Basic steps in hamstring graft harvesting and single bundle ACL reconstruction

1. ACL RECONSTRUCTION

2. Surgical steps
1) examination under anaesthesia
2) arthroscopic diagnostic round
3) addressing the other lesions.
4) graft harvest
5) Graft preparation
6) Preparation of intercondylar notch
7) Femoral tunnel (trans portal)
8) Tibial tunnel
9) Calculation of endobutton CL length and graft
preparation
10)Graft passage and femoral fixation
11) Graft tensioning
12) Tibial fixation
13) closure

3. Lateral leg post : for giving intraop
Valgus stress, opening the medial
compartment
Full knee flexion should be possible
For making transportal femoral tunnel

4. Portals

5. Diagnostic round
• Supra patellar pouch
• Medial and lateral gutter
• Patello- femoral articular surface
• Menisci and Cruciate ligaments and articular
cartilage.

6. Oblique skin incision –
used by experienced
Surgeons. More cosmetic. Saves the nerve
Vertical skin incision
the sartorius tendon is
approximately one finger width
below the tibial tubercle
sartorius fascia is exposed by
sharp and blunt dissection
inside-out technique : the conjoined tibial insertion of the two tendons is
detached from the tibia by making an inverted L-shaped incision
through the sartorius fascia

7. bluntly release the interconnecting fascial bands
right-angled type clamp is used to
separate the two tendons from the
undersurface of the sartorius fascial
flap
-a closed Brand-type tendon stripper,(7.4mm)
or a tendon harvester (Linvatec, Largo, Fla)
-extensive fascial connections that extend from
inferior border of the semitendinosus tendon
to the medial head of the gastrocnemius.
-- advance the tendon stripper
parallel to the tendon by a slow, steady,
rotating motion
Ideal length- 20-26 for gracilis/24-30 for SemiT

9. 2 – graft preparation
• graft preparation board (Graft Master II;
Smith & Nephew Endoscopy).
• Residual muscle fibers removed with a
metal ruler, a large curet.
• running, baseball-style whipstitch of a
No. 2 nonabsorbable suture.
Doubled gracilis and
semitendinosus tendon (DGST) graft

12. Anterolateral portal
VIEW OF FEMORAL ATTACHMENT OF ACL

13. 3 – Notch preparation
• Using currete and Burr
• Autograft requires a 2 mm clearance
• The proximal outlet of the notch should not be
enlarged; rather, it is carefully identified with
the knee at 90° flexion.
• a 5.5-mm full-radius resector to resect the soft
tissue

14. •

17. Transportal femoral tunnel preparation
Advantages –
1) The ability to position the femoral tunnel in a more
anatomic position lower down the sidewall of the lateral
femoral condyle
2) The freedom to locate the starting position of the tibial
tunnel anywhere along the medial surface of the tibia
3) The freedom to drill a steeper and therefore longer tibial
tunnel
4) The possibility of drilling the femoral tunnel before drilling
the tibial tunnel, which helps maintain joint distention,
improving joint visualization during the remainder of the
procedure
Disadvantage –
1) unconventional field of view in the notch that can result in
spatial disorientation with knee 120 degree flexed
2) more horizontal femoral tunnel that results in the
EndoButton implant's lying on the weaker metaphyseal
bone of the distal femur

18. Knee flexed 75-90 Knee flexed 110
Over the top guide
30 mm depth
Intact posterior wall

20. FEMORAL TUNNEL PREPARATION
• 6 mm anterior to the over-the-top spot in approximately
the 11-o'clock position on the right knee or the 1-o'clock
position on the left knee, at the junction of the arch of
the roof and the lateral wall of the condyle
approximately 8 mm lateral to the posterior cruciate
ligament
• The external landmark for the guide is the midportion of
the femur approximately 3 cm proximal to the over-the-
top spot. The angle of the wire should be approximately
45 degrees to the femur and should be as close as
possible to the plane of the previously placed tibial
guidewire. at least 2 mm of lateral cortex should remain
posterior to the wire to prevent “blowing out” the
posterior wall of the condyle. Ensure that it is 6 mm
anterior to the over-the-top spot position by flexing the
knee 90 degree.
• 8 mm reamer followed by 10 mm is used. The tunnel is
drilled within 5-8 mm of the far cortex.
• For endobutton , 4-5 mm tunnel is drilled through far
cortex.

22. • Intra-articular reference point - just posterior to
the center of the anterior cruciate ligament
footprint approximately 2 mm anterior to
the peak of the medial tibial spine, which is
approximately 7 mm anterior to the
posterior cruciate ligament, just medial to
the inner edge of lateral meniscus.
• Advance the guidewire into the joint, and
carefully identify its direction of passage

29. Patellar tendon harvesting
• 6-cm medial parapatellar incision starting
inferior to the patella and extending distally
medial to the tibial tuberosity
• 10-mm-wide graft or one third of the
tendon, whichever is smaller used
• cut made about 10 mm wide × 20 mm long
measured from the bony tip of the patella.
• 25-mm-long cuts distally, and free the tibial
graft with a curved osteotome

32. GRAFT PREPARATION
 contour the graft until it fits through a 10-
mm trial
drill three holes in each bone plug
place a 5-0 nonabsorbable suture through
each drill hole

33. Thank You