Surgical Approach 1: ACL Reconstruction Bone Patellar Tendon Bone Graft
J. Richard Steadman, MD

Case Study: Torn Anterior Cruciate Ligament

Slide 1. I'm going to talk about a procedure that's been around for a while, but as I go through the procedure based on the careful follow-up we've done with our patients, I'll try to make you aware of some improvements that we've made in this procedure over time. Nothing spoils results like time, so we have long-term follow-up on our patients.

As I've gone through the evolution of the procedure, I still do the same operation. I just do it a couple of different ways, particularly, the rehabilitation. I think that if I had to choose the most positive thing that comes from the research we've done in the last few years, it's the fact that we've learned just how important rehabilitation is and what the rehabilitation should be.


Slide 2. This patient was a young active male. Magnetic resonance imaging (MRI) shows an anterior cruciate ligament (ACL) tear. There's a question of meniscus injury, and a question of chondral injury. The patient has been treated by another physician and arrives at the office in a situation where he's got full extension, his swelling is down, and he has good quadriceps control.

The other point that I'd like to make before I decide to go ahead with surgery is the temperature differential between the 2 knees. I'd like for the temperature differential to be very close because I think if they have an inflammatory process going on in the knee, you're more likely to get postoperative inflammatory changes and that is not good.


Database on Torn Anterior Cruciate Ligament Among Young Male Athletes

Slide 3. In our clinical research database, we have 11,000 knee surgeries that we've accumulated over the last 12 years. And in that database we found 283 males who were similar to this patient and the average age was about 22 years. There was a lot of discrepancy on length of time to surgery, and so the average total number of days reflects that some people I didn't operate on for several years for various reasons.

Usually if I saw a patient who had the same injury, the time from injury to surgery would be between the 2- to 3-week timeframe, but it could be less. The decision as to when to operate does not depend so much on a time schedule, but on the condition of the knee. And the most people have gone to that. At one point people were saying you should wait for 6 weeks. Another person said you should wait for 3 weeks. I think the condition of the knee guides me and tells me it's time to proceed.


Slide 4. When we look at other ligament pathologies that are frequently associated with these ACL injuries, medial collateral ligament (MCL) is by far the most common, and it's common to have at least a partial tear of the MCL. My approach is that unless it's a knee dislocation where the MRI shows that the MCL is significantly displaced, and that can happen, I usually fix the ACL and leave the MCL.

I try to do an acute repair if I've got a combination of ACL and posterior cruciate ligament (PCL), and found that to be a useful treatment. I also found that it's a lot easier than doing a full reconstruction and is usually successful in these early cases.

One thing I'd like to emphasize on multiple ligament injuries is that almost every patient I see has a posterior lateral sprain along with their ACL injury, and generally those will heal spontaneously. But if the lateral collateral ligament (LCL) is lax or torn, it needs a guidance system to make the posterior lateral corner heal. Whereas I think you can leave the MCL and not worry so much about it because they virtually always heal if you have an ACL as a backup. With the LCL you're protecting the posterior lateral corner. So I would always make sure that I had a solid repair or reconstruction of the LCL in the combination of ACL and LCL injury.


Slide 5.
The chondral injuries are also very important. I think it's important to talk to the patient about chondral injuries before you do the surgery. For acute chondral full thickness defects my choice is a microfracture, but there are a number of other choices. Unless you talk to the patient about this ahead of time, they won't be expecting the rehabilitation that they're presented with after the surgery. I think it's very helpful to have an MRI to be able to figure that out.

As far as meniscus injuries, we make every effort to repair a torn meniscus, and if it is a locked bucket-handle tear we make every effort to repair anything that is even close to being reparable. The rule of thumb that I use is that if you have a perfect meniscus for repair, it's probably a 90% success rate, but if you have a 70% chance of success with a less optimum tear, I would do that repair because you can't do it later. You either do it then or it's too late. I'm very aggressive about these meniscus injuries, particularly lateral meniscus tears, because I think the detrimental effect of losing your lateral meniscus is significant arthritis in a very short time.


Slide 6. Another approach that I've developed, as I learned more about rehabilitation, is that if you have an unstable and locked meniscus and it requires protection after the surgery, I do the procedure in 2 stages. And if there's a trochlea defect that requires a significant change in my rehabilitation, I do it in 2 stages. I'll do the trochlea defect microfracture, I'll do the repair of the locked meniscus, and then I'll get full mobility back and come back for the ACL. I think this is extremely important because I've learned that the rehabilitation is what separates great results from pretty good results.

So if a repaired meniscus or treatment of a chondral defect trochlea interferes with the rehabilitation from an ACL, then I'd rather do it another time.


Graft Choices for Anterior Cruciate Ligament Surgery

Slide 7. Surgeons can say, "I got a good result from my ACL surgery." But unless you restore the kinematics of the knee -- in other words, the way the knee works, the flexion, and extension -- you haven't really given that patient what they deserve. Because if you don't restore the kinematics in the joint, don't restore the normal spaces in the joint, then after 5 or 10 years you're going to be treating them for significant arthritis.

