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Anterior Cruciate Ligament Reconstruction Using a Ribbon-Like Graft With a C-Shaped Tibial Bone Tunnel.

ABSTRACT: According to recent anatomic studies, the anterior cruciate ligament (ACL) appears to be a flat, "ribbon-like" structure, with a thin, oval-shaped insertion on the femur and a C-shaped tibial insertion. According to this anatomy, we describe an ACL-reconstruction technique that aims to approximate this natural anatomy. The basic principle of this technique is not to use conventional round tunnels but create tunnel shapes that resemble more closely the original ACL insertion sites. Using either a rectangular quadriceps tendon graft or a "flat" hamstring graft may not only provide a biomechanical advantage with increased rotational stability but also improve bone-tendon healing due to increased bone-tendon contact and decreased diffusion length. Creating a C-shaped tibial tunnel also avoids laceration of the anterior horn of the lateral meniscus, which is frequently harmed during conventional tibial tunnel drilling.

SUBMITTER: Fink C

PROVIDER: S-EPMC7029192 | biostudies-literature | 2020 Feb

REPOSITORIES: biostudies-literature

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Anterior Cruciate Ligament Reconstruction Using a Ribbon-Like Graft With a C-Shaped Tibial Bone Tunnel.

Fink Christian C Smigielski Robert R Siebold Rainer R Abermann Elisabeth E Herbort Mirco M

Arthroscopy techniques 20200122 2

According to recent anatomic studies, the anterior cruciate ligament (ACL) appears to be a flat, "ribbon-like" structure, with a thin, oval-shaped insertion on the femur and a C-shaped tibial insertion. According to this anatomy, we describe an ACL-reconstruction technique that aims to approximate this natural anatomy. The basic principle of this technique is not to use conventional round tunnels but create tunnel shapes that resemble more closely the original ACL insertion sites. Using either a ...[more]

PMID: 32099779

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Project description:Anterior cruciate ligament (ACL) injuries are among the most common lesions in orthopaedics practice, but still today, rates up to 24% of unsatisfactory results are reported. Unaddressed anterolateral complex (ALC) injuries have been claimed to be responsible for residual anterolateral rotatory instability (ALRI) after isolate ACL reconstruction and have demonstrated to increase graft failure. In this article, we present our technique for reconstruction of the ACL and anterolateral (ALL) ligament combining the advantages of the anatomical position and the intraosseous femoral fixation to ensure anteroposterior and anterolateral rotational stability. Technique Video Video 1 This video demonstrates our surgical technique for combined anatomic anterior cruciate ligament (ACL) and antero-lateral ligament (ALL) reconstruction. The knee is positioned, and examination under anaesthesia is performed confirming high-grade pivot shift. Medial and lateral landmarks are signed. A small anteromedial incision is performed, and semitendinosus and gracilis tendons are harvested using an open stripper. Care is taken to leave the distal insertion of both tendons intact. The two tendons are then whipstitched together at both extremities with high-resistance wires. Diameter is measured, and preparation of the graft is completed. On the lateral aspect of the knee, lateral femoral epicondyle, Gerdy’s tubercle and fibular head are identified and marked. A 3-cm incision is performed just posterior to the lateral epicondyle. Fascia lata is incised, and the anatomical femoral insertion of the anterolateral ligament is identified, proximal and posterior to the lateral epicondyle. With the help of an assistant, using an outside-in technique, a guide pin is positioned from the femoral insertion of the ALL to the femoral footprint of the ACL, and a tunnel of appropriate diameter is drilled. Tibial tunnel is then drilled using a standard technique. After positioning of the screw wire in the femoral socket, the graft is shuttled with two graspers through the tibial and femoral tunnels. After cyclic loading, femoral fixation is performed with the knee at 30° of flexion and neutral rotation. Lateral collateral ligament is identified and isolated, with the help of a curved forcep. The graft is then shuttled beneath the collateral ligament, from posterior to anterior. This can be done directly or with the help of a shuttling wire. A small vertical incision is performed, halfway between the Gerdy’s tubercle and the fibular head. With the help of a needle, the anatomic tibial insertion of the ALL is identified, about 10 mm below the articular surface. Fluoroscopy can be used for confirmation. The graft is passed underneath the fascia latae. Fixation of the graft in the tibial anatomical ALL insertion is performed with a low-profile staple, keeping the knee in full extension and neutral rotation. Finally, proper tension of the graft is demonstrated. If additional tension is required, the tibial portion of the ACL can be pulled using the distal whipstitch, and the tibial fixation can be added using an interference screw.

Dataset Information

Anterior Cruciate Ligament Reconstruction Using a Ribbon-Like Graft With a C-Shaped Tibial Bone Tunnel.

Publications

Anterior Cruciate Ligament Reconstruction Using a Ribbon-Like Graft With a C-Shaped Tibial Bone Tunnel.

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