1. Early results of anatomical ACL Reconstruction using The all-inside, Trans-lateral technique
S Srinivasan, Y Hamed, R Shah, Dipen K Menon
Kettering General Hospital NHS Foundation Trust (Affiliated teaching hospital: University of Leicester)
COKS2017: Noosa, Queensland, Australia
Sunday, 15/10/2017

2. Disclosures & ACKNOWLEDGEMENTS
No conflict of interests
Individual contributions
Mr S Srinivasan
Registrar
Data collection & Analysis
Mr Y Hamed
Specialist trainee
Data collection
Mr R Shah
Mr Dipen K Menon
FRCS (Eng) Tr & Orth
Member: BASK
Consultant T&O
Planned and guided study
Performed all operations
Acknowledgements:
Anaesthetist: Dr A Sultan, FRCA, Consultant Anaesthetist
Theatre Nurse: Mrs Sandra Roberts (Staff Nurse)
COKS2017: Noosa, Queensland, Australia
Sunday, 15/10/2017

3. TRANS-LATERAL ANATOMICal ACL RECONSTRUCTION
Technique pioneered in the UK by Wilson et al (Basingstoke). Modifications to anatomical technique and instrument design
Detailed technical description in Logan et al KSSTA 2012 & Wilson et al Arthros Tech 2013
Sockets prepared from inside-out, in the anatomical footprint of ACL. Single bundle ACLR using quadrupled ST
COKS2017: Noosa, Queensland, Australia
Sunday, 15/10/2017

4. Anatomical considerations
Femoral and tibial ACL attachments
Arthroscopic view of ACL femoral attachment
COKS2017: Noosa, Queensland, Australia
Sunday, 15/10/2017

5. Socket/ tunnel placement within the anatomical ACL
footprint results in knee
kinematics closer to the
intact knee
COKS2017: Noosa, Queensland, Australia
Sunday, 15/10/2017

6. TRANS-LATERAL ANATOMICAL ACL RECONSTRUCTION: TECHNIQUE
Supine, Knee flexed to 90 degrees (Side support & Foot-rest). Tourniquet
EUA, Arthroscopy & Supplementary procedures (e.g.: Menisceal repair, Chondroplasty)
Portals: Central Medial (viewing portal) & Central Lateral (working portal): lower and more central than standard portals
Notch debridement: RF device (calibrated device available)
COKS2017: Noosa, Queensland, Australia
Sunday, 15/10/2017

7. patient positioning Side support and foot rest
Knee in 90 degree flexion
Adductor canal: Saphenous
Nerve block
COKS2017: Noosa, Queensland, Australia
Sunday, 15/10/2017

8. portals Central medial Central lateral
COKS2017: Noosa, Queensland, Australia
Sunday, 15/10/2017

9. Graft preparation Graft harvest (Semitendinosus only): Length: 270mm
Graft quadrupled. Secured with 2 Cortical adjustable suspensory fixation devices: usual length of prepared graft: 67-70mm
Graft diameter measured
Graft Pre-tensioned. Compressed: in graft sizer
Prepared graft on graft
work-station: Tensioned
COKS2017: Noosa, Queensland, Australia
Sunday, 15/10/2017

10. sockets
Socket preparation using a flip-cutter (mid- bundle position, drilled from inside-out)
Femoral socket depth: 20mm
Tibial socket depth: 30-35mm
COKS2017: Noosa, Queensland, Australia
Sunday, 15/10/2017

11. Femoral & tibial sockets
Femoral socket with
fibre stick within
Tibial socket with flip-cutter
within
COKS2017: Noosa, Queensland, Australia
Sunday, 15/10/2017

12. TRANS-LATERAL ANATOMICAL ACL RECOnSTRUCTION: TECHNIQUE
Graft remnant debrided to allow smooth passage of prepared graft
Avoid soft-tissue bridge or intertwining in the lead sutures
Pre-tensioned graft is fixed, by flipping the buttons of the device. Winched into each prepared socket by reciprocal toggling of the sutures of the 2 Cortical adjustable suspensory fixation devices (Femoral side first)
COKS2017: Noosa, Queensland, Australia
Sunday, 15/10/2017

