ACL made simple / Don Johnson. p. cm. Includes bibliographical references and index. ISBN (alk. paper). 1. Anterior cruciate ligament. 2.
Table of contents
The lateral tear is done in the reverse fashion. This rotation of the tibial plateau will catch the posterior horn of the meniscus between the tibia and femoral condyle, producing a clunk and causing pain. The meniscus tugging on the pain-sensitive synovium at its peripheral attachments produces the pain. The test is notoriously inaccurate, and in most situ- ations the pain with full flexion and rotation is sufficient to confirm an injury to the meniscus.
The mechanism of the popping with the McMurray test is demon- strated in the video on the CD. It shows the tibial plateau subluxing forward and trapping the posterior horn of the meniscus between the femur and the tibia. This is associated with a clunk. It also illustrates why the unstable knee has a high incidence of meniscal tears. Valgus stress is applied to the knee to test the medial collateral ligament.
Diagnosis of the ACL Injury 1 has no motion, but is painful on stress. The site of tender- ness on the ligament can determine the site of injury i. The examination of the collaterals is important to determine whether the ACL injury is isolated. Anterior Drawer Test This test is generally not useful for detecting injury in the acute situa- tion Fig.
The drawer becomes positive in the chronic case with capsular laxity. Do not confuse the anterior motion with the knee that is posteriorly subluxed and the anterior motion of pulling the knee to the neutral position. Always check for the tibial step. Physical Examination 21 Figure 2. The active Lachman test.
Quadriceps Active Test Figure 2. This is indicative of an ACL-deficient knee.
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This nonweight -bearing exercise is called open kinetic chain exercise. Open kinetic chain exercise is also seen with the patient on the quadriceps machine in a fitness room. The athlete sits on the leg exten- sion machine and extends the knee. In the early rehabilitation phase, this exercise must be avoided to prevent strain on the recently implanted graft.
Associated Ligament Injuries It is always important to perform a posterior drawer test Fig. If this is done routinely, you will not miss a posterior cruciate ligament 22 2. The posterior drawer test for PCL laxity. The video on the CD demonstrates the posterior drawer test. Imaging Plain Radiographs The screening examination should be a simple anteroposterior and lateral radiograph of the knee.
This will reveal open growth plates, ACL bony avulsions, significant osteochondral fractures, tibial plateau frac- tures, or epiphyseal fractures. Tomograms If the radiograph is negative, but considerable bony tenderness exists, then tomograms should be done to rule out plateau fractures.
Computed Tomography Scan The 3-D scan can help plan treatment for associated tibial plateau fractures. Examination Under Anesthesia and Arthroscopy 23 Bone Scan If the pain persists, this scan may confirm occult bony injury. Magnetic Resonance Imaging In a few situations, magnetic resonance imaging MRI will change your management of an injury. The diagnosis of the ACL tear should be made clinically. If the loss of extension persists, the MRI can be performed to determine whether this is a bucket-handle tear or an impingement of the ACL bundle, a cyclops lesion.
The meniscus tear should be repaired early and, in some situations, the ACL reconstruction should be delayed until a good range of motion has been achieved after the meniscus repair. In the cyclops lesion, both the debridement of the ligament ends and the ACL reconstruction can be done simultaneously as described by Pinczewski. Remember that a good physical examination by an expe- rienced physician is more reliable than an MRI. Examination Under Anesthesia and Arthroscopy The arthroscope has been the key to unlocking the diagnosis of knee pathology Fig. The arthroscope has improved the diagnosis of knee injuries, but the scope examination is only one aspect of the puzzle.
One of the mistakes residents make is to go ahead with the arthroscopy before performing a clinical examination of the knee. The examination under anesthesia EUA is a valuable adjunct to the diagnostic work- up. At this time, the grading of the laxity may be documented. It is often difficult to examine the very large knee of a football player with multi- ple ligament injuries in the training room. The EUA may be the only means of making the diagnosis. Arthroscopy of the acute knee presents no more technical prob- lems than with the elective case.
The hemarthrosis must first be Hushed out. The synovium and ligamentum mucosum around the ACL must frequently be removed to fully assess the degree of liga- ment injury. The hook is used to probe the two bundles, and to assess tension. The video on the CD shows how the diagnostic arthroscopy must be performed in a similar fashion each time, so that the knee will be completely examined and no region forgotten.
This must be done before any surgical procedures are started. The arthroscope is the key to unlocking the secrets of the knee. The video shows the arthroscopic view of the torn ACL. The menis- cus and articular surface should be completely examined. The capsular injury may be seen by inspecting the gutters, and examining over and under the meniscus. If there is significant capsular tearing, then gravity pressure only, rather than a pump, should be used.
The ACL tear has produced a stump at the front of the knee that prevents full extension. This mimics a locked knee. The fat pad in front of the ligament has to be removed to visualize the ligament, and the ligament must be probed to assess its status. This ligament tear may have been produced by the narrow stenotic notch. The diagnostic examination of the knee must be complete to detect any meniscal injuries.
The video demonstrates the chronic ACL tear. The residual ligament is probed with a hook, and it can be appreciated that it is not attached to the femoral condyle. The natural history of the partial tear is controversial. Reports suggest that both conservative and operative treatment offer good results.
This suggests that patients in high-demand sports require reconstruction. Freunsgaard and Johnannsen had good results with con- servative treatment in patients who avoided high-demand athletics, and Buckley and colleagues reported that the degree of anterior cruciate tear did not correlate with outcome. Only half of their patients were able to resume their previous level of sports activity. This anterior excursion is greater than the opposite side, but less than 5 mm of the side-to-side difference measured on the KT arthrometer.
Pivot-Shift Test The pivot-shift test must be negative or only a slight glide to produce a diagnosis of a partial tear See Fig. If the test is positive, the knee is clinically unstable and should be regarded as anterior cruciate defi- 26 Physical Examination 27 dent. The pivot shift is the most important assessment of the partial tear. The slope of the curves that are pulled with the KT 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 corresponds to the firm end point to the Lachman test. The third curve on the right is the anterior cruciate deficient knee with complete rupture. The stronger the pull, the more anterior displacement. The force displacement curve of the partial ACL tear. Therefore, it is not a useful tool for diagnosing partial tears of the anterior cruciate liga- ment.
It is difficult to estimate how much of the ligament is still present. Arthroscopic Assessment Arthroscopic assessment of the anterior cruciate ligament tear is diffi- cult for two reasons. First, it is hard to see the ligament without remov- ing the synovium and fat pad. Second, it is only an estimate of the degree of tearing of the ligament. It seems to be best to try to estimate Figure 3.
Treatment Options 29 Figure 3. The laxity of the ACL is demonstrated with a probe. A hook probe must be used to examine the ligament proximally to see where the ligament is attached — to the side wall, the roof, or the posterior cruciate ligament. The best position is the side wall at the normal site of the anterior cruciate ligament.
The most common situation is to see the ligament attached to the posterior cruciate ligament. It has attenuated to a small band attached to the side wall. This amount of ligament laxity should allow a return to sports without a reconstruction. Treatment Options Partial Tears The treatment options for a patient with partial ACL tear are to give up or modify his or her sports activities.
The patient who can modify his 30 3. Partial Tears of the ACL sports activities and avoid pivotal sports will do well with a partial ante- rior cruciate ligament injury. This is the only parameter that the indi- vidual has control over, and that point should be emphasized when counseling athletes. Brace and Arthroscopy The use of a brace combined with modification of activity can be suc- cessful.
Sometimes a meniscal injury will still cause a giving way sensa- tion. The best long-term outcome for the young patient is to have a meniscal repair. The dilemma is whether to reconstruct the ACL. The results of a meniscal repair are much better when the knee has been reconstructed and is stable. ACL Reconstruction If there is a positive pivot -shift test or a small bundle attached to the femur, and the athlete wants to be active in pivoting sports, anterior cru- ciate ligament reconstruction should be considered.
Indications for ACL Reconstruction The patient who is a candidate for reconstruction of the ACL is the com- petitive, pivoting athlete who is involved in sports such as soccer, rugby, and basketball. In addition, the patient should have clinical symptoms of instability, with a history of giving way, a positive Lachman, and pivot- shift test with more than 5 mm side-to-side difference on the KT arthrometer. Not all tears of the ACL need operative repair. The treat- ment options for the elite athlete, who needs reconstruction, as well as the inactive patient, who needs no reconstruction, are fairly limited.
It is the recreationally active individual whose ACL injury requires counseling for the best treatment plan. There are a number of factors to consider in this decision, including, as Shelbourne has emphasized, age, chronicity, activity level, and associated injury to the meniscus and articular surface. Age of the Patient The older patient may be more likely to modify his lifestyle and accept a conservative treatment program, while the younger patient, who is involved in competitive sports, wants to return as quickly as possible to high-level sports without the use of a brace.
Activity Level and Intensity The competitive football or soccer player will likely require a recon- struction to continue playing at the same level. If the KT arthrometer side-to-side difference was greater than 7 mm, the chance of a better outcome was with surgical reconstruction. Size of Athlete The forces that a b lineman exerts on his knee with pivoting are much more that the b tennis player.
In the case of the former, surgical reconstruction should be considered. If the patient is not involved in sports then he will usually have no giving way episodes, and no surgical treatment is necessary. Giving way in the sedentary patient is more likely the result of meniscal pathology. The meniscus may be treated by arthroscopy, and the patient can continue with the nonoperative treatment program.
