ACL Reconstruction

ACL
ACL Reconstruction
utilizing press-fit fixation on hamstrings
without hardware - by Hans H. Paessler
1 Introduction
Reconstruction of the ACL using the hamstring has recently
become of increasing interest. Fixation using endo buttons is
the most common method. The disadvantages of this fixation
away from the point of insertion are:
• enlargement of the tunnel
• creep at the tendon-tape transition along with giving of the
tendon construct and permanent elongation (Höher et al*)
(3.8+/-0.8mm). This is also known as the Bungee effect.
Fixation close to the insertion has been suggested and such
methods have already been used successfully:
1. Fixation using an interference screw
2. Suspension of loops using transverse rods
Disadvantages of these techniques are:
• hardware costs
• problems with revision surgery
• awkward and time-consuming
Alternative solution
A technique has been developed with the following major features:
• Fixation close to the point of insertion
• Avoidance of hardware
• Simple graft preparation
2
Horizontal skin incision
• less risk of sensory nerve injury
• better cosmesis
Harvest of the hamstring tendons can be performed through a
2-3 cm horizontal incision over the pes anserinus (one fingerbreadth below the tibial tubercle). The skin incision is infiltrated
with 15 ml 0.25% bupivacain with 1:100,000 epinephrine
solution followed by intra-articular application of a further
15 ml. This allows harvesting without the use of a tourniquet.
2
ACL Reconstruction
3
3-1
Harvesting of hamstring tendons
using open stripper
Tendon Harvester 8866.951
3-1. With the knee flexed to 90°
the pes anserinus is opened at its proximal border.
3-2. The tendons are exposed. The gracilis tendon is located proximal to the semitendinosus tendon.
3-2
3-3. Retracting the crural fascia with a Kocher clamp, first the
gracilis tendon is grasped using a curved clamp. Maximum manual traction is applied and already most of the "web-like" fascia
bands connecting the undersurface of the crural fascia to the MCL
and the posterior corner of the tibia tear free. Also the interconnecting fascial bands between the two tendons can be released by
traction. The more proximal fascial bands are released by blunt
dissection with scissors, taking care to keep the tip of the scissors
away from the tendon.
3-3
3-4
3-5
3-4. With the tendon under traction using the curved clamp, the
open stripper is positioned on the tendon and its mouth is closed
half way (harvesting position). Traction is applied to the gracilis
tendon and the stripper is gently advanced proximally parallel to
the tendon. The tendon is released from its muscle by pulling the
tendon out of the incison. Now the semitendinosus tendon is harvested in the same way. The strong fascial connections between
the semitendinosus tendon and the medial head of the gastronemicus muscle located approximately 7 cm proximal to the
tibial insertion of the tendon must be divided sharply. If the tendon
stripper cannot be advanced beyond a depth of 12 to 15 cm,
thickened semimembranosus fascia may be present forming a
loop around the semitendinosus tendon. In this case the stripper
should be removed and this sling should be released by finger or
scissors dissection.
3-5 / 3-6. Both tendons are pulled out of the incision. The periostal insertion is divided by a horizontal incision up to the anterior
border of the tibia and then removed forcefully. The common
periostal insertion of both tendons is divided.
3-6
3
Graft preparation
4
Preparation
of hamstring grafts
The ends of each tendon (ST and G) are tied in a
simple knot, which is secured using 4 Ethibond
no. 2 sutures.
4-1. On the workstation remnants of muscle tissue are removed carefully using a raspatory.
4-1
Arthroscopic workstation
8866.902
incl. cover and 2 holding device
(Accessories see ACL basic set)
4-2. A simple knot is tied at the ends of the tendons. The knots are made as tight as possible
by hand and secured by four U-shaped sutures.
4-3. A mark is made 10 mm below the knot of
the semitendinosus graft and 20 mm below the
knot of the gracilis tendon (due to the thicker
knot of the semitendinosus graft, this must be
pulled into the femoral tunnel first followed by
the thinner and therefore 10 mm longer gracilis
tendon). A second mark is made 3 cm below
the first mark. This mark should be visible in the
tibial tunnel within the joint when both grafts are
pulled fully in.
4-2a
4-2b
4-3
4-4. The size of the knots and the smallest diameter of the loops are measured using a transplant template in 0.5 mm steps.
