This document describes a novel surgical technique for primary ACL reconstruction using both autograft and a biomimetic graft. The technique involves a four-stranded anatomical single-bundle reconstruction that places the femoral tunnel low to overlap both the AM and PL bundles. Preliminary results on 18 elite football players showed improved IKDC scores, reduced pivot shift, and allowed return to full athletic performance by 3.5 months. However, long-term follow up is still needed to evaluate the outcomes of this new single-bundle technique.

1. FOUR STRANDED ANATOMICAL S.B TECHNIQUE
FOR
PRIMARY ACL RECONSTRUCTION
USING
BOTH AUTOGRAFT & A BIOMIMETIC GRAFT
A NOVEL TECHNIQUE FOR ELITE FOOTBALL PLAYERS
MR ALEVROGIANNIS STAVROS,MD,PhD
ORTHOPAEDIC SURGEON
S. CONSULTANT IN SPORTS INJURIES.
ATHENS/GREECE

2. AIM OF THE STUDY
• To present our novel
surgical technique
&
preliminary results
for
primary ACL reconstruction
in elite football players

3. MATERIAL-METHOD
• 18 elite football players
• Aug. 2010- Nov.2011
• 8R/10L
• Mean age 23 ( 17-33)
• Acute injury in all cases
• 11 d.(5-15) delay of operation
• 12 concomitant meniscal tears (7 sutured)
• Revised anatomical single bundle technique
• JewelAcl was used
• IKDC ligament evaluation form
• Instrumented knee testing

4. SURGICAL METHOD
• SINGLE BAND ACL-R
 TT technique → high anterior femoral tunnel
 AM technique → damage to the femoral condyle with the drill bit
→ cutting the anterior horn of the medial meniscus
→ incorrect placement of the femoral tunnel due
to loss of orientation with hyperflexion
• CONVENTIONAL DOUBLE BAND ACL-R
• ANATOMIC DOUBLE BAND ACL-R
• ANATOMIC SINGLE BAND ACL-R

5. Why an anatomic ACL-R?
• Every person is different; some
people are short, others are tall.
Similarly, each person has a
different size and shape of the
ACL. In order to properly
reconstruct the ACL it is important
to reproduce each persons
individual anatomy.
• The goals of anatomic ACL
reconstruction are to:
– Restore 80-90% of normal ACL
anatomy
– Regain stability and return to pre-
injury activity level
– Maintain long term knee health

6. ACL ANATOMIC FOOTPRINTS
FEMUR TIBIA

7. The intact AM and PL bundles of the ACL are shown in (A), and the soft tissue remnant of
torn ACL on the femoral side is shown in (B). When the knee is in 90 degrees of flexion, the
femoral insertion sites of the AM and PL are horizontally aligned. The white circles on the
cadaveric specimen picture (A) and the arthroscopic surgery picture (B) show potential
area that the femoral tunnels can be incorrectly placed when a trans-tibial approach and
the clock face concept is used, which is seen in most of our revision cases. Laser scan (C)
and arthroscopic picture (D) show the two bony landmarks on the femoral insertion sites of
the AM and PL bundles when knee is in 90° of flexion

8. S.B TRANSTIBIAL ACL-R

9. FEMORAL TUNNEL POSITION: AN X-RAY COMPARISON
OF DRILLING THROUGH THE TIBIAL TUNNEL vs
DRILLING THROUGH THE MEDIAL PORTAL
Chao D,Pallia C,Young S et al
• 40 ACL recon pts
• Results
- Statistical significance
superior (TT technique)vs
inferior (AM technique)
alignment of femoral tunnel
placement
- TT technique produces a more
anterior femoral tunnel and a
more vertical ACL graft
orientation

10. Clinical Results after S.B ACL-R
• Greatly improved over the last
years
• However, there are many issues
which should be improved in the
future:
-the normal rate (< 2mm) is only
70%
-rotatory control is insufficient
-normal athletic abilities are not
restored even in the “normal”
knee
Renstrom P.ESSKA 2004)

11. CONVENTIONAL D.B ACL-R

12. ANATOMICAL D.B ACL-R

13. FEMORAL TUNNELS IN D.B
TECHNIQUE

14. ANATOMIC D.B SURGICAL
TECHNIQUE

16. CONCLUSIONS FOR D.B ACL-R
• The two bundle reconstruction is an effective
procedure to reconstruct the ACL
• Needs more than 14mm native ACL tibial width
• More rotational stability in almost all clinical papers
in the literature
• Time consuming surgical technique
• Long learning curve
• Difficulty in revision cases
DOUBLE BAND DOUBLE TROUBLE?

