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ACL Reconstruction for Orthopaedic Exams
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ACL Reconstruction for Orthopaedic Exams
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Language: EN.
Segment:0 .
Good evening, everybody, welcome to our usual Wednesday slot. Today, where it's a combination of the FRCS mentor group and ORUK. We are very proud to bring you Mr Shah Punwar.
He's a consultant, knee surgeon based in University Hospital Lewisham in South London. His main areas of expertise are knee and hip replacement surgery, as well as soft tissue sports injuries and soft tissue knee injuries. His particular interest is in partial knee replacements, case arthroplasty and ACL reconstruction. He's a member of the British Association of knee surgery and is committed to medical education.
In 2013, he undertook a fellowship year in complex sports injury training in Perth, Western Australia, and before returning to the UK, had been appointed as a consultant in orthopedic surgery in Lewisham. He we are very pleased with his talk today, which is going to be quite important for the FRC exam controversies in ACL reconstruction. Before before I introduce Mr. panmure, I just want to remind everyone that if you have any questions, please do type in the chat and we will ask the questions at the end.
Also, people who wish to participate in the Viva please do let heiney know you can send them a message or raise your hand in the chat group. And without further ado, Mr. Anwar. It's a real pleasure to hear your talk today. Thank you very much. Thank you. Thank you, swan. Thank you for that introduction.
Thank you to you or ACC. And the FSS mentor group is a topic close to my heart, but hopefully I didn't bite off too much. So let's get on with it. Controversies in reconstruction. I don't have any disclosures I currently use Smith nephew products. We will have one of the longest history in ACL reconstruction work, and there's images here from various sources.
No patient identifiable images, right? What's my object is today? What are the main controversies, graft choices, tunnel placement, mainly on the federal side, to be honest. Fixation choices. The additional procedures you might want to do. And just some small print stuff. Timing of surgery and rehabilitation.
So bone, patellar, tendon, bone. Traditionally, this was the go to graft, easy to harness front of the knee. Is it still the gold standard? Hamstrings certainly were popular during my training and no donor site morbidity, and I would say 90% of the ACL reconstructions you'll see will be hamstrings. Clothes 10 plus or minus telephone block is fairly new, and the Americans seem to be very keen on it.
There are minimal grafting donor harvesting techniques, but time, I think, will tell whether this is a superior graft. Other smaller options are allograft, so donated cadaveric tendon tends to be radiated in slightly weaker than your own tendons or synthetic graft, which was very popular in Australia in the 90s. Such as loss, and there's certainly been a move away from that.
So, you know, what are we looking for looking for a strong graft? Now, your native ACL has a load to failure strength around 2000 newtons. A 10 millimeter bone patellar tendon bone graft has more than that about 3,000 newtons. You're going to get direct bone to bone healing, so that's very strong for strained hamstring graft. About 3,000 to 4000, depending on what you read.
And that's slightly more than the actual bone patellar tendon graft itself. Quad tendon similar allograft range from 24,000. But as you can see, we're all in the region of over 2000. These are very strong. That's not really going to be your initial weakness. This is probably going to be your fixation, particularly when the graph is, you know, bending in so big beating TBE bone cells in the bone.
Popular for heavy mouths, but there is an increased risk of anterior knee pain, patella fracture, patellar tendon contracture. But you get this solid bone to bone healing. Your hamstrings need to be at least 7.5 to eight. Now, if you've got a short, typically short female, you have to just be concerned that you might have quite short tendons. There is a risk of softness, nerve injury, and you can lose the end kick of sprinting.
But largely there's very little donor mobility from taking hamstrings allograft. So donated tendon sort of thing Michael Owen had back in the day, really for professional straight line athletes only. So sprinters or rowers, there's a high rupture rate, but it might be just right to get those people through their careers in some studies, a four times higher rupture rate.
I haven't really talked about return to sport at the level that people were at, but it's something you should send people for because I think it is quite difficult for professional athletes to get back to the same level of sport that they were at. The synthetic grass will eventually fail. It can cause sinusitis and bone cysts. It was very popular in Australia following an Aussie football's football rules player at a large graph and got back to playing very quickly.
