Rev. bras. ortop. vol.50 número4

r e v b r a s o r t o p . 2015;50(4):469–471

www.rbo.org.br

Technical

Note

Anatomical

reconstruction

of

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anterior

cruciate

ligament:

a

logical

approach

Julio

Cesar

Gali

OrthopedicsandTraumatologyService,FaculdadedeCiênciasMédicasedaSaúdedeSorocaba,PontifíciaUniversidadeCatólicadeSão Paulo(PUC-SP),Sorocaba,SP,Brazil

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Articlehistory: Received4July2014 Accepted8July2014 Availableonline7July2015

Keywords:

Kneetrauma/surgery Anteriorcruciateligament reconstruction

Minimallyinvasivesurgical procedures

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Wedescribethesurgicalapproachthatwehaveusedoverthelastyearsforanteriorcruciate ligament(ACL)reconstruction,highlightingtheimportanceofarthroscopicviewingthrough theanteromedialportal(AMP)andfemoraltunneldrillingthroughanaccessory anterome-dialportal(AMP).TheAMPallowsdirectviewoftheACLfemoralinsertionsiteonthemedial aspectofthelateralfemoralcondyle,doesnotrequireguidesforanatomicfemoraltunnel reaming,preventsanadditionallateralincisioninthedistalthirdofthethigh(aswouldbe unavoidablewhentheoutside-intechniqueisused)andalsocanbeusedfordouble-bundle ACLreconstruction.

©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.

Reconstruc¸ão

anatômica

do

ligamento

cruzado

anterior:

uma

abordagem

lógica

Palavras-chave:

Traumatismosdojoelho/cirurgia Reconstruc¸ãodoligamentocruzado anterior

Procedimentoscirúrgicos minimamenteinvasivos

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o

Descrevemosaabordagemcirúrgicaquevimosusandonosúltimosanosparaareconstruc¸ão do ligamento cruzado anterior (LCA) e destacamos a importância da visualizac¸ão artroscópicapeloportalanteromedialeperfurac¸ãodotúnelfemoralporumportal antero-medialacessório,paraqueareconstruc¸ãosejarealmenteanatômica.Essaviapermitea observac¸ãodiretadainserc¸ãofemoraldoLCAnafacemedialdocôndilofemorallateral, nãonecessitadeguiasparaacriac¸ãodotúnelfemoralanatômico,dispensaanecessidade deincisãonoterc¸odistalelateraldacoxa,comoéinevitávelquandoaperfurac¸ãodotúnel femoraléfeitaoutside-in,epermite,também,areconstruc¸ãodoLCAcomduplabanda.

©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevierEditora Ltda.Todososdireitosreservados.

E-mails:juliogali@globo.com,juliogali@note.med.br http://dx.doi.org/10.1016/j.rboe.2015.06.014

470

Introduction

Someyearsago,thetechniquemostcommonlyusedfor recons-tructingtheanteriorcruciateligament(ACL)usingagraftfrom theflexortendonswasviathetranstibialroute,withthefemoral tunnelhighintheintercondylararea.1 _{However,arecentstudy} thatincluded436patientswhounderwentprimaryreconstruction oftheACLaloneusinganautologousgraftshowedthatpatients treatedbymeansofthetranstibialtechniquehadasignificantly higherlikelihoodofrequiringrepeatedsurgeryinthesameknee, incomparisonwiththosetreatedbymeansofananteromedial route.2

There is an overall tendency toward reconstructions that are anatomical in nature, since it is known that creation of non-anatomicaltunnelsmaydiminishjointmobility3_andcause abnormalrotationofthekneeduringdynamicloading.4

Giventhatmanyauthorscalltheirreconstructionsanatomical, aprecisedefinitionofwhatthismeansisneeded.A reconstruc-tionisanatomicalwhenitseekstofunctionallyrestoretheACL toitsnativedimensions,andtoorientatethecollagenand inser-tionsites,withtheintentionofreproducingthenormalanatomy, restoringthekinematicsandpromotinglong-termjointhealth.5

Forgreateraccuracyincreatinganatomicalfemoraltunnels, drillingthembymeansofanaccessoryanteromedialportalhas been recommended.6 _{The aim of this technical note was to} describeatechniqueforanatomicalreconstructionoftheACL, witharthroscopicviewingthroughtheanteromedialportaland drillingofthefemoraltunnelthroughtheaccessoryanteromedial portal.

Surgical

technique

Wemadeanobliqueincisionofaround4cm,intheproximaland medialthirdofthelowerleg,inordertodiminishthelikelihoodof injurytotheinfrapatellarbranchofthesaphenousnerve.7_Then, usinganextractor,weremovedtheflexortendons(gracilisand semitendinosus).

Anassistantatanauxiliarytableremovedtheremainsofthe musclesfromthetendonsandsectionedtheirproximalendso thattheymeasured18cm.Oneoftheendsofeachofthetendons waspassedintotheloopoftheEndobutton®_{andwassuturedto}

itsotherendoveralengthof3cm,usingcomVicryl1.Alsousing Vicryl1,wesuturedthe3cmofthegraftclosesttotheloopofthe Endobutton®_{toeachotherand,inthesameway,totheothertip,}

soastomakeaquadruplegraftof9cminlength.

TwoEthibond5threadswerepassedthroughtheorificesofone sideoftheEndobutton®_{andtwoEthibond2threadsthroughthe}

orificesontheotherside.ThechoiceofEndobutton®_loopsizeis

determinedbythelengthofthefemoraltunnel,whichisdescribed below.

The anterolateraland anteromedialportals forarthroscopy wereconstructed adjacenttothelateralandmedialborders of thepatellarligament,respectively.Theanteromedialportalwas openedatthelevel ofthejointinterlineandthe anterolateral portalwascreatedslightlyproximallytothejointinterline.

