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Arthroscopically Aided ACL Reconstruction

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
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  • Clinical pearls providing practical clinical tips from medical experts
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  • Links to medical evidence and related procedures
<B>A</B>, Saline arthroscopy bag is secured to table to assist in maintaining knee flexion. <B>B</B>, Prepared graft with No. 5 suture and bone plug. <B>C</B>, Complete resection of soft tissue to back of notch for clear viewing of over-the-top spot. <B>D</B>, Increase in tibial guide angle. Length of tunnel can be increased. <B>E</B>, Tibial guide is positioned so that Kirschner wire will enter joint at base of medial tibial spine just medial to center of intercondylar notch. <B>F</B>, Three reference points-inner edge of lateral meniscus, base of medial spine, and posterior cruciate ligament-are used for tibial guide wire. From Canale ST, Beaty JH (eds): Campbell's Operative Orthopaedics, 11th ed. Philadelphia, Elsevier, 2008.
Figure 1 :  A, Saline arthroscopy bag is secured to table to assist in maintaining knee flexion. B, Prepared graft with No. 5 suture and bone plug. C, Complete resection of soft tissue to back of notch for clear viewing of over-the-top spot. D, Increase in tibial guide angle. Length of tunnel can be increased. E, Tibial guide is positioned so that Kirschner wire will enter joint at base of medial tibial spine just medial to center of intercondylar notch. F, Three reference points-inner edge of lateral meniscus, base of medial spine, and posterior cruciate ligament-are used for tibial guide wire. From Canale ST, Beaty JH (eds): Campbell's Operative Orthopaedics, 11th ed. Philadelphia, Elsevier, 2008.

<B>G</B>, Tibial tunnel should be posterior to roof of altered intercondylar notch to prevent graft impingement in knee extension. <B>H</B>, Use of 7-mm femoral offset guide to assist with femoral guide wire placement. <B>I</B>, Derotation slot at 12 o'clock position on femoral tunnel to allow guide wire placement and viewing of recessed graft and to prevent posterior migration of interference screw. <B>J</B>, Use of probe to guide graft into femoral tunnel, with cancellous portion of graft directly anterior. <B>K</B>, With knee flexed more than 100 degrees, guide wire is placed up femoral tunnel through middle cannula. Interference screw is then passed, making sure that guide wire and traction suture is a straight line, thus ensuring minimal divergence between screw and bone plug. From Canale ST, Beaty JH (eds): Campbell's Operative Orthopaedics, 11th ed. Philadelphia, Elsevier, 2008.
Figure 1 :  G, Tibial tunnel should be posterior to roof of altered intercondylar notch to prevent graft impingement in knee extension. H, Use of 7-mm femoral offset guide to assist with femoral guide wire placement. I, Derotation slot at 12 o'clock position on femoral tunnel to allow guide wire placement and viewing of recessed graft and to prevent posterior migration of interference screw. J, Use of probe to guide graft into femoral tunnel, with cancellous portion of graft directly anterior. K, With knee flexed more than 100 degrees, guide wire is placed up femoral tunnel through middle cannula. Interference screw is then passed, making sure that guide wire and traction suture is a straight line, thus ensuring minimal divergence between screw and bone plug. From Canale ST, Beaty JH (eds): Campbell's Operative Orthopaedics, 11th ed. Philadelphia, Elsevier, 2008.

Table 1 : 

Calcified stump of anterior cruciate ligament after chronic tear. From Canale ST, Beaty JH (eds): Campbell's Operative Orthopaedics, 11th ed. Philadelphia, Elsevier, 2008.
Figure 2 :  Calcified stump of anterior cruciate ligament after chronic tear. From Canale ST, Beaty JH (eds): Campbell's Operative Orthopaedics, 11th ed. Philadelphia, Elsevier, 2008.

