The “Footprint” Anterior Cruciate Ligament Technique: An Anatomic Approach to Anterior Cruciate Ligament Reconstruction

To address the technical limitations of the conventional transtibial technique and the steep learning curve associated with double-bundle anterior cruciate ligament (ACL) reconstruction, we have defined a novel “footprint” technique that reliably allows for anatomic single-bundle ACL reconstruction with minimal technical complications. The technique merges the principles of carefully defining the ACL footprint anatomy with the use of a modified anteromedial portal reaming technique with a flexible guidewire and reaming system. The procedure offers the advantages of an anatomic ACL reconstruction by use of anteromedial portal reaming techniques while avoiding the significant technical risks and pitfalls associated with double-bundle reconstruction. Our experience in over 100 footprint ACL reconstructions has been met with excellent clinical success with minimal intraoperative or postoperative complications. The purpose of this article is to outline the key steps of our defined procedure that are critical to achieving a successful outcome.     

Double-Bundle Reconstruction of the Anterior Cruciate Ligament Using the Transtibial Technique

We present an arthroscopic surgical procedure for double-bundle transtibial anterior cruciate ligament reconstruction with 2 tibial and femoral tunnels using autologous semitendinosus and gracilis tendons. The first aim is to attempt to create the femoral tunnels correctly through the tibial tunnels. To achieve this, a new tibial guide was used that permitted the simultaneous preparation of the anteromedial and posterolateral tibial tunnels. The intra-articular landmark is the tibial spine region, whereas the extra-articular landmarks are the anterior profile of the medial collateral ligament and the anterior tibial apophysis. We also describe transverse femoral fixation with biopins (1 for each femoral tunnel) after the preparation of the 2 tibial and femoral tunnels.     

A View From Above: A Modified Patel’s Medial Midpatellar Portal for Anterior Cruciate Ligament Arthroscopic Surgery

The use of flexible positions based on the surgeon’s need to address specific pathology has been advocated in arthroscopic surgery. In this report we reappraise the midpatellar portals popularized by Patel and present a technique modification of the medial midpatellar portal (mMPP) focusing on its use in anterior cruciate ligament primary and revision arthroscopic surgery. The modified mMPP is established under arthroscopic control from a high anterolateral portal. Its location is more proximal than the original Patel’s mMPP. The nearly vertical orientation of the arthroscope and its proximity to the midline offer a wider and almost face-to-face visualization of the intercondylar notch in the coronal plane, which would provide advantages over standard portals. The anteromedial and anterolateral portals may both be used as working portals without crowding because the arthroscope is cranially located. The need to perform notchplasty is reduced, minimizing bleeding from trabecular bone. Aggressive soft-tissue processing in the intercondylar notch to improve visualization is seldom required. The recipient site is less devascularized, which may promote autograft healing. The modified mMPP may also facilitate femoral tunnel placement and setting of an interference screw. It is safe and reproducible and may add to the diagnostic and working capabilities of the knee arthroscopist.     

Anteromedial Portal Technique for the Anterior Cruciate Ligament Femoral Socket: Pitfalls and Solutions

Creating the anterior cruciate ligament (ACL) femoral socket using the anteromedial (AM) portal technique has advantages. Furthermore, the technique is ideal for anatomic double-bundle (particularly posterolateral bundle) and all-inside ACL techniques. However, although the AM portal technique has advantages, the learning curve is steep when making the transition from familiar, transtibial reaming to the AM portal technique for ACL femoral tunnel creation. Complications and challenges are many when learning the AM portal technique. The purpose of this technical note is to describe tips and pearls for surgeons contemplating the transition to the AM portal technique for the ACL femoral socket.     

Allograft Use in Anterior Cruciate Ligament Reconstruction

Anterior cruciate ligament (ACL) reconstruction is one of the most common procedures performed by orthopedic surgeons. While autograft reconstruction remains the gold standard, allograft tissues have become a controversial option for ACL reconstruction. No data currently exist regarding recent trends in graft choices, and no consensus exists over which graft type is most appropriate for which patient. In this article, we examine trends in ACL graft choice at our institution, and review the pertinent information a surgeon must consider when making this decision. We reviewed operating room records from 2002 to 2008 to determine trends in graft choice for primary single bundle ACL reconstruction. Total number of procedures performed, graft choices, and patient ages were recorded. Patients were divided into the following age groups: less than 16, 16 to 20, 21 to 30, 31 to 40, 41 to 50, and over 50. Percent of ACL reconstructions using allograft was calculated for each year, as well as for each age group. Data were analyzed for trends in ACL graft choice over this time period as well as for trends in graft choice by age. We hypothesized that the rate of allograft use in primary ACL reconstruction had increased over time and that allograft use was associated with higher patient age. We also review the risks, safety, and standards for tissue procurement. Allograft use increased significantly (p < 0.001) from 2002 (17%) to 2008 (46%). There was also a significant difference (p < 0.001) in average age of patients receiving allografts (40.4 years) and autografts (26.4 years). Allograft use was significantly associated with higher patient age (p < 0.05) and increased with each successive age group from a rate of 9.9% in patients under 16 to 79.9% in patients over 50. Our study found that allograft use in primary ACL reconstruction has significantly increased from 2002 to 2008 and is significantly more common in older patients.     