But since then, there have been lots of failures, and there's now a position statement from Australia saying don't use them. So what's the reality we'll grow if you're going to choose? It's like anything, it's based on your training, your fellowship and perhaps current trends will influence you. Lots of training opportunities.
Now, as a consultant to go to soft tissue labs and even abroad when we're allowed to travel and keep an eye on what's happening. But I do think the training and your fellowship really does affect what you use. You want low donor site morbidity. Acls tend to be j-k surgery, so you want me to manage pain and hamstring tendons are very versatile. The quadriceps, tendons, relatively new, something I'm looking into and I'm sure those of you younger knee surgeons coming through will be looking into.
And as I said before, your technique, initial fixation is more important when you graft choice. The weak point is tibial fixation. It's a question you might get asked in the fast. Yes, there's greater shear forces. And again, remember the metaphyseal bone on the tibia can be weaker, particularly these patients are deconditioned.
Well, preparation. There is some controversy about tensioning, but it makes sense it's a ligament. It removes creep. If you put on your graft, you can't put on a patellar tendon graft, but for hamstrings useful detention, the vancomycin swab is not really controversial anymore in the papers about using that on your graft. It does reduce infection.
I use it. It's really easy to do. One gram of vancomycin is saline and just soak a swab, prepare your graft and a graft master and wrap it in your hamstrings. There's lots of different configurations. I've just put a diagram of some of the things you can do if you want to make your graft stronger. The classic is the 1 over on the right side.
They're just a quadruple semi tee and bas status graft over usually suspension fixation. There's an interference screw in the tibia. You can triple your semi tenodesis, put the groceries over the top to make a five ton graft. You can if you have 30 centimeters long, both tendons stitch them both together and triple them to make a six strand graft. Hamstrings should be over 7.5 diameter, really eight.
And you want I'm looking for 10 centimeters long. Really for a standard suspension fixation on the FEMA and its evil interference group. So that's going to be about 4 centimeters. And FEMA about 1 and 1/2 centimeters within the joint and about four 4.5 centimeters on the tibia. And you can adjust your tunnel drilling if you have a slightly shorter graft. You need a shorter graft if you're using suspension fixation on both sides.
It's becoming more popular, such as the Office groveling, but doesn't come without its own. Possible complications. So more tunnel placement, probably the most highly debated thing in ACL reconstruction. You need to know your terminology might make something that might come up in the exam instead of proximal distal anterior posterior. We tend to use high, low, deep and shallow deep being posterior, shallow being anterior.
Remember, the knee will be flexed, usually at 90 degrees when you're doing your femoral tunnel and then high for proximal and low for distal. Now, the initial ACL reconstructions were open. I'm not going to talk about those. They violated the fact pad and much more painful procedures. I think I saw one very my first registrar drop back in 2007. The transtibial technique is also.
Not used that often these days, they're still in quite widespread use where you would bend the knees 90, drill through the tibia using over the top guide to put through the tibia, hook over the back of the femoral notch and then you can drill your femoral tunnel. Now, clearly, you'll be constrained by where you've put your tibial tunnel, so you tend to get quite a high graft, really high and vertical, and that doesn't really give you very good.
Rotary control might give you some control, but didn't give you very good rotator control. So we've got a diagram on the right and medial drilling, which I'm sure almost you've seen gives you a greater obliquity, but you do need to Hyper flex the knee. Otherwise, you can get short, shorter tunnels and. There's also the risk of estrogenic damage to the medial epicondyle, particularly if you're drilling a large craft.
But the great obliquity leads to greater territory control. So what's the evolution of affirmative replacement? Now, most of you will have heard of the clock method, say for a right knee, you could use 2300 quite the old fashioned high position and you could use PM for a left knee. Now the disadvantage of the clock face is that that's a 2D description and obviously is 3D the notch.
