The Anterior Cruciate Ligament: Reconstruction and Basic Science1

Cover......Page 1
Related Topics......Page 8
Staying Current: The ACL Database......Page 9
Acknowledgments......Page 10
List of Contributors......Page 12
Historical Descriptions......Page 20
Anterior Cruciate Ligament Injury......Page 0
Insertion Site Anatomy......Page 21
Tensioning Pattern......Page 23
Historical Studies......Page 24
Biomechanics Considerations in Anterior Cruciate Ligament Surgery......Page 26
References......Page 27
Mechanisms of Noncontact Anterior Cruciate Ligament Injuries......Page 29
References......Page 130
Suggested Readings......Page 33
Environmental Risk Factors......Page 35
Introduction......Page 228
Systemic Factors......Page 529
Intraosseous Healing......Page 36
Increased Donor Age......Page 579
Diagnosis......Page 37
Clinical Examination......Page 71
Effects of Fixation Location......Page 594
Neuromuscular Risk Factors......Page 40
Summary......Page 42
References......Page 357
The Incidence of Anterior Cruciate Ligament Injury as a Function of Gender, Sport, and Injury-Reduction Programs......Page 45
Basic Knowledge to Enhance the Graft Remodeling in Anterior Cruciate Ligament Reconstruction......Page 151
Prevalence of Infection......Page 568
Clinical Examination......Page 496
Adverse Effects......Page 49
Advanced Theoretical Considerations......Page 539
Problem 3: What if the Passing Sutures cannot be Pulled out of the Endobutton After Fixation?......Page 51
Gap Size......Page 412
Female-Male Injury Risk Ratio......Page 56
References......Page 57
Analysis of Anterior Cruciate Ligament Injury-Prevention Programs for the Female Athlete......Page 59
Background......Page 278
Biomechanics......Page 244
Graft Preparation......Page 359
Education......Page 61
Interference Screw Fixation......Page 97
Neuromuscular Training: Technique and Strengthening......Page 63
Tunnel Preparation......Page 311
Neuromuscular Training: Comprehensive......Page 65
Fixation Technique......Page 66
Aperture Versus Nonaperture Fixation......Page 67
References......Page 556
Review of Studies That Have Measured the Strain of the Bone-Patellar Tendon-Bone Graft......Page 70
Introduction......Page 221
Venous Complications......Page 475
Application of the Graft Sleeve......Page 350
Graft Fixation......Page 72
Biological Scaffolds......Page 441
Magnetic Resonance Imaging......Page 73
Results......Page 109
Nonoperative Management of Anterior Cruciate Ligament Deficient Patients......Page 77
Causes Of Failure of Primary Procedure......Page 157
Treatment......Page 586
Enhancement of Graft Healing with Gene Therapy......Page 645
Radiolucency......Page 116
Recommendations for Future Work: How Gait Analysis can Guide the Development of Surgical Techniques......Page 629
Treatment Philosophy (Principles)......Page 82
Introduction......Page 86
Methods of Analyzing Tunnel Widening......Page 341
Pathogenesis: Predisposing Factors......Page 229
Definition of knee instability......Page 230
Anterior Cruciate Ligament Surgery and the Effect on Bone Tissue......Page 352
Risk Factors for Iatrogenic Growth Disturbance......Page 299
Individualization......Page 96
Summary......Page 523
Allografts and Infections in Anterior Cruciate Ligament Surgery......Page 241
Possible Problems During Screw Insertion......Page 98
Conclusion......Page 113
Conclusions......Page 99
Stability Rate by Graft Fixation Subgroups......Page 564
Meniscus Tears to Leave in Situ......Page 101
Interference Screws......Page 164
Success Rates......Page 497
Quadriceps Tendon Graft Strength......Page 102
References......Page 103
Why Synthetic Grafts Failed......Page 105
Genetic Predisposition......Page 327
Anterior Knee Problems Related to the Procedure......Page 368
XtraLok Tips and Troubleshooting......Page 346
Future Directions......Page 208
References......Page 580
Exposure of the Tendon......Page 108
History......Page 487
Only About Half of Reconstructed Knees Achieve Stability Symmetrical with the Other Knee......Page 285
Graft Sizing......Page 110
Fixation Strength......Page 404