Anteromedial Portal Technique for Creating the Anterior Cruciate Ligament Femoral Tunnel

There has been a renewed focus on anterior cruciate ligament (ACL) insertional anatomy and its biomechanics. It has been postulated that traditional single-bundle transtibial reconstructions have placed grafts in a less anatomic location relative to the true ACL insertion site. In traditional transtibial techniques, the femoral tunnel is predetermined by the position of the tibial tunnel. It is our belief that achieving the most anatomic position for the graft requires the femoral and tibial tunnels to be drilled independently. Use of the anteromedial portal technique provides us with more flexibility in accurately placing the femoral tunnel in the true ACL insertion site as compared with the transtibial technique. Advantages include anatomic tunnel placement, easy preservation of any remaining ACL fibers when performing ACL augmentation procedures, and flexibility in performing either single- or double-bundle reconstructions in primary or revision settings. This technique is not limited by the choice of graft or fixation and offers the advantage of true parallel screw placement through the same portal as that used for tunnel drilling in the case of interference fixation.     

Medial Patellofemoral Ligament Reconstruction: A Novel Technique Using the Patellar Ligament

In patients with chronic patellofemoral instability, more than 2 episodes of dislocation, and an anterior tuberosity trochlear groove of less than 20 mm as measured on computed tomography or nuclear magnetic resonance imaging, we have developed a technique for medial patellofemoral ligament reconstruction that uses a medial strip of the patellar ligament (PL). The incision started proximally at the level of the superior margin of the patella, centrally between the patellar medial margin and the medial epicondyle. A descending incision was then made, directed toward the superomedial margin of the tibial tubercle. We performed a plane-by-plane dissection up to the peritenon of the PL. With an osteotome, we could remove a 2-cm bone fragment concerning the medial third of the distal insertion of the PL or keep the distal end free. Using a No. 11 scalpel blade, we carefully detached the PL from the patella up to the transition between the proximal third and medial third of the patella. We placed the stitches between the periosteum and the ligament using FiberWire absorbable threads (Arthrex, Naples, FL) to safely rotate the graft. After that, we dissected the medial capsule and approached the femoral medial epicondyle. Then we placed a Krackow suture in the free tendon end using absorbable threads or anchored the threads into 2 holes that were previously drilled, and we secured the end with an absorbable interference screw or anchors. The fixation should be performed with the knee at 15° to 30° of flexion. Then we sutured the distal edge of the vastus medialis muscle to the graft, which bestows a dynamic component upon the reconstruction, and we immobilized the knee with a removable brace.     

应用异体跟腱重建前十字韧带和内侧副韧带

目的　探索应用同种异体跟腱在重建前十字韧带 (ACL)的同时 ,重建受损的内侧副韧带 (MCL)的新方法 ,避免由自体取材造成的再损伤及由此引起的并发症。方法　首先在关节镜下应用经深低温冷冻处理的同种异体跟腱 ,采用等长重建、生物固定的方法 ,重建受损的ACL。然后在辅助切口下同时重建受损的MCL。结果　 9例患者应用同种异体跟腱重建ACL和MCL ,全部病例获得了随访 ,采用Lysholm评分法评估患者手术前后的功能 ,术前平均 4 3 2分 ,术后平均 79 8分 ,优良率77 8%。客观检查 :前抽屉试验术前 9例阳性 ,术后均阴性 ;Lachman征术前 9例阳性 ,术后 1例弱阳性。膝外翻实验术前 9例阳性 ,术后均阴性。术后遗留膝关节疼痛 2例 ;膝关节活动受限 3例。结论　应用同种异体跟腱重建ACL ,可同时重建MCL。供材可提前制作 ,减少了自体取材造成的再损伤及其相应的并发症 ,该技术取材方便 ,手术方法简单 ,无需内固定物     

关节镜下自体髌腱中1／3重建前交叉韧带

关节镜下采用自体骨—髌韧带一骨（Ｂ—ＰＴ—Ｂ），挤压螺丝钉固定，等长重建膝关节前交叉韧带（ＡＣＬ），具有创伤小、关节内环境影响小，而且可同时进行关节内其它手术，术后病人恢复快的特点。手术的关键是获取标准的髌腱两端骨块和股骨、胫骨隧道以及选择等长点，并稳固地将２骨块挤压固定于骨隧道中。作者手术１２例、平均随访９个月，术前抽屉试验１２例阳性，术后２例阳性；轴移试验３例阳性，术后均消失；Ｌａｃｈｍａｎ试验术前１２例阳性，术后１例弱阳性，膝前痛２例。全部病人术后膝关节功能均有明显改善，无髌骨骨折及挤压螺丝钉松动。按照日本骨科学会制定的膝关节疗效评定标准，优５例、良５例、中２例，优良率达８３．３％。故认为关节镜下重建ＡＣＬ手术是一个优良的方法     

Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction: Where Are We Today?

