ACL RECONSTRUCTION- GRAFT
OPTIONS, TUNNEL PLACEMENT &
FIXATION
DR SHEKHAR SRIVASTAV
SR. CONSULTANT- Knee & Shoulder Arthro...
ACL Surgery
ACL TearNo repair
Only Recontruction
Graft Autograft - common
Allograft
ACL RECONSTRUCTION
SUCCESS
Quality of the
Graft
Appropriate
Tunnel Placement
Strong Graft
Fixation
Graft Options
Autograft
 BPTB
 Hamstring
 Quadriceps
Allograft
Bone-Patellar Tendon Graft
 Considered GOLD standard
 Middle third of patellar

tendon harvested(1011mm)
 Incision
-Med...
Skin incision
Take the central slip of 10
mm
Mark bone tendon junction
BPTB Graft
AdvantagesEase of harvest
Consistent size & shape
Strong bone-tendon interface
Strong Bone to Bone fixaton
Good...
BPTB Graft
Dis-advantagesRisk of patellar #
Patellar tendonitis
Patello-femoral pain
Donor site tenderness on
kneeling
Big...
Hamstring Grafts
 Quadrupled Semi-T / Doubled STG graft
 4 strands of Hamstrings = 250% strength of

native ACL
Advantag...
GRAFT HARVEST
GRAFT HARVEST
GRAFT HARVEST
GRAFT HARVEST
GRAFT PREPARATION
GRAFT PREPARATION
Hamstring Grafts
Disadvantages Soft tissue to bone

healing
 Tunnel widening
 Technically difficult than
BPTB
 Loss of...
Quadriceps Tendon Graft
 Bony end on one side

and soft tissue strip on
other
 Cross-sectional area
thicker than BPTB

D...
Quadriceps

tendon graft

INCISION: Anterior midline
Tendon exposure: central third
Harvested with a bone plug
Quadriceps tendon
 Advantage
 Comparatively less harvest site morbidity
 Larger cross sectional area of graft

 Disadv...
Allografts
Advantages No graft site mobidity
 Available off the shelf
 Boon- Multiligamentous Injuries
Disadvantages R...
Which Graft Better?
 Both grafts give excellent results

- Clinically
- Functionally
- Instrumented Examinations
 Choose...
FAILURE OF ACL
Single Most Common
Cause
INCORRECT TUNNEL
PLACEMENT
TUNNELS FOR ACL
LENGTH
DIAMETER
POSITION
TIBIAL TUNNEL
ENTRY POINT
Tibial jig- set at an
angle of 45-550
300 medial to mid
sagital axis
Apprx. 4 cms below
joint li...
Anatomic Tibial Tunnel
EXIT (INTRA ARTICULAR)
LANDMARKS(A) ACL Footprint
Center of ACL
footprint
(B) LATERAL Meniscus
Post...
FEMORAL TUNNEL
12

Access for tunnel placement
-Through the Tibial Tunnel
- Through medial instrument
portal
ANATOMICAL PO...
Anatomic Femoral Tunnel
Anatomic Tibial Tunnel
Graft Passage
Graft Fixation
Graft fixation
 Secure graft fixation is paramount to a successful

reconstruction
 ACL rehab emphasizes on immediate mo...
Ideal fixation
 Strong enough to avoid failure
 Stiff enough to restore knee stabilty
 Secure enough to avoid slippage
Ideal Graft fixation
 Anatomic
 Biocompatible
 Safe and reproducible

 MRI compatible
 Allow easy revision
Graft Fixation
 Choice of graft fixation depends on

-Surgeon preference
-Choice of graft
-Surgical technique
 Fixation ...
Types of Fixation
 Aperture Fixation: at the level of joint
 Interference screws

 Suspensory Fixation:
 Cortical: End...
Femoral Fixation

Graft properties- Strength
Stiffness
Slippage

Graft Tunnel MotionBungee Effect
Windshield Wiper Effect
Bio-Interference Screw Fixation
 Aperture Fixation

 Compaction drilling
 Dependent upon cancellous
bone
 Post wall bl...
Cross pin fixation
 Impacted transversely into
lateral cortex
 Implant passed under
looped graft
 Implant perpendicular...
Endobuttton Fixation
 Fixation at lateral femoral

cortex
 No wear or abration of graft
 Advantages- Osteoporotic
bones...
Tibial Fixation
 Interference screw/