<B>A</B>, Gaff passed along femoral condyle to pull rear entry guide into knee. <B>B</B>, Rear-entry guide is placed in pilot hole in 11 o'clock position on right knee, 6 to 7 mm anterior to over-the-top spot. C, External view of guide, making sure it is at least 1.5 to 2 cm anterior to posterior femoral cortex. From Canale ST, Beaty JH (eds): Campbell's Operative Orthopaedics, 11th ed. Philadelphia, Elsevier, 2008.
Figure 3 :  A, Gaff passed along femoral condyle to pull rear entry guide into knee. B, Rear-entry guide is placed in pilot hole in 11 o'clock position on right knee, 6 to 7 mm anterior to over-the-top spot. C, External view of guide, making sure it is at least 1.5 to 2 cm anterior to posterior femoral cortex. From Canale ST, Beaty JH (eds): Campbell's Operative Orthopaedics, 11th ed. Philadelphia, Elsevier, 2008.

<B>A,</B> Extremity is placed in figure-four position to assist in hamstring harvest. <B>B</B>, Three-centimeter incision is made over pes anserinus tendons. <B>C</B>, Inferior retraction of sartorius tendon, exposing gracilis and semitendinosus tendons. <B>D</B>, Placement of Penrose drain around hamstring tendon to be harvested. <B>E</B>, Two running, interlocking (Krackow) sutures. <B>F</B>, Fixation technique for quadruple hamstring graft. From Canale ST, Beaty JH (eds): Campbell's Operative Orthopaedics, 11th ed. Philadelphia, Elsevier, 2008.
Figure 4 :  A, Extremity is placed in figure-four position to assist in hamstring harvest. B, Three-centimeter incision is made over pes anserinus tendons. C, Inferior retraction of sartorius tendon, exposing gracilis and semitendinosus tendons. D, Placement of Penrose drain around hamstring tendon to be harvested. E, Two running, interlocking (Krackow) sutures. F, Fixation technique for quadruple hamstring graft. From Canale ST, Beaty JH (eds): Campbell's Operative Orthopaedics, 11th ed. Philadelphia, Elsevier, 2008.

Transepiphyseal replacement of anterior cruciate ligament using quadruple hamstring grafts. <B>A</B>, Graphically enhanced lateral view from C-arm after drilling of femoral hole. <B>B</B>, Lateral radiograph of tibia, demonstrating correct position of tibial guide wire. Although guide wire appears to enter tibial tubercle in this view, it actually enters epiphysis medial to tibial tubercle. <B>C</B>, EndoButton continuous loop passed around middle of double tendons and looped on itself. <B>D</B>, Semitendinosus and gracilis tendons pulled up through tibia and out of lateral femoral condyle with use of No. 5 suture in EndoButton. <B>E</B>, EndoButton washer is placed over EndoButton, and washer is pulled back to surface of lateral femoral condyle. <B>F</B>, Quadruple hamstring grafts secured distally by tying No. 5 FiberWire sutures over tibial screw and post. G, Radiograph four months after surgery, showing properly placed transepiphyseal tibial and femoral holes. <B>A, B</B>, and <B>G</B> from Anderson AF: Transepiphyseal replacement of the anterior cruciate ligament using quadruple hamstring grafts in skeletally immature patients. J Bone Joint Surg Am 86-A:201, 2004. <B>C-F</B> redrawn from Anderson AF: Transepiphyseal replacement of the anterior cruciate ligament using quadruple hamstring grafts in skeletally immature patients. J Bone Joint Surg Am 86-A:201, 2004.
Figure 5 :  Transepiphyseal replacement of anterior cruciate ligament using quadruple hamstring grafts. A, Graphically enhanced lateral view from C-arm after drilling of femoral hole. B, Lateral radiograph of tibia, demonstrating correct position of tibial guide wire. Although guide wire appears to enter tibial tubercle in this view, it actually enters epiphysis medial to tibial tubercle. C, EndoButton continuous loop passed around middle of double tendons and looped on itself. D, Semitendinosus and gracilis tendons pulled up through tibia and out of lateral femoral condyle with use of No. 5 suture in EndoButton. E, EndoButton washer is placed over EndoButton, and washer is pulled back to surface of lateral femoral condyle. F, Quadruple hamstring grafts secured distally by tying No. 5 FiberWire sutures over tibial screw and post. G, Radiograph four months after surgery, showing properly placed transepiphyseal tibial and femoral holes. A, B, and G from Anderson AF: Transepiphyseal replacement of the anterior cruciate ligament using quadruple hamstring grafts in skeletally immature patients. J Bone Joint Surg Am 86-A:201, 2004. C-F redrawn from Anderson AF: Transepiphyseal replacement of the anterior cruciate ligament using quadruple hamstring grafts in skeletally immature patients. J Bone Joint Surg Am 86-A:201, 2004.