The patient should be counseled to switch into knee friendly sports, such as cycling and swimming. Brace and Arthroscopic Meniscectomy If the patient is recreationally active, a functional brace will often be sufficient to stabilize the knee for low-demand sports, such as doubles tennis. However if he has giving way in the brace, a meniscal tear may be present.
The younger athlete should have a meniscal repair and recon- struction for the ACL. The long-term results of meniscal repair are better with a stable knee, and the meniscal repair without reconstruc- tion is not an option. The older patient should have a meniscectomy and use a brace for sports. If the patient still gives way in the brace, then consideration should be given to a reconstruction.
Anterior Cruciate Ligament Reconstruction Most young competitive, pivoting athletes should have an ACL recon- struction to stabilize their knees. This will allow them to continue to par- Plea for Conservative Treatment 33 ticipate in sports and, hopefully, prevent late degenerative changes. This means that the athlete who has an early ACL reconstruction will be able to continue to be active without the risk of degenerative osteoarthritic changes in his knee.
The patient who continues in sports with recurrent giving way, as a result of ACL laxity, will have a degenerative knee in 10 to 12 years. The activity level is the only one of these factors that the patient can control. The other treatment options, such as brace and meniscal repair, will only be successful if activity is diminished. Ninety percent of the patients who undergo ACL reconstruction will be able to return to full athletic participation.
However, in some instances, especially with downhill skiing injuries, it can. There is little argument that the young competitive, pivoting soccer player with a positive pivot shift and a 7-mm side-to-side difference on the KT arthrometer needs a reconstruction, but consider another example. Case 1 KB, who is a year-old interior designer and an advanced recreational skier, injured her knee downhill skiing. She had an external rotation, valgus injury with an audible pop in her knee.
The bindings did not release. She was assessed at the ski hill and diagnosed with an ACL tear. Two weeks later, an examination at the clinic revealed an effusion, joint- line tenderness, positive Lachman, and a positive pivot-shift test. She was advised to have a reconstruction and started therapy to improve the range of motion and reduce the effusion. At six weeks after injury, she had a positive Lachman no end point , positive pivot shift, and a KT manual maximum side-to-side difference of 6 mm.
She was advised to proceed with a reconstruction. At three months postinjury, she had a positive Lachman with a firm end point, a pivot glide, and a KT manual maximum side-to-side dif- 34 4. The arthroscopic appearance of a healed ACL. The arthroscopic examination demonstrated normal menisci, normal articular cartilage, and an ACL healed to the femoral condyle. The appearance of the well-healed ACL is shown in Figure 4. In reality, this means a normal appearing bulk of ligament present as opposed to this thin strand of ligament.
No physician would have a problem proceeding with a reconstruction in this situation. Conclusion On the basis of the clinical examination alone, a physician could prob- ably recommend conservative treatment of this injury. Flowever, what the physician cannot assess is how much of the ligament is present. If the patient described above had only the small strand shown in Figure 4.
Yet, a number of skiing patients who have torn the ACL have been documented with clinical examinations and with KT arthrometer read- ings that eventually heal and do not require surgery. In the past, surgery Timing of Surgical Intervention 35 Figure 4. The arthroscopic appearance of a partial healing of an ACL tear. Timing of Surgical Intervention The timing of surgical treatment is controversial.
Shelbourne has shown that reconstruction done acutely results in more stiffness and greater loss of range of motion. To avoid this, reconstruction should be delayed until a full range of motion is achieved. In the Sports Medicine Clinic, after the diagnosis is made, most patients go to physiotherapy to regain range of motion and to reduce the swelling.
No one is reconstructed without full knee extension. If full extension is not gained in physio- therapy, then the torn ACL bundle or a bucket-handle tear of the menis- cus must be treated first. Arthroscopy should be performed to repair the meniscus or excise the cyclops lesion of the ACL before the recon- struction. After the meniscal tear is repaired or excised, physiotherapy is resumed to regain knee extension before the reconstruction. Pinczweski has reported that the cyclops lesion of the ACL may be 36 4. Treatment Options for ACL Injuries removed and the ACL reconstruction done at the same time without risk of limited motion postoperatively, but Shelbourne recommends that repair of the bucket-handle meniscus tear and the ACL reconstruction should be staged.
There are no hard and fast rules, such as wait three weeks before operating. Some patients will have good range of motion and no swelling in one week, and they need only to work on the bike preoper- atively. Other patients will take six or eight weeks to be ready for surgery. The physician should read the tissues. This means to look at the effusion, range of motion, and the induration of the capsule.
The time to operate is when the tissue is soft and compliant, and the range of motion is good. The treatment options are outlined to the patient, who receives an educational information sheet on the options. If he is unde- cided, then a trial of brace management is suggested.
The brace may also be used to try to get the patient through the current season of sport or semester of school. He may be able to participate at a reduced level while waiting to have the reconstruction. Shelton has reported his experience with high school athletes who tear their ACLs early in the season. Thirty of 43 patients returned to play in 6 weeks with a brace, but only 12 had no giving way episodes. Twenty-nine of these patients eventually underwent ACL reconstruction. The downside of this expe- rience is that some of these patients were unable to undergo meniscal repair because of further injury of the meniscus.
It is also important to reexamine and remeasure the KT, as some of these patients will partially heal to a l-i- Lachman. This partial healing may be adequate stability for the recreational athlete. Controversial Treatment Deeisions Other factors that influence the decision to treat are associated lesions, such as chondral fractures, meniscal tears, and other ligament tears, but the real controversies center on the age of the patient, the associated injury to the medial collateral ligament, and the patient with medial compartment osteoarthritis. Older Athlete Age is, in many ways, the least important factor.
The most important is the activity level of the individual, and the next is the degree of insta- bility, or degree of a-p translation. Patient selection may be expanded according to activ- ity level. The younger and more pivotal athlete, who wants to return to sport sooner may be a candidate for the patellar tendon graft. Shel- bourne has reported on return to sports at four months with a contra- lateral patellar tendon graft harvest. Older, more recreational athletes usually have a semitendinosus auto- graft graft or an allograft patellar tendon. There have been several authors, including Brandsson, who have reported positive results of ACL reconstruction in patients more than 40 years of age.
Remember that the patellar tendon graft is for the surgeon, and the semitendinosus graft is for the patient. Immature Athlete Anterior cruciate ligament injuries in skeletally immature adolescents are being diagnosed with increasing frequency. Nonoperative manage- ment of midsubstance ACL injuries in adolescent athletes frequently results in a high incidence of giving-way episodes, recurrent meniscal tears, and early onset of osteoarthritis. In the past, the protocol has been to recommend conservative treatment until the growth plates have closed.
The patients can be divided into prepubescent and postpubescent. The latter are treated in the usual fashion; the former are a treatment dilemma. Because very young athletes i. The concern about ACL recon- struction in the athlete with open growth plates is that there will be premature fusion of the plate, growth arrest, and potential for angular deformities.
DeLee and others have recommended procedures that avoid crossing the growth plates with tunnels. This type of procedure and other extra-articular operations, however, achieve less than satis- factory stability. Stadelmaier, Arnoczsky, and others have shown in the laboratory that a tunnel drilled centrally across the growth plate and filled with a tendon does not cause growth arrest of the epiphyseal plate.
Based on this basic research, several clinicians have reported on a series of young patients with small central tunnels placed through both the femur and tibia and the semitendinosus graft. The tunnels are drilled centrally through the epiphysis and fixed with a button on the periosteal surface. There are no reported growth deformities with this technique. Treatment Options for ACL Injuries The two options to consider with the nine-year-old patient who tears his ACL is restriction of activity and the use of a brace until skeletal maturity. Then consider an intra-articular reconstruction versus an early reconstruction using the semitendinosus graft and button fixation.
This is a common injury seen among skiers who catch an inside edge and externally rotate the knee. Our current protocol at the Sports Medicine Clinic is to treat the MCL with an extension splint, or brace, until it is stable. Then the patient works to regain range of motion and strength, after which recon- struction of the ACL, if necessary, can be performed. After the medial collateral ligament heals, the degree of partial healing of the ACL is usually sufficiently stable for recreational activities.
This patient will often not require surgical reconstruction. In this situation, the patient will have significant symp- toms with pivotal activity. The treatment is a custom-made functional brace with double upright support. If there are still instability symptoms, reconstruction of the ACL must be performed. The MCL may be treated in a variety of ways. The course of the ligament may be picked with an awl to produce bleeding and microfracture of the ligament attachment. This produces scarring and shortening of the MCL. This is an option for a mild degree of laxity.
The next level of treatment is to plicate the ligament with sutures. The attachment site of the MCL on the femur may be removed with an osteotomy and countersunk into the femur about I cm to shorten the ligament. The bone plug is held with a staple. The posterior capsule is plicated to this post of retensioned liga- ment. In severe cases of laxity, the ligament is shortened and reinforced with an autograft or allograft of semitendinosus.
A brace must be used in the postoperative protocol to protect this MCL reconstruction for a prolonged period. The first is the patient with prima- rily ACL laxity symptoms; that is, recurrent giving way and mild activ- ity related pain. This is best treated with an ACL reconstruction alone. The symptoms are pain and giving way associated with a varus knee and medial compartment narrowing on the standing X-rays. This patient should be managed with a combined ACL reconstruction and tibial osteotomy done at the same sitting. It is acceptable to stage the osteotomy as the initial procedure, followed by the ligament recon- struction six months later.
