1. Current Concept in Arthrocopic ACL Reconstruction
Ebrahimzadeh M.H. MD
Department of Orthopedic surgery, Ghaem Hospital
Mashhad University of Medical Sciences, Mashhad, Iran

2. Frequency
It is currently one of the most common orthopedic procedures in the world
6th frequent orthopedic surgery in US
ACL tears each year
annually primary ACL reconstruction, revision

3. The most frequent Orthopedic procedure in US
1. Knee arthroscopy and meniscectomy
2. Shoulder arthroscopy and decompression
3. Carpal tunnel release
4. Knee arthroscopy and chondroplasty
5. Removal of support implant
6. Knee arthroscopy and anterior cruciate ligament reconstruction

5. Who is candidate for ACL reconstruction ?
Knee instability& pain
Young ; athlete
No or a little DJD

6. Graft choices

7. Graft Choices Autografts Bone-patellar tendon-bone
Quadrupled hamstrings (Grac & Semi-T)
Quadriceps tendon

8. Semitendinus&Gracilis

10. BPTB versus Hamestring tendon
Liden et al. Am J Spot Med, 2007; 35
a prospective, randomized study with a 7-Year follow-up. 34/ 37 pt
----No Significant differences in Lysholm score and IKDC score; patient`s function

11. BPTB versus Hamestring tendon
Pinczewski et al. AM Jsport Med. 2007; 37
90 BTBG with 90 ST.Gracilis 10 years Follow-up
No difference in function; Lysholm score, IKDC
More morbidity in donor site in BTBG
More Petellofemoral DJD in BTBG

12. Graft Choices Allograft Bone-patellar tendon-bone Achilles’ tendon
Hamstrings
Quadriceps tendon
Fascia lata

13. Autograft vs. Allograft
Viral disease transmission (1:1million)
Deep freezing leaves some cells (10%)
Freeze-drying & cryo weaken graft; limited self-life
Graft incorporation & remodeling is faster with autografts. (graft is 8-12wks)
Donor site morbidity with autografts

14. Graft Fixation

15. Interfnce screw
Biodegradable
Metalic

16. Bio vs Metal Screw Laxdal G. et al. BioVs Metalic Screw
Am J Sports Medicine 2006
77pts in a prospective randomised study;
6-24 months,,,, the same function outcome
-larger drill hole in bio group

18. Intefrance Screw

19. Transfix

20. Transfix pin/screw Rose et al. :J of Knee Surg, Sport Traumatolo. 2006
Prospective randomized study of Transfix vs Bio screw for hamstring reconstruction
-38 patients with Transfix versus 30 Bio screw with 12 months follow-up
No significant difference in outcome

22. Crosspin/transfix

24. Endobuttom Loop

25. Endobotton Femoral Fixation
Promodos and Joyce. J Tech Orthopedics, 2005
Endobutton for hamesting femoral fixation of ACL recomstruction, technique and results
--139 patients with 2-8 years follow-up
-86% reported normal knee stability

26. Ham. Graft passer for Transfix

27. One bundle or two bundle ACL reconstruction

28. Anatomic versus non-anatomic reconstruction
Anteromedial(vertical) AP stability
Posterolateral(Oblique) Rotational Stability

29. 16 weeks old fetus

35. Two bundles VS one Bundle
Disadvantage of 2 Bundles:
Numbers of femoral tunnels
Operative time
Femoral condyle osteonecrosis, chondrolysis
More technically demanding

36. Two bundles VS one Bundle
JarvelaTimo ; J Knee Surg Sports Tramatol Arthoscpy, 2007, 15 Prospective randomized study with #14 months follow-up 35 pts two bundle 30 pts one bundle --Lysholm Score and IKDC --Rotatinal stability (Pivot shif) better in 2 bundle group

37. Present recommendation for 2 bundles
Only for hands of the most experince ACL surgeon
Standard for patients who perfoms demanding pivoting sports

38. Skeletal Immature ACL Reconstruction

39. Skeletal Immature ACL Reconstruction
6.7% of all ACL tears
Physial sparing reconstuction
--nonisometric ACL reconstruction
Parker Am J Sport Med 1994

40. Partial transphysial ACL reconstruction
--Lo Ik et al. Athroscopy 1997
--No angular deformity
--No LLD

41. Tranepiphysial ACL reconstruction
Guzzanti et al. Am J Sport Med 2003
8 patients with 70 moths of follow-up
Average Knee score 97/100
1.8 mm translation difference
No growth problem

42. Transphysial ACL Reconstruction
Aichroch PM , Patel D. JBJS Br 2002
47 patients with hamestring ACL reonstruction ,,,
3year follow-up
No LLD and no angular deformity

43. Recommendations for adolecent ACL reconstruction
For delaying surgery patients should restrict sports
1-Hamestring is more deserible
Acute and subacute period you can do the sugery

44. The End