Diagnosticarthroscopywasperformedinordertotreatany meniscaland/orchondrallesions,ifthesewerepresent.Toview themedialfaceofthelateralfemoralcondyle,wemovedthe opti-caldevicetotheanteromedialportal.

The accessoryanteromedial portalwasestablished using a number18needle,underdirectviewing,inferiorlyandmedially tothestandardanteromedialportal(Fig.1).Itspositioningis crit-icalforobtainingthecorrectpathwayanddeterminingtheentry pointforthefemoraltunnel,soastoavoidinjuringthesurfaceof themedialfemoralcondyleandthemedialmeniscus,duringthe drilling.

AMP

AAMP

Fig.1–Demonstrationoftheanteromedialportal(AMP) (withtheopticaldevice)andaccessoryanteromedialportal (AAMP)(withguidewire).

Abonepick,introducedthroughtheaccessoryanteromedial portal,isusedtodemarcatethecenterofthefemoralinsertionof theACL,atthejunctionoftheinsertionsofitsanteromedialand posterolateralbands,abovethebifurcatedcrest.8

Aguidewireof2mmindiameterwasintroducedthroughthe accessoryanteromedialportalandwasplacedatthelocation pre-viouslymarkedoutbythebonepick.Itwasdrivenintothebone ofthelateralfemoralcondyleforafewmillimeters,bymeansof oneortwohammerblowstoitsextra-articularend.

Followingthis,theguidewirewasintroducedbymeansofa drillingdevice,withtheaimofcrossingthelateralcorticalbone ofthelateralfemoralcondyle.Forthisdrillingoperation,theknee wasflexedat110◦_{,inordertoprotectthecommonfibularnerve}

andsothatthefemoraltunnelcouldhavegreaterlength.9 Acannulateddrillbitof5mmindiameterwasplacedaround theguidewireandwasusedtocreatethefemoraltunnel.Thedrill bitandguidewirewerethenremovedandameasuringdevicewas usedtodeterminethelengthofthefemoraltunnel.Thediameter ofthefemoraltunnelneededtobethesameasthatofthegraft.

Theguidewirewasputbackintotheaccessoryanteromedial portalandwasinsertedintothefemoraltunnel,untilithadgone beyondthecorticalboneofthelateralfemoralcondyle.Adrillbit ofthesamediameterasthegraftshouldbeusedtoincreasethe diameterofthepreexistingtunnel,foralengththatis10mmless thanthetotallengthofthetunnel,sothattheEndobutton®_could

beupended.

ThemeasurementoftheEndobutton®_{loopshouldbenomore}

rev bras ortop.2015;50(4):469–471

471

LFC

LFC

A

B

Fig.2–(A)Viewthroughanterolateralportal;(B)view throughanteromedialportal.Thearrowindicatesthe intercondylarcrest.LFC=lateralfemoralcondyle.

thebonetunnelsforuniontooccurbetweentheboneandthe graft.10

Toconstruct thetibialtunnel, weusedadrillingguidethat wasappropriatefortheACL,adjustedtothemarkof55◦_.This

wasintroducedtothejointthroughtheanteromedialportal,while theopticaldevicewasintroducedthroughtheanterolateralportal. Theguidewasplacedonthetibiabetweentheanteromedialand posterolateralbands,laterallytothemedialintercondylar tuber-cle,inthesamedirectionasthemiddlepartoftheanteriorrootof thelateralmeniscus.Thediameterofthedrillbitforconstructing thetibialtunnelwasalsothesameasthediameterofthegraft.

AdrillingguidewirewithVicryl1threadplacedinoneofits orificeswaspassedthroughtheaccessoryanteromedialportal,the femoraltunnelandthelateralskinofthethigh,whileadoubleend ofVicryl1waskeptinsidethejoint.

Next,thisendwaspulledintothetibialtunnelwiththeaidof agrasperorprobe,andwasbroughttotheexternalregionofthe lowerleg.

ThegraftwaslashedusingVicryl1andwaspassedthrough thetibialandfemoraltunnels.Followingthis,theEndobuttonwas “upended”,whichprovidedfemoralfixation.Weappliedmanual tensioningtothethreadsofthetibialendofthegraft,withthe kneeflexedat20◦_,11_{andwefixedthegraftinthetibialtunnel}

usingametalinterferencescreworabsorbablescrew.

Final

comments

1. Inouropinion,viewingthroughtheanteromedialportal pro-videsa clearviewof themedialfaceofthelateral femoral condyle,withthepossibilityofaclearerviewofthefemoral

Fig.3–(A)Viewthroughanterolateralportal,with guidewireplacedintheanteromedialportal;(B)view throughanteromedialportal,withguidewireplacedinthe accessoryanteromedialportal.

insertionoftheACL,incomparisonwiththeviewobtained throughtheanterolateralportal(Figs.2and3).

2. Thistechniquedoesawaywiththeneedforguides,sincethe insertionoftheACLismarkedoutbythesurgeon,usingabone pick.

3. Thereisnoneedforanadditionalincisioninthedistaland lateralthigh,aswouldoccurwiththeoutside-intechnique. 4. Ifthetunnelsareconstructedthroughtheaccessory

antero-medialportalwithduecare,thisdoesnotcauseanyinjuryto thecartilageofthemedialfemoralcondyle,ortothemedial meniscus.

5. Withthistypeofviewing,itisalsopossibletomake recon-structions usingothergrafts,suchasdouble-band,selective (augmentation)and thosethatpreservethe remaining liga-ment.

Conflicts

of

interest

Theauthordeclaresnoconflictsofinterest.

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