And you probably wonder how I realized that. I did a lot of surgeries in the late 1980s and early 1990s where we didn't respect the kinematics like we do today. And because we've done the research in these areas and looked back at our cases, we said that we're doing too many second surgeries for tightness in the joint. Then we did another study that showed that if you have tightness in the joint, you're much more likely to get arthritis in the joint. So when you think about success after surgery, you might think, "I've got a good, tight knee." But if it's too tight, you've given the patient an arthritic joint within 5 to 10 years.


Slide 8. Let's talk about graft choices. There are actually a lot of good graft choices and my personal favorite is a bone-patellar tendon-bone. But there are excellent studies, excellent results from semitendinosus (ST), quad tendon, allograft bone-tendon-bone (BTB), and allograft Achilles, which is another successful material for reconstruction. So I'm not as much worried about the material as I am about treating the patient after the surgery. My cospeaker may talk about a different material than I use, but I think we would both go to a similar position on the femur and to a similar position on the tibia, and then we would use a rehabilitation program that restores the kinematics of the joint. That's what makes you have successful results.


Slide 9. In the cases that we reviewed from our database, we had 194 patellar BTB reconstructions. And of those, 9 were staged, and the reason for the staging was the situation where you have either significant chondral changes, which require more protection than I would accept for my postop rehabilitation, or meniscus tears that require a lot of protection too. But if I can do a meniscus repair and do my normal rehabilitation, I'll do it and then it's a single procedure. I don't hesitate to do the procedures in 2 stages.


Slide 10. My personal favorite is a 2-incision technique and although it's not the most popular technique today, it's still pretty popular; a lot of people still use the 2-incision technique. I like it because I can assure that I get the right position. I can be far enough back on the femur, I can be in the right position on the tibia, and if I have some sort of calamity during the surgery, I've got a back up every time. I can always get the position I want; I can always get the fixation I want. If I felt I could do that with some other technique, I'd do it, but I feel like I can do it every time with the procedure I'm using, which is why I stick with this procedure. With the bone-to-bone fixation, I haven't had 1 case out of over 2000 ACL reconstructions where the graft has actually pulled loose from its fixation point. So I'm pretty confident that the fixation is good with this procedure.

Another point I'd make is that with the bone-patellar tendon-bone, the graft does regenerate. The strength is basically similar after the surgery. And there's some question on hamstrings, where the position of attachment on the hamstring is after you've taken the hamstring for the graft. I'm not saying that it's a bad thing to take the hamstring, but some feel it doesn't attach automatically to the same position originally it was in, and that may be a bad thing.


Keys to Success After Anterior Cruciate Ligament Surgery

Slide 11. What creates a successful ACL reconstruction? The proper position of the tunnels ensures ideal graft link, and so if you're not in the right position far enough back in the tibia, there is impingement and that's not good. Looking back at many cases that didn't turn out as well as we would have liked, it seems that the main reason for problems with a graft is not fixation in this procedure, it is impingement. And the impingement happens if you put it too close to the bone, if you leave impingement in the notch, and then you're risking that graft, so it is really important to avoid impingement. Fixation has to be strong enough to allow early motion, it has to be strong enough to hold until the bone is fixed, and we need to get the normal biomechanics in the soft tissues around the joint. If we don't get that, chances are we're going to have arthritis in our patients later on. I learned that the hard way because I have a number of patients who are now 10 or 15 years out, and if I knew what I knew today, they wouldn't have arthritis. But, unfortunately, they do.


Slide 12. Another point on the patellar tendon is that if the rehabilitation is not successful, you will get joint stiffness. Another concern after bone-patellar tendon-bone is anterior knee pain. Some people say it is 90%; some people say it is 40%. In our series it's very small. It's less than 2%.


Slide 13. The reason you would get anterior knee pain is scarring and stiffness in the joint. What we've identified as the risk factor is that unless you do patellar mobilization (manually moving the knee cap and the knee-cap tendon) you're going to have tightness in the joint and scarring between the patellar tendon and the tibia, and that is the end for the articular cartilage in the trochlea and the patellar tendon. This manual mobilization, in addition to early range of motion, is the thing that can avoid the arthritis 10 or 15 years from now.


Slide 14.
In terms of the solution to anterior knee pain, I think it's important to the bone graft defects. We use tunnel drillings and we pack those into the defects, so one possible source of pain would be an unfilled defect. Patellar mobilization, as we mentioned earlier, is another super important point, and it has to be manual mobilization. I don't think you can do it any other way. Another thing we do is a loose partial-thickness closure of the patellar tendon so that we don't squeeze it and shorten the tendon. We also do a lateral retinacular decompression. We release the retinaculum on almost every case unless it's a general laxity case. We feel like that allows the patellar tendon to accommodate any shortening -- say 1, 2 mm. If you don't do that then it has to take up the slack somewhere, and I think it's by compression of the patellar tendon against the trochlea.


Slide 15. So if you want to have a lot of pretty good results, don't worry about rehabilitation. But if you want to have excellent results, and I think that's what we're really after, you have to have great rehabilitation and great mobilization.


