ACL Recon.pptx

TATA LAKSANA OPERATIF PADA
CEDERA SENDI LUTUT
Pembimbing : Dr. dr. Bobby Nelwan, SpOT (K)
Audi Hidayatullah Syahbani
Zecky Eko Triwahyudi

Operasi Sendi Lutut
1. ACL Rekonstruksi
2. PCL Rekonstruksi
3. Meniscus Repair
4. Meniscectomy
5. Multiligament Repair
6. MPFL Reconstruction
7. Arthroscopic Diagnostic

ACL Surgery
ACLTear-
No repair
Only Recontruction
Graft -
Autograft - common
Allograft

ACL RECONSTRUCTION
SUCCESS
Quality of the
Graft
Appropriate
Tunnel Placement
StrongGraft
Fixation

Graft Options
Autograft
 BPTB
 Hamstring
 Quadriceps
Allograft

Bone-Patellar Tendon Graft
 ConsideredGOLD standard
 Middle third of patellar
tendon harvested(10-
11mm)
 Incision
-MedialVertical
-Transverse
 10 mm wide graft
harvested
 2.5 mm bone plug from
patella &Tibial tuberosity

Take the central slip of 10
mm

BPTB Graft
Advantages-
Ease of harvest
Consistent size & shape
Strong bone-tendon interface
Strong Bone to Bone fixaton
Good healing

BPTB Graft
Dis-advantages-
Risk of patellar #
Patellar tendonitis
Patello-femoral pain
Donor site tenderness on
kneeling
Bigger incision scar
Loss of sensation lat.to scar

Hamstring Grafts
 Quadrupled Semi-T / DoubledSTG graft
 4 strands of Hamstrings = 250% strength of
nativeACL
Advantages ‒
 Stronger graft
 Smaller Incision-Cosmesis
 Can be used in skeletally immature

Hamstring Grafts
Disadvantages-
 Soft tissue to bone
healing
 Tunnel widening
 Technically difficult than
BPTB
 Loss of Hamstring
strength( apprx 10%)

Quadriceps Tendon Graft
 Bony end on one side
and soft tissue strip on
other
 Cross-sectional area
thicker than BPTB
Disadvantages-
 Donor site risks

Quadriceps tendon graft
INCISION: Anterior midline

Tendon exposure: central third

Quadriceps tendon
 Advantage
 Comparatively less harvest site morbidity
 Larger cross sectional area of graft
 Disadvantage
 Bone block at only one end of graft

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

Which Graft Better?
 Both grafts give excellent results
- Clinically
- Functionally
- Instrumented Examinations
 ChooseGraft
- Experience &Training
- Comfort level

FAILURE OF ACL
Single MostCommon
Cause
INCORRECTTUNNEL
PLACEMENT

TUNNELS FOR ACL
LENGTH
DIAMETER
POSITION

TIBIAL TUNNEL
w
ENTRY POINT
Tibial jig- set at an
angle of 45-550
300 medial to mid
sagital axis
Apprx. 4 cms belo
joint line

Anatomic Tibial Tunnel
EXIT (INTRAARTICULAR)
LANDMARKS-
(A) ACL Footprint
Center ofACL
footprint
(B) LATERAL Meniscus
Post. Border ofAnt.
Horn

FEMORAL TUNNEL
Access for tunnel placement
-Through theTibialTunnel
-Through medial instrument
portal
ANATOMICAL POSITION
Over the top position
- Right Knee-9 ‒10pm
- Left Knee- 2 - 3 am
3
12
9
6

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

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
 FixationOptions
Femoral ‒Interference screws/Intrafix
- Cross pin fixation- Rigidfix/Tranfix
- Endobutton Fixation
Tibial - IntererferenceScrews/ Intrafix
-Suture discs, Post with washer

TypesofFixation
 Aperture Fixation: at the level of joint
 Interference screws
 Suspensory Fixation:
 Cortical: Endobutton,Staples,Screw posts
 Cancellous:Transfixation pins

