Ebrahimzadeh M.H. MD Department of Orthopedic surgery, Ghaem Hospital Mashhad University of Medical Sciences, Mashhad, Iran
Frequency It is currently one of the most common orthopedic procedures in the world 6 th frequent orthopedic surgery in US ACL tears each year annually primary ACL reconstruction, revision
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
Who is candidate for ACL reconstruction ? Knee instability& pain Young ; athlete No or a little DJD
Graft choices
Graft Choices Autografts Bone-patellar tendon-bone Quadrupled hamstrings (Grac & Semi-T) Quadriceps tendon
Semitendinus&Gracilis
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
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
Graft Choices Allograft Bone-patellar tendon-bone Achilles’ tendon Hamstrings Quadriceps tendon Fascia lata
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 8-12wks) Donor site morbidity with autografts
Graft Fixation
Interfnce screw Biodegradable Metalic
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
Intefrance Screw
Transfix
Transfix pin/screw Rose et al. : J of Knee Surg, Sport Traumatolo 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
Crosspin/transfix
Endobuttom Loop
Endobotton Femoral Fixation Promodos and Joyce. J Tech Orthopedics, 2005 Endobutton for hamesting femoral fixation of ACL recomstruction, technique and results patients with 2-8 years follow-up -86% reported normal knee stability
Ham. Graft passer for Transfix
One bundle or two bundle ACL reconstruction
Anatomic versus non-anatomic reconstruction Anteromedial(vertical) AP stability Posterolateral(Oblique) Rotational Stability
16 weeks old fetus
Two bundles VS one Bundle Disadvantage of 2 Bundles: Numbers of femoral tunnels Operative time Femoral condyle osteonecrosis, chondrolysis More technically demanding
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
Present recommendation for 2 bundles Only for hands of the most experince ACL surgeon Standard for patients who perfoms demanding pivoting sports
Skeletal Immature ACL Reconstruction
6.7% of all ACL tears Physial sparing reconstuction --nonisometric ACL reconstruction Parker Am J Sport Med 1994
Partial transphysial ACL reconstruction --Lo Ik et al. Athroscopy 1997 --No angular deformity --No LLD
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
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
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
The End