17. ANATOMIC SINGLE BAND ACL-R
MAJOR INDICATIONS:
• The patient has a very small native ACL size, usually
less than 14 mm. This can be estimated on MRI, but
can only be confirmed at the time of surgery.
• The patient is still growing and his or her growth
plate is not closed.
• The patient has severe arthritis of the knee.
• The patient has multiple knee ligament injuries or a
knee dislocation and multiple other ligaments need
to be reconstructed at the same time.
• The patient has bone that is severely bruised.
• The patient has a small “notch”.

18. ARTHOSCOPIC PORTALS
LP (lateral portal = incision towards the outside of the knee)
MP (medial portal = incision towards the inside of the knee) and
AMP (accessory medial portal = incision even further on the inside of the knee)

19. SURGICAL PROCEDURE-FEMUR
STEP 1
STEP 2
STEP 3

20. ANATOMICAL POINTS FOR
FEMORAL DRILLING

21. SURGICAL PROCEDURE-FEMUR
STEP 4
STEP 5
STEP 6

22. ACL GRAFT LENGTH

23. SURGICAL PROCEDURE-FEMUR
STEP 7
STEP 8
STEP 9

24. FEMORAL TUNNEL IN
ANATOMICAL S.B TECHNIQUE
The femoral tunnel is low and overlaps both the AM
and PL anatomical sites

25. SURGICAL PROCEDURE-TIBIA
STEP 10
STEP 11
STEP 12

26. TIBIAL DRILLING IN
ANATOMIC S.B ACL-R

27. SURGICAL PROCEDURE-TIBIA
STEP 13
STEP 14
STEP 15

28. GRAFT SPIPPAGE & FIXATION

29. ACL-R GRAFTS
• AUTOGRAFTS
-BPTB
 Ipsilateral
 contralateral
-QUADRICERS
-QUADRAPLED ST (indirect fixation recom.)
-DOUBLED STG (↑more fixation options, ↓internal
rotation weakness)
• ALLOGRAFTS
 Achilles tendon
 Posterior tibialis
• XENOGRAFTS (new generation)
 JewelAcl (NeoLigaments)

30. DO WE REALLY NEED BOTH
ST & G FOR ACL-R
– Segawa H., Omori G., Koga Y., Kameo T., Iida S., Tanaka M.
• Rotational muscle strength of the limb after ACL
reconstruction using Semitendinosus and gracilis tendon.
Arthroscopy 18,(2) 177-182. 2002
– Armour T, Forwell L., Kirkley A, Litchfield R, Fowler P.
• Isokinetic evaluation of internal / external tibial rotation
strength following the use of hamstring tendons for ACL
reconstruction. ISAKOS 2003
– Ohkoshi Y.,Inoue C.,Yamane S. Hashimoto T.,Ishida R.
• Changes in muscle strength properties caused by harvesting
of autogenous semitendinosus tendon for reconstruction of
contralateral ACL Arthroscopy 14,(6) 1998 580-584
– Gobbi A., Domzalski M., Pascual J., Zanazzo M.
• Hamstring ACL Reconstruction.Is it Necessary to Sacrifice
the Gracilis? Arthroscopy 2004

31. TENSILE LOAD OF HUMAN ACL
• Intact ACL: 2160±154
• Bone-patellar tendon-bone: 2376 ±151
• Single-strand semitendinosus: 1216±50
• Quadrupled hamstring: 4108±200
• Quadriceps tendon (10mm) : 2352±495

32. JEWEL-ACL
Features and benefits
• Is a specialized textile scaffold which is
rendered versatile for ACL reconstruction
by various structural features. The scaffold
is treated with a proprietary gas plasma
treatment process that increases its surface
energy and renders it hydrophilic
• The continuous tubular form can accommodate a
hamstring tendon
• The open weave sections have appropriate spacing to
encourage tissue ingrowth into the scaffold.
• The densely woven sections have superior handling
properties.
• The JewelACL is a bio-enhanced prosthesis for the ACL
reconstruction.
• The JewelACL can be secured to the bone with currently
available fixation devices.

33. BENEFITS
• Can be implanted as a total tissue sparing device,
or with a single hamstring tendon
• Manufactured from Polyethylene Terephthalate
(polyester)
• Allows early rehabilitation (parallel longitudinal polyester fibres
provide high strength of 3000N)
• Implanted using standard modern ACL guidewire systems
• Stiffness is matched to the semitendinosus tendon to permit load
transfer and encourage cell growth due to plasma-spray.
more than four times as many cells were found on the plasma-treated ligament
surfaces after 14 days’ incubation compared to non plasma-treated polyester surfaces.

