With steady advances in arthroscopically assisted ACL reconstruction techniques and rehabilitation protocols , outcomes of ACL reconstruction have improved substantially since the 1980s. Current minimally invasive techniques of reconstruction emphasized the anatomic placement of high strength ligament grafts using rigid fixation techniques.
The advantage of arthroscopic surgery are:
less operative time
24 hours in the clinic
less post-op pain
faster come back to recreational sports
The treatment for a patient with an acutely torn anterior cruciate ligament (ACL) is individualized by factors such as age, occupation, level of sports participation, and associated intra-articular and ligament injuries. An important consideration in the discussion with the patient is the patient's willingness to modify high-risk activities in the future.
We usually recommend anterior ligament reconstruction in the more physically active individuals of all ages who want to pursue activities that involve lateral movement, sudden stopping, and change of direction. We also suggest reconstruction of the ruptured ACL when there are significant associated meniscus tear(s) and/or a concomitant ligament injury.
The decision to perform reconstructive surgery in someone with symptomatic knee instability due to chronic ACL deficiency is less controversial. Patients with an anterior cruciate deficient knee have had a chance to experience the limitations it imposes on their lifestyle. Usually the reason they have made the appointment with the surgeon is because they no longer want to live with the limitations if something can be done to correct the knee.
For the purpose of anatomic ACL reconstruction, it is essential to understand the anatomy of the native ACL. The ACL consists of two functional bundles, the anteromedial (AM) and the posterolateral (PL) bundles. They are named after the position of their insertion sites on the tibia. This configuration allows them to work together to provide anteroposterior and rotational stability of the knee.
The anatomic area of insertion the two functional bundles of ACL
Femoral insertion areas of two bundles of ACL
Tibial insertion areas of functional bundles of ACL
Hamstrings tendon grafting from the tibia (autograft), to recreate the new ACL (Prof. Hans Paessler)
Graft measurments which determine the diameter of bone tunnel in tibia and femur.
Alternative grafts are:
bone –patelar tendon –bone graft
Quadriceps graft to create the new anterior cruciate ligament.
Hamstrings tendons for anatomic single bundle ACL reconstruction
The graft from hamstrings tendons is ready to transplant for double bundle ACL reconstruction.
The graft from patella - quadriceps tendon is ready to transplant.
ANATOMIC SINGLE BUNDLE RECOSTRUCTION
Tibial tunnel creation. (Video from Prof. Hans Paesler, ATOS Clinic Heidelberg Germany)
ACL reconstruction, femoral tunnel creation
Graft passing through the femoral and tibial tunnels. Fixation.
Anatomic positioning of the graft.
The indication for anatomic single bundle ACL reconstruction are:
When the patient has narrow anatomic knee (femoral intercondylar notch enterance)
severe bone bruising (particular at the lateral femoral condyle)
severe arthritic changes
For anatomic single bundle reconstruction the femoral and tibial tunnels are placed in the center of the measured femoral and tibial ACL insertion site.
Arthroscopic view. Normal ACL
Arthroscopic view. Rupture of ACL.
Arthroscopic view after ACL reconstruction with hamstrings tendon autograft.
DOUBLE BUNDLE ACL RECONSTRUCTION
Based on the advanced knowledge of the double bundle anterior cruciate ligament anatomy, anatomic double bundle technique for reconstruction of the ACL is gaining popularity.
▪ The indications for anatomic double-bundle ACL reconstruction are similar to those for traditional single-bundle reconstruction.
▪ Patients with recurrent instability or episodes of giving way or those who are unable to return to activities of daily living or sports are appropriate for surgical reconstruction.
▪ Patients with complaints of instability and a single-bundle or “partial” tear may benefit from single-bundle augmentation, or double-bundle reconstruction in the event the remaining bundle is incompetent.
Arthroscopic view of two tunnels in the femur
Anatomic double bundle reconstruction of the anterior cruciate ligament.
AUMGMENTATION ACL SURGERY
In rare instances, partial ligamentous disruption of one anterior cruciate ligament bundle may occur. This can occur for rupture of the native ACL, as well as after previous double-bundle ACL reconstruction.
There is multiple benefits of augmentation surgery over removal of the whole ACL and performing a complete primary reconstruction. Leaving the intact bundle preserves the proprioceptive qualities of the native ACL. Single – bundle augmentation is less invasive due to the need for fewer bone tunnels and hardware.
Anatomic view of ACL ligament. AM=anteromedial bundle, PL= posterolateral bundle
Arthroscopic view of double bundle ACL ligament.
a. anterior cruciate ligament.
b. AM bundle rupture. PL bundle is intact.
c. PL bundle rupture. AM bunle is intact.
Anteromedial bundle (AM) bundle intact. The posterolateral bundle (PL) is torn.
Posterolateral bundle graft only. The anteromedial bundle is preserved.
Anteromedial bundle rupture.
The posterolateral bundle is intact.
Anteromedial bundle graft.
ANTERIOR CRUCIATE LIGAMENT RUPTURE IN THE SKELETALLY IMMATURE PATIENTS
Intrasubstance anterior cruciate ligament (ACL) injuries in children and adolescents are being seen with increased frequency and have received increased attention. ACL injury has been reported in 10% to 65% of pediatric knees with acute traumatic hemarthroses in series ranging from 35 to 138 patients. Management of these injuries is controversial.
Nonoperative management of complete tears in skeletally immature patients generally has a poor prognosis, with recurrent instability leading to further meniscal and chondral injury, which has implications in terms of development of degenerative joint disease. A variety of reconstructive techniques have been utilized, including physeal-sparing, partial transphyseal, and transphyseal methods using various grafts.
All skeletally immature patients are not the same. Some have a tremendous amount of growth remaining, while others are essentially done growing.
The vast majority of ACL injuries in skeletally immature patients occurs in adolescents. Management of these injuries in preadolescent children is particularly vexing, given the poor prognosis with nonoperative management, the substantial growth remaining, and the consequences of potential growth disturbance.
In the prepubescent patient with a complete ACL tear without concurrent chondral or repairable meniscal injury, nonreconstructive treatment with a program of rehabilitation, functional bracing, and return to non-high-risk activities is attempted first. Although the results of nonreconstructive treatment are generally poor, with subsequent functional instability and risk of injury to meniscal and articular cartilage, surgical reconstruction poses the additional risk of growth disturbance.
Furthermore, some patients are able to cope with their ACL insufficiency or modify their activities, allowing for further growth and aging such that an adolescent-type reconstruction can later be performed with transphyseal hamstring tendons in a more anatomic manner.
For adolescent patients with growth remaining who have a complete ACL tear, initial nonreconstructive treatment is not advised, because the risk of functional instability with injury to the meniscal and articular cartilage is high the risk and consequences of growth disturbance from ACL reconstruction are less.
For older adolescent patients who are approaching skeletal maturity and who have a complete ACL tear, conventional adult ACL reconstruction is performed with interference screw fixation, using either autogenous central third patellar tendon or autogenous hamstrings.
Anterior Cruciate ligament reconstruction with autograft in girl 13years old.