Issues in Hamstring Grafts
The major issues with the use of hamstring grafts are Graft strength. Graft fixation. Graft healing. Donor site morbidity. Early rehabilitation. Graft strength and stiffness. In one of the earlier studies, Noyes reported that one strand of the semi-t was only 70 the strength of the ACL Fig. 5.6 . However, he Figure 5.6. The ultimate failure load of the normal ACL compared to various grafts. Figure 5.6. The ultimate failure load of the normal ACL compared to various grafts. Figure 5.7. The...
Nonoperative Management Protocol
The nonoperative treatment of the acute injury consists of the following Extension splint and crutches. The length of time on crutches will depend on the degree of associated meniscal capsular injury. Cryotherapy with the Cryo-Cuff helps to reduce the swelling and pain. Physiotherapy to regain range of motion and strength. Nautilus or gym program to strengthen the muscles with machines and to improve the cardiovascular fitness with steppers and bikes. Functional brace to stabilize the knee in...
Physical Examination Lachman Test
The Lachman test is the most definitive and easily performed test for ACL tears Fig. 2.2 . This should be the first test performed, so that the patient can be caught while still relaxed. The knee should be positioned at 20 to 30 of flexion. The upper hand controls the distal thigh, while the lower hand, with the thumb on the tibial tubercle and the fingers feeling to ensure that the hamstrings are relaxed, pulls the tibia forward. The feeling on the normal side is a firm restraint to this...
Posterior Blowout of Femoral Tunnel Problem
Figure 9.16 shows the thin posterior wall of the femoral tunnel, which indicates a weak posterior wall. The use of the interference screw would be contraindicated. It would not be strong enough to insert an interference screw. The screw would force the bone plug of the graft out the back of the tunnel, and loss of fixation would result. When the back wall blowout is recognized, change from interference screw to Endo-button fixation. Another solution is to use the two- incision technique, with...
Noncontact Pivot Internal RotationExternal Rotation
The most common injury mechanism involves no contact with others. The athlete is simply running and abruptly changes direction. The ACL is stressed by the rotation of the tibia, resulting in a tear of the ACL, as illustrated in the video on the CD. The athlete lands in the flexed position, the quadriceps contract, and the tibia is subluxed anteriorly. Then with further flexion, the tibia reduces with a snap. This is the same mechanism that the pivot-shift test mimics. Ireland has reported that...
Intrinsic Joint Laxity
There are contradictory studies on the role of ligamentous laxities. Daniel's study with the KT-1000 arthrometer showed no gender differences in the measurable laxity of the ACL. It has been documented that exercise produces laxity of the ACL, but there are no significant differences in gender. Yu et al. have shown that the ACL has both estrogen and progesterone receptors. The cyclic variation of estrogen may affect the ligament metabolism and make females more prone to injury during the...
Disadvantages Lxc
The main disadvantage is that all the long-term studies have shown high failure rate. There is the potential for reaction to the graft material with synovitis, as seen with the use of the Gore-Tex graft. With the Gore-Tex graft, there was also the increased risk of late hematogenous joint infection. The results that have been reported with the use of the Gore-Tex graft suggest that it should not be used for ACL reconstruction. Unacceptable failure rates have also been reported with the use of...
Tibial Tunnel 1
Figure 6.51 shows the correct external position for the tibial guide. The tip of the Linvatec guide is placed 2-mm medial to the crest of the tibia and 5cm distal to the joint line. The guide is usually set at 55 . The tip of the guide should be adjacent to the medial collateral ligament. The oblique position will allow the positioning of the femoral guide in an oblique position Fig. 7.8 . The result of this is an oblique graft. This graft position has better long-term stability. The tip of the...
Loss of Flexion or Extension Problem
The loss of flexion is due to suprapatellar pouch adhesions, or the tight patellofemoral joint. The loss of extension is the result of anterior notch scarring. The solution for extension loss is to mobilize early with passive extension. If this fails, then arthroscopic excision of the scar and cyclops lesion. The solution to loss of flexion is to manually mobilize patella longitudinally. If this fails, then arthroscopic medial lateral retinacular release should be done. The patella is mobilized...
