acl reconstruction with autogenous semitendonsis and gracilis william r. beach, m.d
TRANSCRIPT
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ACL Reconstruction with Autogenous Semitendonsis
and Gracilis
William R. Beach, M.D.
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Graft Harvest, Fixation and Tensioning
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Graft Harvest• Most important and “stressful”
portion• Incision – two finger breadths
distal and one medial to the tibial tubercle
• Palpate the “speed bumps”• Longitudinal incision down to
bone• Elevate the tendons and view
the tendinous “raphe” from “inside” the fascia
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Graft Harvest
• “Whip-stitch” the free ends of the semi-t and gracilis with #5 suture
• Carefully and completely release the tendinous connections to the gastrocnemius
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Graft Harvest
• “Blunt” tendon stripper to avoid premature tendon amputation
• “Sharp” tendon stripper
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Tibial Tunnel Placement and Notchplasty
Notchplasty • required because we are
replacing an “hourglass with a cylinder”
Howell Guide • couples tibial tunnel
placement and the notchplasty
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Howell Guide• References the tibial tunnel
placement off the roof of the intercondylar notch
• Ideal for acute tears and reconstruction
• Less suited for the chronic “overgrown” intercondylar notch
• The guide is positioned and the pin is drilled in full extension
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Marking The Roof• While the knee is in full
extension the drill can be advanced into and under the roof
• This will outline the minimum amount of roof which must be removed to avoid graft impingement
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Avoiding Lateral Wall Abrasion
• Advance the drill slightly past the entrance of the tibial tunnel
• By carefully flexing the knee the minimum amount of lateral wall is removed to avoid abrasion
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Femoral Tunnel Is the cortex or bony cylinder intact ?
• If the posterior cortex is intact then compression or interference fixation is possible
• If the posterior cortex is incompetent then suspension fixation is necessary
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Fixation Types
• Compression or interference– ex. Metal or resorbable screws
• Suspension– ex. Endobutton, LinX HT or Cross-pin
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Tunnel Requirements for Compression Device
• Competent bony cylinder• Protected posterior cortex• Usually requires creation
of this tunnel in greater degrees of flexion – avoid the “over the top position”
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Tunnel Requirements for Suspension Device
• Competent bony cortex in the proximal portion of the tunnel – Endobutton and LinX
• An intact or defined cortical breach – Endobutton and LinX
• Adequate bone strength to support the cross-pin device
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Peak Loads for Femoral Interference/Compression Fixation
• Metal RCI screw - 214N
• Bioscrew (8mm) - 341N (Brown CH et al - 566 +/-68 N)
• Half millimeter drilling and “over-sized” screw - increased ultimate strength to 530N
• JC Richmond and MJ Friedman, Fall AANA Meeting, 1999.
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Peak Loads for Suspension Fixation Devices
• Lynx HT - 673 Newtons– Innovasive data
• EndoButton (Deknatel tape) - 610-700 Newtons– Rowden et al. AmJSM, 1996.
• EndoButton (continous loop) – two times “stronger and stiffer” than with tape– M.J. Friedman, Fall AANA Meeting, 1999.
• Cross-pins – 850 to 1150N ultimate tensile strength with stiffness of 224N/mm– M.J. Friedman, Fall AANA Meeting, 1999.
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Peak Loads for Tibial Fixation
• Tandem AO Screw and Washer - 1159N
• WasherLoc - 905N
• Screw and Post - 768N
• RCI screw (metal) - 241N
• Resorbable screw - 341N (over-sized screw - 420N)
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ACL TENSIONINGACL TENSIONING
• How ?• When ?• How much ?
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ACL Reconstruction and Tensioning
• Underload - Instability
• Overload - Constrains motion
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Variable Factors
• Viscoelastic Properties– Pretension
– Preoperative tension
– Postoperative tension
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Literature Review
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Human Studies - In Vivo
• Tension on the ACL/PCL changes throughout the arc of motion
FG Girgis et. al. Clin Orth
1975
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ACL Biomechanics• Doubled gracilis and semitendinosus
strength - 4400N– JC Richmond - AANA Fall Meeting,
1999.
• the ACL get tighter in extension• the ACL is more lax in 30 degrees of
flexion
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Review On Tension In The Natural And Reconstructed Anterior Cruciate Ligament
H.N. Andersen, D.A. AmisKnee Surg Sports Trauma
Arthroscopy 2:192 - 202 (1994)
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Andersen and Amis
• Different grafts will require different tensions to restore normal stability
• The joint position (flexion angle) and graft placement are critical
• Little firm evidence for which to base a consistent protocol
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Determination of Graft Tension before Fixation in ACL Reconstruction
Burks RT, Leland R.
Arthroscopy 4:260-6 (1988)
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Human Study - In Vitro
• Determination of Graft Tension Before Fixation in Anterior Cruciate Ligament Reconstruction– Ten cadaveric knees– KT 1000 (Medmetric)– Measured anterior tibial translation with a 20 lb
loadBurks and Leland Arthroscopy 1988
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Burks and Leland
• Goal - to determine the tension needed before graft fixation to restore normal anteroposterior translation
• Arthrometer testing until the 20 lb. anterior drawer equalled the ACL intact drawer
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Burks and Leland
Graft and tension
• bone-tendon-bone - 3.6 pounds
• semitendinosus - 8.5 pounds
• iliotibial band - 13.6 pounds
• The required tension to return anterior translation to normal seems to be tissue specific.
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Tuckahoe Orthopaedics
• Caspari, Meyers, Beach and Galbraith
• Study to determine tensioning affects
• Tensioned and non-tensioned group
• Not completed because of the early identifiable benefits in tensioning
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ACL Pretensioning
• B-T-B complexes were tensioned initially with 16 lbs. via an Instrom device
• Measured 3 min. later the tension was 8 lbs.
• This “creep” stabilized at 3 minutes
M.Goble1997 Metcalf Mem.Sun Valley, ID
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ACL Pretensioning
• Goble suggests– Tensioning the graft and femoral fixation
complex– Cycle the knee through a full ROM and repeat
several cycles– Re-tension the graft after 3 minutes and fixate
the graft to the tibia
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Practical TensioningTension Boot
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Tension Boot• Allows up to 20 lbs. of
tension to be applied to the graft
• Allows cycling of the graft under tension
• Frees the surgeons hands to fixate the graft to the tibia
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Conclusions
• Graft placement is crucial
• Notchoplasty is important
• Graft type is minimally important
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Conclusions
• Graft fixation construct should have minimal strain
• Angle of tensioning 0° - 30°
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Conclusions
• Operative graft tension 5 - 15 lbs.
• Specific to graft type
• Pretension (??)
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Conclusions
Well controlled clinical studies
hold the answers.
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Thank You
Orthopaedic Research of Virginia
For more information on orthopaedics and sports medicine visit our website : www.orv.com
ORV 2000