So it doesn't give you any idea about depth, but it's still useful as aim and I think. We found the time replacement you want to use lots of different things. The ridges are quite commonly used now. There's the luxury into the ridge, so-called residence ridge because you don't want to go above it. With difficult ridge, which is meant to separate the two bundles.
I haven't discussed axilo anatomy. I'm sure most of you are aware of ample and remedial bundle and posterolateral bundle and will actually perhaps challenge that classic description of axilo anatomy in a bit. So from the clock face. Um, we went down to anatomic reconstruction. Now, if you didn't anatomic reconstruction, you can either do a double bundle through to an adult anatomic.
So try and announce a media bundle at the back post that's for the front. Or you can do a single bundle anatomic at the midpoint thermal footprint, and I'll show you some diagrams later. Or you can perhaps go to more higher and deeper position at the back of the knee in the center than to media bundle. Now we've gone from the higher initial graphs, quite vertical going more and more anatomic, and I think there is now a trend to go back to a slightly higher and deeper position.
So instead of PM sort of 1030 on the right, 1 30 on the left, and we'll explain why that might make biomechanical and anatomical sense. The rich technique the image on the right is from one of my cases. You can see an empty lateral wall to get a PC on the side here. We don't tend to not blast these so much in the UK. I think if you do have a very narrow v-shaped notch, maybe in a lady you're going to get impingement against either the side of the notch or the PCL.
You might want to consider some form of notch blasting. But you can often see these ridges and you can see the remnants of the femoral insertion. So I always look and look for elections coverage. And then you can look for coverage. Often the remnants will help you decide where these are. If you don't do anatomic placement, you want to go in the midpoint of the federal footprint, which is quite low, I think.
So there are different ways of doing it. You can measure with no scoppi ruler and often you have to change portals for that because you need to measure on the lateral side. And then you can go in the midpoint of your measurement. So you can measure and go in the midpoint. You can also use the bundles. If you can see the typekit ridge, you could just make a mark there.
And this is a double bundle technique of a single bundle center. The footprint double bundle was popularized by Fred, few in America, but I think it really has fallen out of favor. You've got inadequate graft size. You're going to get graft impingement, tunnel placement problems and that revision you're dealing with for tunnels.
So I think anatomic reconstruction is still definitely a thing, but I think people will tend to go more for a center footprint on the ridge with a single bundle rather than go for a double bundle technique. There are other ways of working out with your ephemeral tunnel is that I don't use. There are grids, there's a Bernard and Hertel grid. You can use operatively Roscoe.
I think you can always use navigation, and these are ways that you can look at your time replacement following surgery, perhaps on a CT scan. I don't use philosophy, but you can take true lateral x-rays, we use it for other knee surgery, such as ampofo reconstruction, and you can use standard percentages that I'll show you later to work out exactly where you want to go.
So the anatomy of the knee has been revisited several times, this classical teaching of entry, medial and lateral bundles has been challenged. There's a recent concept of the ACL being more flat, and ribbon like tends to be coming from this paper by smiggle from Poland, but working with very well known London knee surgeon Andrew Williams. The recent concept is that it's more flat and ribbon like, and there are two different types of fiber attachment direct fibers which appear to be carrying more load both historically and I think microscopically.
And they're attached high and deep within the region of tenotomy to bundle and then indirect fibers, which have a weaker attachment and take less of a load. This is the paper, it's freely available on the internet, and I'd recommend you have a look at it. So this is source in the paper. This is the posterior femoral cortex. This is the back of the notch.
This red line is the direct fibers, which seem to have a very double tight mark has been described, seem to have a very strong attachment to the back of the knee and look how far back it is. You really want to go as far back as you dare, and this yellow one is indirect fibers in the region of the posterolateral bundle, the so-called posterior bundle not quite as distinct. So they propose that we should put icons in the region of the direct fiber insertion.
Now this agrees with another concept from Stephen Howell Perla McAllister called the ideal federal location. And this session Zimmer Biomet website, though it's come from lots of different research with the lovely, lovely bits on the website and even gets you to choose where you'd put your own tunnel. So ideal stands for isometric. We want the potential relationship similar to Native ACL ACL.