References......Page 111
Introduction......Page 112
Graft Preparation......Page 371
Scientific Rationale......Page 158
Low-Tension Grafts......Page 179
Harvesting the Semitendinosus and Sectioning the Accessory Semitendinosus......Page 114
Time of Harvest......Page 115
Noninterference Screw Fixation......Page 128
Who Should Use this Technique?......Page 117
Fix the Soft Tissue Graft to the Femur......Page 254
References......Page 276
Pearls and Pitfalls of the Technique......Page 162
Conclusions......Page 118
Fashioning the Graft......Page 121
Closure......Page 122
Hamstring Anterior Cruciate Ligament Reconstruction with a Quadrupled or Tripled Semitendinosus Tendon Graft......Page 127
Specific Factors Associated With Increased Tunnel Widening......Page 593
History......Page 129
The Argument for Less Length Being Sufficient......Page 132
Type of Graft......Page 436
Bone Quality......Page 133
Finishing the Femoral Tunnel......Page 134
Surgical Technique......Page 153
Animal Models......Page 213
Uses......Page 135
Antibiotic Administration......Page 571
Complications......Page 492
4ST Free Graft Without Bone Block......Page 136
Surgical Technique for Avoiding Posterior Cruciate Ligament and Roof Impingement and Replicating the Tension Pattern of the Innfact Anterior Cruciate Ligament......Page 142
References......Page 592
Use of the Transtibial Technique to Avoid Posterior Cruciate Ligament and Roof Impingement of an Anterior Cruciate Ligament Graft......Page 138
Definition, Complications, and Diagnosis of Roof Impingement......Page 139
Easy, Secure, and Consistent Pullout Anterior Cruciate Ligament Graft Fixation with Double-Spike Plates......Page 140
Validation of Tibial Guide......Page 143
References......Page 144
The Anteromedial Portal for Anterior Cruciate Ligament Reconstruction......Page 146
Basic Science and Graft Histology......Page 417
Comments......Page 388
Suggested Readings......Page 150
Biomechanical Results......Page 212
Suggested Readings......Page 156
Example of Stiffness Principle......Page 224
Imaging......Page 488
Graft Fashioning......Page 167
Graft Placement......Page 168
Graft Tensioning and Fixation......Page 169
References......Page 607
Harvest a Bone Dowel from the Tibial Tunnel......Page 172
Introduction......Page 403
Relaxation of Graft Tension after Surgery......Page 410
A Modified Complexity Hypothesis Model......Page 637
Preparation of the Femoral Tunnels......Page 173
Double Bundle......Page 485
Chemical Treatments......Page 335
Conclusions......Page 176
References......Page 177
Anatomical Double-Bundle Anterior Cruciate Ligament Reconstruction with a Semitendinosus Hamstring Tendon Graft......Page 178
Allograft Versus Autograft......Page 328
Conclusions......Page 182
TroubleShooting......Page 183
References......Page 422
Introduction......Page 185
Femoral Interference Screw Fixation......Page 304
Stage I......Page 186
Histological Studies......Page 439
Surgical Landmarks......Page 187
Creation of Tibial and Femoral Tunnels......Page 263
Specific Steps......Page 188
Rehabilitation......Page 192
Results......Page 193
References......Page 314
Arterial Complications......Page 196
References......Page 320
Introduction......Page 203
Hamstring Autograft......Page 597
Discussion......Page 209
Fixation Biomechanics......Page 211
Patellar Tendon and Hamstring Tendon Autografts......Page 216
Conclusions......Page 325
Alternative Intratunnel Tibial Fixation Techniques......Page 218
References......Page 344
Definition and Examples of High- and Low-Stiffness Fixation......Page 222
Preferred Fixation Technique......Page 225
Conclusion......Page 226
References......Page 516
Peak Bone Mass and Natural Bone Losses......Page 557
Discussion......Page 231
Why Avoid Hyperextension?......Page 355
Conclusion......Page 232
Technique 10: Modified Physical Therapy for the First 2 Months After Surgery......Page 233
Introduction......Page 235
Redrilling if the First Tunnel Is too Short......Page 236
TGF-beta......Page 644
Preparing the Endobutton/Graft Construct......Page 237