The third scenario is the patient with advanced medial compartment osteoarthritis and residual ACL laxity. The injury usually is long standing; the knee is in varus, but lacks exten- sion. The patient at this point has pain, but not giving way. The best treatment is a tibial osteotomy. The closing wedge osteotomy of Coven- try has been the standard, but the opening wedge osteotomy is becom- ing popular. 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 pivotal motions. Note that Martinek has shown that knee bracing is not required after ACL reconstruction.
Counseling concerning knee friendly sports and activities. Gradual return to sports as the range of motion and strength improves. Follow-up evaluation to assess the success of the conservative program. The nonoperative program for the chronic ACL deficient knee consists of the following: The use of a functional custom fitted brace, such as the DonJoy Defiance brace.
A progressive strengthening exercise program for the hamstrings and quadriceps conducted in a gym. Cardiovascular condition- ing should also be done with bicycling, stair climbing, and similar activities. Counseling for activity modification to reduce pivoting sports. Knee friendly sports such as biking and cross country skiing should be encouraged, rather than basketball and soccer. A young competitive pivotal athlete who wants to return to sports.
The failure of a nonoperative program, with persistent pain, swelling, and giving way. A desire to increase the level of athletic activity without the use of a brace. A repairable meniscal tear in a young athlete. The meniscus repair has a high failure rate unless the knee is stabilized with an ACL reconstruction. The most frequently asked questions, with appropriate responses, are given below.
What Is the ACL? The ACL is the main crossed ligament in the middle of the knee that connects the femur thigh bone with the tibia shin bone. It controls the rotation of knee and prevents giving out of the knee with pivotal motions of the leg. You only need to have an ACL reconstruction if you are physically active in pivotal sports such as basketball, volleyball, or soccer. Some patients can use a brace, modify their activities, and resume sports without surgery. The best option for the young, pivotal athlete is to have a reconstruction to prevent episodes of giving way because of ACL laxity.
With each rein- jury, there is risk of further damage to the meniscus and articular carti- lage. The ACL can be reconstructed with fairly predictable results, but the long-term outcome depends on the damage to the meniscus and articular surface. The goal of the ACL reconstruction is to provide a stable knee and prevent further damage to the meniscus and articular cartilage. The answer is no. The ACL is used only during pivoting motions.
Some- times the giving way sensation may be the result of a torn meniscus that may be repaired with a minor operation. An older, recreational athlete may function fine with activity modification and the use of a brace. Every surgical procedure has a risk benefit, and ACL reconstruction is no exception. If the patient can modify activities to avoid pivotal motions, the knee may function well without surgery. The patient pursuing this approach will probably suffer giving way episodes, accompanied by pain and swelling.
In the long term, this will cause wearing of the inside of the knee osteoarthritis. The patient who wants to carry on with vigorous pivoting sports should have an opera- tion to reconstruct the knee. It does not matter whether the ligament is partially or completely torn. The MRI can determine if the ligament is com- pletely torn, but cannot differentiate the degree of laxity. In the acute situation, the meniscus tear may be repaired. In the long term, the removal of all, or part of the meniscus, is associ- ated with an increased incidence of osteoarthritis.
The answer is four to six months, but sometimes, it may take as long as one year to fully return to a pivotal sport. It depends entirely on the type of work. If the work involves physical activity, it will take three to four months or until your legs are strong enough. If the work is sedentary, it will probably take two to three weeks. Driving can be resumed when weight bearing is comfortable. This usually is sooner when the left knee is involved. Is Physical Therapy Necessary? How Hard Is It? Physical therapy is necessary for approximately one to six weeks postoperatively.
The therapy goal is to reduce the pain and swelling, regain range of motion, and increase the strength of the muscles. To view the rehabilitation program, see Chapter 8. Which Graft Is Better: The choice of a graft is almost immaterial. The outcome of the ACL reconstruction depends not so much on the type of graft, but on the technique of placing the graft in the correct position, the fixation of the graft, and the postoperative rehabilitation.
Because of the minimum harvest site morbidity, the most common graft used in our sports clinic is the hamstring graft. The patellar tendon graft is used for the athlete who wants to return to sports quickly, for example, at three months. The earlier return to activities is based on the faster healing of the bone-to- bone healing of the patellar tendon graft when compared to the tendon- to-bone healing with the hamstring graft. The latter may take as long as three months to heal. In a recent metaanalysis of the literature com- paring the hamstring and patellar tendon grafts, no significant difference in outcome was found.
What About Synthetic Grafts? Synthetic materials are not routinely used to substitute for the ACL because of the higher incidence of failure. These materials are indicated in special situations, such as multiple ligament injuries or some reoperations. Surgical Indications 43 What About the Allograft? The allograft is obtained from a cadaver, so a minimal risk of disease transmission exists.
In addition, the graft takes longer to incorporate and often has tunnel enlargement as a result. Long-term results have shown more failures with the use of the allograft than with other options. After the surgery, the patient will have to use a Zimmer extension splint, or a functional brace for four to six weeks to protect the graft until it heals to the bone. The patient can return to sports four to six months after surgery, but with the brace on.
The brace can be discarded a year after the procedure. How Are the Screws Removed? Surgery is not required to remove the screws. Because the screws now used are made of a special sugar-type compound, they will dissolve within a couple of years after the surgery. Is the Surgery a Day Care Procedure?
The answer is yes. The patient will spend just a few hours in the hospi- tal day care recovery room after the surgery. It also can cause more damage to the articular surface and the meniscus, thereby leading to later osteoarthritis. There is some weakness of the hamstrings after removal of the semitendinosus and the gracilis tendons. There is usually no weakness after patellar tendon harvest, but pain around the kneecap is common postoperatively. Giving way should be prevented by activ- ity modification, bracing, or surgical reconstruction.
This means that athletes who have 44 4. Treatment Options for ACL Injuries a reconstruction and continue to be active can have a normal knee after 10 years. The complications that may occur after ACL reconstruction are those that are related to any surgical procedure such as infection and deep venous phlebitis i. The complications specifi- cally related to the operation are loss of range of motion, anterior knee pain, persistent pain and swelling, and residual ligament laxity because of graft failure. An injury to the nerves or blood vessels after this type of surgery is extremely uncommon.
In the s, Erickson popularized the patellar tendon graft autograft that Jones had originally described in This became the most popular graft choice for the next three decades. In the light of harvest site morbidity and postoperative stiffness asso- ciated with the patellar tendon graft, many surgeons began to look at other choices, such as semitendinosus grafts, allografts, and synthetic grafts.
Fowler and then Rosenberg popularized the use of the semi- tendinosus. However, even Fowler was not convinced of the strength of the graft. Then, Kennedy and Fowler developed the ligament augmen- tation device LAD to supplement the semitendinosus graft. The initial experience was usually satisfac- tory, but the results gradually deteriorated with longer follow-up. Allograft was another choice that avoided the problem of harvest site morbidity. The initial allograft that was sterilized with ethylene oxide had very poor results. Today the freeze-dried, fresh-frozen, and cryo- preserved are the most popular methods of preservation of allografts.
The allograft has become a popular alternative to the autograft because it reduces the harvest site morbidity and operative time. The aggressive postoperative rehabilitation program advocated by Shelbourne in the s greatly diminished the problems associated with the patellar tendon graft. Before that, the patient had to be an athlete just to survive the operation and rehabilitation program. The 45 46 5. Graft Selection aggressive program emphasized no immobilization, early weight bearing, and extension exercises.
There was renewed interest in the semitendinosus during the mid- s. Biomechanical testing on the multiple-bundle semitendinosus and gracilis grafts demonstrated them to be stronger and stiffer than other options. This knowledge combined with improved fixation devices such as the Endo-button gave surgeons more confidence with no-bone, soft tissue grafts. The Endo-button made the procedure endoscopic, thereby eliminating the need for the second incision. Fulkerson, Staubli, and others popularized the use of the quadriceps tendon graft. This again reduced the harvest morbidity, especially when only the tendon portion was harvested.
Shelbourne has described the use of the patellar tendon autograft from the opposite knee. Fie claims that this divides the rehabilitation between two knees and reduces the recovery time. With the contralat- eral harvest technique, the average return to sports for his patients was four months. With both the patellar tendon and the semitendinosus added to the list of graft choices, the need for the use of an allograft is minimized.
The latest evolution is to use an interference fit screw to fixate the graft at the tunnel entrance. This produces a graft construct that is strong, short, and stiff. It means that the surgeon now has to learn just one technique for drilling the tunnels and can chose whatever graft he or she wishes: Successful ACL reconstruction depends on a number of factors, including patient selection, surgical technique, postoperative rehabilita- tion, and associated secondary restraint ligamentous instability.
Errors in graft selection, tunnel placement, tensioning, or fixation methods may also lead to graft failure. Comparative studies in the literature show that the outcome is almost the same regardless of the graft choice. The most important aspect of the operation is to place the tunnels in the correct position. The choice of graft is really inciden- tal. With the evolution of the 4-bundle graft and improved fixa- Patellar Tendon Graft 47 Evolution in Graft Choice 90 80 70 60 50 40 30 20 10 0 90 91 92 93 94 95 96 97 98 99 0 1 Figure 5.
