Arthroscopically Aided ACL Reconstruction

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SAMPLE EXCERPT
- Full procedure text, video and illustrations available with the full product
PRE-PROCEDURE
INDICATIONS
  • Treatment can be operative or nonoperative.
  • There are several variables that determine operative versus nonoperative treatment.
    • Sports activity level
      • Jumping, hard cutting, and pivoting sports: football, basketball, soccer
        • Clear candidates for anterior cruciate ligament reconstruction
      • Lateral motion with less jumping or hard cutting: baseball, skiing, racquet sports
        • Consider anterior cruciate ligament reconstruction
      • Linear sports: track, running
        • Possible nonoperative treatment
    • Sport skill level
      • Recreational athletes may be more willing to undergo nonoperative treatment.
    • Age
      • More elderly patients may benefit from nonoperative treatment.
    • Associated injuries
      • Lateral meniscal tears are commonly observed in acute anterior cruciate ligament tears.
CONTRAINDICATIONS
  • Patients with associated medial collateral ligament injury may have impaired flexion that impairs rehabilitation. Flexion should be restored prior to surgery.
EQUIPMENT
  • Standard knee arthroscopy set
  • Depending on the graft used, specific guides for placement of the graft
ANATOMY
  • The anterior cruciate ligament consists of two functional bundles
    • Anteromedial
    • Posterolateral
      • These are named based on their insertion point into the tibia.
  • The relationship between the two bundles is dependent on the flexion angle of the knee.
    • In extension, bundles are parallel
      • Posterolateral bundle tightens in extension
        • The posterolateral bundle also tightens during internal and external rotation of the knee.
    • In flexion, bundles are crossed
      • Anteromedial bundle tightens in flexion, while posterolateral bundle loosens.

PROCEDURE
Sample excerpt does not include step-by-step text instructions for performing this procedure
The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

POST-PROCEDURE
TECHNIQUES
  • Post-Procedure: Bone-Patellar Tendon-Bone Graft: Endoscopic
  • Post-Procedure: Bone-Patellar Tendon-Bone Graft: Two-Incision
  • Post-Procedure: Endoscopic Quadruple Hamstring Graft
  • Post-Procedure: Transepiphyseal Replacement of Anterior Cruciate Ligament Using Quadruple Hamstring Grafts
  • Post-Procedure: Physeal Sparing Reconstruction of the Anterior Cruciate Ligament

Post-Procedure: Bone-Patellar Tendon-Bone Graft: Endoscopic

POST-PROCEDURE CARE

See Table 2.

