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

2. 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
Byung-III Lee, M.D. Kyung-Dae Min, M.D, et al.
Arthroscopy: The Journal of Arthroscopic & Related Surgery Volume 22, Issue 3 , March 2006

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

28. Tibial Guide Wire Placement & Tunnel Creation

29. Tibial Tunnel Creation

30. Femoral Tunnel Creation

43. Thank you