ACL Flashcards
Benefits of suspensory fixation
Circumferential graft to tunnel healing. Can be used in cases of posterior wall blowout. Less graft slippage for all soft tissue grafts. May have better pull-out strength than aperture.
Downsides of suspensory fixation
Windshield wiper and Bungee cord effect which can lead to tunnel widening and graft stress and failure. lack of rigid aperture fixation.
Benefits for aperture fixation
Rigid fixation with lower risk for tunnel widening. Cheaper with metal screws. Compresses graft to bone.
Downsides for aperture fixation
Immune response to biocomposite screws leading to tunnel widening and graft failure. Screw breakage with biocomposite.
fixed loop vs adjustable loop suspension devices
Fixed loop is biomechanically superiorly
How common is windshield wipering
50-100% in ACL. Though the signfiicanti s unclear.
Downsides of tunnel expansion
Excssive shearing motion impedes biologic incorporation, bone loss comoplicates revision surgery. OR tunnel expansion is of no consequence
Root tear classification
Laprade. Type 1 is partial, 2 is complete, 3 is complete with bucket handle, 4 is complete but long oblique, 5 is root avulsion
meniscofemoral ligaments and posterior root
help preserve function of the laterla meniscus, limit extrusion
Donot site pain for the different grafts
8-18% QT, 22% hamstring, 40% BTB
Benefits of quadriceps tendon
Decreased kneeling pain and anterior numbness, preserved hamstring flexor tendon.
Downsides of quadriceps
Other than the surgical risks, extensor mechanism weakness, early extension deficits.
How common are Lat men psoterio rrot teras
7-14% incidence. Krych and laprade have separately noted their heigh incidence and occult nature on MRI, even when looking specifically for them.
So you did a procedure you didn’t ocnsent for?
Unfortunately that is how it is listed on the consent form, however I do discuss with patients and get their consent in the informed consent process to repair any meniscus tears that are present at the time of surgery. In my pre-op clinic note and day of surgery H&P I reiterated the plan to repai rany meniscus tears as possible, and listed the procedure as such. It was incorreclty transcirbed and I should have been more diligent in changing it to the broader wording.
Shelbourne KD, Roberson TA, Gray T. Long-term Evaluation of Posterior Lateral Meniscus Root Tears Left In Situ at the Time of Anterior Cruciate Ligament Reconstruction. The American Journal of Sports Medicine. 2011;39(7):1439-1443. doi:10.1177/0363546511398212
At a mean of 10 years’ follow-up of posterior lateral meniscus root tears left in situ, mild lateral joint-space narrowing was measured without significant differences in subjective or objective scores compared with controls. This study provides a baseline that can be used to compare the results of procedures used to treat these tears in other manners.
Benefit of lateral meniscus root repairs
Decreased degenerative joint disease, improved function, particularly rotational control (if they ask to specify)
BTB risks
Anterior knee pain in 17.4% of patients, kneeling pain. Patellar fracture 0-2%, patellar tendon rupture 0.25%, patellar tendinitis, 17.4% vs. 11.5 in HS autografts for anterior knee pain. INcreased risk of OA.
COntraindications for BTB
kneeling sports or activities like wrestlers, plumbers. Patients with pre-operative anterior knee pain
Benefits to BTB
GOld standard with longest clinical history, bone to bone healing in 6 weeks, higher return to sports than HA autografts and lower failure rate in young athletic patients. More consistent graft size especially in young
BTB re-rupture rates
1.9% to 6.6%
hamstring re-rupture rates
4.9-17.5%
Downsides of allograft
Expensive, infectious disease risk, delayed incorporation, higher failure ate (up to 25%), only use in patients >40 or multilig), lower return to sport compared to autograft 43% vs. 75%
benefits of allograft
No harvest site morbidity, deceased surgical time, predictable graft size
Freedman KB, D’Amato MJ, Nedeff DD, Kaz A, Bach BR. Arthroscopic Anterior Cruciate Ligament Reconstruction: A Metaanalysis Comparing Patellar Tendon and Hamstring Tendon Autografts. The American Journal of Sports Medicine. 2003;31(1):2-11
There were 1348 patients in the patellar tendon group (21 studies) and 628 patients in the hamstring tendon group (13 studies). The rate of graft failure in the patellar tendon group was significantly lower (1.9% versus 4.9%) and a significantly higher proportion of patients in the patellar tendon group had a side-to-side difference of less than 3 mm on KT-1000 arthrometer testing than in the hamstring tendon group (79% versus 73.8%). There was a higher rate of manipulation under anesthesia or lysis of adhesions (6.3% versus 3.3%) and of anterior knee pain in the patellar tendon group (17.4% versus 11.5%) and a higher incidence of hardware removal in the hamstring tendon group (5.5% versus 3.1%).