Femoral Fixation
Graft properties- Strength
Stiffness
Slippage
Graft Tunnel Motion-
Bungee Effect
Windshield Wiper Effect

Bio-Interference Screw Fixation
 Aperture Fixation
 Compaction drilling
 Dependent upon cancellous
bone
 Post wall blowout
 - Concern- Graft
maceration & failure at
physiological loading

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

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

Tibial Fixation
 Interference screw/
Intrafix
 Suture post
 Dual fixation

Complications
Pre-op consideration
 Patient selection- Non compliant/
Apprehensive
 Timing of the operation
 ImmatureAthlete
 Med.CompOA withACL insufficiency

Complication- Graft
Graft harvest
 Graft cut short
 Small size
revent
 careful harvest technique
 Cut all band attached before
using stripper
Dropped graft
 Careful passing of graft
 Another graft harvest

Complications
femoral tunnel
Improper tunnel placement-
Anterior femoral tunnel
 Residents ridge
Use femoral tunnel guides
Solution
Notchplasty Posterior
wall blow-out
 Endobutton or transfix

Complications
Tibial Tunnel
Improper tibial tunnel- anterior
tunnel placement
 Intra-articular landmarks
 Check guide wire impingement
before drilling
Solution
 Notchplasty
 Chamfering of the tunnel

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

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

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

Class knee
ification of
Stabilizers
3
Popliteus
Biceps Femoris
Central Complex
ACL
PCL
Med Menx
Lat Menx
Medial Complex
MCL
Postromedial
Capsule
Semi-Memb
Pes anserinus
Lateral complex
IT Tract
LCL

PCL
Three components:
AL Bundle: Long and thick part, 2X the size of PMB
Tightens in flexion
PM Bundle: Tight in extension
Meniscofemoral ligaments: mechanically very strong
Anterior: Humphrey’s ligament
Posterior: Wrisberg’s ligament

Ant Meniscofemoral lig of Humphrey
PostGrad Orth Deiary Kader

a.Ant Meniscofemoral lig
Humphrey
b. Post Meniscofemoral lig
Wrisberg

PCL
✦ The strongest ligament in the knee
✦ It is “a central stabilizer”
✦ Originates from a broad crescent-shaped area MFC
✦ Inserts centrally posteriorly 1–1.5cm below articular
surface of the tibia
✦ Average length of 38 mm and diameter of 13 mm
✦ PCL and quadriceps are dynamic partners in
stabilizing the knee in the sagittal plane
67

PCL
Mechanism of Injury
RTA
– High Velocity
– Often MLI
Sports
Uncommon
– Low Velocity
– Usually Partial
68

Mechanism of injury
 3% of all knee injuries
 Dashboard Injury at 90° is the most common
 Falling on a flexed knee with foot in plantar flexion
 Forced hyperextension (>30º) is associated with
multi-ligament injury
 High association with fracture femur

Presentation
Acute isolated PCL injury is commonly missed
Present with very little pain in the knee without hemarthrosis
There may be only bruising at the popliteal fossa.
Chronic PCL injury on the other hand may present with pain in
the medial compartment or anterior knee pain.

In isolation, it often causes little long-term
instability. However, it may lead to medial or
PFJ pain (OA) at a later date.
More troublesome in soccer players due to
difficulty in deceleration.
Presentation 2

Diagnosis 2
Clinical
 Posterior drawer test at 90° and 30°
 Quadriceps active drawer test. Flexion 60°
 Posterior sag sign (step-off)
 Posterolateral rotatory instability (Dial test prone)
 External rotation recurvatum test

Diagnosis 1
MRI & PCL
Clinical examination is more reliable than MRI scan
The PCL may be dysfunctional despite normal MRI
Kneeling stress x-ray
Measure the degree of translation

Grading of PCL instability
Normal tibia step-off is 10 mm at 90° flexion
Instability could be mild, moderate or severe
 Grade I instability is when there is a 5-mm step-off
 Grade II instability is when there is no step-off (flush)
 Grade III instability is when there is –5 mm step-off
There is a high association between Grade III PCL
injury and posterolateral corner injury.

