Lacey Matthew, Lamplot Joseph, Walley Kempland C, DeAngelis Joseph P, Ramappa Arun J
Matthew Lacey, Joseph Lamplot, Kempland C Walley, Joseph P DeAngelis, Arun J Ramappa, Department of Orthopaedic Surgery, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA 02215, United States.
World J Orthop. 2017 May 18;8(5):379-384. doi: 10.5312/wjo.v8.i5.379.
To describe an approach to anterior cruciate ligament (ACL) reconstruction using autologous hamstring by drilling the anteromedial portal in the presence of an intramedullary (IM) femoral nail.
Once preoperative imagining has characterized the proposed location of the femoral tunnel preparations are made to remove all of the hardware (locking bolts and IM nail). A diagnostic arthroscopy is performed in the usual fashion addressing all intra-articular pathology. The ACL remnant and lateral wall soft tissues are removed from the intercondylar, to provide adequate visualization of the ACL footprint. Femoral tunnel placement is performed using a transportal ACL guide with desired offset and the knee flexed to 2.09 rad. The Beath pin is placed through the guide starting at the ACL's anatomic footprint using arthroscopic visualization and/or fluoroscopic guidance. If resistance is met while placing the Beath pin, the arthroscopy should be discontinued and the obstructing hardware should be removed under fluoroscopic guidance. When the Beath pin is successfully placed through the lateral femur, it is overdrilled with a 4.5 mm Endobutton drill. If the Endobutton drill is obstructed, the obstructing hardware should be removed under fluoroscopic guidance. In this case, the obstruction is more likely during Endobutton drilling due to its larger diameter and increased rigidity compared to the Beath pin. The femoral tunnel is then drilled using a best approximation of the graft's outer diameter. We recommend at least 7 mm diameter to minimize the risk of graft failure. Autologous hamstring grafts are generally between 6.8 and 8.6 mm in diameter. After reaming, the knee is flexed to 1.57 rad, the arthroscope placed through the anteromedial portal to confirm the femoral tunnel position, referencing the posterior wall and lateral cortex. For a quadrupled hamstring graft, the gracilis and semitendinosus tendons are then harvested in the standard fashion. The tendons are whip stitched, quadrupled and shaped to match the diameter of the prepared femoral tunnel. If the diameter of the patient's autologous hamstring graft is insufficient to fill the prepared femoral tunnel, the autograft may be supplemented with an allograft. The remainder of the reconstruction is performed according to surgeon preference.
The presence of retained hardware presents a challenge for surgeons treating patients with knee instability. In cruciate ligament reconstruction, distal femoral and proximal tibial implants hardware may confound tunnel placement, making removal of hardware necessary, unless techniques are adopted to allow for anatomic placement of the graft.
This report demonstrates how the femoral tunnel can be created using the anteromedial portal instead of a transtibial approach for reconstruction of the ACL.
描述一种在存在股骨髓内钉的情况下，通过钻前内侧入路进行自体腘绳肌前交叉韧带（ACL）重建的方法。
术前影像学检查确定股骨隧道的拟定位后，移除所有硬件（锁定螺栓和髓内钉）。以常规方式进行诊断性关节镜检查，处理所有关节内病变。从髁间去除ACL残端和外侧壁软组织，以充分显露ACL足迹。使用具有所需偏移量的经皮ACL导向器进行股骨隧道定位，膝关节屈曲至2.09弧度。在关节镜直视和/或透视引导下，通过导向器从ACL的解剖足迹处开始置入Beath针。置入Beath针时若遇到阻力，应停止关节镜检查，并在透视引导下移除阻碍的硬件。当Beath针成功穿过股骨外侧时，用4.5 mm Endobutton钻进行扩钻。若Endobutton钻受阻，应在透视引导下移除阻碍的硬件。在这种情况下，Endobutton钻扩钻时更易受阻，因为其直径比Beath针大且刚性增加。然后使用最接近移植物外径的尺寸钻股骨隧道。我们建议至少7 mm直径，以尽量降低移植物失败的风险。自体腘绳肌移植物直径一般在6.8至8.6 mm之间。扩钻后，膝关节屈曲至1.57弧度，通过前内侧入路置入关节镜以确认股骨隧道位置，参考后壁和外侧皮质。对于四股腘绳肌移植物，然后以标准方式采集股薄肌和半腱肌肌腱。将肌腱进行锁边缝合、四股编织并塑形，以匹配准备好的股骨隧道直径。如果患者自体腘绳肌移植物的直径不足以填充准备好的股骨隧道，可使用同种异体移植物进行补充。重建的其余部分根据外科医生的偏好进行。
保留硬件给治疗膝关节不稳定患者的外科医生带来了挑战。在交叉韧带重建中，股骨远端和胫骨近端的植入硬件可能会干扰隧道定位，因此除非采用允许移植物解剖定位的技术，否则必须移除硬件。
本报告展示了如何使用前内侧入路而非经胫骨入路来创建股骨隧道以重建ACL。