<B>A</B>, Technique of physeal sparing, combined intraarticular and extraarticular reconstruction of anterior cruciate ligament with use of autogenous iliotibial bone graft. <B>A</B>, Iliotibial band harvested through an oblique lateral knee incision. <B>B</B>, Iliotibial band graft is detached proximally, left attached distally, and dissected free from the lateral patellar retinaculum. <B>C</B>, Iliotibial band graft brought through knee with use of full-length clamp placed from anteromedial portal through over-the-top position into lateral incision. <B>D</B>, Graft brought through over-the-top position. <B>E</B>, Clamp is placed from proximal medial incision in leg under intermeniscal ligament, and groove is made in anteromedial tibial epiphysis with use of rasp. From Kocher MS, Garg, S, Micheli LJ: Physeal sparing reconstruction of the anterior cruciate ligament in skeletally immature prepubescent children and adolescents. J Bone Joint Surg Am 2005;87:2371.
Figure 6 :  A, Technique of physeal sparing, combined intraarticular and extraarticular reconstruction of anterior cruciate ligament with use of autogenous iliotibial bone graft. A, Iliotibial band harvested through an oblique lateral knee incision. B, Iliotibial band graft is detached proximally, left attached distally, and dissected free from the lateral patellar retinaculum. C, Iliotibial band graft brought through knee with use of full-length clamp placed from anteromedial portal through over-the-top position into lateral incision. D, Graft brought through over-the-top position. E, Clamp is placed from proximal medial incision in leg under intermeniscal ligament, and groove is made in anteromedial tibial epiphysis with use of rasp. From Kocher MS, Garg, S, Micheli LJ: Physeal sparing reconstruction of the anterior cruciate ligament in skeletally immature prepubescent children and adolescents. J Bone Joint Surg Am 2005;87:2371.

<B>F</B>, Graft is brought through knee in over-the-top position and under intermeniscal ligament. <B>G</B>, Graft is brought out of proximal medial incision in leg. It is sutured to intermuscular septum and periosteum of lateral femoral condyle through lateral knee incision, and it is sutured in a trough to periosteum of proximal medial tibial metaphysis. <B>H</B>, Schematic appearance of combined intraarticular and extraarticular reconstruction. <B>F-G</B> from Kocher MS, Garg, S, Micheli LJ: Physeal sparing reconstruction of the anterior cruciate ligament in skeletally immature prepubescent children and adolescents. J Bone Joint Surg Am 2005;87:2371. H redrawn from Kocher MS, Garg, S, Micheli LJ: Physeal sparing reconstruction of the anterior cruciate ligament in skeletally immature prepubescent children and adolescents. J Bone Joint Surg Am 2005;87:2371.
Figure 6 :  F, Graft is brought through knee in over-the-top position and under intermeniscal ligament. G, Graft is brought out of proximal medial incision in leg. It is sutured to intermuscular septum and periosteum of lateral femoral condyle through lateral knee incision, and it is sutured in a trough to periosteum of proximal medial tibial metaphysis. H, Schematic appearance of combined intraarticular and extraarticular reconstruction. F-G from Kocher MS, Garg, S, Micheli LJ: Physeal sparing reconstruction of the anterior cruciate ligament in skeletally immature prepubescent children and adolescents. J Bone Joint Surg Am 2005;87:2371. H redrawn from Kocher MS, Garg, S, Micheli LJ: Physeal sparing reconstruction of the anterior cruciate ligament in skeletally immature prepubescent children and adolescents. J Bone Joint Surg Am 2005;87:2371.


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
Table 2 : 

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