Treatment
Treat acute, isolated PCL injury conservatively
 Extension brace with calf support
 (Posterior Tibial Support, PTS Brace) until the
pain subsides (4-6 weeks) with quadriceps
rehabilitation
 Start early passive motion only in prone position to
maintain anterior tibia translation.

Surgical reconstruction
Indications
 Acute combined injuries
 Acute bony avulsion
 Symptomatic chronic PCL injuries that failed
rehabilitation.
 There is no difference in clinical outcome between
single and double bundle PCL reconstruction.

20
PCL Reconstruction

Complications
graft tensioning, insecure
Immediate
Neurovascular injury popliteal vessels
Infection
Technical error → tunnel placement,
fixation
Delayed
Loss of motion
Avascular necrosis (medial femoral condyle)
Recurrent or persistent laxity (common) when a combined injury is
not adequately addressed

What are the structures in the
Posterolateral Complex of the
Knee?
22

Posterolateral Complex
Components:
– Biceps, ITB, Popliteus, Popliteofibular
ligament, arcuate ligament, LCL
Function
– Resists External and Varus rotation
Mechanism of Injury
– Direct blow to anteromedial tibia
– Hyperextension/varus
23

The Posterolateral Corner
(PLC)
Primary stabilisers of external tibial
rotation at all knee flexion angles
Secondary restraints to anterior and
posterior translation
81

Resist Ext Rotation of Tibia
The LCL is a cord like structure 5-7 cm in length
Primary static restraint to varus opening of the knee
Secondary restraint to posterolateral rotation
The popliteus is a static and dynamic external rotation stabiliser.
The popletiofibular ligament acts as
a primary restraint to external rotation of
the tibia on the femur at 30º of flexion 82

(PLC)
Isolated PLC sectioning produce a maximal
Average increase of 13° of tibial ER at 30° of knee flexion
Average increase of 5.3° of tibial ER at 90°
Isolated PCL sectioning has no effect on external tibial rotation
Combined injury to the PCL and PLC leads to ER of 20.9° at
90° of knee flexion
83

Posterolateral Complex Injury
Physical Examination
– Dial Test
• Increased External rotation (30o, 90o)
– Posterolateral external rotation test
– External rotation recurvatum
27

LCL Examination
Opening @ 30º only
– Isolated LCL Injury
Opening @ 0º
– Injury to Posterolateral Capsule (+ Dial)
– Usually with ACL +/or PCL injury
Palpate LCL in Figure 4 Position
28

30
Fib
Pop
Extension
The popliteus tendon inserted
10 mm distal
5 mm posterior to the lateral epicondyle
The LCL inserted
2 mm proximal
4 mm posterior to the lateral epicondyle

31
Fibula head

32
Popliteofibular LIG

Imaging
Plain Films
Check for Biceps/LCL Avulsion fracture
MRI
Can be helpful
90

Injury--Treatment
Partial
– Grade I & II Instability with a good end point
– Nonsurgical Treatment
– 1-3 week immobilisation in extension
Complete Acute
– Primary repair best
– Augment with allo/auto graft
Complete Chronic
– Reconstruct Popliteus and LCL 91

PLC Reconstruction
The reconstruction can be:-
✴Fibula based such as modified Larson’s technique or
✴Combined tibia and fibula based such as LaPrade’s
anatomical reconstruction.
92

The principles of surgery
93
Early repair/ Recon (within 3 weeks) of torn and detached ligaments,
tendons and capsule in acute injuries. A combination of early repair and
reconstruction has been shown to provide better results.
Late reconstruction of the two or three of the main stabilisers of the
posterolateral corner of the knee i.e. the lateral collateral ligament,
Popliteus tendon, and popliteofibular ligament in chronic cases.
Combined ACL/PCL and PLC injury must be treated by reconstruction of all injured
ligaments. Isolated ACL or PCL reconstruction without addressing the PLC will
ultimately fail.