COMPLICATIONS
  • See Table 2 for significant and less common problems.
  • Impingement
    • Signs and symptoms indicating impingement
      • Loss of full extension
      • Persistent effusion
      • Anterior knee pain
      • Clicking or popping in the anterior part of the knee that is painful with terminal extension
    • Postoperative radiographs are reviewed to make sure that the tunnels are correctly placed and that an obvious impingement is not demonstrable.
      • A lateral radiograph should be obtained with the knee in extension to:
        • Ensure the tibial tunnel is posterior to the foot of the intercondylar notch
        • Ensure screw placement in the femur is in the posterior aspect of the intercondylar notch
  • Arthrofibrosis
    • Treat with antiinflammatory medication and supervised therapy.
      • If motion fails to progress over 4 to 6 weeks of therapy and the patient has less than 90 degrees flexion after 6 weeks of supervised physical therapy, gentle manipulation and possibly arthroscopic evaluation should be considered.
  • Postoperative infections
    • Uncommon with arthroscopic anterior cruciate ligament reconstructions
    • Signs and symptoms indicating early infection:
      • Persistence or recurrence of temperature 5 to 6 days after the procedure with increased pain
      • Loss of knee motion
      • Heat or erythema at the knee site
    • If knee aspiration shows a white cell count to be elevated, often in the range of 20,000/ L or more, arthroscopic irrigation and evaluation of the graft should be performed.
    • A combination of intravenous antibiotics for 2 to 3 weeks followed by oral antibiotics to complete a 6-week course of organism-specific antibiotic treatment is necessary.
ANALYSIS OF RESULTS
  • Patellar tendon and hamstring grafts, when fixed at the joint line with secondary fixation on the tibia, have almost equal results.
    • Wagner found slightly better results with a hamstring, but most studies show comparable results with newer fixation techniques.
OUTCOMES AND EVIDENCE
  • Stability and failure rates
    • Five-year follow-up studies of anterior cruciate ligament reconstruction using autograft bone-patellar tendon-bone grafts and hamstring grafts show similar results.
  • Stiffness and strength
    • Slightly better with bone-patellar tendon-bone, but overall results are comparable
    • Allograft studies at 5- and 7-year follow-up are similar to those with autograft for the following reasons:
      • The incidence of effusions and apparent graft rejection has decreased.
      • Graft procurement and sterilization techniques have improved.
    • Failure rates
      • Stable at about 7% to 8% at 5-year follow-up when graft failure is the cause of the poor outcome
        • Other studies measure failure by KT-1000 testing, incidence of the knee giving way, or failure of the patient to return to a previous sporting activity.
          • If these parameters are used to measure surgical failure, the percentage ranges from 5% to 52%.
    • Failure has important economic and emotional consequences.
    • Five-year follow-up studies of anterior cruciate ligament reconstruction, using autograft bone-patellar tendon-bone grafts and hamstring grafts show similar results.
    • Meniscal damage has been shown to occur in approximately
      • 40% at 1 year
      • 60% at 5 years
      • Approximately 80% at 10 years
        • This is the same incidence as degenerative joint disease seen at 10 years.
    Procedure: Bone-Patellar Tendon-Bone Graft: Endoscopic

    Post-Procedure: Bone-Patellar Tendon-Bone Graft: Two-Incision

    POST-PROCEDURE CARE

    See Table 2.

    COMPLICATIONS
    • See Table 2 for significant and less common problems.
    • Impingement
      • Signs and symptoms indicating impingement
        • Loss of full extension
        • Persistent effusion
        • Anterior knee pain
        • Clicking or popping in the anterior part of the knee that is painful with terminal extension
      • Postoperative radiographs are reviewed to make sure that the tunnels are correctly placed and that an obvious impingement is not demonstrable.
        • A lateral radiograph should be obtained with the knee in extension to:
          • Ensure the tibial tunnel is posterior to the foot of the intercondylar notch
          • Ensure screw placement in the femur is in the posterior aspect of the intercondylar notch.
    • Arthrofibrosis
      • Treat with antiinflammatory medication and supervised therapy.
        • If motion fails to progress over 4 to 6 weeks of therapy and the patient has less than 90 degrees flexion after 6 weeks of supervised physical therapy, gentle manipulation and possibly arthroscopic evaluation should be considered.
    • Postoperative infections
      • Uncommon with arthroscopic anterior cruciate ligament reconstructions
      • Signs and symptoms indicating early infection:
        • Persistence or recurrence of fever 5 to 6 days after the procedure with increased pain
        • Loss of knee motion
        • Heat or erythema at the knee site
      • If knee aspiration shows a white cell count to be elevated, often in the range of 20,000/ L or more, arthroscopic irrigation and evaluation of the graft should be performed.
      • A combination of antibiotics intravenously for 2 to 3 weeks followed by oral antibiotics to complete a 6-week course of organism-specific antibiotic treatment is necessary.
    ANALYSIS OF RESULTS
    • Patellar tendon and hamstring grafts, when fixed at the joint line with secondary fixation on the tibia, have almost equal results.
      • Wagner in his study found slightly better results with a hamstring, but most studies show comparable results with newer fixation techniques.
    OUTCOMES AND EVIDENCE
    • Stability and failure rates
      • Five-year follow-up studies of anterior cruciate ligament reconstruction, using autograft bone-patellar tendon-bone grafts and hamstring grafts show similar results.
    • Stiffness and strength
      • Slightly better with bone-patellar tendon-bone, but overall results are comparable.
      • Allograft studies at 5- and 7-year follow-up are similar to those with autograft for the following reasons:
        • The incidence of effusions and apparent graft rejection has decreased.
        • Graft procurement and sterilization techniques have improved.
    • Failure rates
      • Stable at about 7% to 8% at 5-year follow-up when graft failure is the cause of the poor outcome
        • Other studies measure failure by KT-1000 testing, incidence of the knee giving way, or failure of the patient to return to a previous sporting activity.
          • If these parameters are used to measure surgical failure, the percentage ranges from 5% to 52%.
      • Failure has important economic and emotional consequences.
      • Five-year follow-up studies of anterior cruciate ligament reconstruction, using autograft bone-patellar tendon-bone grafts and hamstring grafts show similar results.
      • Meniscal damage has been shown to occur in approximately
        • 40% at 1 year
        • 60% at 5 years
        • Approximately 80% at 10 years
          • This is the same incidence as degenerative joint disease seen at 10 years.
Procedure: Bone-Patellar Tendon-Bone Graft: Two-Incision

