Can you walk me through how you perform an ACL reconstruction?
- For main ligaments around the knee, ACL, PCL, MCL, LCL, the most injured is the ACL, not a lot of ability to heal itself, MCL does, ACL tears are non contact injuries, either torn or not torn, used to try and sue it together, uptick in “repairs” recently, reconstruction is the golden standard, don’t drill a tunnel all the way through, some will still make an entire tunnel in the tibia, general trend is to do sockets, not tunnels, bone tendon bone (metal screws to fit, interference screw), soft tissue vs bone plugs (soft tissue inside the tunnel, the bone will eventually grab it), suspensory fixation, devices that can go in and put absorbable nonmetal into the socket and will twist open, absorbable is very useful because the body just has to heal, bone to bone heals quicker, bone to bone with a screw can lead to tunnel widening (with a screw the bone will never heal and the tunnel can get larger),
- Main fixation points now are endo-button and the tightrope, suspensory fixation (what Dr. Schell uses the most) tighten it from the outside, a button that is sitting on the cortex, very small but very strong, only holds until it is no longer needed
- Aperture fixation, mimic and limit and type of hole around the graft where it goes into a tunnel
- Can take 30 minutes, some take 3 hours
What specific tools do you use throughout the procedure?
- Arthroscopic, drills, drill pins, 3 mm, flip cutter,
We are looking at improving a tibial guide/femoral guide device, how can we go about that?
- Higher grad bioabsorbable, general techniques of how to make it adjust more robustly, how can you make it as anatomic as possible, PRP vs plate load plasma, screw or suspensory fixation is the general technique
- Get it to be fixed purely aperture (not having it to get into bone as often)
- Ideal is to not have to drill any tunnel into the bone but you would have to perfectly size the graft, with the sockets, you don’t have to find the exact size
- Arthrex, meniscus repair devices have gotten attention, a screw is a screw, there’s not much to change here,
- If we could figure out a way to create an implant that has very strong fixation that you didn’t have to get a deep socket or tunnel that is easy to implant
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- He would like to drill a tunnel to 5 mm in length and have it fixed rigidly and you won’t get that widening, it is ingrained in our minds that we need 15-20 mm in the socket, shorter socket with just as strong demonstration it is more ideal
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We are unsure if you can change the angle from the other axial planes (kind of like how we draw a 3D sphere and cylinder)
- Always going to be linear, different ways of drilling, he drills anterior medial put a pin in the femur, then drill a socket, on the tibia use a flip cutter, position exactly where you want it, the angle does not truly matter, all that really matters is where the opening of the hole is, the only time is when there is a child that has a growth plate, all we care about is where the graft is going to be inside the knee, the further down you are on the clock face, the more rotation you have, it all matters where the femoral hole beings and tibial hole begins, the femoral hole is more important, the majority of failure of ACLs is not the fixation
Do you perform Lamaire LET
- Not as often, the bear is a pediatric orthopedic surgeon in mass gen,
- If the tendon is there you can grab the top of the tendon, and stick it on the side of the bone to tighten it, one guy would use fiber tape, if its loose, sometimes he just tightens the acl
- If so, how do you figure out the angle to drill at?
Does the Lemaire LET method interfere with drilling?
- Tunnel convergence can become an issue when you have multiple injuries in the knee
- When fixing the LCL in the femur, he is angling the tunnels more posterior and distal but wont drill all the way through, not a huge issue, one surgeon would drill two tunnels in the tibia and two in the femur
Are there any other issues when performing surgeries that
- Sometimes it is hard to see certain areas of the knee
- Colonoscopy – a camera that can turn multiple angles,
- Artrex came out with a nanoscope
- Have a camera that is thinner but still maintains the quality and can curve around
- Sometimes when trying to get to the back of the knee it is hard to see what is going on around there
- The hip scopes, people generally use it for a 30 and a 70, the hip is so contour that you can really see around the horizon