Anterior Cruciate Ligament Reconstruction

13 Anterior Cruciate Ligament Reconstruction


William W. Colman, W. Norman Scott


Injury to the anterior cruciate ligament (ACL) is common. Arthroscopic ACL reconstruction is performed to restore stability to the unstable knee. Bone—patellar—bone autograft is currently the most popular choice of graft, with numerous clinical reports demonstrating its success in terms of both knee stability and return to sports.


Patient Presentation and Symptoms



  1. Injury to the ACL is a common injury, especially in the individual active in athletics.
  2. ACLs are usually torn with a sudden twisting or landing injury but also can be caused by a direct blow, most commonly a valgus force to a planted foot.

Indications


Factors such as age, sex, activity level, soft tissue laxity, and associated injuries all play a role in the decision to recommend ACL reconstruction. The ideal candidate is a young athlete (high school, college or professional) who requires twisting, cutting, or running for participation in his or her sport.


Contraindications


Acute sepsis or a patient lacking a clear understanding of the rehabilitation required


Physical Examination



  1. A knee with an acutely torn ACL will show swelling and a loss of range or motion.
  2. A chronic ACL tear will demonstrate a positive anterior drawer, Lachman, and pivot shift tests.
  3. Swelling and stiffness usually abate in the chronic setting.

Diagnostic Tests



  1. Standard radiographic knee views: anteroposterior (AP), lateral, Merchant, standing AP bent knee
  2. Magnetic resonance imaging (MRI) of the knee is not always necessary but is a very accurate test to confirm the diagnosis of ACL tear and also show other intraarticular and extraarticular injuries.

Preoperative Planning and Timing of Surgery


It is best to delay surgery until swelling has subsided and range of motion has returned to near normal.


Special Instruments



  1. ACL graft knife 9 mm Mitek No. 595209
  2. Microsagittal saw
  3. Sagittal saw blade 9.5 mm × 25.5 mm Hall/Zimmer No. 5053-238 (Warsaw, IN)
  4. Tibial guide Acufex No. 013657
  5. Sizing tubes 9 mm Acufex No. 013524
  6. Isotac tibial guides
  7. Cannulated drill bit 9 mm Acufex No. 013662
  8. Twist drill 1.6 mm × 127 Microaire No. 8054-010

Patient Position


Supine position with the affected knee positioned over the break in the operating room (OR) table


Surgical Procedure


Diagnostic Arthroscopy


Perform this through an anterolateral portal to survey the joint and confirm ACL disruption. Note any other injuries present in the joint that may need to be addressed later in the procedure.


Graft Harvesting



  1. Position the OR table elevated and flexed with the patient’s knee over a bolster.
  2. Make a vertical or slightly oblique skin incision from the inferior aspect of the patella to a point just medial to the tibial tubercle.
  3. Dissect the peritenon to identify the edges of the tendon from the patella to the tibial tubercle.
  4. Use 9-mm graft for women and 10-mm graft for men.
  5. Using a catamaran or double-scalpel blade, incise the longitudinal inner third of the patellar tendon. Continue the blade proximally and distally to make etch marks in the soft tissue over the bone of the patella and the tibia.
  6. Using a knife and ruler, make horizontal etch marks at 25 mm on the patella and 25 mm on the tubercle to mark the end of grafts.
  7. Place a Steri-Strip at 10 mm on the blade of an oscillating saw to mark the thickness of the patella and tibial cut.
  8. Using a microsagittal saw, cut the medial, lateral, and terminal aspects of the patella and tibial tubercle corresponding to the etch marks made in the soft tissues on the bone. Cut the patella with a triangular cross section to minimize the chance of postoperative fracture.
  9. Using a curved osteotome, complete the tibial cut at the insertion of the patellar tendon proximally.
  10. Pry the graft loose using the curved osteotome and deliver the graft to the back table for graft preparation.

Preparing the Graft



  1. Remove all extraneous soft tissue from the bone and tendon.
  2. Using a rongeur, trim the excess bone from the ends of the graft so it can pass through the appropriate-sized tubes (9 mm for women and 10 mm for men).
  3. Drill 1 hole into the tibial graft using a 3/32-inch drill bit and place three No. 5 Ethibond sutures through these holes.
  4. Drill three holes into the patella end of the graft and place two No. 5 Ethibond sutures through these holes.
  5. These holes are oriented perpendicular to the cancellous surface to avoid transection by the interference screw.
  6. Mark with blue ink the cancellous portion of the grafts for identification inside the joint.