MENISCUS
 Menisci is a crescentric shaped
fibro cartilagenous structures
between the condyles of femur &
tibia
 Peripheral edges are thick,
convex& fixed to inner surface of
capsule.

 Triangular in cross section
 Covers peripheral 2/3 rd of
articular surface.

Each menisci has
 2 ends---- anterior and posterior horns
 2 borders----outer and inner border
 2 Surfaces ---upper and lower

Attachments to Tibia
 Margins – Coronary ligaments
 Inter condylar area – by Horns
 To Medial Collateral Ligament

Attachments to FEMUR
1)Menisco femoral ligaments.
Ligament of Humphrey(anterior
menisco femoral)
Ligament of Wrisberg(posterior
menisco femoral)
2) To Popliteus tendon
To each other- transverse ligament.

BLOOD SUPPLY
 Superior & Inferior
branches of medial &
lateral geniculate arteries
 Perimeniscal capillary
plexus within the synovium
& capsule

VASCULAR ZONES
 Red-red zone-fully vascular
 Red-white :minimal blood
supply
 White-white: fully avascular

FUNCTIONS OF MENISCI
 Joint lubrication
 Joint stability- ( rotary)
 Joint nutrition
 Shock absorbers-reduce the stress on articular cartilage
 Load bearing function
 Deepening the cavity

 Prevents impingement during joint motion.
 Medial meniscus – provides stability toAnterior
Cruciate Ligament deficient knees.(ACL)

History
 1773- William Bromfeild- meniscal locking
 1803- William Hay – Internal Derangement of Knee.
 1834-John Reid- Pathology of Meniscal tear.
 1885- ThomasAnnan Dale-Operation for displaced
meniscal tear.
 1918-Kenji Takagi-Cystoscope into a cadaveric knee

 1928- McMurray- sign of torn meniscus
 1962 –Arthroscopic surgery begins

MENISCAL INJURIES
 Injury with rotational force ,on a partially flexed knee
.Eg:Foot ball players,Kabadi players
 Most common site- posterior horn
 Most common type- longitudinal tear
 Length ,depth, position of tear– position of the
meniscus in relation to condyles at the time of injury.

Pedisposing Factors
 Trauma
 Meniscal cyst
 Decreased mobility of the meniscus
 Discoid meniscus
 Aging- degeneration
 Abnormal mechanical axis- ligamentous laxity.

 Congenitaly relaxed joints
 Inadequate tone and musculature.

O’CONNOR CLASSIFICATION OF TEARS
1. Longitudinal tears
2. Horizontal tears
3. Oblique tears
4. Radial tears
5. Variations-flap tears
complex tears
( degenerative )

LONGITUDINAL TEARS
 Most common
 young
 Post trauma
 2 types-
Vertical incomplete tear
Vertical complete
Displaced tear
(bucket handle)

HORIZONTAL TEARS
 Extend from inner margin to
capsule horizontally
 Common in posterior horn of
medial meniscus & lateral
meniscus

OBLIQUE TEARS
 Full thickness extending obliquely
from the inner margin into the body
Types
 Anterior oblique or posterior oblique
 Commonly seen at the junction of
middle & posterior 1/3 of medial
meniscus

RADIAL TEARS
 Extend radially from inner margin
into the body
 Common in middle 1/3 of lateral
meniscus
 3 types - complete
-incomplete
-parrot beak tear-(Radial
tear with longitudinal or oblique
extension)

FLAP TEARS
 Oblique tears with a
horizontal cleavage
 Superior or inferior
 Degenerative

COMPLEX TEARS
 Combination of all the above
 Common in chronic meniscal lesions & degenerative
menisci
 Predisposing conditions:
* Discoid lateral meniscus
*Meniscal cyst
*Calcium pyrophosphate deposition

Lateral meniscus Tears
 Less common
- Lateral meniscus is more mobile
- not attached to the ligaments
-Forcible external rotation of femur on fixed tibia with
knee in flexion.---anterior horn tear
-Medial rotation of femur on fixed tibia followed by
violent flexion- posterior horn tear