Intrafix
 Suture post
 Dual fixation
POST-OP
Complications
Pre-op consideration
 Patient selection- Non compliant/
Apprehensive
 Timing of the operation
 Immature A...
Complication- Graft
Graft harvest
 Graft cut short
 Small size
Prevent
 careful harvest technique
 Cut all band attach...
Complications
femoral tunnel
Improper tunnel placementAnterior femoral tunnel
 Residents ridge
 Use femoral tunnel guide...
Complications
Tibial Tunnel
Improper tibial tunnel- anterior
tunnel placement
 Intra-articular landmarks
 Check guide wi...
IMPINGEMENT TEST
Complications
Neurovascular most
serious complication
 Vessel behind Post. Horn
Lat. meniscus
 Early recognition and
pro...
Complication
 Recurrent Effusions

-Debris during surgery
-Reaction to bioabsorbable implants
-Vigourous physio
Managemen...
To Summarise
 Autografts are better option than allograft
 Both BPTB & Hamstring grafts work equally

well
 Appropriate...
THANK YOU
Visit

www.delhiarthroscopy.
com
ARTHROSCOPY KNEE
 Commonest surgery

performed in UK
 Treatment Ligamentous
and soft tissue injury of
knee
 > precise a...
ARTHROSCOPIC ACL RECONSTRUCTION
Ligaments of the Knee
Cruciate Ligaments
 Anterior (ACL) resists

anterior translation
 Posterior (PCL) resists

posteri...
Mechanism of Injury
ACL injury mechanism of
injury
 Twisting on fixed foot
 Blow to the knee
 Hyperextension
 78% are ...
Examining the Patient
 History

Pain & Instability
 Examination
 Motion of knee and degree of

swelling
 Ligament spec...
MANAGEMENT
1/3 - No symptoms, Normal life
1/3 - Occasional instability,no strenuos activity
1/3 - Constant instability and...
ACL Reconstruction
We’ll walk through an ACL reconstruction

using the patient’s own grafts
Bony Tunnels are very precisely drilled in the tibia and femur to recreat
the normal anatomic position of the ACL . The gr...
SCORECARD
ENDOSCOPIC
Small incision
Less pain
Less morbidity
Accuracy
Early function
Cosmesis

OPEN
x
x
x
x
x
x
Acl Reconstruction Surgery In Delhi Dr. Shekhar Srivastav 09971192233
Acl Reconstruction Surgery In Delhi Dr. Shekhar Srivastav 09971192233
Acl Reconstruction Surgery In Delhi Dr. Shekhar Srivastav 09971192233
Acl Reconstruction Surgery In Delhi Dr. Shekhar Srivastav 09971192233
Acl Reconstruction Surgery In Delhi Dr. Shekhar Srivastav 09971192233
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Acl Reconstruction Surgery In Delhi Dr. Shekhar Srivastav 09971192233

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ACL Reconstruction Surgery in Delhi by Dr. Shekhar Srivastav - Dr. Shekhar Srivastav is an Orthopedic Surgeon attached to Sant Parmanand Hospital, Delhi with special interest in Knee & Shoulder surgery. After obtaining his M.S. Orthopedics degree he has undergone training in various centers in India and Abroad which has helped him in understanding the Orthopedics problems and their Management. He did his AO/ ASIF fellowship at University Hospital, Salzburg, Austria in 2006 and recieved training in Arthroscopy & Sports Medicine at TUM, Munich (Germany) & Rush Orthopedics Centre, Chicago( USA). He has an experience of more than fifteen years of diagnosing and treating Orthopedics & Trauma patients.

Check Out Details at http://www.delhiarthroscopy.com

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Acl Reconstruction Surgery In Delhi Dr. Shekhar Srivastav 09971192233

