Current concepts

1. Dr.Subodh Pathak

2. Common Questions………..
When to Check ACL injury??
How to Check??
When to Operate??
Fixation Methods???

3. Patient Presents with H/O fall
• In Acute Swollen Knee----Anterior Drawer Difficult because cant flex till
90 degree
• Do Lachman Test--------------POSITIVE
• Varus /Valgus Test in Knee Extension----POSITIVE
• MRI to be done if injury is severe with Positive Findings

4. Lachman test Anterior Drawer test

5. •If None of test POSITIVE
• Wait for 3 weeks for Acute Event to Subside
• Test Again for Lachman and Anterior Drawer Test
• If test Positive -----Confirm with MRI

6. If in ACUTE stage ACL tear is confirmed
If OPERATED Immediately then Surgeon will face lot of blood
oozing and haziness in the background of the Scopy Field.
BRACE the
KNEE for 1-3
weeks for the
Soft tissue to
HEAL

7. SURGERY IN ACUTE PHASE
• May also cause Extravasation of fluid into the Extra articular
Compartment and may cause Compartment Syndrome.
• Some Literature states Fibrosis if OPERATED IMMEDIATELY????

8. Patients whose ligaments were reconstructed within the 1st
week after injury (Group I) had a statistically significant increased
incidence of arthrofibrosis (limited extension, scar tissue) over
patients who had ACL reconstruction delayed 21 days or more.

9. Partial Tear of ACL
• AM Bundle attached at
10 Clock Position
• PL Bundle attached at
9.30 Position
HOW MUCH???

10. • The ACL is composed of two separate bundles, the AM and the
PL.
• The intra-articular length of the ligament is between 28 and
31mm.
• The attachment sites on the tibia and femur have a fairly small
isometric center.
• The ACL and PCL are closely intertwined and are called the
“central pivot.

11. Femoral Foot Prints of ACL
A: Intercondylar Ridge
B:Bifurcate Ridge

12. In Knee Arthroscopy
• In Arthroscopy in 90 degree of Flexion…
The AM Bundle is more Vertical, (Deep & high) and
fill the Hollow space of the Notch.
The PL Bundle curve Horizontally (Shallow &
Low)near the articular surface of Femoral Condyle. It
is Lax to some extent in 90 Knee Flexion.

15. Recent Advancement ----Replace only torn part
BUT anatomical point should be well Visualized
WHOLE
LIGAMENT?? TORN BUNDLE
REMEMBER: AM Bundle Controls Anterior Stability
PL bundle Controls Rotational Knee Stability to some extent

16. Anteromedial portal VS TransTibial Portal
• Anteromedial portal approach makes it easier to access the
femoral footprint of the AM and PL bundles.
• ACL position is lower and more horizontal in Anteromedial
procedure than that achieved when performing the transtibial
procedure.
• A femoral tunnel placed too far anteriorly in Transtibial could
result in a vertically oriented graft, which is different from the
oblique orientation of the native ACL.

18. A: TransTibial
B:AnteroMedial

20. • RESULTS:There were no differences in the center of the femoral tunnels on the Blumensaat's line
between the two groups (mean 23.5% (4.2) for the transtibial technique and 26.0% (4.3) for the
AM portal technique (P = n.s.). In the height of the femoral condyle, the center of the tunnels was
significantly lower in the AM portal technique group [mean 34.7% (3.8) vs. 24.0% (7.9) (P <
0.001)]. In the tibia, the center of the tunnel in the sagittal plane was significantly posterior in the
transtibial technique (mean 55.4% (4.9) vs. 44.4% (3.7) (P < 0.001).
• CONCLUSIONS: The AM portal technique places the femoral and tibial tunnels more centrally
in the ACL footprint when compared with the transtibial technique (More Anatomical)

21. Mayer and Mc Keevers Tibial Spine #
Classification
• Type I fracture is an undisplaced fracture of tibial
eminence
• Type II fracture is partially displaced fracture, in
which the anterior part of the avulsed fragment is
displaced superiorly from the bone bed and gives a
beak like appearance on the lateral x-rays.
• Type III fracture is completely displaced fracture
and there is no contact of avulsed fragment to the
bone bed.
• Type III A involves only ACL insertion and
• Type III B involves entire Intercondylar eminence.
•Type IV include comminuted
fractures of tibial spine.

