Moutzouros Vasilios, Castle Joshua P, Kasto Johnny, Gasparro Matthew, Pratt Brittaney A
Department of Orthopedic Surgery, Henry Ford Health System, Detroit, Michigan, USA.
Video J Sports Med. 2024 Dec 3;4(6):26350254241290825. doi: 10.1177/26350254241290825. eCollection 2024 Nov-Dec.
Anterior cruciate ligament (ACL) ruptures occur frequently, with ACL reconstruction among the most commonly performed orthopaedic sports surgeries. The remnant ACL is typically debrided for visualization. However, further evidence has suggested that this remnant tissue contains a wealth of proprioceptive nerve fibers and a vascular blood supply. Theoretically, preserving the ACL remnant may improve joint proprioception and graft synovialization. Therefore, ACL hybrid remnant preservation reconstruction (HRPR) was developed to preserve and tension the native remnant in combination with an ACL reconstruction.
Patients with proximal tears or femoral-sided avulsions, Sherman type 1 or 2, may be indicated for ACL-HRPR.
In this technique, we use a bone-patellar tendon-bone (BTB) autograft, which can be harvested based on the surgeon's preference. After performing a diagnostic arthroscopy, the notch of the knee is debrided, with care to preserve the tibial ACL remnant. The tibial remnant is then undermined with electrocautery. Nonabsorbable suture is passed through the remnant tissue. A tibial guide is placed, and a pin is drilled just posterior to the tibial insertion. Next, the appropriately sized tibial tunnel is drilled just posterior to the tibial remnant insertion. Using an anteromedial-portal technique with the knee maximally flexed, an over-the-top guide with appropriate offset is used to insert the guide pin, and the femoral tunnel is drilled. The proximal graft bone block and the remnant sutures are then passed through the femoral tunnel. Metal screws are then inserted to fix the BTB graft bone blocks on the femoral side, followed by the tibial side. Backup fixation is also used by placing a biocomposite anchor 1 cm distal to the tibial tunnel.
A myriad of techniques exist for preserving the ACL remnant. For the present surgical technique, a retrospective cohort revealed that patients undergoing ACL-HRPR achieved full range of motion without extension loss and equivalent patient-reported outcomes, without increased complication rates.
DISCUSSION/CONCLUSIONS: For patients with femoral-sided ACL tears or avulsion, ACL-HRPR is a viable option that may augment traditional ACL reconstruction.
The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
前交叉韧带（ACL）断裂频繁发生，ACL重建是最常见的骨科运动手术之一。通常会清理ACL残端以利于观察。然而，更多证据表明，该残余组织含有大量本体感觉神经纤维和血管血供。从理论上讲，保留ACL残端可能会改善关节本体感觉和移植物滑膜化。因此，开发了ACL混合残端保留重建术（HRPR），将保留和拉紧天然残端与ACL重建相结合。
近端撕裂或股骨侧撕脱（Sherman 1型或2型）的患者可能适合进行ACL-HRPR。
在该技术中，我们使用骨-髌腱-骨（BTB）自体移植物，可根据外科医生的偏好获取。进行诊断性关节镜检查后，清理膝关节切迹，注意保留胫骨ACL残端。然后用电灼术在胫骨残端下方进行分离。不可吸收缝线穿过残余组织。放置胫骨导向器，并在胫骨附着点后方钻孔插入导针。接下来，在胫骨残余附着点后方钻出合适大小的胫骨隧道。使用膝关节极度屈曲的前内侧入路技术，使用具有适当偏移量的过顶导向器插入导针，并钻出股骨隧道。然后将近端移植物骨块和残余缝线穿过股骨隧道。然后插入金属螺钉在股骨侧固定BTB移植物骨块，接着在胫骨侧固定。还通过在胫骨隧道远端1厘米处放置生物复合锚钉进行辅助固定。
存在多种保留ACL残端的技术。对于当前的手术技术，一项回顾性队列研究显示，接受ACL-HRPR的患者实现了全范围活动且无伸展受限，患者报告的结果相当，并发症发生率未增加。
讨论/结论：对于股骨侧ACL撕裂或撕脱的患者，ACL-HRPR是一种可行的选择，可能会增强传统的ACL重建。
作者证明已获得本出版物中出现的任何患者的同意。如果个体可识别，作者已随本投稿包含患者的豁免声明或其他书面批准形式以供发表。
