Place the guide at the center of the ACL Footprint. Advance the Pin a few millimeters to notch the bone. Then check to ensure that the pin correlates to the mark made earlier. Use a twisting motion to remove the Femoral Footprint Guide.
Insert the mono-fluted Sentinel Drill Bit over the guide pin through the accessory anteromedial portal with the cutting edge facing away from the femoral condyle and advance the Drill Bit to the femoral ACL footprint. Using a piston-like back and forth motion, drill the femoral socket to the desired depth cautiously to prevent blow out of the lateral femoral cortex. Keeping the hand off of the trigger, slide the Sentinel Drill Bit past the medial femoral condyle and out of the portal, making sure to keep the blade oriented away from the condylar surface.
Use the XO Button Drill Bit to drill the femoral channel. Advance the drill bit through the lateral cortex. Using the XO Button Drill Bit as you would use a standard depth gauge, manually pull back on the bit to hook the head of the drill bit on the external femoral cortex to confirm the aperture to cortex length. Remove the XO Button Drill Bit leaving the graft passing guide pin in place. Place the two free ends of the #2 passing suture through the eyelet of the guide pin. Then, pull the guide pin through the femur laterally, making sure to keep a finger in the suture loop to prevent it from being pulled into the knee joint. Once the suture ends are retrieved laterally, pull the looped end of the suture all the way to the entrance of the femoral tunnel.
Set the angle of the Pinn-ACL Guide to 55 degrees. Insert the tip into the anteromedial portal, placing the tip of the guide into the center of the tibial ACL footprint. Next, advance the external guide sleeve flush to the anterior tibial cortex. Using the ConMed Linvatec M-Power 2 handpiece and pin-driver attachment, advance the guide pin until it meets the point of the guide arm. Then, depress the Pinn-ACL drill guide lever to remove the sleeve. Remove the Pinn-ACL guide from the guide pin and joint. Place a curette over the point of the guide pin to protect against inadvertent advancement when drilling. Use the appropriate size Badger or Sentinel Drill Bit to drill the tibial tunnel.
Using the appropriate size SE Graft Tensioner Drill/Guide, place the guide in the tibial tunnel and position two Breakaway pins and then remove the guide Retrieve the loop through the tibial tunnel using Suture Retrieval Forceps. With the suture loop exposed externally, load the suture strands of the XO Button loaded graft into the passing suture loop and pull them through the femoral tunnel, making sure to keep the graft construct outside of the tibia. Tying the appropriate bundle strands to the left and right tensioner wheels allows the bundles to be individually and accurately tensioned. Apply the desired graft tension and then cycle the knee to alleviate laxity. Hold the knee at fifteen degrees and set the desired final tension.
ACL Reconstruction using JewelAcl graft
FOUR STRANDED ANATOMICAL S.B TECHNIQUE FOR PRIMARY ACL RECONSTRUCTION USING BOTH AUTOGRAFT & A BIOMIMETIC GRAFTA NOVEL TECHNIQUE FOR ELITE FOOTBALL PLAYERS MR ALEVROGIANNIS STAVROS,MD,PhD ORTHOPAEDIC SURGEON S. CONSULTANT IN SPORTS INJURIES. ATHENS/GREECE
AIM OF THE STUDY• To present our novel surgical technique & preliminary results forprimary ACL reconstruction in elite football players
MATERIAL-METHOD• 18 elite football players• Aug. 2010- Nov.2011• 8R/10L• Mean age 23 ( 17-33)• Acute injury in all cases• 11 d.(5-15) delay of operation• 12 concomitant meniscal tears (7 sutured)• Revised anatomical single bundle technique• JewelAcl was used• IKDC ligament evaluation form• Instrumented knee testing
SURGICAL METHOD• SINGLE BAND ACL-R TT technique → high anterior femoral tunnel AM technique → damage to the femoral condyle with the drill bit → cutting the anterior horn of the medial meniscus → incorrect placement of the femoral tunnel due to loss of orientation with hyperflexion• CONVENTIONAL DOUBLE BAND ACL-R• ANATOMIC DOUBLE BAND ACL-R• ANATOMIC SINGLE BAND ACL-R
