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.
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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
11. BPTB Graft
AdvantagesEase of harvest
Consistent size & shape
Strong bone-tendon interface
Strong Bone to Bone fixaton
Good healing
12. 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
13. 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
20. Hamstring Grafts
Disadvantages Soft tissue to bone
healing
Tunnel widening
Technically difficult than
BPTB
Loss of Hamstring
strength( apprx 10%)
21. Quadriceps Tendon Graft
Bony end on one side
and soft tissue strip on
other
Cross-sectional area
thicker than BPTB
Disadvantages Donor site risks
26. Quadriceps tendon
Advantage
Comparatively less harvest site morbidity
Larger cross sectional area of graft
Disadvantage
Bone block at only one end of graft
27. 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
28.
29. Which Graft Better?
Both grafts give excellent results
- Clinically
- Functionally
- Instrumented Examinations
Choose Graft
- Experience & Training
- Comfort level
33. Anatomic Tibial Tunnel
EXIT (INTRA ARTICULAR)
LANDMARKS(A) ACL Footprint
Center of ACL
footprint
(B) LATERAL Meniscus
Post. Border of Ant.
Horn
34. 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
39. 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
40. Ideal fixation
Strong enough to avoid failure
Stiff enough to restore knee stabilty
Secure enough to avoid slippage
51. 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
57. 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
59. 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
61. 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
62. 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)
63. 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
64. 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.
66. 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.