ACL reconstruction: from basic to controversies Introduction

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ACL reconstruction from basic to controversies
Introduction
EFORT Vienna 2009 ExMex 1
PD Dr med Jacques Menetrey Unité
dOrthopédie et Traumatologie du Sport (UOTS)
Service de chirurgie orthopédique et
traumatologie de lappareil moteur University
Hospital of Geneva, Geneva Switzerland
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Outline

• Introduction
• Indication to ACL reconstruction
• M Marcacci
• Graft choice for ACL
• P Djian
• Tunnel positioning
• J Karlsson
• Graft fixation
• C Fink
• ACL reconstruction Single or double bundles?
• R Siebold
• Controversial cases discussion
• All

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Introduction

• First mentioning in Egyptian Papyrus
• 3000 BC
• Hippocrates (460-370 BC) typical subluxation of
  the knee caused by cruciate ligament deficiency
• Claudius (129-199 BC) ligament genu cruciata

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Macro-anatomy
ACL in the notch Occupies the 66 superior of
the notch Envelopped by a synovial sheath
Direction anterior, medial and distal Length
32 millimeters (22-41mm) Width 7-12 millimeters
32 mm

Dienst et al Orthop Clin N Am 2002
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Macro-anatomy

• Variation of the shape and size
• according to the level of the section
• proximal 34 mm2
• mid-prox 33 mm2
• median 35 mm2
• mid-distal 38 mm2
• distal 42 mm2
• Surfaces are constant whatever the
• angle of flexion of the knee

Dienst et al Orthop Clin N Am 2002 Harner et al J
Orthop Res 1995
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Macro-anatomy

• - Two bundles AM and PL
• 1) Antero-medial (AM)
• Posterior and proximal on the femur
• Anterior and medial on the tibia
• Tension and length increase during the flexion
  passive

PL
AM
Dienst et al Orthop Clin N Am 2002
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Macro-anatomy
AM 38.0 mm (12) PL 15.4 mm (-32)
Hollis et al J Biomech Eng 1991
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Tibial insertion
Siebold et al Arthroscopy 2008

• On the slope of the medial tibial spine
• 11 millimeters (8-12 millimeters) wide
• 17 millimeters (9-21 millimeters) in AP

• Tibial insertion is more solid and bigger than
  on the femur

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Femoral insertion
Siebold et al Arthroscopy 2008

• Width 8 - 2mm
• Length 15 -2 mm

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Biomechanics

• Load to failure 2160 (157) N
• Stiffness 242 (28) N/mm
• Control anterior tibial translation
• Sustain 87 applied anterior force at 30of knee
  flexion

Woo et al Am J Sports Med 1991 Butler et al J
Bone Joint Surg 1980
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Biomechanics

110 N anterior drawer
In situ force in PL is greater than in AM between
the extension and 45 of knee flexion. In situ
force in PL changes in function of the flexion
angle. In situ force in AM remains relatively
constant.
Sakane et al J Bone Joint Surg 1996
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Epidemiology

• ACL injury occurs in athletes or in the
  physically active
• Highest incidence seen in adolescent playing
  sports that involve pivoting
• Football, alpine skiing, basketball, handball

Engström et al Am J Sports Med 1991 Arendt Dick
Am J Sports Med 1995 Myklebust et al J Med Sci
Sports 1998 Sernert et al Scand J Med Sci Sports
2002 Piaseki et al Am J Sports Med 2003 Lohmander
Arthritis Rheum 2004 Griffin et al Am J Sports
Med 2006 Lohmander et al Am J Sports Med 2007
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Epidemiology

• Young women have 3-5x higher risks of injury when
  participating in these sports
• Football, alpine skiing, basketball, handball

Engström et al Am J Sports Med 1991 Arendt Dick
Am J Sports Med 1995 Myklebust et al J Med Sci
Sports 1998 Sernert et al Scand J Med Sci Sports
2002 Piaseki et al Am J Sports Med 2003 Lohmander
Arthritis Rheum 2004 Griffin et al Am J Sports
Med 2006 Lohmander et al Am J Sports Med 2007
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Epidemiology

• Annual incidence 81 per 100000 in Sweden for the
  ages between 16 and 64 years old in the general
  population
• Based on subacute MRI hospital emergency - for
  acute rotational knee injury with effusion

Frobel et al J Scand Med Sci Sports 2007
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Epidemiology

• 38000 high school students
• 175000 ACL injuries/year

Murray M Clin Sports Med 2009
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Open questions

• Indication who operates ?
• Its a human being affair !!
• ACL and OA?
• Associated lesions !
• Peripheral lesions (LCL/PLC-MCL/PMC)
• Cartilage (osteochondral)
• Meniscal injury

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Open questions

• Surgical technique, which is the best ?
• A la carte strategy
• Post-op regimen ?
• Individualization-trust the patient !!

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Thank you for your attention
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Epidemiology

• ACL injury 130000/year
• MCL injury 60000/year
• MCLACL injury 30000/year

ACL study Group Engelberg 2008
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Epidemiology

• Annual incidence 30 per 100000 in Denmark
• Based on an in-hospital clinical diagnosis of ACL
  rupture

Nielsen Yde J Trauma 1991
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Tibial insertion
Siebold et al Arthroscopy 2008

• Beware anatomical DB reconstruction cant
  always be feasible