4-4
4
Transplant template 8866.952
Ø 6.0 - 12.0 mm
Tunnel placement
45°
10:00 h
ACL Reconstruction
5
Placement
of femoral tunnel
• K-wire placed at 10 or 2 o’clock
• 4 mm alignment device, anteromedial portal
• knee flexed to 120°
4 mm
The disadvantage of transtibial drilling of the femoral tunnel is that
the position of the tunnel is too steep in the notch (11-12 or 12-1
o’clock) missing the anatomical point of insertion. By drilling
through the anteromedial portal, on the other hand, the centre of
the anatomical point of insertion is always reached.
Using the 4 mm offset drill guide, a K-wire is drilled into the
cortical bone through the medial portal under fluoroscopic control,
positioned at 10 or 2 o’clock and to a depth of 3-4 mm. The
knee is then flexed at 120 ° to 130° and the K-wire drilled slightly
deeper.
Alignment wire 8869.811
(K-wire) Ø 2.4 mm / WL 430 mm
Transtibial drill guide*
Offset 4 mm 8868.241
5 mm 8868.251
6 mm 8868.261
7 mm 8868.271
*incl. 1 alignment wire (8869.811)
5
Femoral tunnel
6
Drilling the cortical bone
Using a cannulated drill over the K-wire, a tunnel
with a diameter corresponding to that of the tendon loops is drilled until cancellous bone is reached at a depth of 5-7 mm.
Cannulated drill capacity 2.5 mm / WL 140 mm
6.5 mm 8866.803
7.0 mm 8866.804
7.5 mm 8866.805
8.0 mm 8866.806
also: Handle 8869.821
7
Completion of the femoral
tunnel
The femoral tunnel is completed using a bone
harvesting tube. Insertion of a bone harvesting
tube with the same diameter as the used drill bit.
The tube is driven forward using a hammer until
the lateral cortex is reached. In order to avoid
damage to the tube, its is replaced by the drill
bit for perforation of the cortex.
ACL-Tubular Chisel Set 8866.301
consiting of:
6 tubular chisels for tunnel preparation:
7.0 x 6.0 mm / 7.5 x 6.5 mm / 8.0 x 7.0 mm
8.5 x 7.5 mm / 9.0 x 8.0 mm / 9.5 x 8.5 mm
1 handle attachment
6 Pushrods
2 Tubular Chisels for Graft Harvesting:
9.0 x 8.2 mm / 10.4 x 9.2 mm
not illustrated:
Tray for sterilisation, storage
and holding the complete
ACL-Instrument Set
also:
ACL Mallet 8866.956
Sealing membrane for handle
(pack of 10) 8920.911
6
Femoral tunnel
ACL Reconstruction
8
Cancellous bone preserved
• Cancellous bone is preserved for filling the
femoral tunnel
9
Placement of a cannulated
impactor
An impactor with a diameter corresponding to
that of the drill is inserted 12 mm deep into the
femoral tunnel. A K-wire is inserted through the
impactor, perforating the skin at the lateral thigh.
A skin incision of 10-12 mm is made at the point
where the K-wire perforates it, and the underlying
fascia is split longitudinally.
Standard Impactors* (pack of 10)
6 mm / 7 mm / 7.5 mm / 8 mm / 8.5 mm /
9 mm / 9.5 mm / 10 mm / 10.5 mm / 11 mm
*parts of ACL Impactor Set (8866.101)
also:
ACL Mallet 8866.956
10
Overdrilling the K-wire
A tunnel is drilled over the K- wire using a cannulated
drill with a diameter matching that of the knot.
Cannulated drill capacity 2.5 mm / WL 140 mm
9.0 mm 8866.808
10.0 mm 8866.811
11.0 mm 8866.813
also: Handle 8869.821
7
Femoral tunnel with bottleneck
11
Impaction of bottleneck
• Hammering in of the impactor and finishing
the bottleneck.
Impacting the spongy bone as far as the cortical
bone prevents subsequent sintering of the knot in
the bottleneck.