We want it really to stay the same length throughout a range of motion as best as possible. The D stands for Direct fibers, as we discussed before. An eccentric means it doesn't have to be in the center of the footprint. They're saying go higher in the footprint and in the middle portion, which agrees with that smiggle paper, and they're completely separate concepts from different parts of the world.
Equidistant so halfway, the top and bottom the notch, which is the good interrogative check. And in real life, you're going to be using your experience in intraoperative checks. So I clear the notch at the back and I do look for the top and the bottom, the notch. I look for the articular cartilage, and it does tend to be in the middle because remember, if you're drilling, say, an 8 millimeter graft tunnel by the time you've marked your tunnel, it's going to be 4 millimeters bigger forward and 4 millimeter backwards, so you have to take that into account.
The a stands for anatomic and the L stands for low tension. The anatomic, I think, stands for. You know, in the media bundle, they're not going for a central footprint position. And there's a diagram, which is on that website. And the green part, they're sort of shows the confluence of where they think all these things coincide. So it's where all these circles overlap in this sort of position, which I agree is high in deep in the region of the direct fiber insertion.
So where do I put it? I put it in the sense of ventromedial tunnel. So behind the typekit ridge, just slightly knowing that by the time I've drilled, it'll be say I'm drilling an 8 millimeter tunnel. Most commonly, it'll be 4 millimeters behind the 4 minutes in front, but always behind the Buffalo Ridge and just under the lt-col ridge. Now clap worthy at now, also with Andy Williams, and the Danish registry has shown a higher failure rate of 3.5% times in the slap worthy study, using an anatomic tunnel placement that's more the low, more shallow placement.
So, you know, I would go for that. And medial bundle and I would leave at least 2 millimeters of posterior wall. So if it goes to the back, there is a risk of blowout. That's not always a bad thing if you're using suspension fixation, but you need to know that you've done it. So I show you a picture later, and I always check the posterior walls intact.
So family time, a drilling technique is also controversial. We talked about Sean's debut. I don't think many of you will be doing that anymore. You tend to view from what I tend to view, mainly for the lateral portal and ready to view from the medial portal. If I can't get around the corner and I can't get a good view, and if you are viewing from an intermediate portal, you drill from an accessory and media portal.
Most tunnels are drilled inside out, but outside in came in, mainly through Arthrex. There's the flip cutter, which you make a hole laterally on the FEMA. You put in the FlipCutter device and then you can drill from the lateral flow inwards, open the little clip cutter and then drill your socket backwards that way so you can get socket rather than a tunnel.
If you do that on both sides, you can sometimes have graft socket mismatch as you can have patellar tendon socket mismatch. And so sometimes people just drill an outside wind tunnel in the FEMA and a whole tibial tunnel from outside in as normal because you don't want to have more problems. But it is an attractive technique. The graph link hotfix technique flexible versus rigid dreamers. I think there's a lot to be said for rigid, flexible dreamers.
You can probably get less than an oblique tunnel and you can get around the medial epicondyle, but there are many in use. Stryker have them, and certainly I haven't used any as of yet. Just beware your short tunnels aren't familiar drilling. There's three stages to a straightforward and no button drill. First, it's a 2.5 millimeter beef pin. If if you can measure that and it doesn't feel right, you can readjust.
By the time we drilled a 4.5 Indo button drill, you get a good measurement. It can be difficult to change because you get tunnel convergence. You can still change at that stage. But once you drill the big acorn reamer, then it is quite difficult to change. So need to Hyper flex? Be careful where your hand is.
I tend to go about 30 degrees from the midline out to the side when I'm drilling for the unfamiliar portal and I get my hands slightly. And once you do quite a few, you know where your pinch should come out and you're looking for a tunnel about 40 to 4 to 5. It's quite consistent. If you've got it right. So these are the different views.