13. Graft Graft with knee in 90 degree Graft: femoral attachment flexion
COKS2017: Noosa, Queensland, Australia
Sunday, 15/10/2017

14. Graft fixation
Tensioning of graft with knee in almost full extension in reverse-Lachman position
Repeated cycling and re-tensioning possible
COKS2017: Noosa, Queensland, Australia
Sunday, 15/10/2017

15. fully tensioned graft COKS2017: Noosa, Queensland, Australia
Sunday, 15/10/2017

16. EARLY results
43 consecutive patients had Trans-lateral, All-inside, Anatomical, Single bundle ACL reconstruction ( ). Prospective data collection
Males: Females: 4
1 non-surgical mortality: prior to 1 year FU
Minimum 1 year Follow-up
Mean Age: 27.05yrs (Range: 16-49yrs)
Tegner-Lysholm score
Mean (Range)
Pre-operative
68.5 (29-95)
Post-operative
(38-100)
COKS2017: Noosa, Queensland, Australia
Sunday, 15/10/2017

17. LYSHOLM SCORE COKS2017: Noosa, Queensland, Australia
Sunday, 15/10/2017

18. RADIOLOGICAL RESULTS AP and Lateral x-rays
Femoral socket: Bernhard & Hertel grid, Am J Knee Surg,1997
All femoral sockets in our study measured to be in the accurate position described by Columbet et al, Arthroscopy, 2006
Tibial socket: Amis-Jakob line, Knee Surg Sports Traumatol Arthros, 1998: Recommended position of the centre of socket on the line: (41-44%)
Tibial socket position ranged from 32-47% in our study (Mean: 41.8%)
COKS2017: Noosa, Queensland, Australia
Sunday, 15/10/2017

19. RADIOLOGICAL ASSESSMENT
40.2%
ACL centre
27% along
Blumensaat’s line
& 34% of the height
of the intercondylar notch
Bernhard-Hertel grid
Amis-Jakob line
COKS2017: Noosa, Queensland, Australia
Sunday, 15/10/2017

20. immediate post-operative X-rays
COKS2017: Noosa, Queensland, Australia
Sunday, 15/10/2017

21. X-RAYS: 1 YEAR POST-SURGERY
COKS2017: Noosa, Queensland, Australia
Sunday, 15/10/2017

22. Socket position on MRI SCANS
COKS2017: Noosa, Queensland, Australia
Sunday, 15/10/2017

23. complications No cases of posterior wall blow-out No graft ruptures
No infections
1 intra-operative complication: button deployed in error in the pilot hole on the femoral side and needed supplementary fixation with a staple. Good clinical outcome at 1 year
No hardware failure
COKS2017: Noosa, Queensland, Australia
Sunday, 15/10/2017

24. Advantages of Trans-Lateral, Anatomical acl reconstruction
Sockets: Bone conserving compared to tunnels
Post-operative pain scores are better, 2 RCTs (Lubowitz et al, Arthroscopy 2013, Benea et al, Knee 2014)
Femoral socket drilled from inside-out (Accurate, Flexible, Excellent view from medial portal).
Medial portal drilling: technically more demanding (Lubowitz, Arthroscopy 2009)
COKS2017: Noosa, Queensland, Australia
Sunday, 15/10/2017

25. Advantages of Trans-Lateral, Anatomical acl reconstruction
Socket positions reproducible
Single hamstring tendon harvest: preserves hamstring strength (Yosmaoglu et al, KSSTA 2011) (Gracilis available as graft or secondary stabiliser)
Quadrupled ST thicker than conventional ST- Gracilis combination
Adjustable loop fixation equivalent to fixed loop constructs clinically
COKS2017: Noosa, Queensland, Australia
Sunday, 15/10/2017

26. CONCLUSION The early results of this technique are encouraging
In this series we were able to reproduce the results of the Basingstoke group (Yasen et al, 2017)
COKS2017: Noosa, Queensland, Australia
Sunday, 15/10/2017

27. Thank-you
COKS2017: Noosa, Queensland, Australia
Sunday, 15/10/2017