ACL reconstruction with preservation of remnant of ACL
H. Makhmalbaf MD
Consultant Orth & Knee Surgeon
Mashhad University, Iran
22.2.2012 , Kish
Arthroscopy: The Journal of Arthroscopic & Related Surgery
Volume 22, Issue 3 , March 2006
Byung-III Lee, M.D. Kyung-Dae Min, M.D, et al.
Arthroscopic Anterior Cruciate Ligament Reconstruction With the
Tibial-Remnant Preserving Technique Using a Hamstring Graft
We propose that
• It enhances the revascularization & Cellular proliferation of the graft
• It preserves proprioceptive function
• To place the graft anatomically without impingement
• Preserve as much as possible of the remnant as a source of reinnervation
Surgical technique
• Developed to maximize the preservation of the tibial remnant
• Semitendinous & gracilis tendon harvest distally attached
• Femoral & tibial tunnels created
• Tibial tunnel at the ACL remnant
• Preserve the tibial remnant
Surgical Technique
• The grafts are pulled through tibial tunnel
• And ACL remnant and the femoral socket
• The ACL remnant is compacted
• The graft is secured proximally by sutures in the lateral femoral condyle
• And at the tibia with double staples by
• A belt-buckle method
Advantages of the technique
• Maximal preservation of the tibial remnant
• No roof impingement by
• Intrasynovial anatomic placement of the graft
• The simplicity of the procedure
• The minimal need for hardware
Advantages
• The economic benefit
• Potential prevention of tibial tunnel enlargement by preventing leakage of SF
• Optimal treatment of torn ACL is controversial
• Difficult to reproduce natural biomechanical and anatomic function of ACL
Discussion
• ACL functions as a sensory organ
• Providing proprioceptive information &
• Initiating protective & stabilizing muscular reflexes
• In ACL recons. proprioception is correlated with both functional outcome & Patient’s satisfaction
• Most of the MCRP’s are located distally
• Best reconstructive procedure ?
• The role of mechanoreceptors in ACL
• Good results depend on :
• Mechanical stability &
• Quality of recovery of proprioception
Roles of tibial remnant
• To enhance revascularization & Cellular proliferation of the graft
• To preserve proprioceptive function &
anatomic placement of the graft
• Without roof impingement
• Facilitate the vascular ingrowth and ligamentization of the grafted ACL
After treatment
• Knee immobilized in extension brace
• For 1 to 2 weeks
• Quadriceps setting exercises then:
• Active or ROM exercises
• After 4 weeks, full ROM &
• Closed chain exercises
Discussion
• Usually we find a tibial remnant
• Especially in acute cases
• The remnant enhances revascularization & Cellular proliferation of the graft
• Preserves some proprioceptive function
• Thus the remnant should be preserved
Discussion
• The weak link in recons. is point of graft fixation
• In hamstring ACL graft the ideal suture must have a high ultimate tensile load & experience minimal plastic deformation when loaded
• Ethibond sutures are used