34. FASTLOK
• Is recommended for secure fatigue
resistant fixation of JewelAcl
directly to bone
• Consists of a titanium alloy staple
and buckle providing a unique
triple clamping action to minimize
slippage under repeated loading
• Staples firmly gripped by impactor
so easy to use for insertion and
removal from bone
• Designed for easy application
through small incisions
• Sliding hammer attaches to
impactor to help remove staples

35. ACL-R (JewelAcl-X/O BUTTON)
in an elite 25 y. male athlete.

36. ACLR (JewelAcl-X/O BUTTON) +
CHONDROPLASTY MFC(Chondromimetic)
in a 33 y. male elite athlete.

37. Postoperative regime:
modified aggressive protocol
• Functional knee brace in full extension
• CPM 0-900 same day of operation
• Priority to full extension recovery
• Partial weight bearing 6 weeks (modified due
to meniscal suturing)
• Closed kinetic chain for 2 w.p.o
• Return to full-power training program 2.5 m.p.o
• Return to full athletic performance at 3.5 m.p.o

38. IKDC
PASSIVE MOTION DEFICIT (PRE-OP)
PRE-OP IKDC SCORE (%)
PASSIVE MOTION DEFICIT
91
100
80
60
40
20 6,6
2,4 0
0
A B C D
Lack of extension

39. PRE-OP IKDC SCORE (%)
ROLIMETER LAXITY
100
90
80
70
60
50
50
39
40
30
20
10
0 0
0
A B C D
C + D > 85%

40. PRE-OP PIVOT SHIFT
18
16
14
12
12
10
8
6
4
4
2
2
0
0
equal +glide ++ clunk +++ gross

41. GLOBAL IKDC PRE-OP SCORE (%)
100
90
80
70 65,6
60
50
40
30 22,4
20
10 9,5
2,5
0
A B C D
C + D = 86%

42. RESULTS
•18 pts, 1 y f.u
•Passive motion deficit
17
18 Lack of extension
16
14
12
10
8
6
4
2 1
0 0
0
A B C D

43. RESULTS
ROLIMETER LIGAMENT EVALUATION
18
16
16
14
12
10
8
6
4
2 1 1
0
0 0
-3 to -1 mm -1 to 2 mm 3 to 5 mm 6 to 10 mm > 10 mm

44. RESULTS: Pivot Shift
n 18
16
14
13
12 %
p = 0.001 10
Preop
8 84
Postop
%
6
3
4
2 0
0
A equal B glide C clunk D gross

45. RESULTS
PIVOT SHIFT
18
16 15
14
12
10
8
6
4
2 2
1
0 0
equal +glide ++ clunk +++ gross

46. RESULTS: GLOBAL IKDC SCORE (%)
Subjective score IKDC: 92 ±4.6 (75-100)
(Pre-op : 60,3)
100
90
80 71,6
70
60
50
41 38 Pre-op
40
Post-op
30
20 P = 0.003A
20 12 14,4
10 2 1
0
A B C D
A + B = 79%

47. SCORE IKDC GLOBAL POST OP %
100
90
80
70
60
50 47,8 pré-op
41,3 43,5
40 post-op
32,7
30
20 13 13
10 6,5
2,2
0
A B C D

48. GLOBAL SCORE IKDC at F.U.
50
50
45
40
35 32
30
24 pre-op
25
F-U
20
15 12
10
10 8
5 2 2
0
A B C D

49. LIMITATIONS OF ANATOMIC
S.B ACLR
• Anatomic free hand single-bundle ACLR has
some limitations when compared to anatomic
double-bundle reconstruction.
– It cannot recreate the two functional bundles (AM
and PL) of the ACL.
– It can cover less of the size of the normal ACL,
typically 65-85% of the ACL insertion site
recreated, vs. 80-90% in double-bundle
reconstruction.
– Prospective, randomized trial and long term f.up
needed

50. CONCLUSIONS
• Lower pivot shift rate in comparison with S.B ACL-R,
almost similar to anatomic D.B (↓ arthritis?)
• Very short lurning curve
• Not time consuming technique
• Use of new generation xenografts offers more
aggressive rehab protocol.
• Quicker return to sports (pre-injury level)
• A good alternative for elite athletes
• Need controlled prospective randomized trial studies
and long term f.u