Why an anatomic ACL-R?• Every person is different; some people are short, others are tall. Similarly, each person has a different size and shape of the ACL. In order to properly reconstruct the ACL it is important to reproduce each persons individual anatomy.• The goals of anatomic ACL reconstruction are to: – Restore 80-90% of normal ACL anatomy – Regain stability and return to pre- injury activity level – Maintain long term knee health
The intact AM and PL bundles of the ACL are shown in (A), and the soft tissue remnant oftorn ACL on the femoral side is shown in (B). When the knee is in 90 degrees of flexion, thefemoral insertion sites of the AM and PL are horizontally aligned. The white circles on thecadaveric specimen picture (A) and the arthroscopic surgery picture (B) show potentialarea that the femoral tunnels can be incorrectly placed when a trans-tibial approach andthe clock face concept is used, which is seen in most of our revision cases. Laser scan (C)and arthroscopic picture (D) show the two bony landmarks on the femoral insertion sites ofthe AM and PL bundles when knee is in 90° of flexion
FEMORAL TUNNEL POSITION: AN X-RAY COMPARISON OF DRILLING THROUGH THE TIBIAL TUNNEL vs DRILLING THROUGH THE MEDIAL PORTAL Chao D,Pallia C,Young S et al• 40 ACL recon pts• Results- Statistical significance superior (TT technique)vs inferior (AM technique) alignment of femoral tunnel placement- TT technique produces a more anterior femoral tunnel and a more vertical ACL graft orientation
Clinical Results after S.B ACL-R• Greatly improved over the last years• However, there are many issues which should be improved in the future: -the normal rate (< 2mm) is only 70% -rotatory control is insufficient -normal athletic abilities are not restored even in the “normal” knee Renstrom P.ESSKA 2004)
CONCLUSIONS FOR D.B ACL-R• The two bundle reconstruction is an effective procedure to reconstruct the ACL• Needs more than 14mm native ACL tibial width• More rotational stability in almost all clinical papers in the literature• Time consuming surgical technique• Long learning curve• Difficulty in revision casesDOUBLE BAND DOUBLE TROUBLE?
ANATOMIC SINGLE BAND ACL-R MAJOR INDICATIONS:• The patient has a very small native ACL size, usually less than 14 mm. This can be estimated on MRI, but can only be confirmed at the time of surgery.• The patient is still growing and his or her growth plate is not closed.• The patient has severe arthritis of the knee.• The patient has multiple knee ligament injuries or a knee dislocation and multiple other ligaments need to be reconstructed at the same time.• The patient has bone that is severely bruised.• The patient has a small “notch”.
ARTHOSCOPIC PORTALSLP (lateral portal = incision towards the outside of the knee)MP (medial portal = incision towards the inside of the knee) andAMP (accessory medial portal = incision even further on the inside of the knee)
DO WE REALLY NEED BOTH ST & G FOR ACL-R– Segawa H., Omori G., Koga Y., Kameo T., Iida S., Tanaka M. • Rotational muscle strength of the limb after ACL reconstruction using Semitendinosus and gracilis tendon. Arthroscopy 18,(2) 177-182. 2002– Armour T, Forwell L., Kirkley A, Litchfield R, Fowler P. • Isokinetic evaluation of internal / external tibial rotation strength following the use of hamstring tendons for ACL reconstruction. ISAKOS 2003– Ohkoshi Y.,Inoue C.,Yamane S. Hashimoto T.,Ishida R. • Changes in muscle strength properties caused by harvesting of autogenous semitendinosus tendon for reconstruction of contralateral ACL Arthroscopy 14,(6) 1998 580-584– Gobbi A., Domzalski M., Pascual J., Zanazzo M. • Hamstring ACL Reconstruction.Is it Necessary to Sacrifice the Gracilis? Arthroscopy 2004
JEWEL-ACL Features and benefits• Is a specialized textile scaffold which is rendered versatile for ACL reconstruction by various structural features. The scaffold is treated with a proprietary gas plasma treatment process that increases its surface energy and renders it hydrophilic• The continuous tubular form can accommodate a hamstring tendon• The open weave sections have appropriate spacing to encourage tissue ingrowth into the scaffold.• The densely woven sections have superior handling properties.• The JewelACL is a bio-enhanced prosthesis for the ACL reconstruction.• The JewelACL can be secured to the bone with currently available fixation devices.
