1. ACL Reconstruction Surgery
W.J.Leach
Consultant Orthopaedic Surgeon
Western Infirmary
Glasgow

2. The Holy Grail Reconstruct ligament Repair meniscus injury
Prevent meniscus injury
Return to full function
No OA!

3. ACL Reconstruction Major advances in last 15-20 years
Restores stability
Return to function
Reduces risk of meniscal tears
90% normal or near normal in short to medium term

4. Reconstructing the ACL?

5. “Anatomical “ placement of the ACL on femur

6. Surgical Placement of Femoral ACL Insertion 1990s
Somebody moved the ACL!
Isometry

7. Femoral placement Advent of arthroscopy
Placement to suit surgical jigs

8. Femoral tunnel placement
Transtibial – may be too vertical ( 1 or 11 o’clock) with OTT guide
AM portal – beware MFC when drilling, flex to 120

9. Femoral Tunnel Placement
Single bundle – mid-point more akin to AM bundle
Outside in - retrodrilling

10. Tibial Tunnel Placement
Just anterior to MCL distally
Exit through stump of ACL
7mm anterior to PCL
40% A-P on lateral

11. Two bundles better than one!
Attempt to recreate normal anatomy
Hypothesis that less OA changes develop
Technically demanding
Time consuming

12. Lubowitz et al. Am J Sports Med 2008 Meta-analysis (single bundle v
Lubowitz et al. Am J Sports Med 2008 Meta-analysis (single bundle v. double bundle)
NO DIFFERENCE!

13. ACL Graft types
Hamstring (4-strand)
BTB
Allograft

14. RCTs Hamstring v. BTB Grafts in ACL Reconstruction
Feller and Webster 2003
NO DIFFERENCE
Laxdal et al 2005
Maletis et al 2007
Ejerhed et al 2003

15. Carey, Spindler et al JBJS 2009. Systematic review – allograft v
Carey, Spindler et al JBJS Systematic review – allograft v.autograft
NO DIFFERENCE!

16. Foster, Ryan et al. Am J Sports Med 2010. Systematic review allograft v. autograft
NO DIFFERENCE!

17. What I do…. BTB - hypermobile, pro footballer, rugby
HT – majority, anterior knee pain, kneelers

18. Tibial Insertion Through stump of ACL remnant 7mm anterior to PCL
Elbow or PCL aimer degrees
Start tibial tunnel just anterior to MCL fibres

19. Femoral tunnel Transtibial – OTT aimer 10 o’clock
Outside in – retroreamer

20. Fixation
Hamstring – Closed loop endobutton proximally, bioabsorbable screw distally
BTB – metal interference screws