1. ACL Reconstruction M Prud’homme-Foster Academic Half Day March 1st , 2012

2. Outline • Background • Diagnosis • Operative v. Non-Operative • Surgical techniques • Anatomy • Anatomic double-bundle • Complications • Rehabilitation • Outcomes

3. Background:Burden of Disease • 6 per 1000 patients per year • 80 000 to 250 000 ACL injuries per year USA • 100 000-200 000 ACL reconstruction in USA per year • Cost: $12,000-20,000 • $1-3 Billion dollars

4. Background: Epidemiology • Risk group 16-39 yoa • Females 4 times the rate of males • Noncontact ACL: two to eightfold increase in females • Contralateral rupture same as re-rupture of ACLR: 6%

5. Diagnosis • History • Often noncontact, pivoting or landing • Swelling (hemarthrosis) • Unstable +/- difficulty WB • P/E • Difficult in acute: muscle spasms, effusion, meniscal pathology

6. Diagnosis • Lachman Test • 20-30° flexion • Estimate anterior displacement: normal, marginal or soft • Pivot shift Test • Relocation @ 20-40°: 0(absent), 1+(pivot glide), 2+(pivot shift), 3+(momemtary locking) • Anterior Drawer Test • 90° flexion

7. Diagnosis • Plain radiography: • r/o abnormalities associated • Segond fracture: lateral capsular ligament • Posterior to Gerdy’stubercule, supero-anterior to fibular head • Avulsion of insertion, joint space narrowing • MRI • 95% accuracy • Bony abnormalities

8. Diagnosis • Instrumented Ligament Testing • Side to side diff: <3 mm normal, >3mm pathalogic • EUA with arthroscopy

9. Operative v Non-Operative • No evidence suggesting that systematic treatment of ACL • Knee stability improved by surgery or by neuromuscular rehabilitation • Risks of OA remains high

10. Operative v Non-Operative • ACL screening can identify copers • Similar percentage of copers and noncopers return to sporting activity • Screening algorithm: KOS-Sport, Global Knee Function Rating, hop tests, Quadriceps index

11. Operative v Non-Operative • Excellent outcomes reported in appropriately selected patients, motivated, symptomatic • 50 years and older?

12. Surgical Treatment: options • Patellar tendon, iliotibial tract, hamstring tendons • Autologous v. allograft • Single-, double-, triple-bundle • Anatomic • Two-, Three portal • Transtibial

13. Surgical Treatment: historical • 1980s: isometric tensioning • Transtibial • Focus on reducing anterior translation • Today’s focus • Anatomical replication • Decrease rotatory instability (pivot) Pivot shift correlated with clinical outcomes

17. AMM bundle is the primary stabilizer to • tibial anterior drawer through wide range of motion • AML bundle is the secondary stabilizer in deep flexion angles • PL bundle is the crucial stabilizer to hyperextension • as well as tibial anterior drawer at full extension

25. Complications

27. Sport specific comparative date sparse • Outcomes often mix sports • Differ in level of sport • Return to sport most common outcome reported • Not standardized • Conclusion: Return to cutting and pivoting sports less likely than