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Arthroscopic ACL reconstruction using semitendinosus and gracillis tendon:

Arthroscopic ACL reconstruction using semitendinosus and gracillis tendon DR THIT LWIN SENIOR LECTURER UMS

Slide 2:

Introduction Apply anatomy Mechanism of injury Diagnosis : clinical examination+ imaging study Biomechanical basis and justification Surgical technique Post operative management

Introduction :

Introduction ACL tear is not life-threatening injury but can severely impair the ADL & QOL. ACL reconstruction is accepted modality of treatment but it has different methods of surgical technique, grafts and variable outcomes.

Slide 9:

The ligament is intra-articular but extrasynovial being composed of 3 main bundles anteromedial, posterolateral, and intermediate. The ligament courses obliquely, running from the tibia anteriorly and medially to the femur posteriorly, superiorly, and laterally. The broad tibial footprint lies at a point one third to one half the distance between the medial and lateral tibial spines, 5–7 mm anterior to the posterior cruciate ligament (PCL). On the femoral side, the attachment lies on the medial aspect of the lateral femoral condyle, just anterior to the posterior aspect of the intercondylar notch.

Slide 10:

31 to 35 mm in length and 31.3 mm 2 in cross section Origin: from the posterior part of the medial surface of the lateral femoral condyle within the condylar notch well posterior to the longitudinal axis of the femoral shaft Insertion: on the tibial plateau , medial to the insertion of the anterior horn of the lateral meniscus in a depressed area anterolateral to the anterior tibial spine.

Mechanism of tear:

Mechanism of tear

Slide 12:

Injury to the anterior cruciate ligament (ACL) is very common and usually the result of a twisting of the leg while applying full downward pressure. A "popping" sound at the time of injury Knee swelling within 6 hours of injury Pain, especially when you try to put weight on the injured leg

Slide 15:

A line drawn parallel to the patella accentuates the posterior tibial sag. Posterior tibial sag. To observe posterior tibial sag place patient supine and put 90 º of flexion at the knee and hip. In such a position, gravity pulls posteriorly on the tibia, and in the case of PCL disruption, the tibia falls even or behind the femoral condyles. Comparison should be made to the opposite knee.

Slide 16:

anterior draw test commonly is performed to diagnose anterior cruciate ligament injury.

Slide 17:

MRI is used as an aid to diagnose anterior cruciate ligament injury. MRI has a sensitivity of 95%.

Graft Choices:

Graft Choices Autografts Bone-patellar tendon-bone (BPTB) Quadrupled hamstrings (Gracillis & Semi-tendinosus) Quadriceps tendon Allograft -BPTB -hamstrings -quadriceps -archille’s -fascia lata

Autograft vs. Allograft:

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

Slide 20:

The different grafts BPTB Quad T Hamstring

BPTB versus Hamestring tendon:

BPTB versus Hamestring tendon Pinczewski et al. AM Jsport Med. 2007; 37 90 BTBG with 90 ST.Gracilis 10 years Follow-up More morbidity in donor site in BTBG More Petello-femoral Degenerative Joint Disease in BTBG ( anterior knee pain)

Biomechanical basic of Graft :

Biomechanical basic of Graft blood supply to the ligament is from the middle geniculate artery, quadruple-stranded semitendinosus-gracilis tendon graft with both ends folded in half and combined. has an ultimate tensile load ( as high as 4108 N). also provides a multiple bundle replacement graft that may better approximate the function of the two-bundle anterior cruciate ligament

ACL Reconstruction - Hamstring Justification :

ACL Reconstruction - Hamstring Justification 1. Produces better initial strength and stiffness . 2. Quadruple graft results in larger cross-sectional diameter than bone-patellar-bone. 3. Initial fixation required for daily living activities is exceeded. 4. Anterior knee pain is less. 5. Quadriceps weakness is avoided. 6. Incision is cosmetically better. 7. Morbidity (complications from the graft) is lower. 8. Return to activity time is comparable.