 Less chance of bucket handle tear
 More chance for transverse tear
 Common location –posterior horn
 Common type---longitudinal horn
 Length, depth and position of tear depend on the position
of the meniscus in relation to femur and tibia

Tears associated with Cystic degeneration
 Trauma ---- degeneration or secondary mucinous
changes in the periphery.
Tears associated with congenital anomalies
Discoid meniscus hyper mobility

Clinical diagnosis
History
 May be asymptomatic
 Pain
 Sports injuries
 Trauma
 Giving way
 Locking

Physical signs
 Effusion
 Quadriceps wasting
 Joint line tenderness
 Limitation of movements.

Special
tests.
 Mc Murray test.
 Apley’s grinding test

McMurray test
 Fully flex the knee
 Externally rotate the leg
 Keep the fingers on the medial joint
line.
 Slowly abduct and external rotate
the knee.
 Click and pain is indicative

 Fully flex ,internally rotate and extend the leg.
 If a click or pain elicit confirms this after examining
the other normal knee for clicks of other origins like
tendon and soft tissues snapping etc.

Apleys grinding test
 Prone position
 Bend examiner knee and press the
patients thigh .
 Hold the ankle and the foot by both
hands
 Compress the leg down wards and
rotate internaly and externally.
 If patient elicit pain it indicated
meniscal tear

DIFFERENTIAL DIAGNOSIS
 Loose bodies
 Osteochondritis dissecans

INVESTIGATIONS
 X-Ray-Antero posterior ,lateral view of knee &
intercondylar notch view
 Magnetic Resonance Imaging (MRI)-sensitivity
 Arthroscopy
 Arthrography

Magnetic Resonance Imaging (MRI)
Grade I –increase in signal,not extending to articular
surface
Grade II- linear increased density,not extending to
articular surface
GradeIII-signal extending to articular surface

ARTHROSCOPY
 Gold standard for diagnosis and treatment
 Thorough inspection of menisci, ligaments &cartilage
is possible
 Anteromedial or anterolateral portals
 Full extent ,type, site of tears & degenerative changes
can be seen

HEALING OF MENISCUS
 Determined by blood supply
Fibrin clot formation
Proliferation of vessels into fibrin scaffold
Proliferation of differentiated mesenchymal cells
Cellular fibro-vascular scar formation

HEALING RESPONSE
 Radial tears healed with fibrocartilaginous scar- 10
weeks
 Maturation of scar takes longer.

MANAGEMENT
 NON- SURGICAL
 SURGICAL

NON SURGICAL MANAGEMENT
Indications
 Incomplete meniscal tear
 Asmall stable peripheral tear (5mm) without any other
injuries.

Conservative treatment
 Grion-ankle cylindrical cast -4 x 6 weeks
 Toe-touch partial weight bearing
 Rehabilitative exercise program for 6 weeks to
strengthen quadriceps, hamstrings, gastro-soleus
&hip.

OPERTIVE MANAGEMENT
 Meniscal repair
 Meniscectomy
 Enhancement of meniscal repair
 Meniscal allograft

Meniscal repair
 Depend on the location of the tear, its morphology and
patients factors
 Peripheral tear--- Red on Red region
 Also on red on white region
 Size <1-2 cm
 Vertical longitudinal tears are ideal

Meniscal Repair
 young patient shows better outome
 Can be done Open orArthroscopicaly

Meniscal repair-Contarindication
 Tear>3 cm
 Transverse tear even in periphery
 Flap tear, radial tear, vertical tear with secondary
lesions.
 Ligament instability

OPEN MENISCAL REPAIR
 For posterior 1/3rd tear not more than 2mm from the
menisco synovial junction
Advantage
 More precise suture placement
 Sutures placed vertically through meniscus
 Better preparation of site

ARTHROSCOPIC MENISCAL REPAIR
 Patient selection
 Tear debridement of local synovial , meniscal and
capsular abrasions
 Suture placement

