ACL Reconstruction Surgery in Delhi by Dr. Shekhar Srivastav - Dr. Shekhar Srivastav is an Orthopedic Surgeon attached to Sant Parmanand Hospital, Delhi with special interest in Knee & Shoulder surgery. After obtaining his M.S. Orthopedics degree he has undergone training in various centers in India and Abroad which has helped him in understanding the Orthopedics problems and their Management. He did his AO/ ASIF fellowship at University Hospital, Salzburg, Austria in 2006 and recieved training in Arthroscopy & Sports Medicine at TUM, Munich (Germany) & Rush Orthopedics Centre, Chicago( USA). He has an experience of more than fifteen years of diagnosing and treating Orthopedics & Trauma patients. Check Out Details at http://www.delhiarthroscopy.com

1. ACL RECONSTRUCTION- GRAFT
OPTIONS, TUNNEL PLACEMENT &
FIXATION
DR SHEKHAR SRIVASTAV
SR. CONSULTANT- Knee & Shoulder Arthroscopy
Delhi Institute of Trauma & Orthopedics,
Sant Parmanand Hospital, Delhi

2. ACL Surgery
ACL TearNo repair
Only Recontruction
Graft Autograft - common
Allograft

3. ACL RECONSTRUCTION
SUCCESS
Quality of the
Graft
Appropriate
Tunnel Placement
Strong Graft
Fixation

4. Graft Options
Autograft
 BPTB
 Hamstring
 Quadriceps
Allograft

5. Bone-Patellar Tendon Graft
 Considered GOLD standard
 Middle third of patellar
tendon harvested(1011mm)
 Incision
-Medial Vertical
-Transverse
 10 mm wide graft
harvested
 2.5 mm bone plug from
patella & Tibial tuberosity

6. Skin incision

7. Take the central slip of 10
mm

10. Mark bone tendon junction

11. BPTB Graft
AdvantagesEase of harvest
Consistent size & shape
Strong bone-tendon interface
Strong Bone to Bone fixaton
Good healing

12. BPTB Graft
Dis-advantagesRisk of patellar #
Patellar tendonitis
Patello-femoral pain
Donor site tenderness on
kneeling
Bigger incision scar
Loss of sensation lat.to scar

13. Hamstring Grafts
 Quadrupled Semi-T / Doubled STG graft
 4 strands of Hamstrings = 250% strength of
native ACL
Advantages
 Stronger graft
 Smaller Incision- Cosmesis
 Can be used in skeletally immature

14. GRAFT HARVEST

15. GRAFT HARVEST

16. GRAFT HARVEST

17. GRAFT HARVEST

18. GRAFT PREPARATION

19. GRAFT PREPARATION

20. Hamstring Grafts
Disadvantages Soft tissue to bone
healing
 Tunnel widening
 Technically difficult than
BPTB
 Loss of Hamstring
strength( apprx 10%)

21. Quadriceps Tendon Graft
 Bony end on one side
and soft tissue strip on
other
 Cross-sectional area
thicker than BPTB
Disadvantages Donor site risks

22. Quadriceps
tendon graft
INCISION: Anterior midline

23. Tendon exposure: central third

24. Harvested with a bone plug

26. Quadriceps tendon
 Advantage
 Comparatively less harvest site morbidity
 Larger cross sectional area of graft
 Disadvantage
 Bone block at only one end of graft

27. Allografts
Advantages No graft site mobidity
 Available off the shelf
 Boon- Multiligamentous Injuries
Disadvantages Risk of disease transmission
 Weak graft
 Delayed incorporation
 Not universally available,Expensive

29. Which Graft Better?
 Both grafts give excellent results
- Clinically
- Functionally
- Instrumented Examinations
 Choose Graft
- Experience & Training
- Comfort level

30. FAILURE OF ACL
Single Most Common
Cause
INCORRECT TUNNEL
PLACEMENT

31. TUNNELS FOR ACL
LENGTH
DIAMETER
POSITION

32. TIBIAL TUNNEL
ENTRY POINT
Tibial jig- set at an
angle of 45-550
300 medial to mid
sagital axis
Apprx. 4 cms below
joint line

33. Anatomic Tibial Tunnel
EXIT (INTRA ARTICULAR)
LANDMARKS(A) ACL Footprint
Center of ACL
footprint
(B) LATERAL Meniscus
Post. Border of Ant.
Horn

34. FEMORAL TUNNEL
12
Access for tunnel placement
-Through the Tibial Tunnel
- Through medial instrument
portal
ANATOMICAL POSITION
-Over the top position
- Right Knee-9 10pm
- Left Knee- 2 - 3 am
3
9
6

35. Anatomic Femoral Tunnel

36. Anatomic Tibial Tunnel

37. Graft Passage

38. Graft Fixation

39. Graft fixation
 Secure graft fixation is paramount to a successful
reconstruction
 ACL rehab emphasizes on immediate movement
and weight bearing
 High demand on initial graft fixation
 Ultimate long term success of an ACL
reconstruction depends on healing of the graft
fixation sites and biological healing

40. Ideal fixation
 Strong enough to avoid failure
 Stiff enough to restore knee stabilty
 Secure enough to avoid slippage