The evolution of the graft choice. The white bar is the hamstring graft. The swing to hamstring grafts then became largely patient driven. When the patients went to therapy after the initial ACL injury, they saw how easy the rehabilitation was for the hamstring tendon and opted for that graft. The main choices of graft for ACL reconstruction are the patellar tendon autograft, the semitendinosus autograft, and the central quadri- ceps tendon, allograft of patellar tendon, Achilles tendon, or tibialis anterior tendon, and the synthetic graft.
Patellar Tendon Graft The patellar tendon graft was originally described as the gold-standard graft. It is still the most widely used ACL replacement graft i. Shelbourne has pushed the envelope further with the patellar tendon graft. He has recently reported on the harvest of the patellar tendon graft from the opposite knee, with an average return to play of four months postoperative.
The advantages of the patellar tendon graft are early bone-to-bone healing at six weeks, consistent size and shape of the graft, and ease of 48 5. The disadvantages are the harvest site morbidity of patellar tendonitis, anterior knee pain, patellofemoral joint tightness with late chondromalacia, late patella fracture, late patellar tendon rupture, loss of range of motion, and injury to the infrapatellar branch of the saphe- nous nerve. Most of the complications are the result of the harvest of the patellar tendon.
This is still the main drawback to the use of the graft. This is the young athlete who wants to return to sports quickly and is going to be more aggressive in contact sports for a longer period of time. There is no upper age limit for patellar tendon reconstruction, but the younger athlete has more time to commit to knee rehabilitation. If the patellar tendon is the gold standard of grafts, then this is the graft of choice for the professional, or elite, athlete.
Finally, the competitive athlete understands the value of the rehabilita- tion program and will not hesitate to spend three hours a day in the gym. Most nonpivotal athletes can usually cope without an ACL. Cyclists, runners, swimmers, canoeists, and kayakers, for example, can function well in their chosen sport without an intact ACL.
Athletic Lifestyle This operation should be reserved for the athletic individual. In most activities of daily living the ACL is not essential. If the nonathlete has giving way symptoms, it is probably the result of a torn meniscus and not a torn ACL. The meniscal pathology can be treated arthroscopically, and the patient can continue with the use of a brace as necessary.
Patellar Autograft Disadvantages Harvest Site Morbidity The main disadvantage of the patellar tendon graft is the harvest site morbidity. The problems produced by the harvest are patellar ten- donitis, quadriceps weakness, persistent tendon defect, patellar fracture, patellar tendon rupture, patellofemoral pain syndrome, patellar entrap- Patellar Tendon Graft 49 ment, and arthrofibrosis. The common long-term problem is kneeling pain. Kneeling Pain The most common complaint after patellar tendon harvest is kneeling pain. This can be reduced by harvesting through two transverse inci- sions.
This reduces the injury to the infrapatellar branch of the saphe- nous nerve. Patellar Tendonitis Pain at the harvest site will interfere with the rehabilitation program. The strength program may have to be delayed until this settles. The problem is usually resolved in the first year, but it can prevent some high performance athletes from resuming their sport in that first year.
Quadriceps Weakness The quads weakness may be the result of pain and the inability to par- ticipate in a strength program. If significant patellofemoral symptoms develop, the athlete may be unable to exercise the quads. Persistent Tendon Defect If the defect is not closed, there may be a persistent defect in the patel- lar tendon.
This results in a weaker tendon. Patella Entrapment If the defect is closed too tight, the patella may be entrapped, and patel- lar infera may result. This will certainly result in patellofemoral pain, because of an increase in patellofemoral joint compression. Patella Fracture The fracture may occur during the operation or in the early postopera- tive period. Intraoperative patella fracture may be the result of the use of osteotomes. If the saw cuts are only 8-mm deep and 2.
The late fractures are produced by the overruns of the saw cuts. The overruns may be prevented by cutting the proximal end in a boat shape. The left X-ray Fig. The right X-ray Fig. X-ray of displaced transverse patellar fracture at three months postoperative. X-ray of postoperative internal fixation with cannulated AO screws and figure-of-eight wire. Patellar Tendon Graft 51 Figure 5. The method of cutting the patellar bone plug to avoid a late fracture. The proximal transverse saw cut is critical Fig.
The stress risers that go beyond the edge of the bone block should be avoided. An overrun of 2 mm may cause a late transverse patellar fracture. If there are overruns, the burr may be used at the corner to round these cuts. The fracture is usually sustained by muscular contraction. Change to making the proximal cuts boat shaped to prevent the stress risers Fig.
The graft is usually cut to this shape to pass into the joint; now it is just cut in that shape before removing it. Tendon Rupture This may occur if a very large graft is taken from a small tendon. The standard is a mm graft, measured with a double-bladed knife. The bone blocks are trimmed to 9 mm to make the graft passage easier. Graft Selection Figure 5. Patellofemoral Pain This topic is controversial in the literature. The older literature reported a high incidence of patellofemoral pain associated with ACL recon- struction.
However, most of the disability could be blamed on rehabili- tation programs that consisted of immobilization. There is no doubt that some patients will develop pain, some will develop crepitus, and some will have tendonitis, but results have improved with more aggressive rehabilitation programs with early motion and weight bearing. To prevent the patella from being bound down, the patella should be mobilized daily by the physiotherapist. Arthrofibrosis This severe problem is rarely seen now in ACL reconstructions. The true condition is idiopathic and is probably the result of fibroblastic pro- liferation.
As a result, very little can be done to prevent it. It may be more common in the patient who forms keloid. The more common condition of loss of range of motion may be the result of incorrect tunnel placement or postoperative immo- Hamstring Grafts 53 bilization. The loss of extension was almost completely eliminated by changing to an exten- sion splint. The acceptance of aggressive physiotherapy to regain exten- sion eliminated the problem. This problem of postoperative stiffness made the use of a synthetic ligament, with no immobilization, very attractive. The reoperation for loss of range of motion is now very uncommon.
Contraindications to Harvest of the Patellar Tendon Preexisting Patellofemoral Pain Is preexisting patellofemoral pain a contraindication to harvesting the patellar tendon? The conventional wisdom is yes; it would not be a wise procedure in this situation. Rather, it is like hitting a sore thumb with a hammer! In the past, when chondromalacia was seen at the time of arthroscopy, the graft choice would be changed to hamstrings.
The Small Patellar Tendon The harvesting of the central third of the patellar tendon in a small tendon is more theoretical than practical. The advice in a small patient with a tendon width of only 25 mm would be to take a narrower graft of 8 to 9 mm or use another graft source. Preexisting Osgoode-Schlatters Disease Shelbourne has reported that a bony ossicle from Osgoode-Schlatters disease is not a contraindication to harvest of the patellar tendon. Because the fragment usually lies within the bony tunnel, this bone may be incorporated into the tendon graft.
Hamstring Grafts Advantages of Hamstring Grafts The main advantage of the hamstring graft is the low incidence of harvest site morbidity. After the harvest, the tendon has been shown by MRI to regenerate. The 4-bundle graft is usually 8 mm in diameter, which is a larger cross-sectional area than the patellar tendon. The harvest of the semitendinosus seems to leave the patient with minimal flexion weakness.
One study did show some weakness of internal rotation of the tibia after hamstring harvest. Injury to the saphenous nerve is rare and can be avoided with careful technique. The fixation of the graft remains one of the controversial issues. Issues in Hamstring Grafts The major issues with the use of hamstring grafts are: Graft strength and stiffness. The ultimate failure load of the normal ACL compared to various grafts. Hamstring Grafts 55 Figure 5. The composite hamstring graft is twice the strength and stiffness of the native ACL.
This was widely quoted as a reason to use the patellar tendon graft rather than the hamstring. With the advent of the multiple bundles of hamstrings, this graft now has twice the strength of the native ACL Fig. Sepaga later reported that the semitendi- nosus and gracilis composite graft is equal to an 11 -mm patellar tendon graft.
Hamner, however, emphasized that the strength is only additive if the bundles are equally tensioned. Each one has strengths and weaknesses. Pinczewski pioneered the use of the RCI interference fit metal screw for soft tissue fixation. The use of a similar type of bioabsorbable screw that was used in bone tendon bone fixation was a natural evolution. To overcome the weak fixation in poor quality bone, the use of a round pearl, made of PLLA or bone, was developed.
The Endo-button, popularized by Tom Rosenberg, was improved with the use of a continuous polyester tape. This made the fixation stronger and avoided the problems of tying a secure knot in 56 5. Graft Selection the tape. The cross-pin fixation has proven to be the strongest, but has a significant fiddle factor to loop the tendons around the post.
The Arthrex technique is the easiest to use. Weiler, Caborn, and colleagues have summarized the current concepts of soft tissue fixation.
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The estimates of the force on the normal ACL during activities of daily living are as follows: This form of fixation has a low failure strength, but is clinically successful. The gold standard of the interference fit screw fixation of the bone tendon bone, to N, has been used to compare the soft tissue fixation. The pullout strengths also vary from tibia to the femur.
The femoral pullout is higher because the tunnel is angled to the graft and the pull is against the screw that is placed endoscopically. In the tibial tunnel, the graft pulls away from the screw in the direct line of the tunnel. The initial fixation points were at a distance from the normal anatomi- cal fixation of the ACL.
The trend has been to move the fixation closer to the internal aperture of the tunnel. This shortening of the intra- articular length has improved the stiffness of the graft. The pullout strength of bioabsorbable screw can vary widely depending on its composition. The screw fixation has also been shown to be bone quality dependent. These considerations should be taken into account when choosing a femoral fixation device for soft tissue grafts. Disadvantages The disadvantages of the hamstring graft are the various methods used to fix the graft to bone, including staples, Endo-button, and interference fit screws.
