Ebrahimzadeh M.H. MDDepartment of Orthopedic surgery, Ghaem HospitalMashhad University of Medical Sciences, Mashhad, Iran

Frequency

It is currently one of the most common orthopedic procedures in the world

6th frequent orthopedic surgery in US 100000 ACL tears each year 75 000 annually primary ACL

reconstruction, 3000-1000 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

AutograftsBone-patellar tendon-boneQuadrupled 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-boneAchilles’ tendonHamstringsQuadriceps tendonFascia lata

Autograft vs. Autograft vs. AllograftAllograft

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 weakest @ 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. 2006

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

--139 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 Present recommendation for 2 recommendation for 2

bundlesbundles Only for hands of the most experince

ACL surgeon

Standard for patients who perfoms demanding pivoting sports

Skeletal Immature ACL

Reconstruction

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

Recommendationsfor 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 EndThe End