Stripping of the Tendon
The tendon stripper is pushed up along the tendon to remove it from its muscular attachment Fig. 6.35 and Fig. 6.36 . The tendon must be cut free from the bands that attach to the gastrocnemius. If there is even Figure 6.36. The stripping of the tendons with the closed-loop tendon stripper. Figure 6.36. The stripping of the tendons with the closed-loop tendon stripper. a small band, it causes the tendon to kink, and the stripper may cut it off short Fig. 6.37 . The full length of the harvested...
KT1000 Measurements Joint Injection and Femoral Nerve Block
First confirm which is the correct side. The physician's initials Fig. 6.3 should be visible on the correct knee. The low profile leg holder is high on the thigh to allow the graft passing wire to penetrate the anterolat-eral thigh. The tourniquet is placed proximal under the leg holder. Figure 6.2. The KT-1000 arthrometer measurement of the anterior-to-posterior motion of the knee. Figure 6.2. The KT-1000 arthrometer measurement of the anterior-to-posterior motion of the knee. Figure 6.3. The...
Diagnostic Arthroscopy and Meniscal RepairMeniscectomy
The portals must be accurately placed to visualize all aspects of the knee Fig. 6.5 . The high lateral portal, at the corner of the patellar tendon and the patella, is the first portal to establish. The medial portal may be identified with an 18-guage needle before it is cut with the knife Fig. 6.6 . The W maneuver initially scans the entire knee Fig. 6.7 . The order of the examination is as follows 1. Suprapatellar pouch. Examine the synovium and look for loose bodies. Figure 6.5. The...
The Technique of the BioStinger Insertion
The appropriate length of BioStinger Linvatec, Largo, FL selected, is usually 13 mm, and loaded on the cannulated wire of the delivery unit Fig. 6.20 . The cannula is placed against the meniscus and 2 mm of cannulated wire is delivered into the torn fragment Fig. 6.21 . The fragment is then reduced to the peripheral rim. When the torn fragment is reduced, the cannulated wire is advanced into the rim using the slider bar on the side of the device Fig. 6.22 . The BioStinger is inserted into the...
Loose Fixation of Interference Screws Problem
If the screw is not put parallel to the tunnel, it may result in posterior penetration of the femoral tunnel. The screw may come loose in the joint. The appropriate size of screw, one that gives good purchase on the graft, must be used. Use a two-pin passer to place the femoral screw in the femoral tunnel Fig. 6.62 . Visualize the screw guide wire in the notch for the tibial tunnel. If the guide wire is in the tunnel, the screw should follow the guide wire. In soft tissue graft fixation, use a...
Tunnel Malposition Tibial Tunnel Anterior Problem
The tibial tunnel is drilled anterior Fig 9.10 . The result is failure of the graft by anterior notch impingement. If the tunnel is just slightly anterior, chamfer back of tunnel to move it more posterior. The usual situation is similar to Figure 9.10. The coring reamer can be used to position the tunnel in the correct position. The bone plug is used to graft the old anterior tunnel. Before drilling the tunnel, use a K-wire and if necessary reposition the wire to the correct position before...
Notchplasty and ACL Stump Debridement
The ACL stump is removed with a combination of the shaver and the electrocautery. In most cases no bone is removed, only the soft tissue from the wall of the notch. There is still considerable controversy over the extent of the notchplasty. Some surgeons do a notchplasty in only 10 of their cases. Others always do one. The author thinks that the answer lies somewhere in between. Each physician should do what needs to be done to accommodate an 8 to 10 mm graft. In cases with a very narrow...
The KT1000 Arthrometer
The KT-1000 arthrometer will normally show a side-to-side difference of less than 5mm Fig. 3.1 . The slope of the curves that are pulled with the KT-2000 demonstrate the difference. Force of 15,20, and 30 pounds is applied to the vertical axis of the knee the horizontal axis shows millimeters of displacement. The curve on the left shows the normal anterior cruciate ligament. The middle curve shows that there is initially more displacement, but then a firm restraint to anterior translation. This...
Introduction
During the past decade, the anterior cruciate ligament ACL has become a familiar term. Most athletes have heard about it or know someone who has had an injury to the ACL Fig. 1.1 . This book provides comprehensive information about the ACL that will help the caregiver make an informed decision on the best management of any injury. The ACL is the main stabilizer of the knee for athletic pivotal activities. The first repair of the cruciate ligament was attributed to Hay Groves in 1917. Then, in...