Notchplasty and Passing the Graft



  1. Make a superomedial portal for an additional inflow to improve the visualization during the notchplasty.
  2. Put an infrapatellar medial portal inside the vertical incision.
  3. Using a combination of motorized shaver and burr, perform a lateral notchplasty, being sure to remove enough bone to eliminate possible impingement of the graft.
  4. Debride the stump of the tibial insertion of the ACL.
  5. Remove the synovium around the posterior cruciate ligament (PCL) to help visualization.
  6. Place the tip of the tibial guide (set at 55 degrees) through the anteromedial portal.
  7. Place the tip of the guide on a point determined by a line that continues from the anterior horn of the lateral meniscus and intersects the medial tibial line. This point should be just anterior to the PCL.
  8. The origin of the tibial guide is placed medially one fingerbreadth from the tibial tubercle and two finger-breadths inferior to the joint line.
  9. Drill a guidewire (1.6 mm) through the tibial guide until it enters the joint and then remove the tibial guide.
  10. Using a cannulated reamer (9 or 10 mm), drill the tibial tunnel.
  11. Rasp the posterior cortex to prevent graft impingement.
  12. Place a 7-mm offset femoral tunnel indicator guide at the 2 o’clock position (left knee) and gently tap a small hole to leave an imprint for the location of the center of the femoral tunnel. After drilling with a 10-mm drill this will leave a 2-mm posterior cortical wall remaining.
  13. Place a guidewire through the tibial tunnel and into the femoral tunnel imprint and drill up to 38 mm (approximately 1.5 inch).
  14. Using a cannulated reamer (9 or 10 mm), carefully drill the femoral tunnel up to 30 mm. It is helpful to back out and check to be sure that posterior blowout has not occurred.
  15. Switch scope to medial portal to examine the femoral tunnel and check to be sure that posterior blowout has not occurred.
  16. Flex the knee and the femur and drill a Beath needle through the tibial tunnel and the femoral tunnel and out through the anterior femoral skin. If the Beath needle is placed anteriorly in the tunnel, a more anterior skin exist is ensured.
  17. Insert the sutures of the tibial end of the graft into the eye of the Beath needle and pull the Beath needle up and anterior, thus pulling the suture through the joint and out through the anterior femur.
  18. Guide the graft through the tibial tunnel and into the femoral tunnel by pulling anterior on the suture and guiding the graft with a probe. The patellar end of the graft should enter the tibial tunnel simultaneously
  19. Making sure the blue mark on the graft is anterior, place a Nitinol guidewire through the fat pad and into the small space anteriorly between the graft and the femoral bone. The Nitinol has a different orientation from that of the graft and tunnel. To improve parallelism, flex the tibia past 90 degrees while placing the wire.
  20. Secure the graft in the femur by screwing an interference screw (7 mm × 25 mm) over the Nitinol wire.
  21. Check for bony impingement through a range of motion and remove additional bone if necessary.
  22. Raise the foot of the bed.
  23. Mobilize the three sutures, leaving the tibial drill hole and pull tension on the sutures while flexing and extending to check if the graft is proud of the tibial cortex.
  24. If the bone graft is not proud of the proximal tibial cortex, then tie under tension over a post (6.5-mm screw and washer), which is placed just distal to the tibial tunnel.
  25. Use the Lachman test to check for graft tension; also check with the arthroscope.
  26. Bone graft the patellar defect with bone remaining from the graft cleaning and close the wound in layers.

Tips and Pearls



  1. There are two types of ACL tibial guides: one in which the tip of the guidewire comes out at the tip of the guide, and one in which the tip comes out at the elbow of the guide. It is important to know the difference.
  2. It is helpful to verify the posterior aspect of the tibial plateau with a probe to ensure the tibial tunnel will not be too posterior.
  3. While reaming the tibial tunnel, placing the shaver over the guidewire will ensure that the tibial tunnel will not be too posterior.
  4. While placing the femoral interference screw, protect the PCL with a blunt elevator or similar instrument.

Pitfalls and Complications



  1. If blowing out the back occurs, place the graft in the over-the-top position, with the graft tied over a post. The graft needs to be removed from the joint and an additional two sutures placed through the graft for extra fixation.
  2. If the graft at the tibial end is too proud, it may be necessary to burr the distal tibial cortex to ensure that the graft is not too proud. Enable the suction on the burr to facilitate this maneuver.

Postoperative Care



  1. Continuous passive motion at 0 to 60 degrees is started in the recovery room and continued for 1 week. Immediate weight bearing is allowed.
  2. Physical therapy starts immediately and follows an aggressive 6-month protocol. Return to sports is allowed when the strength in the operated leg is 90% of the contralateral leg.

Suggested Readings


Insall JN, Scott WN, eds. Surgery of the Knee, 3rd ed., vol. 1. New York: Churchill Livingstone, 2001


Jones K. Reconstruction of the anterior cruciate ligament using the central one-third of the patellar ligament. J Bone Joint Surg Am 1970;52:1302


Noyes F, Matthews D, Mooar P. The symptomatic anterior cruciate deficient knee: II—The success of rehabilitation, activity modification and counseling on functional disability. J Bone Joint Surg Am 1983;65:163


Shelbourne KD, Nitz P. Accelerated rehabilitation after anterior cruciate ligament reconstruction. Am J Sports Med 1990;18:292


Shelbourne K, Gray T. Anterior cruciate ligament reconstruction with autogenous patellar tendon graft followed by accelerated rehabilitation: a two- to nine-year follow up. Am J Sports Med 1997;25:786


Related posts:

Ligament Injuries: Anterior Cruciate Ligament with Quadriceps Tendon Reconstruction Total Knee Replacement: Medial Release via Osteotomy Ligament Advancement in Total Knee Arthroplasty Ligament Injuries: Posterior Cruciate Ligament Arthroscopic Abrasion Arthroplasty Ligament Injuries: Anterior Cruciate Ligament Reconstruction with Hamstring Tendons

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Aug 4, 2016 | Posted by in ORTHOPEDIC | Comments Off on Anterior Cruciate Ligament Reconstruction

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