41. Ideal Graft fixation
 Anatomic
 Biocompatible
 Safe and reproducible
 MRI compatible
 Allow easy revision

42. Graft Fixation
 Choice of graft fixation depends on
-Surgeon preference
-Choice of graft
-Surgical technique
 Fixation Options
Femoral Interference screws/Intrafix
- Cross pin fixation- Rigidfix/ Tranfix
- Endobutton Fixation
Tibial - Intererference Screws/ Intrafix
- Suture discs, Post with washer

43. Types of Fixation
 Aperture Fixation: at the level of joint
 Interference screws
 Suspensory Fixation:
 Cortical: Endobutton, Staples, Screw posts
 Cancellous: Transfixation pins

44. Femoral Fixation
Graft properties- Strength
Stiffness
Slippage
Graft Tunnel MotionBungee Effect
Windshield Wiper Effect

45. Bio-Interference Screw Fixation
 Aperture Fixation
 Compaction drilling
 Dependent upon cancellous
bone
 Post wall blowout
 - Concern- Graft
maceration & failure at
physiological loading

46. Cross pin fixation
 Impacted transversely into
lateral cortex
 Implant passed under
looped graft
 Implant perpendicular to
graft
 Highest ultimate load
failure and stiffness
 Concern- tunnel widening
and windshield wiper effect

47. Endobuttton Fixation
 Fixation at lateral femoral
cortex
 No wear or abration of graft
 Advantages- Osteoporotic
bones & femoral tunnel
blowout
 Problems- fixation away
from aperture- tunnel
widening & bungee effect

48. Tibial Fixation
 Interference screw/
Intrafix
 Suture post
 Dual fixation

49. POST-OP

50. Complications
Pre-op consideration
 Patient selection- Non compliant/
Apprehensive
 Timing of the operation
 Immature Athlete
 Med. Comp OA with ACL insufficiency

51. Complication- Graft
Graft harvest
 Graft cut short
 Small size
Prevent
 careful harvest technique
 Cut all band attached before
using stripper
Dropped graft
 Careful passing of graft
 Another graft harvest

52. Complications
femoral tunnel
Improper tunnel placementAnterior femoral tunnel
 Residents ridge
 Use femoral tunnel guides
Solution
 Notchplasty
Posterior wall blow-out
 Endobutton or transfix

53. Complications
Tibial Tunnel
Improper tibial tunnel- anterior
tunnel placement
 Intra-articular landmarks
 Check guide wire impingement
before drilling
Solution
 Notchplasty
 Chamfering of the tunnel

54. IMPINGEMENT TEST

55. Complications
Neurovascular most
serious complication
 Vessel behind Post. Horn
Lat. meniscus
 Early recognition and
prompt repair
 Careful handling of
shaver and burr in
posterior compartment

56. Complication
 Recurrent Effusions
-Debris during surgery
-Reaction to bioabsorbable implants
-Vigourous physio
Management- Repeated aspirations
 Infection - < 1%
Management- antibiotics & arthroscopic deb.
 Stiffness
- Improper tunnels
- Post-op arthrofibrosis
- Cyclops lesion
- Inadequate physio/ non-compliant patient
Management- Gentle MUA / Arthr. Adesiolysis

57. To Summarise
 Autografts are better option than allograft
 Both BPTB & Hamstring grafts work equally
well
 Appropriate tunnel placement is essential to
prevent failure
 Fixation method should be biological,
reproducible & should have sufficient strength
to allow early mobilisation & rehab
USE IT OR LOSE IT

58. THANK YOU
Visit
www.delhiarthroscopy.
com

59. ARTHROSCOPY KNEE
 Commonest surgery
performed in UK
 Treatment Ligamentous
and soft tissue injury of
knee
 > precise and accurate
than open method
 Less morbidity and early
rehab

60. ARTHROSCOPIC ACL RECONSTRUCTION

61. Ligaments of the Knee
Cruciate Ligaments
 Anterior (ACL) resists
anterior translation
 Posterior (PCL) resists
posterior translation
Collateral Ligaments
 Medial (MCL) resists
medially directed force
 Lateral (LCL) resists
laterally directed force

62. Mechanism of Injury
ACL injury mechanism of
injury
 Twisting on fixed foot
 Blow to the knee
 Hyperextension
 78% are non- contact
injuries (Noyes et al)

63. Examining the Patient
 History
Pain & Instability
 Examination
 Motion of knee and degree of
swelling
 Ligament specific tests of the
knee
 Lachman test
 Anterior and Posterior Drawer

64. MANAGEMENT
1/3 - No symptoms, Normal life
1/3 - Occasional instability,no strenuos activity
1/3 - Constant instability and pain
 ACL deficient- little higher rate of future medial
meniscus tearing and arthritis.

65. ACL Reconstruction
We’ll walk through an ACL reconstruction
using the patient’s own grafts

66. Bony Tunnels are very precisely drilled in the tibia and femur to recreat
the normal anatomic position of the ACL . The graft is passed and
secured in bones.

68. SCORECARD
ENDOSCOPIC
Small incision
Less pain
Less morbidity
Accuracy
Early function
Cosmesis
OPEN
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