Post-Procedure: Endoscopic Quadruple Hamstring Graft

POST-PROCEDURE CARE
  • Table 2 provides detail on appropriate post-procedure care. However, when the hamstring graft is used, the rehabilitation is typically at a slower pace.
  • The patient generally is allowed to return to full activity at around 9 months.
COMPLICATIONS
  • See Table 2 for significant and less common problems.
  • Impingement
    • Signs and symptoms indicating impingement
      • Loss of full extension
      • Persistent effusion
      • Anterior knee pain
      • Clicking or popping in the anterior part of the knee that is painful with terminal extension
    • Postoperative radiographs are reviewed to make sure that the tunnels are correctly placed and that an obvious impingement is not demonstrable.
      • A lateral radiograph should be obtained with the knee in extension to:
        • Ensure the tibial tunnel is posterior to the foot of the intercondylar notch.
        • Ensure screw placement in the femur is in the posterior aspect of the intercondylar notch.
  • Arthrofibrosis
    • Treat with antiinflammatory medication and supervised therapy.
      • If motion fails to progress over 4 to 6 weeks of therapy and the patient has less than 90 degrees flexion after 6 weeks of supervised physical therapy, gentle manipulation and possibly arthroscopic evaluation should be considered.
  • Postoperative infections
    • Uncommon with arthroscopic anterior cruciate ligament reconstructions
    • Signs and symptoms indicating early infection:
      • Persistence or recurrence of temperature 5 to 6 days after the procedure with increased pain
      • Loss of knee motion
      • Heat or erythema at the knee site
    • If knee aspiration shows a white cell count to be elevated, often in the range of 20,000/ L or more, arthroscopic irrigation and evaluation of the graft should be performed.
    • A combination of intravenous antibiotics for 2 to 3 weeks followed by oral antibiotics to complete a 6-week course of organism-specific antibiotic treatment is necessary.
ANALYSIS OF RESULTS
  • Patellar tendon and hamstring grafts, when fixed at the joint line with secondary fixation on the tibia, have almost equal results.
    • Wagner found slightly better results with a hamstring, but most studies show comparable results with newer fixation techniques.
OUTCOMES AND EVIDENCE
  • Stability and failure rates
    • Five-year follow-up studies of anterior cruciate ligament reconstruction using autograft bone-patellar tendon-bone grafts and hamstring grafts show similar results.
  • Stiffness and strength
    • Slightly better with bone-patellar tendon-bone, but overall results are comparable.
    • Allograft studies at 5- and 7-year follow-up are similar to those with autograft for the following reasons:
      • The incidence of effusions and apparent graft rejection has decreased.
      • Graft procurement and sterilization techniques have improved.
  • Failure rates
    • Stable at about 7% to 8% at 5-year follow-up when graft failure is the cause of the poor outcome
      • Other studies measure failure by KT-1000 testing, incidence of the knee giving way, or failure of the patient to return to a previous sporting activity.
        • If these parameters are used to measure surgical failure, the percentage ranges from 5% to 52%.
    • Failure has important economic and emotional consequences.
    • Five-year follow-up studies of anterior cruciate ligament reconstruction, using autograft bone-patellar tendon-bone grafts and hamstring grafts show similar results.
  • Meniscal damage has been shown to occur in approximately
    • 40% at 1 year
    • 60% at 5 years
    • Approximately 80% at 10 years
      • This is the same incidence as degenerative joint disease seen at 10 years.
Procedure: Endoscopic Quadruple Hamstring Graft

