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ACL Reconstruction - Hamstring Autograft

Planning

B

Basic Preoperative Plan

1

Radiographic and MRI assessment

  • diagnose ACL tear and any other pathology that will be addressed during the ACL reconstruction
  • asses for physeal closure on femur and tibia

2

discuss options with the patient

  • discuss graft options with the patient

3

Execute surgical walkthrough

  • describe key steps of the operation verbally to attending prior to beginning of case.
  • description of potential complications and steps to avoid them
C

Room Preparation and Patient Positioning

1

Surgical instrumentation

  • arthroscopy tower and ACL tray

2

Room setup and equipment

  • operative table, choice of using leg post, leg holder or neither

3

Exam under anesthesia

  • once the patient is under anesthesia
  • examine the operative and non-operative leg
  • assess range of motion, Lachman, Pivot Shift, LCL, MCL, and pulse exam

4

Patient positioning

  • place patient supine on the table
  • a thigh tourniquet may be placed
  • if using a leg post, position the patient’s heels at the edge of the bed and shift the patient closer to the side of the post
  • ensure that the post is in the proper location to produce a valgus stress
  • if using a leg holder, the end of the bed is often lowered allowing the operative leg to flex to 90 degrees free
  • the non-operative leg is either placed in a well leg holder or on padding
  • the operative leg must be able to flex to at least 120 degrees
  • if using a leg holder, a non-sterile assistant will need to unlock the top of the holder when high flexion is needed

Technique

D

Hamstring Harvest and Graft Preparation

1

Make incision

  • approximately 3cm incision can be made located approximately 3 finger breaths distal to the joint line and 2 finger breaths medial to the tibial tubercle
  • the pes tendons can usually be palpated prior to incision

2

Find and Incise Sartorial Fascia

  • dissect thought subcutaneous tissue until the sartorial fascia is identified
  • The pes tendons should e palpable deep to the sartorial fascia
  • a blunt object such as a freer elevator or the tip of the closed Metzenbaum scissors can be slid behind the sartorial fascia from superior to inferior once the superior border is found
  • this will protect the MCL which is deep to the sartorial fascia
  • once the sartorial fascia is elevated with the blunt object it can be incised longitudinally

3

Expose the gracillis and semitendinosis tendons

  • the tendons will be located on the deep aspect of the sartorial fascia
  • Clamp the superior border of the incised sartorial fascia and use the scissors to release the superior medial edge in a hockey stick fashion for exposure of the tendons.

4

Elevate and Isolate the tendons

  • use a right angle clamp to bluntly release the tendons from the deep portion of the sartorial fascia

5

Harvest tendons

  • whip stitch the ends of each tendon
  • release adhesions until the tendons have good recoil when tension is applied
  • use the tendon stripper to harvest the tendons
  • keep the knee flexed when harvesting to protect the saphenous nerve

6

Prepare the graft

  • remove the remaining muscle fibers from the tendons with a metal ruler or large curette
  • double both tendons over a central suture or around the device for fixation
E

Diagnostic Arthroscopy

1

Portals

  • anterolateral
  • an 11 blade is used to create the portal at a 45 degree angle into the joint just lateral to the patella tendon and just inferior to the distal pole of the patella
  • insert the blunt trocar at the same angle as incision
  • anteromedial
  • often created under direct visualization once the medial compartment is entered
  • place knee in approximately 30 degrees of flexion with valgus moment applied
  • use a spinal needle to assess direction and appropriate superior/inferior direction visualizing the entrance from the lateral viewing portal
  • the medial portal should be located just superior to the medial meniscus and able to provide access to the anatomic ACL footprint on the femur as well and the medial meniscal root if needed

2

Perform diagnostic arthroscopy

  • visualize
  • suprapatellar pouch
  • patellofemoral joint
  • lateral gutter
  • medial gutter
  • medial compartment
  • visualize the medial femoral condyle and follow it while bringing the knee into slight flexion and applying a valgus stress to the knee as you go into the medial compartment
  • the foot will be positioned on your opposite hip for control
  • medial meniscus, medial femoral condyle, and medial tibial plateau
  • once the anteriomedial portal is created, a probe is used to assess the medial meniscus and cartilage
  • intercondylar notch – ACL/PCL
  • use probe to assess the ACL and PCL
  • lateral compartment
  • the surgeon can bring the leg into a figure-4 position or place the operative limb on the surgeon's hip to create a varus stress and flexion to the knee to enter the lateral compartment
  • lateral meniscus, lateral femoral condyle, and lateral tibial plateau
  • a probe is used to assess the lateral meniscus and cartilage
F