You can get, this one in the middle was viewing from a standard lateral portal. You get a slightly better view than that. But if you say you've got to be like this and you weren't quite happy that you could see properly the back of the notch, you could change to a high entry media portal and then you could drill through an accessibility media portal and you get more face on. I tend to put my sister into media portal a little bit more in to avoid the medial epicondyle, and depending where you put your hand, you can change because of the tunnel.
Some people like very short tunnels. Obviously, if you've got a short graft or you're using a quadruple semi tee, you might want to purposely draw short tunnels. The typical tunnel is less controversial, really. I tend to use anatomical landmarks, the posterior border of the anterior horn or the lateral meniscus, such anterior horn lateral meniscus.
No, you don't have that knee replacements. You can see that the ACL starts very anteriorly, you want to go in the middle, really if you go to a be tight inflection. So I find the posterior border of the anterior horn tends to be slightly red, obviously seen. And then you triangulate with the PC out of the back, and the medial tibial spine is also into eminence in front of the PCL, and you use a 55 degree tip of Elmer elbow.
I tend to prefer a tip am so that I know exactly where the y is going to come out. If you increase your angle, you're get a sight longer tunnel. And conversely, if you decrease your angle in a shorter tunnel, which might be useful. Again, that paper, which talked about the ribbon attachment, there's some nice anatomical specimens showing that the tibia attachment is more C shaped than two discrete bundles.
They actually say the bundle theory might be more of an illusion as the ribbon wraps around itself. And if you look closely where the posterior lateral bundle is meant to be on the tibia, it's actually in the area of the Anshul root attachment or to natural meniscus. So, you know, I'm not, you know, I do think there might be a sea change in ACL anatomy. Certainly, this is not what I was taught when I finished training, but you can find lots of things about this in the literature now.
This is just a picture from a recent case. How I actually do it. You're clear the notch use a shaver, get to the back a 45 degree, or it's quite useful because you can hook the back of the notch and then you can just come forward. You know, it's 5 millimeters from the tip of the oil to that Black mark, so I can measure that to be at least 5 millimeters to the back.
And then I put it in using the clock face and the ridges and where the anteromedial bundle I think was before. And you can see I made sure I've got a posterior wall. So clear all the swoff with your shaver and make sure you've got a posterior wall and you can actually look up the tunnel. For the typical tunnel, this is actually a one, tenodesis. It's quite red and then. It will pass your graft check, there's no impingement in extension, so you straight up the graph.
And that's sort of a standard picture I expect to see. How do you evaluate your time? Replacement should get some imaging following surgery, ideally before the patient leaves or at least the next clinical appointment. Plain x-rays are fine. My colleague prefers to do, and that is very accurate and there is a CT protocol within our trust. So you can closely monitor the tunnel placement and adjust your practice, and you could use those grids as before.
You can't really do a talk on ACLs without mentioning Lipinski and the Sydney experience. And I often refer back to this poster because it tells you where what you should be looking for on a plane. Post-operative X-ray of an ACL reconstruction and essentially femoral tunnel should really be as far back as possible. So about 86% along blue line and the tibial tunnel should be no more than 50% along the lateral tibial plateau.
But I find that quite useful way of assessing the presence of results tunnel placement. But you do need good quality x-rays, particularly the lateral. And in this paper and study, they found a higher failure rate. So 17% compared to seven percent, which was significant if your tibial tunnel was over 50% posterior. So the typical tunnel placement in the app plane does appear to be a crucial.
Fixation, how are you going to fix your graft? There's two main types. Interference or cortical suspension, permettendo bone grafts. Usually fix of screws. Lipinski, I think, developed the reverse $30 eye screw, which is a niche thing you might get asked in an exam used for thermal fixation the right knee to stop your graft being twisted.
You want to ideally put in front of your bone block, so that's just a niche thing. The reverse side screw soft tissue grafts you tend to use called suspension on the FEMA. You can use fix loops or adjustable loops. Now the popular ones are the Arthrex tie rope. It's also the pull up, and Smith nephew also have an adjustable one now screw on the tibia. It can be metal, a stainless steel nonrenewable peak, which is not a global but doesn't show up an X-ray or an observable screw.
