ACL reconstruction with preservation of remnant of ACL
H. Makhmalbaf MD
Consultant Orth & Knee Surgeon
Mashhad University, Iran
22.2.2012 , Kish
Arthroscopy: The Journal of Arthroscopic & Related Surgery
Volume 22, Issue 3 , March 2006
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
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
Acutely torn ACL remnant
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
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
Femoral socket preparation
Femoral socket along the guide pins
Guide pin for tibial tunnel
The guide pins switched to looped wires
The loop sutures pulled out
The remnant tissue is compacted
Sutures are tied
Belt-buckle fashion suture
No loop impingement in extension
Second look surgery
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
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
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
• Best reconstructive procedure ?
• The role of mechanoreceptors in ACL
• Good results depend on :
• Mechanical stability &
• Quality of recovery of proprioception
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
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
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
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
Tibial Guide Wire Placement & Tunnel Creation
Tibial Tunnel Creation
Femoral Tunnel Creation
Thank you