Seating the Endobutton......Page 238
Cause 1......Page 239
Comment......Page 240
Graft-Tunnel Mismatch......Page 242
References......Page 243
Medial Collateral Ligament......Page 361
Indications......Page 261
Freezing......Page 245
Whipstitch Technique......Page 246
Graft Passed Through the Endobutton-CL Loop and Sutures Used to Tie the Endobutton to the Femoral Post......Page 247
The Femoral Post Technique Can Salvage the Following Situations......Page 248
Results......Page 291
EZLoc Femoral Fixation of a Soft Tissue Graft......Page 250
Preoperative Rehabilitation......Page 520
Torsional Strength......Page 252
Hamstring Versus Bone-Patellar Tendon-Bone Graft......Page 253
Summary......Page 255
Troubleshooting the EZLoc......Page 257
Stratis ST Femoral Fixation System......Page 259
Introduction......Page 358
Postoperative Rehabilitation Phase II......Page 262
Tibial Fixation......Page 274
Creation of Transverse Tunnel......Page 264
Insertion of the Graft Block......Page 265
Pearls and Pitfalls......Page 267
References......Page 565
Introduction......Page 270
Notchplasty and ACL Stump Removal......Page 271
U-Guide Position and Cortical Length Measurement......Page 272
Rehabilitation......Page 373
In Vitro Biomechanical Data Using Porcine Tibiae and Bovine Flexor Tendons......Page 282
References......Page 283
Introduction......Page 284
Posterior Cruciate Ligament......Page 287
Suggested Readings......Page 293
Anterior Cruciate Ligament Reconstruction Utilizing the Rigidfix for Femoral-Sided Fixation......Page 294
Endobutton......Page 587
Introduction......Page 301
Femur Fracture......Page 381
Interference Screws......Page 302
Interference Screw Position......Page 306
Femoral Hybrid Fixation......Page 309
Tibial Hybrid Fixation......Page 312
Anatomical Retroscrew Anterior Cruciate Ligament Fixation: Single- and Double-Bundle Anterior Cruciate Ligament Reconstruction with Retroscrew Biointerference in a Single Femoral Socket......Page 316
Suggested Readings......Page 321
Fastlok Device for Tibial Fixation of a Tripled or Quadrupled Semitendinosus Autograft for Anterior Cruciate Ligament Reconstruction......Page 322
Introduction......Page 526
Suggested Readings......Page 326
Tubularization......Page 329
Quadriceps Tendon Autograft or Tendo-Achilles Allograft......Page 330
Passage of the Graft, Fixation, and Tensioning......Page 331
Troubleshooting......Page 332
WasherLoc and Bone Dowel Surgical Technique......Page 333
High-Tension Grafts......Page 334
Strategies That Promote Tendon-Tunnel Healing......Page 336
Fixation of the graft in the tibial tunnel......Page 345
Osteoporosis......Page 590
Intratunnel Tibial Fixation of Soft-Tissue Anterior Cruciate Ligament Grafts: Graft Sleeve and Tapered Screw......Page 347
Tibial Tubercle Fracture......Page 620
Biocompatibility and Histology of Fixation Site Healing......Page 348
Cycling, Running, and Elliptical Training......Page 349
Graft Passage......Page 351
Cross-Pin Fixation......Page 605
Patella Fracture......Page 618
Tunnel Sizing......Page 360
Example 2: Dynamic Functional Knee Stability Using Nonlinear Analysis......Page 505
Four-Strand Hamstring Versus Bone-Patellar Tendon-Bone Stability Rates......Page 364
Screw Breakage......Page 366
Closure and Postoperative Dressings......Page 367
Suggested Readings......Page 369
Muscular Inhibition After Anterior Cruciate Ligament Reconstruction......Page 374
Parallelism and Divergence......Page 376
Conclusion......Page 378
Tibial Exposure......Page 382
Femoral Exposure......Page 383
Tibial Tunnel......Page 384
Postoperative Management......Page 572
Femoral Tunnel......Page 385
Contralateral Graft......Page 386
Ipsilateral Graft......Page 387
Special Considerations with Contralateral Graft......Page 389
References......Page 500
Bone-Patellar Tendon-Bone Anterior Cruciate Ligament Reconstruction Using the Endobutton Continuous Loop Bone-Tendon-Bone Fixation System......Page 390
The Timing of Strengthening in Physical Therapy......Page 540
Introduction......Page 398
Summary......Page 401