Suspension on both sides are becoming more popular because you can use shorter grass, but you've got to be careful. About the strength of your tibial bone. Some people worry about using tight suspension and buttons on tibia because, you can crumple the cortex there and certainly you can crumple the cortex with the staple. The reports of tissue reaction insists and breakage usually bioresorbable screws, so I don't use those anymore.
And with the other screws in the revision scenario, you can remove them. Some people use a secondary fixation, a stapler or a screw to prevent shear. You might have unobservable which stitches where you will have on the tibial side, and you can tie those around a post on the tibia. You usually increase this freedom to by 1 millimeter might be something you're asked.
Femoral bone tends to be very hard to be using a screw up there. You, you don't tend to be lying to line, and you can use a screw in the femur for soft tissue grafts. There are other methods which I haven't mentioned the transfix where you can drill through the femoral or lateral cortex, and put two sort of pins in, and there's a special jig for that which is popular in the transtibial technique.
But though I've seen that used, it's not something I think you'll might see in very modern practice. Where you fix the graph is a little bit controversial. You should check our high symmetric it is by looking at how far the graph moves up and down. Typical tunnel when you go through a range of motion tend to fix and tenths degrees of flexion push down to the tibia.
If you fix too tight, it'll stretch out. You might limit flexion. But again, you don't want to fix things too loose. There were tension devices. Some people use them. There are a bit fiddly, particularly if they want all four strands to be separated. So I tend to just pull very hard. OK, your assisted to pull very hard.
I use an end button, the FEMA. At present, I have used other fixation methods. The most common one is a 15 millimeter. They still stock everything from 10 to about 30, probably in your hospitals. It's a fixed loop. It's got the longest track record. The disadvantage is you have to ream a slightly longer socket.
Your big socket or tunnel then necessary in order to flip the button. And any of you struggle to flip it, and the button will know that it's important not to shortchange yourself and try and be careful when you're pulling those grafts through and protect your fingers. It's quite easy to pull the wires to cut, cut through into and just cut your fingers.
It's a badge of honor. So I use a bias or screw made of peek. It's not resolvable, it's MRI compatible. If I need to scan people again, particularly within a meniscus repair. Occasionally, minuscule repairs might be symptomatic. They may fail. You may want an MRI. I usually use about 35 millimeter screw tunnel tenotomy 40 to 40 five, and I don't want to go into the joint, but I want to get as much sort of boundary fixation on the tibia as I can.
I whip with fiber while others use bond. You could use Velcro, but I want to protect the graft, particularly from the screw. I'll just check time. Seven already. So interference groups and police continue. Everybody is OK, I'll continue. Fringe groups. You've got to be aware of screw divergence.
So where you put your guideline is really important. So I take a little guidewire and I put it into the typical tunnel. And I like to see it coming out in front of the graph. Ideally, if it's in the middle of the graph, then you could damage your screw going. Your graph going in. It could take a little bit of work to make sure you know what our guide wire is.
The length is controversial. Some want as long as possible to get a picture fixation. But you don't, especially when you're using metal screws, you don't want to protrude into the joint. So I think 35 millimeters fine. I don't use screw and sheet types. They're a bit fiddly. You may see it. We've mentioned the reverse thread.
You a feminist collegians, when you see them in ACL reconstructions. Actually, we're getting a lot of people coming through very late, especially with covid, and you still have to assess normal meniscal lesions to see whether I repairable, but that's a different, different talk. I just want to mention the slap lesion, which doesn't actually stand for anything.
It just stands, I think, like a ramp, but it's a posterior meniscus to tear, which I have seen. You can hook it. It probably heals by itself. In the majority of cases, because a good healing environment, once you've done an ACL, but burn Bertrand egawa test, another big name French name in acls, he's popularizing posture, medial portals and a little spiral hook to repair properly.
You can try and repair them from the front. I've done that, but it's worth trying to get possibly the porcelain, perhaps in a kind of a first Latter tenodesis that's come back into Vogue the international ligament around for a long time. In fact, the early ACL reconstruction were actually articular. But since 2013, in this class study, it's got a resurgence in interest, and it might explain the second fracture, something that might come up in the exam.