Post-Procedure: Transepiphyseal Replacement of Anterior Cruciate Ligament Using Quadruple Hamstring Grafts

POST-PROCEDURE CARE

Rehabilitation must be geared to the age of the young patient.

COMPLICATIONS
  • See Table 2 for significant and less common problems.
  • Impingement
    • Signs and symptoms indicating impingement
      • Loss of full extension
      • Persistent effusion
      • Anterior knee pain
      • Clicking or popping in the anterior part of the knee that is painful with terminal extension
    • Postoperative radiographs are reviewed to make sure that the tunnels are correctly placed and that an obvious impingement is not demonstrable.
      • A lateral radiograph should be obtained with the knee in extension to:
        • Ensure the tibial tunnel is posterior to the foot of the intercondylar notch
        • Ensure screw placement in the femur is in the posterior aspect of the intercondylar notch.
  • Arthrofibrosis
    • Treat with antiinflammatory medication and supervised therapy.
      • If motion fails to progress over 4 to 6 weeks of therapy and the patient has less than 90 degrees flexion after 6 weeks of supervised physical therapy, gentle manipulation and possibly arthroscopic evaluation should be considered.
  • Postoperative infections
    • Uncommon with arthroscopic anterior cruciate ligament reconstructions
    • Signs and symptoms indicating early infection:
      • Persistence or recurrence of temperature 5 to 6 days after the procedure with increased pain
      • Loss of knee motion
      • Heat or erythema at the knee site
    • If knee aspiration shows a white cell count to be elevated, often in the range of 20,000/ L or more, arthroscopic irrigation and evaluation of the graft should be performed.
    • A combination of antibiotics intravenously for 2 to 3 weeks followed by oral antibiotics to complete a 6-week course of organism-specific antibiotic treatment is necessary.
ANALYSIS OF RESULTS
  • Patellar tendon and hamstring grafts, when fixed at the joint line with secondary fixation on the tibia, have almost equal results.
    • Wagner found slightly better results with a hamstring, but most studies show comparable results with newer fixation techniques.
OUTCOMES AND EVIDENCE
  • Stability and failure rates
    • Five-year follow-up studies of anterior cruciate ligament reconstruction using autograft bone-patellar tendon-bone grafts and hamstring grafts show similar results.
  • Stiffness and strength
    • Slightly better with bone-patellar tendon-bone, but overall results are comparable.
    • Allograft studies at 5- and 7-year follow-up are similar to those with autograft because of the following:
      • The incidence of effusions and apparent graft rejection has decreased.
      • Graft procurement and sterilization techniques have improved.
  • Failure rates
    • Stable at about 7% to 8% at 5-year follow-up when graft failure is the cause of the poor outcome
      • Other studies measure failure by KT-1000 testing, incidence of the knee giving way, or failure of the patient to return to a previous sporting activity.
        • If these parameters are used to measure surgical failure, the percentage ranges from 5% to 52%.
    • Failure has important economic and emotional consequences.
    • Five-year follow-up studies of anterior cruciate ligament reconstruction, using autograft bone-patellar tendon-bone grafts and hamstring grafts show similar results.
    • Meniscal damage has been shown to occur in approximately
      • 40% at 1 year
      • 60% at 5 years
      • Approximately 80% at 10 years
        • This is the same incidence as degenerative joint disease seen at 10 years.
Procedure: Transepiphyseal Replacement of Anterior Cruciate Ligament Using Quadruple Hamstring Grafts