Strength and Stiffness:

Strength and Stiffness strength Hamstring 4590N Patellar 2646N Normal ACL 1725N ( Ref: The American Journal of Orthopedics – Nov 2002) stiffness Hamstring 861N Patellar 392N Normal ACL 242N ( Ref: The American Journal of Orthopedics – Nov 2002) Quadruple stranded hamstring is 250% the strength of the normal ACL. Hamstring grafts have a stiffness of 2X the patellar tendon and 3X the normal ACL stiffness. (Ref: )

Slide 25:

Cross Sectional Area of Grafts Hamstring Circular graft. Tunnel Diameter Area. 6mm = 28 mm 2 7mm = 38 mm 2 9mm = 64 mm 2 10mm = 79 mm 2 Patellar Rectangular graft. Rectangle area. 10mm X 3mm = 30 mm 2 (Ref: Proceedings from the 16th Annual Fall Course of the AANA – Nov 1997) The average cross sectional quadruple hamstring graft will measure 7-9mm in diameter.

Surgical technique:

Surgical technique Position of patient Portals : total 5 ‘anterolateral, anteromedial, Tendon harvesting Preparation of graft Graft reconstruction

Slide 27:

Preparation : Position of patient Position of knee (support) Normal saline

Right knee:

Right knee

Slide 33:

Feel and identify the tendon first. A 1½" incision is made. The gracilus and semi-tendinosis are harvested using a tendon stripper.

Slide 34:

- place the leg in a 90 O of flexion - make a small longitudinal incision opposite the tibial tuberlce, midway between the tubercle and the posterior edge of the tibia; - palpate the pes anserinus ; - generally only the gracilis and semitendinosus will be felt, since the sartorius thins out well proximal to its insertion; ( nemonics:Say Gray before Tea) - attempt to identify the saphenous nerve; - open the tendon sheath and release adhesions and fibrous extensions that attach to the sheath; - pes anserinus is exposed thru a short verticel incision;

Harvesting :

Harvesting Direction of tendon stripper

Slide 38:

Graft Diameter

Slide 39:

Tibial guide

Slide 40:

- semitendinosus and gracilis tendons are harvested proximally w/ appropriately sized tendon stripper (Brand type tendon stripper); - residual muscle is removed; - semiT should be placed in a moistened sponge, but is not be submerged in saline, since this may cause tendon swelling; - paratenon surrounding the semitendinosus should be preserved;

Slide 41:

Preparation of a four-stranded tendon graft for screw fixation in ACL

Slide 43:

Anterior cruciate ligament reconstruction with hamstrings. Intraarticular semitendinosus cruciate ligament reconstruction.

Slide 45:

A hole (tunnel) is drilled in the upper tibia and exits into the center of the joint at the original ACL insertion. Drilling continues until another hole is drilled in the femur. These tunnels will be used to insert the hamstring tendon.

Intraoperative photo of drill hole in femur for ACL:

Intraoperative photo of drill hole in femur for ACL

Slide 49:

The four strand hamstring graft is pulled through the tibial tunnel into the femoral socket and held tightly.

Ham. Graft passer for Transfix:

Ham. Graft passer for Transfix

Slide 51:

Graft is anchored to tibia. Each tendon bundle is uniformly compressed against the bone without overlap. This encourages rapid growth into the bone of each strand of the quadruple hamstring graft.

Slide 52:

Grafts are inserted through a tunnel that is drilled through the shin bone (tibia) and thigh bone (femur). The graft is then pulled through the tunnel and fixated with screws. The two bright objects in this X-ray are screws in the thigh bone (above) and shin bone (below).

Slide 53:

Arthroscopic anterior cruciate ligament (ACL) reconstruction (right knee). The tendon of the semitendinosus muscle was prelevated, folded and used as an autograft (1). It appears through the remnant of the injured original ACL (3). The autograft then courses upwardly and backwardly in front of the posterior cruciate ligament (2).