Furthermore, the graft harvest can be difficult, the tendons can be cut off short, and there is a longer time for graft healing to bone, approximately 10 to 12 weeks. Interference Fit Screws 57 Table 5. Ultimate load to failure of femoral fixa- tion devices. The rehabilitation protocol should reflect the type of fixation used. All the femoral fixation devices provide reasonable fixation Table 5. The cyclic load is more important than the ultimate load to failure. The interference screw fares worst with cyclic loads. Interference Fit Screws The interference fit screw is shown is Figure 5.
Advantages The advantages are as follows: Quick, familiar, and easy to use. Disadvantages The disadvantages are as follows: Longer graft preparation time. Damage to the graft with the screw. Divergent screw has poor fixation. Removal of metal screw makes revision difficult. The interference screw fixation of the soft tissue graft in a cadaver model. Several refinements have been made to the interference screw tech- nique to increase the pullout strength and cyclic load performance.
The end of the graft may be backed up with a round ball of PLLA, the Endo- Pearl Linvatec, Largo, FL or bone to abut against the screw and prevent the slippage of the graft under the screw. The tunnels may be dilated or compacted when the bone is osteopenic. A longer screw with a heavy whipstitch in the graft improves pullout strength. The leader sutures from the graft may be tied over a button or post on the tibial side to back up the screw fixation. Cross-Pin Fixation The cross-pin fixation is shown in Figure 5. May individually tension all bundles of graft. The Arthrex transfix pin fixation of soft tissues.
The EUA may be the only means of making the diagnosis. Arthroscopy of the acute knee presents no more technical problems than with the elective case. The synovium and ligamentum mucosum around the ACL must frequently be removed to fully assess the degree of ligament injury. The hook is used to probe the two bundles, and to assess tension. The video on the CD shows how the diagnostic arthroscopy must be performed in a similar fashion each time, so that the knee will be completely examined and no region forgotten. This must be done before any surgical procedures are started.
The arthroscope is the key to unlocking the secrets of the knee. The video shows the arthroscopic view of the torn ACL. The meniscus and articular surface should be completely examined. The capsular injury may be seen by inspecting the gutters, and examining over and under the meniscus.
The ACL tear has produced a stump at the front of the knee that prevents full extension. This mimics a locked knee. The fat pad in front of the ligament has to be removed to visualize the ligament, and the ligament must be probed to assess its status. This ligament tear may have been produced by the narrow stenotic notch. The diagnostic examination of the knee must be complete to detect any meniscal injuries. The video demonstrates the chronic ACL tear.
The residual ligament is probed with a hook, and it can be appreciated that it is not attached to the femoral condyle. This anterior excursion is greater than the opposite side, but less than 5 mm of the side-to-side difference measured on the KT arthrometer. Pivot-Shift Test The pivot-shift test must be negative or only a slight glide to produce a diagnosis of a partial tear See Fig.
The pivot shift is the most important assessment of the partial tear. The slope of the curves that are pulled with the KT 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 stronger the pull, the more anterior displacement. The force displacement curve of the partial ACL tear.
Therefore, it is not a useful tool for diagnosing partial tears of the anterior cruciate ligament. First, it is hard to see the ligament without removing the synovium and fat pad. Second, it is only an estimate of the degree of tearing of the ligament. It seems to be best to try to estimate Figure 3.
Treatment Options 29 Figure 3. The laxity of the ACL is demonstrated with a probe. A hook probe must be used to examine the ligament proximally to see where the ligament is attached—to the side wall, the roof, or the posterior cruciate ligament. The best position is the side wall at the normal site of the anterior cruciate ligament.
The most common situation is to see the ligament attached to the posterior cruciate ligament. It has attenuated to a small band attached to the side wall. This amount of ligament laxity should allow a return to sports without a reconstruction. Treatment Options Partial Tears The treatment options for a patient with partial ACL tear are to give up or modify his or her sports activities.
The patient who can modify his 30 3. Partial Tears of the ACL sports activities and avoid pivotal sports will do well with a partial anterior cruciate ligament injury. This is the only parameter that the individual has control over, and that point should be emphasized when counseling athletes.
Sometimes a meniscal injury will still cause a giving way sensation. The best long-term outcome for the young patient is to have a meniscal repair. The dilemma is whether to reconstruct the ACL. The results of a meniscal repair are much better when the knee has been reconstructed and is stable. ACL Reconstruction If there is a positive pivot-shift test or a small bundle attached to the femur, and the athlete wants to be active in pivoting sports, anterior cruciate ligament reconstruction should be considered.
Indications for ACL Reconstruction The patient who is a candidate for reconstruction of the ACL is the competitive, pivoting athlete who is involved in sports such as soccer, rugby, and basketball. In addition, the patient should have clinical symptoms of instability, with a history of giving way, a positive Lachman, and pivotshift test with more than 5 mm side-to-side difference on the KT arthrometer.
Not all tears of the ACL need operative repair. The treatment options for the elite athlete, who needs reconstruction, as well as the inactive patient, who needs no reconstruction, are fairly limited. It is the recreationally active individual whose ACL injury requires counseling for the best treatment plan.
There are a number of factors to consider in this decision, including, as Shelbourne has emphasized, age, chronicity, activity level, and associated injury to the meniscus and articular surface. Age of the Patient The older patient may be more likely to modify his lifestyle and accept a conservative treatment program, while the younger patient, who is involved in competitive sports, wants to return as quickly as possible to high-level sports without the use of a brace. Activity Level and Intensity The competitive football or soccer player will likely require a reconstruction to continue playing at the same level.
If the KT arthrometer side-to-side difference was greater than 7 mm, the chance of a better outcome was with surgical reconstruction. Size of Athlete The forces that a lb lineman exerts on his knee with pivoting are much more that the lb tennis player. In the case of the former, surgical reconstruction should be considered. If the patient is not involved in sports then he will usually have no giving way episodes, and no surgical treatment is necessary. Giving way in the sedentary patient is more likely the result of meniscal pathology.
The meniscus may be treated by arthroscopy, and the patient can continue with the nonoperative treatment program. The patient should be counseled to switch into knee friendly sports, such as cycling and swimming. However if he has giving way in the brace, a meniscal tear may be present. The younger athlete should have a meniscal repair and reconstruction for the ACL. The long-term results of meniscal repair are better with a stable knee, and the meniscal repair without reconstruction is not an option.
The older patient should have a meniscectomy and use a brace for sports. If the patient still gives way in the brace, then consideration should be given to a reconstruction. Anterior Cruciate Ligament Reconstruction Most young competitive, pivoting athletes should have an ACL reconstruction to stabilize their knees. This will allow them to continue to par- Plea for Conservative Treatment 33 ticipate in sports and, hopefully, prevent late degenerative changes. This means that the athlete who has an early ACL reconstruction will be able to continue to be active without the risk of degenerative osteoarthritic changes in his knee.
The patient who continues in sports with recurrent giving way, as a result of ACL laxity, will have a degenerative knee in 10 to 12 years. The activity level is the only one of these factors that the patient can control. The other treatment options, such as brace and meniscal repair, will only be successful if activity is diminished. Ninety percent of the patients who undergo ACL reconstruction will be able to return to full athletic participation. However, in some instances, especially with downhill skiing injuries, it can. There is little argument that the young competitive, pivoting soccer player with a positive pivot shift and a 7-mm side-to-side difference on the KT arthrometer needs a reconstruction, but consider another example.
Case 1 KB, who is a year-old interior designer and an advanced recreational skier, injured her knee downhill skiing. She had an external rotation, valgus injury with an audible pop in her knee. The bindings did not release. She was assessed at the ski hill and diagnosed with an ACL tear.
Two weeks later, an examination at the clinic revealed an effusion, jointline tenderness, positive Lachman, and a positive pivot-shift test. She was advised to have a reconstruction and started therapy to improve the range of motion and reduce the effusion.
At six weeks after injury, she had a positive Lachman no end point , positive pivot shift, and a KT manual maximum side-to-side difference of 6 mm. She was advised to proceed with a reconstruction. The arthroscopic appearance of a healed ACL. The arthroscopic examination demonstrated normal menisci, normal articular cartilage, and an ACL healed to the femoral condyle.
The appearance of the well-healed ACL is shown in Figure 4. In reality, this means a normal appearing bulk of ligament present as opposed to this thin strand of ligament. No physician would have a problem proceeding with a reconstruction in this situation. Conclusion On the basis of the clinical examination alone, a physician could probably recommend conservative treatment of this injury. However, what the physician cannot assess is how much of the ligament is present.
If the patient described above had only the small strand shown in Figure 4. Yet, a number of skiing patients who have torn the ACL have been documented with clinical examinations and with KT arthrometer readings that eventually heal and do not require surgery. In the past, surgery Timing of Surgical Intervention 35 Figure 4. The arthroscopic appearance of a partial healing of an ACL tear. Timing of Surgical Intervention The timing of surgical treatment is controversial.
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Shelbourne has shown that reconstruction done acutely results in more stiffness and greater loss of range of motion. To avoid this, reconstruction should be delayed until a full range of motion is achieved. In the Sports Medicine Clinic, after the diagnosis is made, most patients go to physiotherapy to regain range of motion and to reduce the swelling. No one is reconstructed without full knee extension. Arthroscopy should be performed to repair the meniscus or excise the cyclops lesion of the ACL before the reconstruction.