Post-Procedure: Physeal Sparing Reconstruction of the Anterior Cruciate Ligament

POST-PROCEDURE CARE
  • Touch-down weight bearing is allowed for 6 weeks.
  • Immediate mobilization from 0 to 90 degrees is allowed for the first 2 weeks.
    • Continuous passive motion from 0 to 90 degrees is used for the first 2 weeks postoperatively.
  • A protective hinged knee brace is used for 6 weeks after surgery.
    • Use motion limits of 0 to 90 degrees for the first 2 weeks.
  • Progressive rehabilitation consists of:
    • Range-of-motion exercises
    • Patellar mobilization
    • Electrical stimulation
    • Pool therapy (if available)
    • Proprioception exercises
    • Closed-chain strengthening exercises during the first 3 months postoperatively followed by straight-line jogging
    • Polymetric exercises
    • Sport cord exercises
    • Sport-specific exercises
  • Return to full activity, including sports that involve cutting, usually are allowed at 6 months postoperatively.
    • A custom-made knee brace is used routinely during cutting and pivoting activities for the first 2 years after the return to sports.
COMPLICATIONS
  • Impingement
    • Signs and symptoms indicating impingement
      • Loss of full extension
      • Persistent effusion
      • Anterior knee pain
      • Clicking or popping in the anterior part of the knee that is painful with terminal extension
    • Postoperative radiographs are reviewed to make sure that the tunnels are correctly placed and that an obvious impingement is not demonstrable.
      • A lateral radiograph should be obtained with the knee in extension to:
        • Ensure the tibial tunnel is posterior to the foot of the intercondylar notch
        • Ensure screw placement in the femur is in the posterior aspect of the intercondylar notch.
  • Arthrofibrosis
    • Treat with antiinflammatory medication and supervised therapy.
      • If motion fails to progress over 4 to 6 weeks of therapy and the patient has less than 90 degrees flexion after 6 weeks of supervised physical therapy, gentle manipulation and possibly arthroscopic evaluation should be considered.
  • Postoperative infections
    • Uncommon with arthroscopic anterior cruciate ligament reconstructions
    • Signs and symptoms indicating early infection:
      • Persistence or recurrence of temperature 5 to 6 days after the procedure with increased pain
      • Loss of knee motion
      • Heat or erythema at the knee site
    • If knee aspiration shows a white cell count to be elevated, often in the range of 20,000/ L or more, arthroscopic irrigation and evaluation of the graft should be performed.
    • A combination of intravenous antibiotics for 2 to 3 weeks followed by oral antibiotics to complete a 6-week course of organism-specific antibiotic treatment is necessary.
ANALYSIS OF RESULTS
  • Patellar tendon and hamstring grafts, when fixed at the joint line with secondary fixation on the tibia, have almost equal results.
    • Wagner found slightly better results with a hamstring, but most studies show comparable results with newer fixation techniques.
OUTCOMES AND EVIDENCE
  • Stability and failure rates
    • Five-year follow-up studies of anterior cruciate ligament reconstruction using autograft bone-patellar tendon-bone grafts and hamstring grafts show similar results.
  • Stiffness and strength
    • Slightly better with bone-patellar tendon-bone, but overall results are comparable.
    • Allograft studies at 5- and 7-year follow-up are similar to those with autograft for the following reasons:
      • The incidence of effusions and apparent graft rejection has decreased.
      • Graft procurement and sterilization techniques have improved.
  • Failure rates
    • Stable at about 7% to 8% at 5-year follow-up when graft failure is the cause of the poor outcome
      • Other studies measure failure by KT-1000 testing, incidence of the knee giving way, or failure of the patient to return to a previous sporting activity.
        • If these parameters are used to measure surgical failure, the percentage ranges from 5% to 52%.
    • Failure has important economic and emotional consequences.
    • Five-year follow-up studies of anterior cruciate ligament reconstruction, using autograft bone-patellar tendon-bone grafts and hamstring grafts show similar results.
    • Meniscal damage has been shown to occur in approximately
      • 40% at 1 year
      • 60% at 5 years
      • Approximately 80% at 10 years
        • This is the same incidence as degenerative joint disease seen at 10 years.
Procedure: Physeal Sparing Reconstruction of the Anterior Cruciate Ligament
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