The anatomic approach to anterior cruciate ligament (ACL) reconstruction has been a growing trend in orthopaedics. Progress made over the last 7 years has led to a greater understanding of the ACL anatomy and its 2 bundles. Surgeons are now more equipped to restore the native anatomy and knee kinematics than ever before. The University of Pittsburgh experience and technique have been described and have evolved to include several key principles. These include the restoration of native ACL anatomy, insertion sites, and double-bundle tension patterns with the utilization of an accessory medial portal to provide an individualized approach to ACL reconstruction. The purpose of this technical note is to provide surgeons with a technical update regarding the anatomic approach to ACL surgery. Most of this article will be focused on anatomic double-bundle ACL reconstruction, but it must be emphasized that this is a concept rather than just a technique and should be applied to all ACL reconstructions to provide a more anatomic and individualized result.     

可吸收界面螺钉重建膝关节前交叉韧带术后并发症

目的探讨采用可吸收界面螺钉重建膝关节前交叉韧带术后可能发生的并发症。方法采用PolyL-lacticacid(聚左旋乳酸)材料制作的可吸收界面螺钉重建膝关节前交叉韧带36例,术后6周、3个月、6个月、1年后定期进行物理检查、关节活动测量仪(KT2000)及摄X线片检查。结果本组均获随访,术后6周复查发现有关节肿胀及皮肤温度升高等滑膜炎体征2例(5%),其中1例经非手术治疗后痊愈,但另1例经KT2000检查及物理检查有关节松弛。术后股骨远端及胫骨近端出现弥漫性骨质吸收现象有3例(8%)。术后20个月后复查发现有1例胫骨隧道轻度扩大并伴伸直受限(2%)。结论不论是用金属还是可吸收界面螺钉重建都有可能出现隧道扩大及关节松弛等并发症。但是术后反应性滑膜炎、股骨远端及胫骨近端弥漫性骨吸收现象是否与采用可吸收界面螺钉直接相关,还有待于进一步观察及研究。     

改良关节镜下前交叉韧带重建术的安全性研究

目的探讨关节镜下经前内侧入路（anteromedial,AM）建立股骨隧道的膝关节前交叉韧带（anterior cruciateligament,ACL）移植重建手术的改良方法的安全性。方法 2010年1～10月采用改良AM方法完成ACL重建20例（实验组）,2009年1～12月采用传统AM方法完成ACL重建20例（对照组）,比较2组股骨隧道的长度,股骨隧道斜度,股骨外髁后壁爆裂和后外侧管神经损伤的情况。结果实验组术中股骨隧道长度为（41.8±4.1）mm,显著长于对照组（37.2±4.4）mm（t=3.421,P=0.002）。实验组股骨隧道冠状角度为51.9°±7.7°,显著大于对照组39.1°±5.8°（t=5.938,P=0.000）。对照组1例出现股骨隧道后壁爆裂,2组其余患者未发现后壁爆裂和后外侧血管神经损伤。结论改良AM方法可以增加ACL重建手术的安全性。     

Hybrid Anterior Cruciate Ligament Reconstruction: Introduction of a New Technique for Anatomic Anterior Cruciate Ligament Reconstruction

Recently, anatomic or double-bundle reconstruction of the anterior cruciate ligament (ACL) has been presented in an effort to more accurately restore the native anatomy. These techniques create 2 tunnels in both the femur and tibia to reproduce the bundles of the ACL. However, the increased number of tunnels, particularly on the femoral side, has raised some concerns among authors and surgeons. We describe a technique to reconstruct the 2 distinct bundles of the ACL by using a single femoral tunnel and 2 tibial tunnels, the “hybrid” ACL reconstruction. The femoral tunnel is drilled through an anteromedial arthroscopy portal, which allows placement in a more anatomic position. Fixation in the femur is achieved with a novel device that separates a soft-tissue graft into 2 independently functioning bundles. Once fixed in the femur, the anteromedial and posterolateral bundles of the graft are passed through respective tunnels at the anatomic footprint on the tibia. These bundles are independently tensioned, which creates a reconconstruction that is similar to the native ACL. The technique presented provides surgeons with an alternative to other double-bundle techniques involving 4 tunnels.