After the meniscal tear is repaired or excised, physiotherapy is resumed to regain knee extension before the reconstruction. Pinczweski has reported that the cyclops lesion of the ACL may be 36 4. Treatment Options for ACL Injuries removed and the ACL reconstruction done at the same time without risk of limited motion postoperatively, but Shelbourne recommends that repair of the bucket-handle meniscus tear and the ACL reconstruction should be staged. There are no hard and fast rules, such as wait three weeks before operating.
Some patients will have good range of motion and no swelling in one week, and they need only to work on the bike preoperatively. Other patients will take six or eight weeks to be ready for surgery. The physician should read the tissues. This means to look at the effusion, range of motion, and the induration of the capsule.
The time to operate is when the tissue is soft and compliant, and the range of motion is good. The treatment options are outlined to the patient, who receives an educational information sheet on the options. If he is undecided, then a trial of brace management is suggested.
The brace may also be used to try to get the patient through the current season of sport or semester of school. He may be able to participate at a reduced level while waiting to have the reconstruction. Shelton has reported his experience with high school athletes who tear their ACLs early in the season. Thirty of 43 patients returned to play in 6 weeks with a brace, but only 12 had no giving way episodes.
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Twenty-nine of these patients eventually underwent ACL reconstruction. The downside of this experience is that some of these patients were unable to undergo meniscal repair because of further injury of the meniscus. This partial healing may be adequate stability for the recreational athlete. Older Athlete Age is, in many ways, the least important factor. The most important is the activity level of the individual, and the next is the degree of instability, or degree of a-p translation.
Patient selection may be expanded according to activity level. The younger and more pivotal athlete, who wants to return to sport sooner may be a candidate for the patellar tendon graft. Shelbourne has reported on return to sports at four months with a contralateral patellar tendon graft harvest. Older, more recreational athletes usually have a semitendinosus autograft graft or an allograft patellar tendon.
There have been several authors, including Brandsson, who have reported positive results of ACL reconstruction in patients more than 40 years of age. Remember that the patellar tendon graft is for the surgeon, and the semitendinosus graft is for the patient. Immature Athlete Anterior cruciate ligament injuries in skeletally immature adolescents are being diagnosed with increasing frequency.
Nonoperative management of midsubstance ACL injuries in adolescent athletes frequently results in a high incidence of giving-way episodes, recurrent meniscal tears, and early onset of osteoarthritis. In the past, the protocol has been to recommend conservative treatment until the growth plates have closed. The patients can be divided into prepubescent and postpubescent. The latter are treated in the usual fashion; the former are a treatment dilemma. Because very young athletes i.
The concern about ACL reconstruction in the athlete with open growth plates is that there will be premature fusion of the plate, growth arrest, and potential for angular deformities. DeLee and others have recommended procedures that avoid crossing the growth plates with tunnels. This type of procedure and other extra-articular operations, however, achieve less than satisfactory stability.
Based on this basic research, several clinicians have reported on a series of young patients with small central tunnels placed through both the femur and tibia and the semitendinosus graft. There are no reported growth deformities with this technique. Treatment Options for ACL Injuries The two options to consider with the nine-year-old patient who tears his ACL is restriction of activity and the use of a brace until skeletal maturity.
This is a common injury seen among skiers who catch an inside edge and externally rotate the knee. Our current protocol at the Sports Medicine Clinic is to treat the MCL with an extension splint, or brace, until it is stable. Then the patient works to regain range of motion and strength, after which reconstruction of the ACL, if necessary, can be performed. This patient will often not require surgical reconstruction.
The treatment is a custom-made functional brace with double upright support. If there are still instability symptoms, reconstruction of the ACL must be performed. The MCL may be treated in a variety of ways. The course of the ligament may be picked with an awl to produce bleeding and microfracture of the ligament attachment. This produces scarring and shortening of the MCL.
This is an option for a mild degree of laxity. The next level of treatment is to plicate the ligament with sutures. The attachment site of the MCL on the femur may be removed with an osteotomy and countersunk into the femur about 1 cm to shorten the ligament. The bone plug is held with a staple. The posterior capsule is plicated to this post of retensioned ligament. In severe cases of laxity, the ligament is shortened and reinforced with an autograft or allograft of semitendinosus.
A brace must be used in the postoperative protocol to protect this MCL reconstruction for a prolonged period. This is best treated with an ACL reconstruction alone. The symptoms are pain and giving way associated with a varus knee and medial compartment narrowing on the standing X-rays. This patient should be managed with a combined ACL reconstruction and tibial osteotomy done at the same sitting.
It is acceptable to stage the osteotomy as the initial procedure, followed by the ligament reconstruction six months later. The third scenario is the patient with advanced medial compartment osteoarthritis and residual ACL laxity. The injury usually is long standing; the knee is in varus, but lacks extension.
The patient at this point has pain, but not giving way. The best treatment is a tibial osteotomy. The closing wedge osteotomy of Coventry has been the standard, but the opening wedge osteotomy is becoming popular. 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. Functional brace to stabilize the knee in pivotal motions. Note that Martinek has shown that knee bracing is not required after ACL reconstruction. Counseling concerning knee friendly sports and activities. Gradual return to sports as the range of motion and strength improves. Follow-up evaluation to assess the success of the conservative program.
A progressive strengthening exercise program for the hamstrings and quadriceps conducted in a gym. Cardiovascular conditioning should also be done with bicycling, stair climbing, and similar activities. Knee friendly sports such as biking and cross country skiing should be encouraged, rather than basketball and soccer. A young competitive pivotal athlete who wants to return to sports. The failure of a nonoperative program, with persistent pain, swelling, and giving way. A desire to increase the level of athletic activity without the use of a brace.
A repairable meniscal tear in a young athlete. The meniscus repair has a high failure rate unless the knee is stabilized with an ACL reconstruction. The most frequently asked questions, with appropriate responses, are given below. What Is the ACL? The ACL is the main crossed ligament in the middle of the knee that connects the femur thigh bone with the tibia shin bone.
It controls the rotation of knee and prevents giving out of the knee with pivotal motions of the leg. You only need to have an ACL reconstruction if you are physically active in pivotal sports such as basketball, volleyball, or soccer. Some patients can use a brace, modify their activities, and resume sports without surgery. The best option for the young, pivotal athlete is to have a reconstruction to prevent episodes of giving way because of ACL laxity. With each reinjury, there is risk of further damage to the meniscus and articular cartilage.
The ACL can be reconstructed with fairly predictable results, but the long-term outcome depends on the damage to the meniscus and articular surface. The goal of the ACL reconstruction is to provide a stable knee and prevent further damage to the meniscus and articular cartilage. The answer is no. The ACL is used only during pivoting motions. Sometimes the giving way sensation may be the result of a torn meniscus that may be repaired with a minor operation. If the patient can modify activities to avoid pivotal motions, the knee may function well without surgery.
The patient pursuing this approach will probably suffer giving way episodes, accompanied by pain and swelling. In the long term, this will cause wearing of the inside of the knee osteoarthritis. The patient who wants to carry on with vigorous pivoting sports should have an operation to reconstruct the knee. It does not matter whether the ligament is partially or completely torn.
If the knee is lax, as can be measured by clinical examination or with the KT arthrometer, the ACL is not functioning to protect the knee against pivotal motions. The MRI can determine if the ligament is completely torn, but cannot differentiate the degree of laxity.
In the acute situation, the meniscus tear may be repaired. In the long term, the removal of all, or part of the meniscus, is associated with an increased incidence of osteoarthritis. The answer is four to six months, but sometimes, it may take as long as one year to fully return to a pivotal sport. It depends entirely on the type of work. If the work involves physical activity, it will take three to four months or until your legs are strong enough. If the work is sedentary, it will probably take two to three weeks.
Driving can be resumed when weight bearing is comfortable. This usually is sooner when the left knee is involved. Is Physical Therapy Necessary? How Hard Is It? Physical therapy is necessary for approximately one to six weeks postoperatively. The therapy goal is to reduce the pain and swelling, regain range of motion, and increase the strength of the muscles. To view the rehabilitation program, see Chapter 8. Which Graft Is Better: The choice of a graft is almost immaterial.
Because of the minimum harvest site morbidity, the most common graft used in our sports clinic is the hamstring graft. The patellar tendon graft is used for the athlete who wants to return to sports quickly, for example, at three months. The earlier return to activities is based on the faster healing of the bone-tobone healing of the patellar tendon graft when compared to the tendonto-bone healing with the hamstring graft. The latter may take as long as three months to heal. What About Synthetic Grafts? Synthetic materials are not routinely used to substitute for the ACL because of the higher incidence of failure.
These materials are indicated in special situations, such as multiple ligament injuries or some reoperations. Surgical Indications 43 What About the Allograft? The allograft is obtained from a cadaver, so a minimal risk of disease transmission exists. In addition, the graft takes longer to incorporate and often has tunnel enlargement as a result. Long-term results have shown more failures with the use of the allograft than with other options. After the surgery, the patient will have to use a Zimmer extension splint, or a functional brace for four to six weeks to protect the graft until it heals to the bone.
The patient can return to sports four to six months after surgery, but with the brace on. The brace can be discarded a year after the procedure. How Are the Screws Removed? Surgery is not required to remove the screws. Because the screws now used are made of a special sugar-type compound, they will dissolve within a couple of years after the surgery.