22. Tibial Spine Fracture
• ACL may be torn at femoral attachment ,Midsubstance,
or Tibial end or with Tibial Spine Fracture
• If Big chunk of Tibial Spine fix with SS wire
Endobutton or Cannulated Cancellous screw.

23. If we try to do a Primary ACL repair then shattered
Tibial Bed will not allow ISOMETRIC POINT
• If the Tibial Spine Fragment is Shattered then
gives a small Contact & Poor Hold.
• If all there is associated ACL partial Tear ,which
is partially shredded

24. ASSOCIATED INJURIES
• Posterior Cruciate Ligament
• Medial Collateral Ligament
• Posterio Lateral Corner

25. • Both Ligaments Reconstructed in One Sitting
• Easy to See for PCL Tibial Attachment in absence of ACL
• Drill PCL tibial hole first as it will be difficult to see after leakage of
fluid due to other Holes.
PCL +ACL Injury

26. ACL WITH MCL INJURY
ACL repair in next sitting
MCL requires IMMOBILIZATION in plaster for
4-6 weeks

27. • Surgery to be done in 2 Sittings
LCL+POSTERIOLATERAL CORNER+ACL+PCL
1st LCL + PLC and IMMOBILSE THE KNEE FOR 4-6 WEEKS
2ND ACL +PCL AFTER GETTING Free ROM

29. •STRONG Enough to avoid Failure
•STIFF Enough to restore Knee Stability
•SECURE enough to avoid Slippage

30. Important Factors in Surgeons Hands
Graft
Selection
Graft
Positioning
Graft
Fixation
Rehabilitation

31. How to Fix??
ENDOBUTTON
BONE MULCH SCREW RIGID FIX
BIOSCREW
RCI SCREW
SMARTSCREW

32. •APERTURE FIXATION: At joint Level
Interference Screws
•SUSPENSORY FIXATION:Far Cortex
Cortical: Endobuttons,Tightrope,Staples,Screw &washers.
Cancellous:Transfixation Pins

33. Interference Screws
• Interference is defined as the amount by which diameter of the screw
exceeds the gap between graft and the tunnel.
Length of Screw
Size & Geometry of Screw
Divergence of Screw
Torque of Insertion
Screw material
BMD

34. Divergence > 15 Compromises
Stability Screw Size
• 1 Size more than tunnel
diameter in Soft tissue Graft
• Same Size in Bone plug Graft

35. INTRAFIX WasherLoc tibial fixation EZLoc femoral fixation device

36. 3 Types of Graft Motion
• Longitudinal Motion called
BUNGEE CORD EFFECT
• Horizontal motion called WIND
WIPER EFFECT
• Creep of graft tissue leading to
ELONGATION.

37. Endobutton
• First Generation Suspensory Fixation.
• Femoral tunnel had 2 parts :Insertion part
and Connection part
• Insertion part drilled to diameter of graft
• Connection part is of 4.5mm

38. • Femoral tunnel Length – Desired graft
Insertion length= Loop length.
• Insertional Tunnel Length should be
10mm more than desired graft
Insertion Length.

39. • If the Tunnel Length is 60mm, Desired insertion length is
40mm then the loop length should be 20mm and insertion
tunnel should be 50mm long

40. • Second Generation Suspensory
Fixation
• Loop Length reduced after flipping
by Tightening the rope
• Allows full Length filling of Graft
part of Femoral Tunnel

41. TightRope
TightRope RT

42. Advantages of TightRope
• Dramatic reduction in Tunnel widening and the bungy effect of the graft
• No loop length calculations are required
• Fill the entire socket with the graft, promoting advanced healing Socket
• Less instrumentation required
• One size fits all thus removing the need to stock a variety of sizes.
• The ability to redeploy the implant if it is caught in soft tissue
• 980N (Load to Failure)
• Easy to deploy

43. Double Bundle Technique

44. • The positions of the two femoral tunnels were at 11:00 and 9:30
o’clock (right) and 1:00 and 2:30 o’clock (left) with the same diameter
as that of the proximal diameter of each graft for the AM and PL
bundles.
• Care has to be taken to leave a distance of at least 1 mm between the
two tunnels to avoid overlapping.

46. Parallel guide K-wire inserted with the parallel guide

47. Two femoral sockets in the double-
bundle reconstruction Grafts for the PL and AM bundles