Technical Considerations

Slide 16. A few points on technical considerations.


Slide 17. You'd like to have a technique that's reproducible every time. You'd like to have a proper tunnel position every time, and I think with the technique that we use virtually every time we're satisfied with our position. If you can do it with 1 incision, if you can do it with no incisions, whatever it takes, but you can't sacrifice the end result to have a trickier procedure. The whole trick of surgery is to get the graft in the right place, and if it goes through a range of motion, it doesn't stretch and tear, you have a great chance for success.

Impingement can appear either medial/lateral or superior/inferior, so patients can have either a medial/lateral in the notch or a superior/inferior in the notch. And if you have impingement, it will wear the graft and the graft will be weaker every time.

We feel that we have reliable fixation with interference fit, and I always have a back-up plan if things don't work out the way we'd like.


Slide 18. Important in the 2-incision technique is the tibial entry and the femoral entry. The angle of entry on the femur should be at least a 45 degree angle because as it comes through the notch, it'll reflect the normal angle of the cruciate. Fixation is with an interference screw, and chances are you're going to have a graft that looks just as the ligament looked before.


Slide 19. Impingement -- I can't emphasize enough how important it is -- lateral decompression, and bone grafting the defects, all these keep you from having the anterior knee pain that people talk about after BTB surgery.


Why the Tunnel Position Is Important and Other Surgical Considerations

Slide 20. Why is position important? If the position is such that you can take the knee through a full range of motion, there's no stretching; if there's stretching on the graft, you're going to have an injury to the graft during activity. If you have the right position and it can go through a full range of motion, you have a normal Lachman test, and you won't get a weak graft. Once again, the whole idea is to have the right tension on the ligament through the range of motion by having the graft in the right position.


Slide 21.
Our tibia position is 6 mm lateral to the medial wall (it seems a little medial but I'm making sure I don't have lateral impingement, which is the worst thing), and 7 to 9 mm anterior to the PCL. Posterior cruciate ligament is important because it's where the wall drops off. So if you're in that position, you're very unlikely to have any impingement.


Slide 22. Once again, you like to have a nice angle when you drill outside in for your femoral position of tunnel.


Slide 23. I do notchplasty on most patients, but unlike most surgeries, my notchplasty is generally posterior, not anterior, because I want an oval back wall so that I don't get impingement. I sound like I'm fixated on impingement, but I've looked back on enough cases that I think, "If I hadn't had impingement, this patient would have done a lot better."


Slide 24. The anatomy in the notch does vary. Some people have a flat back wall, some people have a curved back wall, but most people don't have an oval back wall. To avoid impingement, I virtually always do a notchplasty to create that oval back wall so there's no impingement as the graft goes through the joint.


Slide 25. The technical considerations for failure of the surgery are positioning of the tunnel, impingement, inadequate fixation of the tunnels, and failure to heal to the tunnel wall. Virtually you never get failure to heal to the tunnel wall.


Slide 26. Once again, reproducibility is the main reason for doing this procedure and it's the way I do it. I'm not arguing against doing it another way, but for me, it's the best way. And if the technique is reproducible, and if I have the right position and a little flexibility on my position on the tibia and femur, then I feel more comfortable about the long-term outcome.


Slide 27. I believe heartily in saving the meniscus if possible. If I have a 70% chance of saving the meniscus, I'll take that chance because I don't have a 70% chance of putting it back in if I don't save it the first time. So I'm very aggressive about saving meniscus, particularly the lateral side.


Important Aspects of Rehabilitation

Slide 28. In terms of rehabilitation, if you don't maintain the interval between the patellar tendon and the tibia, it's a bad thing. If you have scarring of the suprapatellar pouch, it's a bad thing because it causes increased compression.

The patellar tendon, as you flex the knee, comes closer to the tibia. As you extend, it goes away from the tibia. Unless you restore that, then your chances of having a great result from your surgery are almost zero. That's where postop rehabilitation becomes increasingly important.


Slide 29. We did a study at Columbia University, in New York, NY -- Ahmad was the principal investigator -- where we looked at the effect of scarring on the tibia and in the suprapatellar pouch.


Slide 30. We found if you have scarring in these 2 areas, not only do you affect the patellofemoral joint, but you also affect the whole joint. In other words the femoral joints are also affected. So you just have to avoid this situation.


Slide 31. Stiffness is an issue, and the stiffness is usually in the areas that we talked about. It's very rare to have a graft rupture from being too aggressive in early rehabilitation. I haven't seen it happen in my cases and I used to be very aggressive in my rehabilitation.


Slide 32. Overall, from the surgery that I do, less than 2% have complications, and it's because I try to look at all the different possibilities. Loss of motion would be a possibility, graft site morbidity would be a possibility, wound healing is rare, and fixation failure almost never occurs because we have good solid fixation to bone and the bone heals.


Slide 33. Currently I'd say that mobilization is the key to this surgery. If a patient at 6 weeks after surgery has good strength but decreased mobility, it's almost 100% they're going to need another surgery for mobility. If they have good mobility, they can always build strength, and it's almost 100% they'll be successful.


















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