Is the Surgery a Day Care Procedure? The answer is yes. The patient will spend just a few hours in the hospital day care recovery room after the surgery. It also can cause more damage to the articular surface and the meniscus, thereby leading to later osteoarthritis. There is some weakness of the hamstrings after removal of the semitendinosus and the gracilis tendons. There is usually no weakness after patellar tendon harvest, but pain around the kneecap is common postoperatively.
This means that athletes who have 44 4. Treatment Options for ACL Injuries a reconstruction and continue to be active can have a normal knee after 10 years. The complications that may occur after ACL reconstruction are those that are related to any surgical procedure such as infection and deep venous phlebitis i. An injury to the nerves or blood vessels after this type of surgery is extremely uncommon. In the s, Erickson popularized the patellar tendon graft autograft that Jones had originally described in This became the most popular graft choice for the next three decades. In the light of harvest site morbidity and postoperative stiffness associated with the patellar tendon graft, many surgeons began to look at other choices, such as semitendinosus grafts, allografts, and synthetic grafts.
Fowler and then Rosenberg popularized the use of the semitendinosus. However, even Fowler was not convinced of the strength of the graft. Then, Kennedy and Fowler developed the ligament augmentation device LAD to supplement the semitendinosus graft. The initial experience was usually satisfactory, but the results gradually deteriorated with longer follow-up. Allograft was another choice that avoided the problem of harvest site morbidity.
The initial allograft that was sterilized with ethylene oxide had very poor results. Today the freeze-dried, fresh-frozen, and cryopreserved are the most popular methods of preservation of allografts. The allograft has become a popular alternative to the autograft because it reduces the harvest site morbidity and operative time. The aggressive postoperative rehabilitation program advocated by Shelbourne in the s greatly diminished the problems associated with the patellar tendon graft.
Before that, the patient had to be an athlete just to survive the operation and rehabilitation program. The 45 46 5. Graft Selection aggressive program emphasized no immobilization, early weight bearing, and extension exercises. There was renewed interest in the semitendinosus during the mids. Biomechanical testing on the multiple-bundle semitendinosus and gracilis grafts demonstrated them to be stronger and stiffer than other options. The Endo-button made the procedure endoscopic, thereby eliminating the need for the second incision. Fulkerson, Staubli, and others popularized the use of the quadriceps tendon graft.
This again reduced the harvest morbidity, especially when only the tendon portion was harvested. Shelbourne has described the use of the patellar tendon autograft from the opposite knee. He claims that this divides the rehabilitation between two knees and reduces the recovery time. With the contralateral harvest technique, the average return to sports for his patients was four months. With both the patellar tendon and the semitendinosus added to the list of graft choices, the need for the use of an allograft is minimized.
This produces a graft construct that is strong, short, and stiff. It means that the surgeon now has to learn just one technique for drilling the tunnels and can chose whatever graft he or she wishes: Successful ACL reconstruction depends on a number of factors, including patient selection, surgical technique, postoperative rehabilitation, and associated secondary restraint ligamentous instability. Comparative studies in the literature show that the outcome is almost the same regardless of the graft choice.
The most important aspect of the operation is to place the tunnels in the correct position. The choice of graft is really incidental. The evolution of the graft choice. The white bar is the hamstring graft. The swing to hamstring grafts then became largely patient driven. When the patients went to therapy after the initial ACL injury, they saw how easy the rehabilitation was for the hamstring tendon and opted for that graft. The main choices of graft for ACL reconstruction are the patellar tendon autograft, the semitendinosus autograft, and the central quadriceps tendon, allograft of patellar tendon, Achilles tendon, or tibialis anterior tendon, and the synthetic graft.
Patellar Tendon Graft The patellar tendon graft was originally described as the gold-standard graft. It is still the most widely used ACL replacement graft i. Shelbourne has pushed the envelope further with the patellar tendon graft. He has recently reported on the harvest of the patellar tendon graft from the opposite knee, with an average return to play of four months postoperative. The advantages of the patellar tendon graft are early bone-to-bone healing at six weeks, consistent size and shape of the graft, and ease of 48 5.
The disadvantages are the harvest site morbidity of patellar tendonitis, anterior knee pain, patellofemoral joint tightness with late chondromalacia, late patella fracture, late patellar tendon rupture, loss of range of motion, and injury to the infrapatellar branch of the saphenous nerve. Most of the complications are the result of the harvest of the patellar tendon. This is still the main drawback to the use of the graft. This is the young athlete who wants to return to sports quickly and is going to be more aggressive in contact sports for a longer period of time. There is no upper age limit for patellar tendon reconstruction, but the younger athlete has more time to commit to knee rehabilitation.
If the patellar tendon is the gold standard of grafts, then this is the graft of choice for the professional, or elite, athlete. Finally, the competitive athlete understands the value of the rehabilitation program and will not hesitate to spend three hours a day in the gym. Most nonpivotal athletes can usually cope without an ACL. Cyclists, runners, swimmers, canoeists, and kayakers, for example, can function well in their chosen sport without an intact ACL.
Athletic Lifestyle This operation should be reserved for the athletic individual. In most activities of daily living the ACL is not essential. If the nonathlete has giving way symptoms, it is probably the result of a torn meniscus and not a torn ACL. The meniscal pathology can be treated arthroscopically, and the patient can continue with the use of a brace as necessary. Patellar Autograft Disadvantages Harvest Site Morbidity The main disadvantage of the patellar tendon graft is the harvest site morbidity.
The common long-term problem is kneeling pain. Kneeling Pain The most common complaint after patellar tendon harvest is kneeling pain. This can be reduced by harvesting through two transverse incisions. This reduces the injury to the infrapatellar branch of the saphenous nerve. Patellar Tendonitis Pain at the harvest site will interfere with the rehabilitation program. The strength program may have to be delayed until this settles. Quadriceps Weakness The quads weakness may be the result of pain and the inability to participate in a strength program.
Persistent Tendon Defect If the defect is not closed, there may be a persistent defect in the patellar tendon. This results in a weaker tendon. Patella Entrapment If the defect is closed too tight, the patella may be entrapped, and patellar infera may result. This will certainly result in patellofemoral pain, because of an increase in patellofemoral joint compression. Patella Fracture The fracture may occur during the operation or in the early postoperative period. Intraoperative patella fracture may be the result of the use of osteotomes.
The late fractures are produced by the overruns of the saw cuts. The overruns may be prevented by cutting the proximal end in a boat shape. The left X-ray Fig. The right X-ray Fig. X-ray of displaced transverse patellar fracture at three months postoperative. Patellar Tendon Graft 51 Figure 5. The method of cutting the patellar bone plug to avoid a late fracture.
The proximal transverse saw cut is critical Fig. The stress risers that go beyond the edge of the bone block should be avoided. An overrun of 2 mm may cause a late transverse patellar fracture. If there are overruns, the burr may be used at the corner to round these cuts. The fracture is usually sustained by muscular contraction. Change to making the proximal cuts boat shaped to prevent the stress risers Fig. The graft is usually cut to this shape to pass into the joint; now it is just cut in that shape before removing it.
Tendon Rupture This may occur if a very large graft is taken from a small tendon. The standard is a mm graft, measured with a double-bladed knife. The bone blocks are trimmed to 9 mm to make the graft passage easier. Graft Selection Figure 5. Patellofemoral Pain This topic is controversial in the literature. The older literature reported a high incidence of patellofemoral pain associated with ACL reconstruction.
However, most of the disability could be blamed on rehabilitation programs that consisted of immobilization. There is no doubt that some patients will develop pain, some will develop crepitus, and some will have tendonitis, but results have improved with more aggressive rehabilitation programs with early motion and weight bearing. To prevent the patella from being bound down, the patella should be mobilized daily by the physiotherapist.
As a result, very little can be done to prevent it. It may be more common in the patient who forms keloid. The more common condition of loss of range of motion may be the result of incorrect tunnel placement or postoperative immo- Hamstring Grafts 53 bilization. The loss of extension was almost completely eliminated by changing to an extension splint.
The acceptance of aggressive physiotherapy to regain extension eliminated the problem. This problem of postoperative stiffness made the use of a synthetic ligament, with no immobilization, very attractive. The reoperation for loss of range of motion is now very uncommon. Contraindications to Harvest of the Patellar Tendon Preexisting Patellofemoral Pain Is preexisting patellofemoral pain a contraindication to harvesting the patellar tendon?
The conventional wisdom is yes; it would not be a wise procedure in this situation. Rather, it is like hitting a sore thumb with a hammer! In the past, when chondromalacia was seen at the time of arthroscopy, the graft choice would be changed to hamstrings.
The Small Patellar Tendon The harvesting of the central third of the patellar tendon in a small tendon is more theoretical than practical. The advice in a small patient with a tendon width of only 25 mm would be to take a narrower graft of 8 to 9 mm or use another graft source. Preexisting Osgoode-Schlatters Disease Shelbourne has reported that a bony ossicle from Osgoode-Schlatters disease is not a contraindication to harvest of the patellar tendon. Because the fragment usually lies within the bony tunnel, this bone may be incorporated into the tendon graft.
Hamstring Grafts Advantages of Hamstring Grafts The main advantage of the hamstring graft is the low incidence of harvest site morbidity. After the harvest, the tendon has been shown by MRI to regenerate. The 4-bundle graft is usually 8 mm in diameter, which is a larger cross-sectional area than the patellar tendon.
