Preoperative Patient Care A Intermediate 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 4 radiographs of the knee AP lateral merchant tunnel view look for tibia and/or femoral epiphyseal fractures tibial spine avulsion malformation in the tibial spine or femoral notch amount of tibial and femoral epiphyseal closure MRI ACL tear best seen on sagittal view look for combined tissue injury evaluate the maturity of the femoral and tibial epiphyseal physis evaluate the location of the injury proximal femoral avulsions can re repaired primarily 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 continue strengthening exercises postop: 4-6 Week postoperative visit continue strengthening exercises postop: 3 month visit start straight line exercises return to full activity in 6 months B 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 Appropriately orders and interprets advanced imaging studies Radiographs identifies Segond fracture identifies tibial and femoral physeal fractures 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 loss of knee motion treatment sport specific drills return to sport C Preoperative H & P 1 Obtain history and perform physical exam history Age Gender History of present illness [HPI] Past medical history [PMHx] Social history physical exam check for effusion range of motion 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 order 4 views of the knee 3 Perform operative consent describe complications of surgery including surgical technical error leg length discrepancy axial deformity 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 Operative Techniques E Preoperative Plan 1 Physical Exam and Imaging Analysis Evaluate patient for concomitant injuries and lower extremity alignment. An AP hip to ankle x-ray can be obtained pre-op to confirm neutral alignment. If there is valgus present, if may need to be addressed with guided growth. Review MRI for meniscal and chondral pathology F Room Preparation and Patient Positioning 1 Surgical instrumentation Iliotibial band harvester. Options include open tendon stripper or curved meniscal knife. The meniscal knife should have an angled neck to allow for proximal detachment Long, broad Cobb elevator to free subQ tissue off of IT band. Reinforcing suture for graft. #2 nonabsorbable or larger Long curved clamp to retrieve IT band Curved rasp to create groove in tibial ACL footprint Burr to decorticate tibia. Heavy nonabsorbable suture for femoral fixation. #2 or larger. Heavy nonabsorbable suture (#2 or larger) or sturdy suture anchor for tibial fixation 2 OR Table Radiolucent table in case C-arm is needed 3 C-arm Optional 4 Patient positioning Supine at end of bed Lateral thigh post Consider placing tourniquet sterile after IT band harvest as it may impede proximal harvest. Prep up to groin to have access to entire thigh for IT band harvest. 5 Perform appropriate physical exam under anesthesia Lachmann test Pivot Shift Test G Iliotibial Band Harvest and Preparation 1 Incision 4-6 cm oblique incision on lateral knee from lateral joint line up to anterior IT band border 2 Isolate IT band Will be immediately deep to subQ fat Clear subQ tissue with Cobb elevator distally and proximally. Can use a "windshield wiper technique to ensure all adhesions are freed. Free adhesions a little more proximal than you intend to harvest. May need to be as much as 20 cm. 3 Harvest IT Band Identify anterior and posterior borders of IT band and incise 2-3 mm away from each border. Initial length of incisions in IT band should be 4-5 cm. If using open tendon stripper, load incised part of IT band onto stripper and push tendon stripper proximal to desired length and truncate with cutting mechanism specific to stripper. If using meniscal knife, use knife to extend anterior and posterior incisions proximal to desired length. Make sure knife cuts do not converge proximally as this will lead to a small graft. If anything, err on having knife cuts diverge a bit to create a more fan shaped proximal harvest. This will create a thicker graft. To connect the incisions proximally with meniscal knife and detach graft, have the knife positioned at the proximal extent of one of the cuts and angle the knife toward the other cut. Push across proximal IT band to connect the longitudinal cuts and detach graft. If needed, a proximal counter incision can be made on thigh to expose and detach proximal IT band. Release IT band distally from knee capsule but make sure to leave attached to Gerdy's tubercle. Reinforce free end with heavy suture and place graft back into wound for later retrieval. H Diagnostic Arthroscopy 1 Perform Diagnostic Arthroscopy This can be done before or after graft harvest based on surgeon preference/comfort with diagnosis. Evaluate knee in standard fashion for any meniscal and/or chondral pathology Address any pathology as appropriate prior to commencing ACL reconstruction. Debride ACL stump enough to visualize over the top position. I Graft Passage into Knee 1 Clamp Placement Widen anteromedial portal Insert clamp through anteromedial portal and place into over the top position Push clamp through posterolateral aspect of knee joint and advance until it emerges laterally in the IT band defect. Open and close clamp periodically during passage to dilate soft tissues. Palpate where the clamp is going to emerge laterally. Adjust direction as needed to make sure it emerges with IT band defect. 