Tunnel Placement and Site Preparation

1

Debride the ACL footprint

  • the ACL remnant is removed from the notch usually with a shaver and/or a radiofrequency ablation device while noting the anatomic footprint on the femoral and tibial side for later reconstruction.
  • leave a small portion of the footprint intact to permit proper identification of the ACL origin and insertion
  • care is taken not to injure the PCL

2

Notchplasty

  • a notchplasty can be performed if needed using a large shaver or a burr

3

Mark the femoral footprint

  • mark the center of the femoral footprint with an awl or curette with the knee flexed to 90 degrees
  • the anatomic footprint is used as a guide
  • this position is typically 6-7 mm anterior to the back wall to allow 1-2 mm of back wall after tunnel reaming
  • confirm the position of the mark by switching the 30 degree scope to the anteromedial portal, then switch the scope back to the anterolateral portal for viewing

4

Drilling the femoral tunnel

  • the surgeon can choose between an inside-out technique or an outside-in technique of femoral tunnel drilling
  • if performing an inside-out technique the knee is high flexed to at lease 120 degrees and a guide pin is placed through the medial portal into the medial aspect of the lateral femoral condyle at the previously determined position
  • guides are available to help monitor back the femoral condyle back wall distance which should be approximate 1-2 mm
  • the guide pin is driven out the lateral aspect of the leg through the skin
  • this is over reamed to a predetermined distance depending on the chosen graft fixation technique
  • if performing an outside-in technique the camera is placed in the anteromedial portal for viewing, and the specific guide can be placed through the anterolateral portal at the previously determined position
  • a separate lateral incision is made over the lateral leg, and a flip cutting drill-reamer can be used to drill the tunnel
  • sutures are then passed through the femoral tunnel and clamped for later passing of the graft

5

Drilling the tibial tunnel

  • the tibial tunnel can be drilled through the initial graft harvest incision
  • the tibial drill guide is placed through the anteromedial portal while the scope is viewing from the anterolateral portal
  • the guide is placed at the ACL tibial footprint in line with the medial tibial spine roughly at the posterior aspect of the anterior horn of the lateral meniscus
  • the external portion of the guide should be seated flush to the anteriomedial tibia usually midway between the anterior tibial tuberosity and the medial tibial joint line
  • once the tunnel is drilled, the suture in the femoral tunnel can be unclamped and the looped end can be retrieved through the tibial tunnel with the aid of a probe for graft passage
G

Graft Passage and Fixation

1

Pass the graft

  • the femoral sided graft sutures are placed through the looped end of the passing suture which has been brought out through the tibial tunnel
  • tension is applied as the sutures are brought through the joint and out the lateral skin

2

Seat and secure the graft on the femoral side

  • the femoral side of the graft is pulled into the femoral tunnel
  • final fixation is performed as desired

3

Seat and secure the graft on the tibial side

  • the knee can be cycled at this point while pulling tension on the graft through the tibial tunnel
  • proper tensioning is applied to the graft as the tibial side of the graft also fixed into place
H

Wound Closure

1

Wound closure

  • close the harvest site in layer

2

Close the sartorial fascia, the subcutaneous tissue, and skin.

  • close the arthroscopy portals.

Patient Care

K

Preoperative H & P

1

Obtain history and perform basic physical exam

  • history
  • Age
  • Gender
  • History of present illness [HPI]
  • Past medical history [PMHx]
  • Social history
  • physical exam
  • range of motion
  • check for effusion
  • quadricep avoidance gait (does not actively extend knee)
  • Lachman's test
  • most sensitive exam test
  • grading A= firm endpoint, B= no endpoint
  • Grade 1: < 5 mm translation
  • Grade 2 A/B: 5-10mm translation
  • Grade 3 A/B: > 10mm translation
  • PCL tear may give "false" Lachman due to posterior subluxation
  • Pivot shift
  • extension to flexion: reduces at 20-30° of flexion
  • patient must be completely relaxed (easier to elicit under anesthesia)
  • mimics the actual giving way event
  • KT-1000
  • useful to quantify anterior laxity
  • measured with knee in slight flexion and externally rotated 10-30°