Handle
Tubular Chisels* for the femoral tunnel
7.0 x 6.0 mm / 7.5 x 6.5 mm / 8.0 x 7.0 mm
8.5 x 7.5 mm / 9.0 x 8.0 mm / 9.5 x 8.5 mm
* parts of ACL Tubular Chisel Set (8866.301)
Stepped Impactors* (pack of 3) for the bottleneck
10-6 mm / 11-6 mm / 12-6 mm
*parts of ACL Impactor Set (8866.101)
ACL Mallet:
The plastic face protects instruments such as impactors
and bone punches
also: ACL Mallet 8866.956
8
Tibial tunnel
ACL Reconstruction
12
Positioning
the tibial alignment device
• A 2.5 mm K-wire is inserted
• The K-wire is overdrilled
Alignment device 8869.011 comprising:
Basic section with alignment hook (8869.111)
Drill guide Ø 2.5 mm (8869.151)
Drill guide Ø 9.5 mm (8869.152)
Alignment wire (K-wire)
Ø 2.4 mm / WL 300 mm 8869.801
13
Impingement
The impingement probe is placed on the drilling
wire. The knee is then fully extended under
arthroscopic vision with the impingement probe
in position. A clearance of 1-2 mm between the
impingement probe and the roof of the notch is
desirable. Fluoroscopic visualisation and documentation in hyperextension.
Impingement probe
Ø 9 mm 8866.931
Ø 11 mm 8866.932
9
Tibial tunnel
14
Overdrilling the cortical bone
The K-wire is now overdrilled using a drill bit
corresponding to the diameter of the tendon
loops.
Cannulated drill capacity 2.5 mm / WL 140 mm
6.5 mm 8866.803
7.0 mm 8866.804
7.5 mm 8866.805
8.0 mm 8866.806
also: Handle 8869.821
15
Impaction of the tibial tunnel
Perforation of the tibial plateau
The tunnel is now enlarged using impactors starting at 6 mm until the desired size is reached.
Finally, the tibial plateau cortex is perforated with
a drill bit of the same size.
Standard Impactors* (pack of 10)
6 mm / 7 mm / 7.5 mm / 8 mm / 8.5 mm /
9 mm / 9.5 mm / 10 mm / 10.5 mm / 11 mm
*parts of ACL Impactor Set (8866.101)
also:
ACL Mallet 8866.956
Spoon 8436.601
6.5
7.0
7.5
8.0
10
Cannulated drill
mm 8866.803
mm 8866.804
mm 8866.805
mm 8866.806
Pulling in the tendon loops / Conditioning
16
ACL Reconstruction
Pulling in
the tendon loops
• Pulling in the tendon loops from lateral
• The gracilis tendon follows the semitendinosus
tendon.
Using the pulling thread, the Mersilene tapes of
the two transplants are pulled in from lateral.
The gracilis loop with the thinner knot follows the
semitendinosus loop. The sudden halt indicates
that the semitendinosus knot has reached the
graduated part of the tunnel, in other words, the
bottleneck.
Grasping forceps
forceps handle with locking
mechanism, tip with additional
fine teeth
WL 130 mm
Ø 3.4 mm 8488.096
Ø 4.5 mm 8489.096
Alternatively:
Thread puller
Ø 5 mm
WL 350 mm 8869.921
17
Conditioning the graft
The tendons are conditioned by flexing and
extending the knee 20 times with forceful traction
on both loops.
11
Creating a bony bridge / Passing a holding suture
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18
Creating a bony bridge
19
Passing a holding suture
Printed on paper based on cellulose which has been bleached without the use of chlorine.
A hole is drilled 1 cm distal to the tibial exit of the
tunnel with the 4.5 mm drill. A bony bridge is created with a curved clamp.
A holding suture is introduced with a Dechamps
hook. One half of the Mersilene tapes is pulled
through and the ends are then knotted over the
bony bridge with the knee in full extension (5-10°).
19-1
19-2
• Tying the Mersilene tapes over the bridge with
the knee in extension (19-4)
19-3
19-4
Technical specifications subject to change without notice.
• Passing a holding suture using a Dechamp
hook. (19-1 / 19-2)
• Pulling the Mersilene tapes underneath the
bony bridge. (19-3)
RICHARD WOLF GmbH · 75434 Knittlingen · PF 1164 · Phone +49 7043 - 35-0 · Fax +49 7043 - 3 53 00 · GERMANY · [email protected] · www.richard-wolf.com
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*Center for Knee and Foot Surgery and Sports Injuries - ATOS Clinic, Heidelberg, Germany
Medical Director: Prof. Dr. med. Hans H. Paessler
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