ACL Reconstruction Surgery W.J.Leach Consultant Orthopaedic Surgeon Western Infirmary Glasgow

The Holy Grail Reconstruct ligament Repair meniscus injury Prevent meniscus injury Return to full function No OA!

ACL Reconstruction Major advances in last 15-20 years Restores stability Return to function Reduces risk of meniscal tears 90% normal or near normal in short to medium term

Reconstructing the ACL?

“Anatomical “ placement of the ACL on femur

Surgical Placement of Femoral ACL Insertion 1990s Somebody moved the ACL! Isometry

Femoral placement Advent of arthroscopy Placement to suit surgical jigs

Femoral tunnel placement Transtibial – may be too vertical ( 1 or 11 o’clock) with OTT guide AM portal – beware MFC when drilling, flex to 120

Femoral Tunnel Placement Single bundle – mid-point more akin to AM bundle Outside in - retrodrilling

Tibial Tunnel Placement Just anterior to MCL distally Exit through stump of ACL 7mm anterior to PCL 40% A-P on lateral

Two bundles better than one! Attempt to recreate normal anatomy Hypothesis that less OA changes develop Technically demanding Time consuming

Lubowitz et al. Am J Sports Med 2008 Meta-analysis (single bundle v Lubowitz et al. Am J Sports Med 2008 Meta-analysis (single bundle v. double bundle) NO DIFFERENCE!

ACL Graft types Hamstring (4-strand) BTB Allograft

RCTs Hamstring v. BTB Grafts in ACL Reconstruction Feller and Webster 2003 NO DIFFERENCE Laxdal et al 2005 Maletis et al 2007 Ejerhed et al 2003

Carey, Spindler et al JBJS 2009. Systematic review – allograft v Carey, Spindler et al JBJS 2009. Systematic review – allograft v.autograft NO DIFFERENCE!

Foster, Ryan et al. Am J Sports Med 2010. Systematic review allograft v. autograft NO DIFFERENCE!

What I do…. BTB - hypermobile, pro footballer, rugby HT – majority, anterior knee pain, kneelers

Tibial Insertion Through stump of ACL remnant 7mm anterior to PCL Elbow or PCL aimer 50-55 degrees Start tibial tunnel just anterior to MCL fibres

Femoral tunnel Transtibial – OTT aimer 10 o’clock Outside in – retroreamer

Fixation Hamstring – Closed loop endobutton proximally, bioabsorbable screw distally BTB – metal interference screws