports medicine surgeons3 acute complications (0.2%) related to patellar tendon harvest2 patella fx (1 intra-op, 1 post-op); 1 patellar tendon ruptureremains a safe and viable choice
49 OutcomesCentral Third Bone–Patellar Tendon–Bone Anterior Cruciate Ligament Reconstruction: A 5-Year Follow-upJig V. Patel, F.R.C.S., J. Sam Church, B.S.c., M.B., B.S., and Anthony J. Hall, F.R.C.S.All patients had knee flexion within 10 degrees of uninjured legOnly 3 patients had clinical signs of instability on 5 yr follow upEither + Lachman’s, pivot shift, or >3mm diff. on KT-1000
50 OutcomesReconstruction of the anterior cruciate ligament: meta-analysis of patellar tendon versus hamstring tendon autograft.Goldblatt, Richmond, et al Arthroscopy 2005Overall, incidence of instability is not significantly different between the BPTB and HT grafts.However, BPTB was more likely to result in normal Lachman, normal pivot-shift, KT-1000 side-to-side difference < 3 mm, and fewer results with significant flexion loss.
51 OutcomesReconstruction of the anterior cruciate ligament in females: A comparison of hamstring versus patellar tendon autograft.Barrett et al. Arthroscopy 2002CONCLUSIONS: Although not statistically significant, the hamstring group had more failures, more laxity on exam, and more pts with larger KT-1000 differences. These results indicate a trend toward increased graft laxity in female patients undergoing reconstruction with hamstring autograft compared with BTB
55 What I will tell you about…. HamstringsYES, they are:-stronger-easier to harvest-smaller incision-no anterior knee pain-weakness not noticeable long term-outcomes equalB-T-BAnd YES, they are:More difficult harvestMore risky complicationsAnterior knee painLoss of ROMLarger incisionNo better outcomes
56 Complications of BTB grafts MedscapeAnterior knee painLoss of extensionDegenerative joint diseaseExtensor mechanism disruption
57 Anterior knee painSpindler, AJSM, 2004 “When evaluating subjective anterior knee pain or kneeling pain, the results are reproducible and clear-cut.”Kneeling pain50-65% BPTB unable to walk on yrs Ejerhed AJSM 200350% @ 7 yrs Roe AJSM 2005
58 Bach et al. Arthroscopy 2010 Femoral recession Graft rotation Avoiding Mismatch in Allograft Anterior Cruciate Ligament Reconstruction: Correlation Between Patient Height and Patellar Tendon LengthBach et al. Arthroscopy 2010Femoral recessionGraft rotationHybrid fixation
59 Extensor mechanism disruptions 3 acute complications related to patellar tendon harvest2 patella fx (1 intra-op, 1 post-op); 1 patellar tendon ruptureBach et al. Arthrscopy 2008Patellar Tendon Rupture 3 Years After Anterior Cruciate Ligament Reconstruction With a Central One Third Bone–Patellar Tendon–Bone GraftPhillip L. Mickelsen, M.D., et al. Arthroscopy 2001
60 Technical Note Management of Patella Fractures Associated With CentralThird Bone-Patella Tendon-Bone Autograft ACLReconstructions Eugene E. Berg, M.D.Arthroscopy: The Journal of Arthroscopic and Related Surgery. Vol 12, No :
62 Reconstruction of the anterior cruciate ligament: meta-analysis of patellar tendon versus hamstring tendon autograftGoldblatt, Richmond, et al Arthroscopy 2005HT grafts had a reduced incidence of patellofemoral crepitance, kneeling pain, and extension loss
63 What healing problems???Comparison of Clinical Results and Second-Look Arthroscopy Findings After Arthroscopic Anterior Cruciate LigamentReconstruction Using 3 Different Types of GraftsJung Hwan Lee, M.D., et al. Arthroscopy 2010Hamstring autograft group better synovial coverage on second-look arthroscopyBetter synovial coverage on second-look arthroscopy presented better clinical results on the IKDC objective examination form.
64 Graft loosening? Fixation method, not graft type, cause of slippage The truth…PT tendons heal fasterTransfixation better than interference for hamstring grafts??? Ahmad AJSM 2004Tranfixation of STG may be better than interference PT Rowden AJSM 1997Fixation method, not graft type, cause of slippage
68 OutcomesAnterior cruciate ligament reconstruction, hamstring versus bone-patella tendon-bone grafts: a systematic literature review of outcome from surgery.Herrington, et al. Knee 2005The results of the 13 studies included in this review suggest that there is no significant evidence to indicate that one graft is superior. Both the PT and HT grafts appear to improve patients' performance, and therefore both would be good choices for ACL reconstruction
69 OutcomesPatellar tendon or four-strand hamstring? A systematic review of autografts for anterior cruciate ligament reconstructionForster, et al. Knee 2005Overall, there was a greater chance of extension loss (p=0.007) and a trend towards increased PFJ pain (p=0.09) with BTBThere was no difference with Lachman testing, chance of returning to the same level of sport, clinical knee scores, graft ruptures or other complications.
70 OutcomesA prospective, randomized comparison of semitendinosus and gracilis tendon versus patellar tendon autografts for anterior cruciate ligament reconstruction: five-year follow-upSajovic, et al. AJSM 2006CONCLUSION: Both provided good subjective outcomes and objective stability at 5 years.No significant differences in the rate of graft failure were identified.Patients with patellar tendon grafts had a greater prevalence of osteoarthritis at 5 years after surgery.
71 OutcomesHamstring tendon versus patellar tendon anterior cruciate ligament reconstruction using biodegradable interference fit fixation: a prospective matched-group analysis.Wagner et al. AJSM 2004Hamstring tendon graft was superior in knee stability and function. These findings are partially contrary to previous studies and might be attributable to the use of an anatomical joint line fixation for hamstring tendon grafts.
72 OutcomesNo difference in knee function or prevalence of osteoarthritis after reconstruction of the anterior cruciate ligament with 4-strand hamstring autograft versus patellar tendon-bone autograft: a randomized study with 10-year follow-upHomi et al. AJSM 2010No statistically significant differences in clinical outcome at 10 yearsPrevalence of OA significantly higher in operated legNo significant differences between the 2 groups
73 Regardless…………..Educate Factors Affecting Patient Selection of Graft Type in Anterior Cruciate Ligament ReconstructionCohen et al. Arthroscopy 2009Most important factor for a patient choosing a graft for ACL reconstruction is physician recommendationIncreasing trend toward the use of allograft materials for ACL reconstruction63.3% of all graft materials selected
74 J. Richmond. AANA 2010 Author’s Current Surgical Treatment Algorithm “High demand”: eg. Competitive athlete Autologous B-PT-B“Moderate demand”: eg. Recreational athlete Autologous Q-ST&G“Lower demand” or other modifyingcircumstance (age, autologous tendonissues, revision) Allograft (tibialis or B-PT-B)