Slide 54:

After reconstruction, thirty time flexion and extension of knee

Slide 55:

Improper passing suture position at screw-bone interface increases risk of suture laceration and loss of graft tension. Placement of passing suture opposite bone-screw interface decreases risk of suture laceration

Slide 56:

graft fixation by interference screw Inapproprite graft advancement by screw (right)

Slide 57:

Proper relationship of interference screw to bone graft improper advancement of screw leading to potential tendon injury

Slide 58:

Interference screws are the most commonly used form of anterior cruciate ligament graft fixation. Biodegradable Metallic Interference screw



How long until I can play?:

How long until I can play? The healing process- It’s a dead piece of tissue! Graft needs to be re-vascularized “Ligamentization” occurs Vascular Synovial layer wraps around graft in 4-6 weeks

Healing Time:

Healing Time Autologous ACL grafts don’t Transition through necrotic stage Weakest link fixation 4-6 weeks Complete re-vascularization of the graft takes ~20 weeks Remodeling occurs: By one year histological and biochemical properties of ACLR ~ native ACL

Graft Remodeling:

Graft Remodeling Gradual loss of graft strength during initial remodeling Then strength of ACL graft improves gradually Allografts Slightly slower process

Graft Remodeling:

Graft Remodeling • Hamstring graft -Bone to tendon healing -Sharpey’s fibers -Usually complete at 12 weeks ACL autograft resembles normal ACL at 12 months Concern for increased allogenic graft incorporation time doesn’t warrant modification of PT protocol

Slide 66:


Accelerated Rehabilitation Program :

Accelerated Rehabilitation Program General: 1. Hamstring or allograft rehabilitation is generally easier because extensor mechanism is not violated. 2. Graft integration into bone takes longer (10-12 weeks vs. 6 weeks for BTB).

Slide 68:

1. Preoperative phase. 2. Early Postoperative Phase (Week 1). 3. Ambulation and Protection Phase (Weeks 2-3). 4. Concentrated Rehabilitation (Weeks 4-12). 5. Sport Specific Rehabilitation (Weeks 13-24 or more).

Preoperative phase:

Preoperative phase Goals Exercise or Modalities Reduce Swelling. Cold compression cuff. Return knee ROM Heel-slice exercise. Regain hyperextension. Heel-prop and prone hang exercise. Restore normal gait pattern. Gait training, heel to toe crutch. Restore quad control Quad sets, SLRs, multiple angle co-contractions. Educate patient. Review post-op program.

Early Postoperative Phase (Week 1).:

Early Postoperative Phase (Week 1). Goals Exercise or Modalities Eliminate hemarthrosis and pain. CPM (0-30) and cold compression cuff. Achieve hyperextension and flexion of > 90 degrees Heel prop (10 minutes every waking hour) CPM (flexion exercises 6 times daily) Heel-slide exercises. Re-establish leg control. Quad contraction exercises, electrical stimulation if needed, Weight Bearing as tolerated, Crutch use as needed.

Ambulation and Protection Phase (Weeks 2-3). :

Ambulation and Protection Phase (Weeks 2-3). Goals Exercise or Modalities Minimize swelling. Cold compression cuff and Ace wrap. Quad sets 25-50 times per hour. Maintain hyperextension and increase flexion. Heel prop and prone hand exercises, heel-slide to 100-110 degrees, AA flexion. Achieve good leg control. SLRs, multi-angle isometrics, closed chain mini-squats. Progress to normal gait. Wean off immobilizer and crutches as leg control normalizes (by the end of week 3).

Concentrated Rehabilitation (Weeks 4-12).:

Concentrated Rehabilitation (Weeks 4-12). Goals Exercise or Modalities Maintain hyperextension and regain flexion. Heel prop and prone hang exercises. Control swelling. Reduce activity if swelling returns Increase flexion. Heel-slide and towel-pull exercises Increase quadriceps, hamstring and hip strength, and coordination. Stairmaster, calf raises, hip joint exercises, forward lunges. Start stationary biking and stair climb.

Slide 73:

5 . Sport Specific Activities (week 13-24 and greater). Goals are to increase activity levels while avoiding undue stress on the graft. Biking is increased. Rope jumping and straight ahead running can begin at week 16. Initiate lateral shuffles, agility drills, controlled run and cut after 20 weeks. Enrollment in Sports Dynamics ACL Prevention program is encouraged before return to competitive sports. After 24 weeks, the patient may return to full sports participation.

Slide 74:

The most important factor in your recovery… is You!

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