BENEFITS• Can be implanted as a total tissue sparing device, or with a single hamstring tendon• Manufactured from Polyethylene Terephthalate (polyester)• Allows early rehabilitation (parallel longitudinal polyester fibres provide high strength of 3000N)• Implanted using standard modern ACL guidewire systems• Stiffness is matched to the semitendinosus tendon to permit load transfer and encourage cell growth due to plasma-spray. more than four times as many cells were found on the plasma-treated ligament surfaces after 14 days’ incubation compared to non plasma-treated polyester surfaces.
FASTLOK• Is recommended for secure fatigue resistant fixation of JewelAcl directly to bone• Consists of a titanium alloy staple and buckle providing a unique triple clamping action to minimize slippage under repeated loading• Staples firmly gripped by impactor so easy to use for insertion and removal from bone• Designed for easy application through small incisions• Sliding hammer attaches to impactor to help remove staples
ACL-R (JewelAcl-X/O BUTTON) in an elite 25 y. male athlete.
ACLR (JewelAcl-X/O BUTTON) +CHONDROPLASTY MFC(Chondromimetic) in a 33 y. male elite athlete.
Postoperative regime: modified aggressive protocol• Functional knee brace in full extension• CPM 0-900 same day of operation• Priority to full extension recovery• Partial weight bearing 6 weeks (modified due to meniscal suturing)• Closed kinetic chain for 2 w.p.o• Return to full-power training program 2.5 m.p.o• Return to full athletic performance at 3.5 m.p.o
IKDCPASSIVE MOTION DEFICIT (PRE-OP) PRE-OP IKDC SCORE (%) PASSIVE MOTION DEFICIT 91 100 80 60 40 20 6,6 2,4 0 0 A B C D Lack of extension
PRE-OP IKDC SCORE (%) ROLIMETER LAXITY100 90 80 70 60 50 50 39 40 30 20 10 0 0 0 A B C D C + D > 85%
RESULTS: GLOBAL IKDC SCORE (%) Subjective score IKDC: 92 ±4.6 (75-100) (Pre-op : 60,3)100 90 80 71,6 70 60 50 41 38 Pre-op 40 Post-op 30 20 P = 0.003A 20 12 14,4 10 2 1 0 A B C D A + B = 79%
SCORE IKDC GLOBAL POST OP %1009080706050 47,8 pré-op 41,3 43,540 post-op 32,73020 13 1310 6,5 2,2 0 A B C D
GLOBAL SCORE IKDC at F.U. 5050454035 3230 24 pre-op25 F-U2015 12 1010 85 2 20 A B C D
LIMITATIONS OF ANATOMIC S.B ACLR• Anatomic free hand single-bundle ACLR has some limitations when compared to anatomic double-bundle reconstruction. – It cannot recreate the two functional bundles (AM and PL) of the ACL. – It can cover less of the size of the normal ACL, typically 65-85% of the ACL insertion site recreated, vs. 80-90% in double-bundle reconstruction. – Prospective, randomized trial and long term f.up needed
CONCLUSIONS• Lower pivot shift rate in comparison with S.B ACL-R, almost similar to anatomic D.B (↓ arthritis?)• Very short lurning curve• Not time consuming technique• Use of new generation xenografts offers more aggressive rehab protocol.• Quicker return to sports (pre-injury level)• A good alternative for elite athletes• Need controlled prospective randomized trial studies and long term f.u