  1. 1. ACL RECONSTRUCTION- GRAFT OPTIONS, TUNNEL PLACEMENT & FIXATION DR SHEKHAR SRIVASTAV SR. CONSULTANT- Knee & Shoulder Arthroscopy Delhi Institute of Trauma & Orthopedics, Sant Parmanand Hospital, Delhi
  2. 2. ACL Surgery ACL TearNo repair Only Recontruction Graft Autograft - common Allograft
  3. 3. ACL RECONSTRUCTION SUCCESS Quality of the Graft Appropriate Tunnel Placement Strong Graft Fixation
  4. 4. Graft Options Autograft  BPTB  Hamstring  Quadriceps Allograft
  5. 5. Bone-Patellar Tendon Graft  Considered GOLD standard  Middle third of patellar tendon harvested(1011mm)  Incision -Medial Vertical -Transverse  10 mm wide graft harvested  2.5 mm bone plug from patella & Tibial tuberosity
  6. 6. Skin incision
  7. 7. Take the central slip of 10 mm
  8. 8. Mark bone tendon junction
  9. 9. BPTB Graft AdvantagesEase of harvest Consistent size & shape Strong bone-tendon interface Strong Bone to Bone fixaton Good healing
  10. 10. BPTB Graft Dis-advantagesRisk of patellar # Patellar tendonitis Patello-femoral pain Donor site tenderness on kneeling Bigger incision scar Loss of sensation lat.to scar
  11. 11. Hamstring Grafts  Quadrupled Semi-T / Doubled STG graft  4 strands of Hamstrings = 250% strength of native ACL Advantages  Stronger graft  Smaller Incision- Cosmesis  Can be used in skeletally immature
  12. 12. GRAFT HARVEST
  13. 13. GRAFT HARVEST
  14. 14. GRAFT HARVEST
  15. 15. GRAFT HARVEST
  16. 16. GRAFT PREPARATION
  17. 17. GRAFT PREPARATION
  18. 18. Hamstring Grafts Disadvantages Soft tissue to bone healing  Tunnel widening  Technically difficult than BPTB  Loss of Hamstring strength( apprx 10%)
  19. 19. Quadriceps Tendon Graft  Bony end on one side and soft tissue strip on other  Cross-sectional area thicker than BPTB Disadvantages Donor site risks
  20. 20. Quadriceps tendon graft INCISION: Anterior midline
  21. 21. Tendon exposure: central third
  22. 22. Harvested with a bone plug
  23. 23. Quadriceps tendon  Advantage  Comparatively less harvest site morbidity  Larger cross sectional area of graft  Disadvantage  Bone block at only one end of graft
  24. 24. Allografts Advantages No graft site mobidity  Available off the shelf  Boon- Multiligamentous Injuries Disadvantages Risk of disease transmission  Weak graft  Delayed incorporation  Not universally available,Expensive
  25. 25. Which Graft Better?  Both grafts give excellent results - Clinically - Functionally - Instrumented Examinations  Choose Graft - Experience & Training - Comfort level
  26. 26. FAILURE OF ACL Single Most Common Cause INCORRECT TUNNEL PLACEMENT
  27. 27. TUNNELS FOR ACL LENGTH DIAMETER POSITION
  28. 28. TIBIAL TUNNEL ENTRY POINT Tibial jig- set at an angle of 45-550 300 medial to mid sagital axis Apprx. 4 cms below joint line
  29. 29. Anatomic Tibial Tunnel EXIT (INTRA ARTICULAR) LANDMARKS(A) ACL Footprint Center of ACL footprint (B) LATERAL Meniscus Post. Border of Ant. Horn
  30. 30. FEMORAL TUNNEL 12 Access for tunnel placement -Through the Tibial Tunnel - Through medial instrument portal ANATOMICAL POSITION -Over the top position - Right Knee-9 10pm - Left Knee- 2 - 3 am 3 9 6
  31. 31. Anatomic Femoral Tunnel
  32. 32. Anatomic Tibial Tunnel
  33. 33. Graft Passage
  34. 34. Graft Fixation
  35. 35. Graft fixation  Secure graft fixation is paramount to a successful reconstruction  ACL rehab emphasizes on immediate movement and weight bearing  High demand on initial graft fixation  Ultimate long term success of an ACL reconstruction depends on healing of the graft fixation sites and biological healing
  36. 36. Ideal fixation  Strong enough to avoid failure  Stiff enough to restore knee stabilty  Secure enough to avoid slippage
  37. 37. Ideal Graft fixation  Anatomic  Biocompatible  Safe and reproducible  MRI compatible  Allow easy revision
  38. 38. Graft Fixation  Choice of graft fixation depends on -Surgeon preference -Choice of graft -Surgical technique  Fixation Options Femoral Interference screws/Intrafix - Cross pin fixation- Rigidfix/ Tranfix - Endobutton Fixation Tibial - Intererference Screws/ Intrafix - Suture discs, Post with washer
  39. 39. Types of Fixation  Aperture Fixation: at the level of joint  Interference screws  Suspensory Fixation:  Cortical: Endobutton, Staples, Screw posts  Cancellous: Transfixation pins