Classification of Existing Tunnel Positions......Page 405
Magnetic Resonance Imaging......Page 406
The Effect of the Initial Tension on the Tension-Flexion Curve......Page 409
Tensioning Anterior Cruciate Ligament Grafts......Page 416
Skeletally Immature Patients......Page 421
Graft Remodeling and Ligamentization After Anterior Cruciate Ligament Reconstruction......Page 424
Ligamentization Phase of Graft Healing......Page 429
Graft-Tunnel Healing......Page 434
Phase I: Early Postoperative Period......Page 531
Surgical Management......Page 438
Gene Therapy......Page 440
Revision Anterior Cruciate Ligament Reconstruction Using Autologous Hamstring Tendons......Page 444
Graft Failure and Laxity......Page 578
Postoperative Rehabilitation......Page 481
Hardware Management......Page 449
Hardware Removal......Page 450
Tunnel Enlargement......Page 456
Tibia Fixation......Page 457
Revision Anterior Cruiate Ligament Reconstruction......Page 460
Postoperative Rehabilitation......Page 461
Graft Choice: Autograft Versus Allograft......Page 464
Conclusion......Page 465
Postoperative rehabilitation......Page 468
Our experience with a two-stage revision Anterior Cruciate Ligament reconstruction......Page 470
Review of literature......Page 471
Natural History......Page 474
Treatment Options......Page 477
Treatment and Recommendations......Page 478
Physeal-Sparing ACL Reconstruction with the Iliotibial Band......Page 482
Postoperative Rehabilitation......Page 483
Surgical Technique......Page 484
Anesthesia and Positioning......Page 489
Technique for Reconstruction......Page 490
References......Page 493
Anterior Cruciate Ligament Injury Combined with Medial Collateral Ligament, Posterior Cruciate Ligament, and/or Lateral-Side Injury......Page 494
Synovial Fluid Infiltration......Page 499
Suggested Reading......Page 502
Treatment of Meniscus Tears with Anterior Cruciate Ligament Reconstruction......Page 503
Other Causes......Page 585
Restoration of Motion......Page 510
Anterior Cruciate Ligament Reconstruction and Microfracture......Page 511
Anterior Cruciate Ligament Reconstruction and Meniscal Allograft Implantation......Page 512
Anterior Cruciate Ligament Reconstruction and High-Tibial Osteotomy......Page 513
Anterior Cruciate Ligament Strain Behavior During Rehabilitation Exercises......Page 518
Allografts......Page 530
Postoperative Rehabilitation Phase III: Advanced Strengthening......Page 535
Comment......Page 536
History......Page 538
Lower Extremity Cyclical Loading......Page 541
Equipment......Page 542
Summary of Protocol......Page 543
References......Page 622
Radiographic Studies......Page 545
Enhancement of Graft Healing with Growth Factors......Page 547
Suggested Reading......Page 551
Proprioception and Anterior Cruciate Ligament Reconstruction......Page 552
Biofilm Formation......Page 569
Laboratory Findings......Page 570
Authors' Protocol for Persistent Septic Arthritis of the Knee......Page 573
Bacterial Infections......Page 574
Intraoperative Graft Contamination......Page 575
References......Page 640
Stiffness: Prevention and Treatment......Page 582
Introduction......Page 632
Osteoporosis After Anterior Cruciate Ligament Reconstruction?......Page 589
Surgery: A Risk Factor for Osteoporosis?......Page 591
Tunnel Positioning......Page 639
Conclusions......Page 595
Hardware Complications After Anterior Cruciate Ligament Reconstruction......Page 602
Vascular Complications After Anterior Cruciate Ligament Reconstruction......Page 609
Fracture Complications After Anterior Cruciate Ligament Reconstruction......Page 615
Anterior Knee Problems Related To the Graft......Page 624
Central Quadriceps Tendon......Page 627
Example 1: Tibial Rotation......Page 634
Growth Factors and Other New Methods for Graft-Healing Enhancement......Page 642
TGF-beta and EGF......Page 643
Summary......Page 646
A......Page 650
B......Page 652
C......Page 653
E......Page 654
F......Page 655
H......Page 656
I......Page 658
M......Page 659
P......Page 660
R......Page 662
S......Page 664
T......Page 665
Y......Page 667