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One study did show some weakness of internal rotation of the tibia after hamstring harvest. Injury to the saphenous nerve is rare and can be avoided with careful technique. Issues in Hamstring Grafts The major issues with the use of hamstring grafts are: Graft strength and stiffness. However, he Figure 5. The ultimate failure load of the normal ACL compared to various grafts.
Hamstring Grafts 55 Figure 5. The composite hamstring graft is twice the strength and stiffness of the native ACL. This was widely quoted as a reason to use the patellar tendon graft rather than the hamstring. With the advent of the multiple bundles of hamstrings, this graft now has twice the strength of the native ACL Fig. Sepaga later reported that the semitendinosus and gracilis composite graft is equal to an mm patellar tendon graft.
Hamner, however, emphasized that the strength is only additive if the bundles are equally tensioned. Each one has strengths and weaknesses. The Endo-button, popularized by Tom Rosenberg, was improved with the use of a continuous polyester tape. Graft Selection the tape. The Arthrex technique is the easiest to use. The estimates of the force on the normal ACL during activities of daily living are as follows: The pullout strengths also vary from tibia to the femur.
The femoral pullout is higher because the tunnel is angled to the graft and the pull is against the screw that is placed endoscopically. In the tibial tunnel, the graft pulls away from the screw in the direct line of the tunnel. This shortening of the intraarticular length has improved the stiffness of the graft. The pullout strength of bioabsorbable screw can vary widely depending on its composition. Interference Fit Screws 57 Table 5. The cyclic load is more important than the ultimate load to failure. The interference screw fares worst with cyclic loads.
Advantages The advantages are as follows: Quick, familiar, and easy to use. Disadvantages The disadvantages are as follows: Longer graft preparation time. Damage to the graft with the screw. The end of the graft may be backed up with a round ball of PLLA, the EndoPearl Linvatec, Largo, FL or bone to abut against the screw and prevent the slippage of the graft under the screw. The tunnels may be dilated or compacted when the bone is osteopenic.
A longer screw with a heavy whipstitch in the graft improves pullout strength. May individually tension all bundles of graft. Special guides are required. Buttons Buttons are shown in Figure 5. The Endo-button with closed loop tape is strong, if expensive. The plastic button is cheap, available and easy to do.
Considerations 61 Disadvantages The disadvantages are as follows: Fixation site is distant with increase in laxity, with the bungee cord effect. Increased in tunnel widening. Plastic button has low pullout strength, dependent on the sutures. Patients generally do not tolerate metal devices in the subcutaneous area on the front of the tibia. The interference screw gets away from that problem, but has poor performance in cyclic load.
The graft tends to slip out from under the screw as the knee is cycled. Considerations The most important consideration in ACL reconstruction is that the tunnels are put in the correct position. For revi- Table 5. Tendon-to-Bone Healing Studies have shown that it takes at least 8 to 12 weeks for soft tissue to heal to bone, as compared to 6 weeks for bone-to-bone healing with the patellar tendon graft. Recent studies have shown that the compression of the tendon in the tunnel with a screw speeds the time of healing, similar to internal compression in bone healing.
Recently, it has been shown that the internal rotation strength is decreased after the harvest of the semitendinosus. There are rare reported cases of saphenous nerve injury. This puts to rest the argument as to whether the hamstring graft can withstand early aggressive rehabilitation protocols. An assistant can harvest the graft while the surgeon is doing the notchplasty. A bioabsorbable interference screw may be used at the internal aperture of the tunnel to reduce the tendon motion in the tunnel.
The quadriceps tendon graft should reduce the need for the allograft or synthetic in revision cases. Allografts 63 Figure 5. The quadriceps tendon graft. Allografts Advantages The allograft has no harvest site morbidity. With no harvest required, the time of the operative procedure is reduced. Disadvantages The main objection to the use of the allograft is the risk of disease transmission. Jackson has shown that it takes longer for the graft to incorporate and mature, meaning a longer time until the patient can return to sports. In addition, there is a limited availability of allograft materials.
In the literature, Noyes has shown that in long-term 64 5. Graft Selection follow-up, failure rates increase. In the survey of the ACL study group by Campell, none of the members used allografts for primary reconstructions. Synthetic Grafts The best scenario for the use of the LARS synthetic graft is when the graft can be buried in soft tissue, such as in extra-articular reconstruction.
This allows for collagen ingrowth and ensures the long-term viability of the synthetic graft. It will be sure to fail early if it is laid into a joint bare, especially going around tunnel edges, and is unprotected by soft tissue. Advantages There is no harvest site morbidity with the use of the synthetic graft.
The graft is strong from the time of initial implant. There is no risk of disease transmission. Disadvantages 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 the Stryker Dacron ligament and the Leeds-Keio ligament. The ligament augmentation device was also found to be unnecessary. Graft harvest and preparation. Stump debridement and notchplasty. Final inspection and measurement. The criteria for reconstruction is a positive pivot-shift test and a measurement of more than 5 mm in the KT manual maximum side-to-side comparison. The tourniquet is placed proximal under the leg holder.
Hamstring Graft Reconstruction Techniques Figure 6. The KT arthrometer measurement of the anterior-to-posterior motion of the knee. EUA and Documentation 67 Figure 6. The setup for ACL reconstruction showing the tourniquet, the leg holder and the marking to determine the correct site for surgery. The incision for the harvest of the tendon is also marked. The anesthetist uses a peripheral nerve stimulator before the arthroscopy to block the femoral nerve Fig. The dosage is 20 cc of 0. The knee joint and the incisions are injected with 20 cc of bupivacaine 0. The anesthetist gives 30 mg of Toradol intravenously and 1 gm of Ancef intravenously.
The femoral nerve block performed with a nerve stimulator. The physician is now ready to prepare and drape. The order of the examination is as follows: Examine the synovium and look for loose bodies. The anteromedial, anterolateral and the accessory medial portals for ACL reconstruction. The localization of the anteromedial portal with an gauge needle while viewing from the high anterolateral portal.
Patella and femoral trochlea. Examine the articular cartilage. The medial aspect is inspected for a plica. Inspect the synovium and look for loose bodies. Examine the articular surface of the femur and tibia and probe the meniscus with a hook. Inspect the synovium and popliteus tunnel and look for loose bodies.
If there is any doubt about the diagnosis or the type of graft, the diagnostic arthroscopy should be done before the graft harvest. The ACL must be carefully examined. The degree of tear must be assessed. If the tear is partial, with a negative pivot shift, this patient should be treated conservatively. If meniscal repair is required, then the normal medial portal is made, and a second medial accessory low medial portal, to insert the femoral interference screw, will have to be made.
A complete diagnostic arthroscopy should be performed before any meniscal work is done. This ensures that the physician will not forget the lateral compartment if a lot of time is required to perform meniscal repair on the medial side. Asses the entire joint and plan the operative work.
In young patients, every attempt should be made to repair the meniscus rather than resect it. The long-term results of reconstruction are more related to the state of the meniscus than the stability. Indications First of all, who is a candidate for meniscal repair? The algorithm for meniscal repair should consider the following factors. Location The ideal type of meniscal tear to consider repairing is the peripheral tear. This is also referred to as the red on red tear, indicating the degree 72 6.
Hamstring Graft Reconstruction Techniques of vascularity. This tear is amenable only to suture repair. Most commonly the tear is in the red on white region, which also has an acceptable successful repair rate when bioabsorbable devices are used. The short tear of 1 to 2 cm has a better successful repair rate. The vertical longitudinal tear is ideal for repair. Noncompliant patients should not be considered for repair. The younger patient has a higher success rate. The older patient often has the type of degenerative tear that is nonrepairable. Fifty percent of ACL tears are associated with meniscal tears.
In summary, the best candidate for meniscal repair is the young compliant patient with a 2-cm long peripheral longitudinal meniscal tear. There may be a lot of synovium and fat pad that needs to be removed with a shaver in order to visualize the meniscus. In a young patient, this tear should be repaired if possible. The physician should look over the displaced fragment to assess the size of the remaining rim to determine if it is suitable for repair.
Diagram of a bucket-handle tear. The arthroscopic view of a displaced bucket-handle tear of the medial meniscus of the right knee. Hamstring Graft Reconstruction Techniques Step 2: The author uses the blunt arthroscope trocar to push the meniscus back into place under the condyle. The next decision is which technique of meniscal repair is appropriate. The gold standard of repair is considered to be suture repair. The use of inside out sutures requires the use of a separate posterior incision to retrieve the sutures and tie them over the capsule.
The incision avoids injury to the saphenous nerve on the medial side and the peroneal nerve on the lateral side. Preparing and Repairing the Meniscus The tear should be initially probed to determine if it is suitable for repair. The meniscus should be rasped to Figure 6. The reduction of the handle of the tear. The arthroscopic appearance of the reduced bucket-handle tear. Pavlovich has described the technique of stimulation of the meniscal synovial border with electrocautery. The monopolar electrode can be used to stimulate the synovium at the tear. Zhang demonstrated that the meniscus and the rim may be trephinated to produce vascular access channels.
The sutures and the bioabsorbable devices must be placed accurately to reduce the tear and hold it until it is healed. The Posteromedial Incision The next step is to create a posteromedial or posterolateral incision Fig. Hamstring Graft Reconstruction Techniques ament extending distally from the joint line. Blunt dissection is then used to come down upon the joint capsule and the medial gastrocnemius posteriorly and the semimembranosus anteriorly. A retractor is then placed posterior to the medial head of the gastrocnemius.