2

Order basic imaging studies

  • biplanar radiographs of the knee

3

Perform operative consent

  • describe complications of surgery including
  • surgical technical error
  • inadequate fixation
  • overaggressive rehab
  • cyclops lesion
  • infection
  • loss of motion & arthrofibrosis
  • infrapatellar contracture syndrome
  • patella Tendon Rupture
  • RSD (complex regional pain syndrome)
  • patella fracture
  • hardware failure
  • tunnel osteolysis
  • late arthritis
  • local nerve irritation
L

Perioperative Inpatient Management

1

Discharges patient appropriately

  • pain meds
  • schedule follow up for 2 weeks
  • outpatient PT
  • initiate pt POD1
  • aggressive cryotherapy (ice)
  • immediate weight bearing (shown to reduce patellofemoral pain)
  • emphasize early full passive extension (especially if associated with MCL injury or patella dislocation)
  • place in bledsoe brace and cryocuff
M

Outpatient Evaluation and Management

1

Obtains focused history and performs focused exam

  • history
  • mechanism of injury
  • past knee history
  • past treatments
  • physical exam
  • anterior drawer
  • meniscal pain
  • lachman's test
  • most sensitive exam test
  • grading A= firm endpoint, B= no endpoint
  • grade 1: < 5 mm translation
  • grade 2 A/B: 5-10mm translation
  • grade 3 A/B: > 10mm translation
  • PCL tear may give "false" Lachman due to posterior subluxation
  • Pivot shift
  • extension to flexion: reduces at 20-30° of flexion
  • patient must be completely relaxed(easier to elicit under anesthesia)
  • mimics the actual giving way event
  • KT-1000
  • useful to quantify anterior laxity
  • measured with knee in slight flexion and externally rotated 10-30°

2

Appropriately interprets basic imaging studies

  • Radiographs
  • interpret biplanar radiographs of the knee
  • usually normal
  • check alignment, joint space and patella alignment.
  • Segond fracture (avulsion fracture of the proximal lateral tibia) is pathognomonic for an ACL tear

3

Prescribes and manages non-operative treatment

  • physical therapy & lifestyle modifications
  • low demand patients with decreased laxity
  • increased meniscal/cartilage damage linked to
  • loss of meniscal integrity
  • frequency of buckling episodes
  • level I and II activity (e.g. jumping, cutting, side-to-side sports, heavy manual labor)
  • Closed Chain Quad strengthening

4

Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • describes accepted indications and contraindications for surgical intervention

5

Provides post-operative management and rehabilitation

  • postop: 2-3 week postoperative visit
  • wound check
  • diagnose and management of early complications
  • postop: 4-6 Week postoperative visit
  • early rehab
  • focus rehab on exercises that do not place excess stress on graft
  • appropriate rehab
  • isometric hamstring contractions at any angle
  • isometric quadriceps, or simultaneous quadriceps and hamstrings contraction
  • active knee motion between 35 degrees and 90 degrees of flexion
  • emphasize closed chain (foot planted) exercises
  • avoid
  • isokinetic quadricep strengthening (15-30°) during early rehab
  • open chain quadriceps strengthening
N

Advanced Evaluation and Management

1

Recognizes concomitant associated injuries

  • LCL
  • Multiligament
  • OCD
  • PCL
  • Collateral ligaments
  • PL Corner instability
  • perform tests
  • dial test
  • reverse pivot test

2

Orders and interprets advanced imaging studies

  • Radiographs
  • Identifies Segond Fracture
  • MRI
  • ACL tear best seen on sagittal view
  • bone bruising occurs in more than half of acute ACL tears
  • middle 1/3 of LFC (sulcus terminalis)
  • posterior 1/3 of lateral tibial plateau
  • subchondral changes on MRI can persist years after injury

3

Provides complex non-operative treatment

  • WB status
  • bracing as appropriate
  • vascular studies

4

Modifies and adjusts post-operative treatment plan as needed:

  • identifies loss of knee motion
  • sport specific drills
  • return to sport
O

Complex Patient Management

1

Performs revision/transphyseal ACL reconstruction

  • hardware removal
  • outside in drilling techniques

2

Develops unique, complex post-operative management plans

3

Surgically treats complex complications

 

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