SUTURE TECHNIQUES
 Inside-out : Gold standard
 Outside-in
 All inside

INSIDE- OUT TECHNIQUE ( Gold Standard)
 Use zone specific canulas to pass sutures
 Sutures are attached to flexible needle
 Brought out through a posterior skin incision
 Advantage
:can be used in post.1/3 tear
 Disadvantage
: neurovascular injury
costly

OUTSIDE IN TECHNIQUE
 Sutures passed percutaneously across the tear through
18 G spinal needle
 Knot is tied inside the joint
 Repeated every 4-5mm
 Advantage: simple,
safe and cheap
 Disadvantage: cannot be used for posterior.1/3rd tears

ALL INSIDE TECHNIQUE
 For repair of posterior horn peripheral tear
 Needle is inserted into the meniscus & exits within the joint
 Specialised instrumentation needed.
 Allows placement of vertical sutures

Arthroscopic Repair- Disadvantages
Difficulty in intraarticular knot tying
No long term clinical studies
Time away from sports.

After care
 Limit knee flexion to 90 degree
 Low impact activity for 3months
 Full activity after 6months

Bio-absorbable implants
 Poly glycolic acid.
 Poly levolactic acid.
 Raecemic poly lactic acid.
 Poly dexanone.

 All these materials degrade into CO2 and water
 Devices includesAnchors,Arrows, screws and
staplers.

Meniscal repair associated with Anterior
cruciate ligament (ACL)
 There is 30-40% failure rate .
 RepairAnterior cruciate ligament first followed by
meniscal repair

MENISCECTOMY
3 types
 Partial
 Subtotal
 Total
Methods
 Open
 Arthroscopic

PARTIAL MENISCECTOMY
 Less articular cartilage degeneration
 Excision of only torn portion of meniscus .
Indications
 Tears >5mm from menisco-synovial junction.
 Flap tears

 Complex and horizontal.
 Treatment of choice in young adults who require
vigorous activities.
Advantage
 Short operating time.

TOTAL MENISCECTOMY
Indication:
 Meniscus is detached from its periphery.
 Indicated in extensive meniscal tears and degenerative
SUBTOTAL MENISCECTOMY
 Complex tears of posterior horn
 Anterior horn & portion of mid 1/3 of meniscus is
preserved

OPEN –OR- ARTHROSCOPIC ?
 Long term results of arthroscopic meniscectomy are
comparable to skilful open partial meniscectomy.

APPROACHES
Medial meniscectomy
 Single anterio medial
 Second incision:Henderson posteromedial incision
Lateral meniscectomy
 Antero-lateral
 Anterolateral+posterolateral

Postoperative
 Compressive bandage
 Knee immobilized in extension for 1 week
 Quadriceps exercises on next day.
 Crutch walking with partial weight bearing on next day
 Isometric exercises continued till 90 degree of flexion.

Complications
 Haemarthrosis
 Chronic Synovitis
 Synovial fistulae
 Painful neuromas
 Thrombophlebitis

 Infection
 Late degenerative arthritis
 Reflex sympathetic dystrophy

FAIRBANK’S CHANGES
 Post meniscectomy change
 Narrowing of joint space
 Flattening and squaring of femoral condyle
 Antero posterior osteophyte formation

Regeneration of menisci after excision
 After complete meniscectomy – fibrous regeneration
with in 6 weeks to 3 months
 Thinner and narrower than normal meniscus
 Decrease surface area and mobility.

Meniscal transplantation
 No long term study at present
 Meniscal allografts available.
 Survival rates better in patients with no degenerative
changes.
 Correctly sized implants with attached bone blocks
recommended.

Meniscal transplantation
 Allograft and auto graft replacement
 Quadriceps, patellar tendon & infrapatellar pad of fat
are used as allogenic substitutes for meniscus
 No uniformly satisfactory results.

RECENT ADVANCES
 Bioabsorbable meniscal fixators (meniscal dart,arrow)
 Collagen meniscus implant-from bovine achilles tendon
 Synthetic scaffolds
 Future- gene therapy & Stem cells

ACL Recon.pptx

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