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    ACL RECONSTRUCTION SURGERY TECHNIQUES

    Unfortunately, when the anterior curciate ligament (ACL) is diagnosed as torn, surgery is advised as it will not regenerate on its own.

    Nowadays, many techniques are used by orthopaedic surgeons around the world to do this operation but the principle behind each and every one of them relatively stays the same.

    Here is a description of the three most applied procedures to regenerate the anterior curciate ligament (ACL).

    Hamstring tendon graft reconstruction of the ACL

    This procedure necessitates the surgeon to take a piece of the hamstring tendon, which is located in the hamstring of the patient, and use it in place of the torn ligament.

    Anatomy

    Three muscles and their tendons form the hamstrings:

    • The semitendinosus
    • The semimembranosus
    • The biceps femoris

    These tendons cross the knee joint and connect on each side of the tibia. 

    The tendon that is used for this type of ACL reconstruction surgery is taken from the semitendinosus muscle.

    Goal of the surgery

    The main goal of ACL reconstruction surgery is to gain knee stability, more precisely to keep the tibia from moving too far forward under the femur bone. The ACL's main role is indeed to restrain the tibia from doing any exaggerated forward movement of the tibia making this ligament essential in making the knee stable.

    Procedure

    While performing the surgery, most of the surgeons nowadays use an arthroscope (a small camera) to see inside the knee joint. The patient is first put under anaesthesia and the surgeon starts cutting two small openings in the knee. These openings are called portals and allow the arthroscope and the surgical tools to be inserted into the knee. 

    An incision is also made near the knee to collect the semitendinosus tendon that will be used as ACL graft. The surgeon then arranges it into three or four strips in order for the graft to become nearly as strong as the other grafts that can be used to reconstruct the anterior cruciate ligament (patellar tendon).

    Following this, the surgeon prepares the knee to place the graft and removes the remnants of the torn anterior cruciate ligament. Then, holes are drilled in the tibia and in the femur to place the graft. The holes are placed so that the graft can be placed in the same position as the original ACL. To finalize the procedure, screws and staples are used to withhold the graft in position inside the drill holes and stiches are used to close the portals and skin incisions.

    Post-Surgery

    After the surgery took place, the body starts to develop a network of blood vessels in the new ACL. This process, which takes about 12 weeks, is called revascularization. It is the phase during which the graft is at its weakest making stress applied on it very harmful as the chances of stretching or even rupturing become very high at this point.

    Using an arthrometer like the GNRB during this phase is essential as it gives precise feedback on the behaviour of the graft and optimizes the chances of finding knee stability again.

    Advantages and disadvantages

    Advantages

    Disadvantages

    • No pain after surgery
    • Recovery time after surgery longer 
    • ACL graft more fragile

    Patellar tendon graft reconstruction of the ACL (Kenneth Jones or KJ technique)

    This procedure necessitates the surgeon to take a piece of the patellar tendon that is located below the kneecap (aka. patella) of the patient and use it in place of the torn ligament. The graft includes the tendon with pieces of bone tissue located on each end of it.

    Anatomy

    The patellar tendon is a strong and thick band of tissue located in the front of the knee. It starts at the bottom of the patella and attaches itself on the front and upper side of the tibia; also know as the tibial tuberosity.

    During a patellar tendon graft reconstruction surgery, surgeons remove a strip of the patellar tendon located in the middle. Consequently, the graft includes the bony attachment from the bottom of the patella and the tibial tuberosity.

    Goal of the surgery

    The main goal of ACL reconstruction surgery is to gain knee stability, more precisely to keep the tibia from moving too far forward under the femur bone. The ACL's main role is indeed to restrain the tibia from doing any exaggerated forward movement of the tibia making this ligament essential in making the knee stable.

    Procedure

    The procedure used for the patellar tendon graft reconstruction surgery resembles a lot to the hamstring tendon graft reconstruction surgery. An arthroscope (a small camera) is also most of the time used to see inside the knee joint. The patient is first put under anaesthesia and the surgeon starts cutting two small openings in the knee. These openings are called portals and allow the arthroscope and the surgical tools to be inserted into the knee. 

    The difference is that during this surgery, an incision is made below the patella of the knee to collect the bone patellar tendon, which is to be used as the graft. The surgeon takes out the middle section of the tendon, along with the bone attachments on each end. Then, each end of the graft is rounded and smoothed and holes are drilled in each extremity in order to place the strong stitches that will pull the graft.

    Following this, the surgeon prepares the knee to place the graft and removes the remnants of the torn anterior cruciate ligament. Holes are drilled in the tibia and in the femur to place the graft. The holes are placed so that the graft can be placed in the same position as the original ACL. To finalize the procedure, screws are used to withhold the graft in position inside the drill holes with the help of the strong stitches that were placed previously and stitches are placed on both the portals and the skin incision.

    Post-Surgery

    After the surgery took place, the body starts to develop a network of blood vessels in the new ACL. This process, which takes about 12 weeks, is called revascularization. It is the phase during which the graft is at its weakest making stress applied on it very harmful as the chances of stretching or even rupturing become very high at this point.

    Using an arthrometer like the GNRB during this phase is essential as it gives precise feedback on the behaviour of the graft and optimizes the chances of finding knee stability again.

    Advantages and disadvantages

    Advantages

    Disadvantages

    • Recovery is faster
    • Pain in knee can sometimes be felt after surgery

    Allograft reconstruction of the ACL

    Using an allograft to replace a torn ACL is also a possibility nowadays to reconstruct the anterior cruciate ligament. An allograft is tissue that is harvested from an organ donor at the time of death. Surgeons may order these grafts from tissue banks where they are kept in a freezer after having been checked for any type of infection and sterilized. 

    Multiple allografts can be used to replace the torn ACL:

    • the tibialis tendon
    • the patellar tendon
    • the hamstring tendon
    • the achilles tendon

    Generally, surgeons prefer using the patellar tendon allograft because it comes with bone tissue on each end making it easier to fix and heal over time. 

    Advantages and disadvantages

    Advantages

    Disadvantages

    • No body part is taken from the patient
    • Surgery is quicker as no graft needs to be harvested
    • No allograft is available when needed
    • Patient rejecting the graft is a possibility