1. Ebrahimzadeh M.H. MD Department of Orthopedic surgery, Ghaem Hospital Mashhad University of Medical Sciences, Mashhad, Iran

2. Frequency  It is currently one of the most common orthopedic procedures in the world  6 th frequent orthopedic surgery in US  100000 ACL tears each year  75 000 annually primary ACL reconstruction, 3000-1000 revision

3. The most frequent Orthopedic procedure in US  1. Knee arthroscopy and meniscectomy  2. Shoulder arthroscopy and decompression  3. Carpal tunnel release  4. Knee arthroscopy and chondroplasty  5. Removal of support implant  6. Knee arthroscopy and anterior cruciate ligament reconstruction

5. Who is candidate for ACL reconstruction ?  Knee instability& pain  Young ; athlete  No or a little DJD

6. Graft choices

7. Graft Choices  Autografts Bone-patellar tendon-bone Quadrupled hamstrings (Grac & Semi-T) Quadriceps tendon

8. Semitendinus&Gracilis

10. BPTB versus Hamestring tendon  Liden et al. Am J Spot Med, 2007; 35  a prospective, randomized study with a 7-Year follow-up. 34/ 37 pt  ----No Significant differences in Lysholm score and IKDC score; patient`s function

11. BPTB versus Hamestring tendon  Pinczewski et al. AM Jsport Med. 2007; 37  90 BTBG with 90 ST.Gracilis 10 years Follow-up  No difference in function; Lysholm score, IKDC  More morbidity in donor site in BTBG  More Petellofemoral DJD in BTBG

12. Graft Choices  Allograft Bone-patellar tendon-bone Achilles’ tendon Hamstrings Quadriceps tendon Fascia lata

13. Autograft vs. Allograft  Viral disease transmission (1:1million) Deep freezing leaves some cells (10%) Freeze-drying & cryo weaken graft; limited self-life  Graft incorporation & remodeling is faster with autografts. (graft is weakest @ 8-12wks)  Donor site morbidity with autografts

14. Graft Fixation

15. Interfnce screw  Biodegradable  Metalic

16. Bio vs Metal Screw  Laxdal G. et al. BioVs Metalic Screw  Am J Sports Medicine 2006  77pts in a prospective randomised study;  6-24 months,,,, the same function outcome  -larger drill hole in bio group

18. Intefrance Screw

19. Transfix

20. Transfix pin/screw  Rose et al. : J of Knee Surg, Sport Traumatolo. 2006  Prospective randomized study of Transfix vs Bio screw for hamstring reconstruction  -38 patients with Transfix versus 30 Bio screw with 12 months follow-up  No significant difference in outcome

22. Crosspin/transfix

24. Endobuttom Loop

25. Endobotton Femoral Fixation  Promodos and Joyce. J Tech Orthopedics, 2005  Endobutton for hamesting femoral fixation of ACL recomstruction, technique and results  --139 patients with 2-8 years follow-up  -86% reported normal knee stability

26. Ham. Graft passer for Transfix

27. One bundle or two bundle ACL reconstruction

28. Anatomic versus non-anatomic reconstruction  Anteromedial(vertical) AP stability  Posterolateral(Oblique) Rotational Stability

29. 16 weeks old fetus

35. Two bundles VS one Bundle  Disadvantage of 2 Bundles:  Numbers of femoral tunnels  Operative time  Femoral condyle osteonecrosis, chondrolysis  More technically demanding

36. Two bundles VS one Bundle JarvelaTimo ; J Knee Surg Sports Tramatol Arthoscpy, 2007, 15 Prospective randomized study with #14 months follow-up 35 pts two bundle 30 pts one bundle --Lysholm Score and IKDC --Rotatinal stability (Pivot shif) better in 2 bundle group

37. Present recommendation for 2 bundles  Only for hands of the most experince ACL surgeon  Standard for patients who perfoms demanding pivoting sports

38. Skeletal Immature ACL Reconstruction

39.  6.7% of all ACL tears  Physial sparing reconstuction  --nonisometric ACL reconstruction  Parker Am J Sport Med 1994

40. Partial transphysial ACL reconstruction  --Lo Ik et al. Athroscopy 1997  --No angular deformity  --No LLD

41. Tranepiphysial ACL reconstruction  Guzzanti et al. Am J Sport Med 2003  8 patients with 70 moths of follow-up  Average Knee score 97/100  1.8 mm translation difference  No growth problem

42. Transphysial ACL Reconstruction  Aichroch PM, Patel D. JBJS Br 2002  47 patients with hamestring ACL reonstruction,,,  3year follow-up  No LLD and no angular deformity

43. Recommendations for adolecent ACL reconstruction  For delaying surgery patients should restrict sports  1-Hamestring is more deserible  Acute and subacute period you can do the sugery

44.  The End