2 IT Band Passage into Knee Open clamp and place reinforcing sutures from graft in teeth of clamp. Pull clamp back through knee and bring sutures out anteromedial portal. Pull sutures to bring graft to the over the top position and park it there. J Tibial Passageway and Groove Preparation 1 Tibial Incision Create 3-4 cm vertical incision on anteromedial tibia that is medial to tibial tubercle apophysis and distal to proximal tibial epiphysis. It should be fairly in-line with more proximal anteromedial arthroscopic portal. Fluoroscopy can be used in this step to ensure appropriate placement away from both growth plates. Incise down to, but not through, periosteum. Bluntly dissect proximally to level of joint 2 Tibial Groove Creation Bluntly insert curved clamp into knee under intermeniscal ligament. The surgeon's hand will need to be parallel or nearly parallel with floor at this point to get clamp under ligament. Can also place a suture around IM ligament and retract it up to facilitate clamp passage Open clamp to dilate soft tissue passageway Replace clamp with curved rasp Place rasp in tibial ACL footprint and create groove that extends from footprint to anterior tibial border. This will allow for early bony healing of graft in joint and will allow graft to sit a bit more posterior to minimize chance of graft impingement. K Final Graft Placement and Fixation 1 Graft Passage Through Knee Remove rasp and place clamp back in knee under the IM ligament via the tibial incision. Grasp the sutures attached the graft (a portion of them will have been intra-articular this whole time) and pull them under the IM ligament and out the knee via the tibial incision. Pull sutures to advance graft under the IM ligament and out the knee to emerge in the tibial incision. 2 Femoral Fixation Pull on free end of graft while inspecting the graft as it wraps around the lateral femoral condyle. If there is a soft tissue bridge between the graft passageway and the lateral femoral condyle, this should be released with scissors to ensure the graft lies flush against the lateral femoral condyle. Allow knee to hang at a relaxed 90 degrees of flexion With firm tension on the free end of the graft, place 3 to 4 figure 8 sutures securing the graft to the periosteum of the lateral femoral condyle. This will provide femoral fixation of the graft as well as restore rotational stability to the knee. The fixation point of the graft is very near the native femoral footprint of the anterolateral ligament (ALL). DO NOT externally rotate the foot during femoral fixation. This can overconstrain the knee in flexion. 3 Tibial Fixation Place knee in full extension. Expose and incise periosteum in tibial incision. Elevate periosteal flaps with a Cobb Do a minimal elevation laterally as this can be close to tubercle apophysis. Decorticate exposed tibia with burr Pull firm tension on graft to determine final position on the tibia. Place at least three heavy sutures through each periosteal flap and graft. When placing, pass sutures through graft a couple millimeters proximal from where they pass through the periosteum. This will help pull a little more tension on the graft when the knots are tied. Place all sutures prior to tying. With one person pull tension on graft and making sure it is reduced in the incision, a second person will tie the knots. A second assistant can be useful here as well. An alternative mode of fixation can be with an interference screw or knotless suture anchor construct. If this mode of fixation is chosen, the periosteum should still be sutured to the graft for back up fixation and to ensure graft incorporation to periosteum. After final fixation, perform Lachman exam to confirm appropriate tension. L Proximal and Distal Fixation 1 Proximal fixation pass loop device visualize the loop device from the proximal incision expose the lateral femoral cortex position it so you can retrieve from tibial tunnel use a drill tip to palpate the anterior and posterior femoral cortices insert screw drill a hole at the center of the shaft insert a screw with a soft tissue washer do not fully tighten at this point place the suture loop around the screw apply slight tension to the graft this allows the loop to sit in the correct position around the screw tighten the screw 2 Distal fixation tension graft tension distally with flexion/extension maneuvers place a soft tissue staple distal to the growth plate for graft fixation trim the remnants of the graft and check range of motion N Identify and Address Intraoperative Complications and Wound Closure 1 Wound closure use 3-0 and 4-0 biosyn for closure 2 Dressings and immobilization tegaderm and occlusive dressings steri-strips place in bledsoe and cryocuff Postoperative Patient Care O Perioperative Inpatient Management 1 Discharges patient appropriately pain meds outpatient PT initiate pt POD1 aggressive cryotherapy (ice) immediate weight bearing (shown to reduce patellofemoral pain) emphasize early full passive extension (especicially if associated with MCL injury or patella dislocation) place in bledsoe brace and cryocuff schedule follow up in 2 weeks R Post Operative Management 1 Disposition Can be done on outpatient basis but these young patients may require an overnight stay in the hospital for pain management and physical therapy assessment. 2 Weight-Bearing Restrictions Toe-touch weight bearing for 6 weeks to protect suture fixation. 3 Range of Motion Restrictions 0-90 for six weeks post-op in hinged knee brace 4 Physical Therapy Sessions commence 1-2 weeks post-op Therapy will be for a minimum of 6 months and often times 9 months or longer Rehabilitation will focus on neuromuscular reeducation and proper biomechanics. 5 Return to Play Minimum of 6 months after surgery but more dependent on rehabilitation progress. Typical time frame is 9 months.