ACL RECONSTRUCTION

Surgical steps

1) examination under anaesthesia2) arthroscopic diagnostic round3) addressing the other lesions. 4) graft harvest5) Graft preparation6) Preparation of intercondylar notch7) Femoral tunnel (trans portal)8) Tibial tunnel9) Calculation of endobutton CL length and graft

preparation10)Graft passage and femoral fixation11)Graft tensioning12)Tibial fixation13)closure

Lateral leg post : for giving intraop Valgus stress, opening the medial compartment

Full knee flexion should be possible For making transportal femoral tunnel

Portals

Diagnostic round

•Supra patellar pouch•Medial and lateral gutter•Patello- femoral articular surface•Menisci and Cruciate ligaments and

articular cartilage.

Oblique skin incision – used by experiencedSurgeons. More cosmetic. Saves the nerve

Vertical skin incision

the sartorius tendon is approximately one finger width below the tibial tubercle sartorius fascia is exposed by sharp and blunt dissection

inside-out technique : the conjoined tibial insertion of the two tendons is detached from the tibia by making an inverted L-shaped incision through the sartorius fascia

bluntly release the interconnecting fascial bands

right-angled type clamp is used to separate the two tendons from the undersurface of the sartorius fascial flap

-a closed Brand-type tendon stripper,(7.4mm) or a tendon harvester (Linvatec, Largo, Fla) -extensive fascial connections that extend from inferior border of the semitendinosus tendon to the medial head of the gastrocnemius. -- advance the tendon stripper parallel to the tendon by a slow, steady, rotating motionIdeal length- 20-26 for gracilis/24-30 for SemiT

2 – graft preparation

•graft preparation board (Graft Master II; Smith & Nephew Endoscopy).

•Residual muscle fibers removed with a metal ruler, a large curet.

•running, baseball-style whipstitch of a No. 2 nonabsorbable suture.

Doubled gracilis and semitendinosus tendon (DGST) graft

Anterolateral portal

VIEW OF FEMORAL ATTACHMENT OF ACL

3 – Notch preparation

•Using currete and Burr•Autograft requires a 2 mm clearance•The proximal outlet of the notch should

not be enlarged; rather, it is carefully identified with the knee at 90° flexion.

•a 5.5-mm full-radius resector to resect the soft tissue

•

Transportal femoral tunnel preparationAdvantages –1) The ability to position the femoral tunnel in a more

anatomic position lower down the sidewall of the lateral femoral condyle

2) The freedom to locate the starting position of the tibial tunnel anywhere along the medial surface of the tibia

3) The freedom to drill a steeper and therefore longer tibial tunnel

4) The possibility of drilling the femoral tunnel before drilling the tibial tunnel, which helps maintain joint distention, improving joint visualization during the remainder of the procedure

Disadvantage –5) unconventional field of view in the notch that can result

in spatial disorientation with knee 120 degree flexed6) more horizontal femoral tunnel that results in the

EndoButton implant's lying on the weaker metaphyseal bone of the distal femur

Knee flexed 75-90 Knee flexed 110

Over the top guide

30 mm depth Intact posterior wall

FEMORAL TUNNEL PREPARATION

• 6 mm anterior to the over-the-top spot in approximately the 11-o'clock position on the right knee or the 1-o'clock position on the left knee, at the junction of the arch of the roof and the lateral wall of the condyle approximately 8 mm lateral to the posterior cruciate ligament

• The external landmark for the guide is the midportion of the femur approximately 3 cm proximal to the over-the-top spot. The angle of the wire should be approximately 45 degrees to the femur and should be as close as possible to the plane of the previously placed tibial guidewire. at least 2 mm of lateral cortex should remain posterior to the wire to prevent “blowing out” the posterior wall of the condyle. Ensure that it is 6 mm anterior to the over-the-top spot position by flexing the knee 90 degree.

• 8 mm reamer followed by 10 mm is used. The tunnel is drilled within 5-8 mm of the far cortex.

• For endobutton , 4-5 mm tunnel is drilled through far cortex.

•Intra-articular reference point - just posterior to the center of the anterior cruciate ligament footprint approximately 2 mm anterior to the peak of the medial tibial spine, which is approximately 7 mm anterior to the posterior cruciate ligament, just medial to the inner edge of lateral meniscus.

• Advance the guidewire into the joint, and carefully identify its direction of passage

Patellar tendon harvesting•6-cm medial parapatellar incision

starting inferior to the patella and extending distally medial to the tibial tuberosity

•10-mm-wide graft or one third of the tendon, whichever is smaller used

•cut made about 10 mm wide × 20 mm long measured from the bony tip of the patella.

•25-mm-long cuts distally, and free the tibial graft with a curved osteotome

GRAFT PREPARATION contour the graft until it fits through a

10-mm trial drill three holes in each bone plugplace a 5-0 nonabsorbable suture

through each drill hole

Thank You