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Usually, extra-cortical suspensory systems are employed for the fixation of the quadruple reconstruction of hamstrings, although interference screws and staples or combination could also be used.
Repeated flexing-extending cycles of the knee is recommended in order to preinstall the graft before the fixation. Adequate tension of the graft in between 0 and 30o is tested with the probe under arthroscopic control and the surgeon’s perception must be that the tension is the same or very close to the one felt with a normal ACL.
REHABILITATION TIPS
Rehabilitation after ACL revision surgery often are more conservative than the aggressive protocols used for primary surgery. Patients must remember that results are less predictable and they should not exceed the limits indicated for them. A delayed return to intense activities is also expected. Each rehabilitation protocol must be individualized and based on the type of reconstruction performed, the strength of the fixation and the type of graft used and patient.
PEARLS & PITFALLS – SURGICAL TECHNIQUE
ISAKOS ASKS
Tell us about yourself, and we will tell you where you sit in the crowd.
The ISAKOS Newsletter Poll questions are available on the ISAKOS homepage– www.isakos.com. Results and additional comments will be published in the next ISAKOS Newsletter.
1. Do you add Adrenaline to your Arthroscopy fluid?
1. Yes, always
2. Yes, only in the first couple of bags 3. Never
2. Do you read MR/CT imaging of your patients alone or rely on the written report sent?
1. Always read myself, every single one
2. Read myself only unique/complicated
cases
3. Prefer to read these with my radiologists
4. I rely on the written report I get
3. Will you bring your family to ISAKOS in Lyon?
1. No
2. Only my spouse
3. I will bring my spouse and my kids along!
4. How many hours a day (average)
do you think an orthopaedic surgeon should work?
1. 9
2. 11
3. 13
4. 15
5. 24
5. How would you rate your typing and computer skills?
1. 5–Great, use it all the time, very proficient 2. 4
3. 3–Fairly proficient, use occasionally
4. 2
5. 1–Barely proficient, only use it when I have to
Visit Page 42 for the results of the ISAKOS Newsletter 2014: Volume II Poll
Table 5. Key Factors for Functional Recovery After Acl Reconstruction Surgery.
• Active extension produces an important stress on the ACL graft. Must be performed with assistance during the first weeks limited from 30˚ to 0˚.
• Open chain exercises produce maximal shearing forces.
• Close chain exercises do not produce stress on the ACL graft.
Table 6. Criteria for safe return to unrestricted activities
1. Complete range of motion.
2. Quadriceps strength over 85% of contralateral side.
3. Hamstrings strength of 100% of contralateral side.
4. Good ischio/quad muscle balance over 70%.
5. One-legged jump of 85% of length of contralateral side.
6. KT-1000 measured difference of less than 3mm between knees.
CONCLUSIONS
Revision ACL surgery is a challenging procedure with many factors to consider; correct identification of the cause of failure, anatomic positioning of tunnels and careful, individualized rehabilitation protocol are the keys for success in a patient with realistic expectations.
01 Fig 1
02 Fig 2a
03 Fig 2b
04 Fig 3a
05 Fig 3b
06 Fig 4a
07 Fig 4b
Excessive anterior femoral tunnel location (MRI sagittal view) Suitable femoral tunnel positioning leaving 2 mm of posterior wall (arthroscopic intraoperative view).
Intraarticular guide pin exiting at the anteromedial aspect of the ACL tibial footprint (arthroscopic intraoperative view from AL portal)
Intraoperative view during excision of bone-tendon-bone patelar tendon autograft.
Achilles tendon allograft exiting through the tibial tunnel during ACL reconstruction. Tibial fixation was achieved using two 8-mm metal staples.
Widened tibial and femoral tunnel (MRI sagittal view). Tibial tunnel filling with allograft bone cancellous chips
ISAKOS NEWSLETTER 2015: Volume I 17