  40. 40. Femoral Fixation Graft properties- Strength Stiffness Slippage Graft Tunnel MotionBungee Effect Windshield Wiper Effect
  41. 41. Bio-Interference Screw Fixation  Aperture Fixation  Compaction drilling  Dependent upon cancellous bone  Post wall blowout  - Concern- Graft maceration & failure at physiological loading
  42. 42. Cross pin fixation  Impacted transversely into lateral cortex  Implant passed under looped graft  Implant perpendicular to graft  Highest ultimate load failure and stiffness  Concern- tunnel widening and windshield wiper effect
  43. 43. Endobuttton Fixation  Fixation at lateral femoral cortex  No wear or abration of graft  Advantages- Osteoporotic bones & femoral tunnel blowout  Problems- fixation away from aperture- tunnel widening & bungee effect
  44. 44. Tibial Fixation  Interference screw/ Intrafix  Suture post  Dual fixation
  45. 45. POST-OP
  46. 46. Complications Pre-op consideration  Patient selection- Non compliant/ Apprehensive  Timing of the operation  Immature Athlete  Med. Comp OA with ACL insufficiency
  47. 47. Complication- Graft Graft harvest  Graft cut short  Small size Prevent  careful harvest technique  Cut all band attached before using stripper Dropped graft  Careful passing of graft  Another graft harvest
  48. 48. Complications femoral tunnel Improper tunnel placementAnterior femoral tunnel  Residents ridge  Use femoral tunnel guides Solution  Notchplasty Posterior wall blow-out  Endobutton or transfix
  49. 49. Complications Tibial Tunnel Improper tibial tunnel- anterior tunnel placement  Intra-articular landmarks  Check guide wire impingement before drilling Solution  Notchplasty  Chamfering of the tunnel
  50. 50. IMPINGEMENT TEST
  51. 51. Complications Neurovascular most serious complication  Vessel behind Post. Horn Lat. meniscus  Early recognition and prompt repair  Careful handling of shaver and burr in posterior compartment
  52. 52. Complication  Recurrent Effusions -Debris during surgery -Reaction to bioabsorbable implants -Vigourous physio Management- Repeated aspirations  Infection - < 1% Management- antibiotics & arthroscopic deb.  Stiffness - Improper tunnels - Post-op arthrofibrosis - Cyclops lesion - Inadequate physio/ non-compliant patient Management- Gentle MUA / Arthr. Adesiolysis
  53. 53. To Summarise  Autografts are better option than allograft  Both BPTB & Hamstring grafts work equally well  Appropriate tunnel placement is essential to prevent failure  Fixation method should be biological, reproducible & should have sufficient strength to allow early mobilisation & rehab USE IT OR LOSE IT
  54. 54. THANK YOU Visit www.delhiarthroscopy. com
  55. 55. ARTHROSCOPY KNEE  Commonest surgery performed in UK  Treatment Ligamentous and soft tissue injury of knee  > precise and accurate than open method  Less morbidity and early rehab
  56. 56. ARTHROSCOPIC ACL RECONSTRUCTION
  57. 57. Ligaments of the Knee Cruciate Ligaments  Anterior (ACL) resists anterior translation  Posterior (PCL) resists posterior translation Collateral Ligaments  Medial (MCL) resists medially directed force  Lateral (LCL) resists laterally directed force
  58. 58. Mechanism of Injury ACL injury mechanism of injury  Twisting on fixed foot  Blow to the knee  Hyperextension  78% are non- contact injuries (Noyes et al)
  59. 59. Examining the Patient  History Pain & Instability  Examination  Motion of knee and degree of swelling  Ligament specific tests of the knee  Lachman test  Anterior and Posterior Drawer
  60. 60. MANAGEMENT 1/3 - No symptoms, Normal life 1/3 - Occasional instability,no strenuos activity 1/3 - Constant instability and pain  ACL deficient- little higher rate of future medial meniscus tearing and arthritis.
  61. 61. ACL Reconstruction We’ll walk through an ACL reconstruction using the patient’s own grafts
  62. 62. Bony Tunnels are very precisely drilled in the tibia and femur to recreat the normal anatomic position of the ACL . The graft is passed and secured in bones.
  63. 63. SCORECARD ENDOSCOPIC Small incision Less pain Less morbidity Accuracy Early function Cosmesis OPEN x x x x x x
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