acl

Options for MCL

Repair

Reconstruction

Femoral repair of MCL

Technique

Incision

- lateral border femur

- 15 cm proximal to knee joint

- curve anteriorly across patella tendon

Harvest ITB

- expose ITB

- width and length depend on patient size

- usually central 3 cm

- take 25 - 30 cm in length

- tubularise end and leave threads long to pass tendon

Lateral dissection

- expose and elevate LCL

General

- haemarthrosis

- DVT

- infection

Septic Arthritis

Incidence

Issue

Avoiding convergence of ACL tunnel and femoral tunnels of popliteus / LCL

- drill LCL and popliteus femoral tunnels anterior to avoid more posterior ACL tunnel

- avoid drilling LCL femoral tunnel proximal, to avoid more proximal ACL tunnel

Moatshe et al. Am J Sports Med 2017

- avoiding tunnel convergence

- aim LCL and popliteus tunnel anteriorly 35^o

Graft Preparation

Defrost

- in 2 litres normal saline

- can add vancomycin powder

Choose which part of graft to use

- usually central third

- can take either side

- try to leave sufficient graft in case of disasters

- i.e. dropping or rupturing graft

Endobutton + Interference screw +/- staple or post

Advantage

- endobutton simple yet strong fixation

- endobutton eliminates problem if blow out back wall

Incidence

Up to 8% patients with ACL reconstruction will have recurrent instability and graft failure

- increased with surgical inexperience

Graft can

1.  Be inadequate from the start

- inadequate tension

- poor tunnel placement

Concept Accelerated Rehabilitation

Shelbourne 1995

- noticed patients noncompliant with their rehab protocol were doing much better

- looked at what noncompliant patients were doing

- what they were doing was advancing activities as tolerated

Reviewed results of accelerated rehabilitation

- fewer ruptures with better ROM

Major recommendations

NHx

Natural History of ACL deficient knee is variable

- functional instability 15% - 90%

- progression to OA is variable

Depends on level of patient demands / activity

1.  Late meniscal injury in ACL deficient knee

15-25%

2.  Function

Daniels Am J Sports Med 1994

- 292 ACL defecients knees

Anatomy

Developmental Anatomy

Knee joint first appears as a mesenchymal cleft at 8 weeks gestation

- ACL and PCL separate entities by week 10