ACL Reconstruction

with Autogenous Semitendonsis

and Gracilis
William R. Beach, M.D.
 Graft Harvest,
Fixation and Tensioning
 Graft Harvest
• Most important and “stressful”
portion
• Incision – two finger breadths
distal and one medial to the
tibial tubercle
• Palpate the “speed bumps”
• Longitudinal incision down to
bone
• Elevate the tendons and view
the tendinous “raphe” from
“inside” the fascia
 Graft Harvest
• “Whip-stitch” the free
ends of the semi-t and
gracilis with #5 suture
• Carefully and
completely release the
tendinous connections
to the gastrocnemius
 Graft Harvest
• “Blunt” tendon stripper to
avoid premature tendon
amputation
• “Sharp” tendon stripper
 Tibial Tunnel Placement
and Notchplasty
Notchplasty
• required because we are
replacing an “hourglass
with a cylinder”
Howell Guide
• couples tibial tunnel
placement and the
notchplasty
 Howell Guide
• References the tibial tunnel
placement off the roof of
the intercondylar notch
• Ideal for acute tears and
reconstruction
• Less suited for the chronic
“overgrown” intercondylar
notch
• The guide is positioned and
the pin is drilled in full
extension
 Marking The Roof
• While the knee is in full
extension the drill can be
advanced into and under
the roof
• This will outline the
minimum amount of roof
which must be removed
to avoid graft
impingement
 Avoiding Lateral Wall
Abrasion
• Advance the drill
slightly past the
entrance of the tibial
tunnel
• By carefully flexing
the knee the minimum
amount of lateral wall
is removed to avoid
abrasion
 Femoral Tunnel
Is the cortex or bony cylinder intact ?
• If the posterior cortex is
intact then compression
or interference fixation is
possible
• If the posterior cortex is
incompetent then
suspension fixation is
necessary
 Fixation Types
• Compression or interference
– ex. Metal or resorbable screws
• Suspension
– ex. Endobutton, LinX HT or Cross-pin
 Tunnel Requirements for
Compression Device
• Competent bony cylinder
• Protected posterior cortex
• Usually requires creation
of this tunnel in greater
degrees of flexion – avoid
the “over the top position”
 Tunnel Requirements for
Suspension Device
• Competent bony
cortex in the proximal
portion of the tunnel –
Endobutton and LinX
• An intact or defined
cortical breach –
Endobutton and LinX
• Adequate bone
strength to support the
cross-pin device
 Peak Loads for Femoral
Interference/Compression Fixation
• Metal RCI screw - 214N
• Bioscrew (8mm) - 341N
(Brown CH et al - 566 +/-68 N)
• Half millimeter drilling and “over-sized”
screw - increased ultimate strength to 530N
• JC Richmond and MJ Friedman, Fall
AANA Meeting, 1999.
 Peak Loads for Suspension
Fixation Devices
• Lynx HT - 673 Newtons
– Innovasive data
• EndoButton (Deknatel tape) - 610-700 Newtons
– Rowden et al. AmJSM, 1996.
• EndoButton (continous loop) – two times “stronger
and stiffer” than with tape
– M.J. Friedman, Fall AANA Meeting, 1999.
• Cross-pins – 850 to 1150N ultimate tensile strength
with stiffness of 224N/mm
– M.J. Friedman, Fall AANA Meeting, 1999.
 Peak Loads for Tibial Fixation
• Tandem AO Screw and Washer - 1159N
• WasherLoc - 905N
• Screw and Post - 768N
• RCI screw (metal) - 241N
• Resorbable screw - 341N (over-sized screw
- 420N)
 ACL
ACL TENSIONING
TENSIONING

• How ?
• When ?
• How much ?
ACL Reconstruction and
Tensioning
• Underload - Instability
• Overload - Constrains motion
Variable Factors
• Viscoelastic Properties
– Pretension
– Preoperative tension
– Postoperative tension
Literature Review
Human Studies - In Vivo

• Tension on the ACL/PCL changes

throughout the arc of motion

FG Girgis et. al.

Clin Orth
1975
 ACL Biomechanics
• Doubled gracilis and semitendinosus
strength - 4400N
– JC Richmond - AANA Fall Meeting,
1999.
• the ACL get tighter in extension
• the ACL is more lax in 30 degrees of
flexion
 Review On Tension In The Natural And
Reconstructed Anterior Cruciate Ligament

H.N. Andersen, D.A. Amis

Knee Surg Sports Trauma
Arthroscopy 2:192 - 202 (1994)
 Andersen and Amis
• Different grafts will require different
tensions to restore normal stability
• The joint position (flexion angle) and graft
placement are critical
• Little firm evidence for which to base a
consistent protocol
Determination of Graft Tension before
Fixation in ACL Reconstruction

Burks RT, Leland R.

Arthroscopy 4:260-6 (1988)
 Human Study - In Vitro
• Determination of Graft Tension Before
Fixation in Anterior Cruciate Ligament
Reconstruction
– Ten cadaveric knees
– KT 1000 (Medmetric)
– Measured anterior tibial translation with a 20 lb
load
Burks and Leland
Arthroscopy 1988
 Burks and Leland

• Goal - to determine the tension needed before

graft fixation to restore normal anteroposterior
translation
• Arthrometer testing until the 20 lb. anterior drawer
equalled the ACL intact drawer
 Burks and Leland
Graft and tension
• bone-tendon-bone - 3.6 pounds
• semitendinosus - 8.5 pounds
• iliotibial band - 13.6 pounds
• The required tension to return anterior
translation to normal seems to be tissue specific.
 Tuckahoe Orthopaedics

• Caspari, Meyers, Beach and Galbraith

• Study to determine tensioning affects
• Tensioned and non-tensioned group
• Not completed because of the early
identifiable benefits in tensioning
 ACL Pretensioning

• B-T-B complexes were tensioned initially

with 16 lbs. via an Instrom device
• Measured 3 min. later the tension was 8 lbs.
• This “creep” stabilized at 3 minutes

M.Goble
1997 Metcalf Mem.
Sun Valley, ID
 ACL Pretensioning
• Goble suggests
– Tensioning the graft and femoral fixation
complex
– Cycle the knee through a full ROM and repeat
several cycles
– Re-tension the graft after 3 minutes and fixate
the graft to the tibia
Practical Tensioning
Tension Boot
 Tension Boot
• Allows up to 20 lbs. of
tension to be applied
to the graft
• Allows cycling of the
graft under tension
• Frees the surgeons
hands to fixate the
graft to the tibia
 Conclusions

• Graft placement is crucial

• Notchoplasty is important
• Graft type is minimally important
 Conclusions

• Graft fixation construct should

have minimal strain
• Angle of tensioning 0° - 30°
 Conclusions

• Operative graft tension 5 - 15 lbs.

• Specific to graft type
• Pretension (??)
 Conclusions

Well controlled clinical studies

hold the answers.
 Thank You
Orthopaedic Research of Virginia

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