Anterior Cruciate Ligament - Wheeless' Textbook of Orthopaedics

- Discussion:
- anatomy of ACL
- biomechanics of ACL:
- epidemiology_of_ACL_injuries:
- mechanism: ACL Tear:
- natural history of the ACL-deficient knee
- partial ACL injury
- pediatric ACL injuries:

- Evaluation of ACL Injuries:
- examination

- Surgical Management:
- graft placement theory:
- femoral tunnel
- tibial tunnel:
- surgical techniques:
- bone patellar bone reconstruction:
- hamstring reconstruction:
- allograft reconstruction:
- extra-articular reconstruction:
            - double bundle reconstruction:
                - many techniques described with one or two tibial and one or two femoral tunnels
                - much biomechanical data confirms that both bundles are necessary to restore
                - ACL function
                       - main findings are that PL bundle contributes to rotational stability closer to full extension

- Distribution of in situ forces in ACL in response to rotatory loads Single– versus two–femoral socket ACL reconstruction technique:
- AM bundle reconstruction restores tibial anteroposterior translational stability but not rotational stability

- The effectiveness of reconstruction of ACLwith hamstrings and patellar tendon . A cadaveric study comparing anterior
tibial and rotational loads.

- Clinical advantages versus single bundle technique not yet identified.

                    - Anatomical reconstruction of the anterior cruciate ligament in goats.
                    - Biomechanics of a double prosthetic ligament in the anterior cruciate deficient knee
                    - A comparative study of single- and double-bundle ACL reconstructions in sheep

- Difficulty is how to measure/quantify improved rotational stability

- Technical complexity and complications still need to be overcome before it becomes gold standard.

- Multiple techniques published with no established benefit yet

- Anatomic double bundle ACL reconstruction: a literature review

    - graft fixation techniques:
    - post operative care and complications:
- arthrofibrosis:

- Adjunctive Techniques:
- management of concomitant meniscal tears:
- chondral injuries
    - anteromedial instabilility
    - anterolateral instability:
           - lateral collateral ligament
       - posterolateral instability
   - references:
                  - The Influence of the Integrity of Posterolateral Structures on Tibiofemoral Orientation When an ACL Graft is Tensioned
                  - Anterolateral rotational knee instability: role of posterolateral structures
    - posterior cruciate ligament
- high tibial osteotmy
- indicated w/ concomitant varus alignment;
- varus classification:
- primary varus:
- varus alignment due to the underlying tibiofemoral alignment;
- there is no associated posterolateral ligament deficiency or abnormal lateral joint opening;
- double varus:
- there is an associated deficiency of the lateral collateral ligament;
- varus alignment is increased as a result of both tibiofemoral osseous alignment and abnormal lateral joint opening;
- triple varus:
- there is deficiency of all of the posterolateral structures;
- varus alignment increases on standing, and a varus recurvatum position is present;
- generally HTO is performed months prior to performing ACL reconstruction;
- in the report by Frank R. Noyes et al (2000), the authors followed 41 young patients who had ACL deficiency, genu varus angulation,
and varying amounts of posterolateral ligament deficiency;
- all patients were treated with high tibial osteotomy and, in the majority (N = 34), ACL reconstruction a mean of 8 months later;
- posterolateral reconstructions were also required in 18 knees;
- patient rating of the knee condition was normal or very good in 37% (15 knees) and good in 34% (14 knees);
- references:
- High Tibial Osteotomy and Ligament Reconstruction for Varus Angulated Anterior Cruciate Ligament-Deficient Knees.
- High tibial osteotomy and ligament reconstruction in varus angulated, ACL-deficient knees. A 2-7 year follow-up study