Maybe that lateral capsule evolution is the actual ligament, and in revisions and hyper extenders marked laxity. Very high performance people. You might want to do it at the same time as your ACL reconstruction. You can just take a strip of white band. There's a Macintosh and La Mer method. They're quite similar, just different insertion points.
I tend to go just posterior and proximal to the lateral control epicondyle. So you take a straight pointy bend feed on the ACL back to your tibia tibia. You can fix it with anchors at that point, just posterior to the lateral epicondyle or a staple, you can get convergence with the ACL tunnels. You normally go more anterior and proximal with that tunnel and then get good out there.
They've got some big studies coming out now. They've shown decrease failure rates. If you use it with primaries, which stands to reason, it's a greater fixation. You could over constrain the lateral compartment, so don't pull too hard. You're not meant to pull much on it. And some say the ban is a Main Street to internal rotation and tibia.
So you're going to reduce your pivot shift. So you've got hyperextended that explosive pivot shift. You might want to do a left tenodesis. There are other methods you can use. Hamstrings, as well as an elegant method of using a semitendinosus for the ACL and the gosselaar for your Allen, but it's fairly straightforward.
Apart from the capsule can be quite thin underneath the LCL and you've got to cut the IT band over the LCL, so mark it carefully. Make sure you've got a good length about 12 centimeters you need. You're going to flip it over and then carefully dissect under the ACL LCL. Sorry to pass your graft. Uh, it'd be good to look at the mask based guidelines now if you're going for the exam, as it's good to look at all the bombast guidelines.
They've got a consensus statement on ACL injuries. There's some controversial areas such as DVT prophylaxis, and I follow my trust protocol. If it's an operation lower limb over 60 minutes of combined anesthetic surgical time, you should consider chemical prophylaxis. So I give a week of click Sign. They say there's no need, there's no risk factors. Interestingly, they say you can perform meniscal repair.
If you've got an acute, you lock knee and it's not ready for an ACL because you haven't got the expertise or the knees. Not quiet, but ideally performing at the same time. I recommend you have a look at that timing of surgery. Generally, you wait until the knees quiet. There's a risk of fibrosis. You start too early, but elite athletes might be ready quicker.
They've got game ready, they've got ice baths. The very motivated everybody gets pre habilitation these days, and it's safe to operate as soon as the knee has full active extension and is bending freely to over 90 with minimal swelling. So if you've got somebody motivated, you could operate within three weeks. It doesn't happen. Usually on the NHS, particularly during this COVID time rehab.
Now you may well know about open and closed chain, and traditionally there were two phases to ACL rehab. First, graft protection for six weeks, then graft strengthening. Now it's controversial as to when your grass at the weakest, your grass being neovasc rise. They might be the weakest at six weeks, so I often think we should slow down around then. But there's lots of protocols.
Now where they're combining open and closed chain and our biomechanical studies showing you can have increased forces on the knee with closed chain. So just like, say, Achilles tendon injuries got accelerated rehab, and what remains the same is initial focus reducing effusion, regaining a range of motion six weeks. You want to see full extension because hard to get that back then you work on flexion and allow jogging at three months.
Return to contact sports is 9 months to a year, particularly football. The slap slope is beyond the scope of this talk. There's a greater failure rate with higher TB, a slope, so revision cases, you might want to do a slope changing osteotomy and osteotomy again, an old technique coming back into Vogue. And you know, something you may see a lot of. So come towards the end.
Now there are some unanswered questions, which patients do well with, you know, not management. You can certainly try not open sedentary patients, and that makes sense unless they've got symptomatic instability and those over 40 willing to try the approach. I know people have done very well. No, not. The risk of egawa in the ACL deficiency has not been proven yet, you would say an unstable joint is more at risk of arthritis, but it's not been proven.
And osteoarthritis itself is contraindicated in ACL reconstruction. So I think it's still a controversial area. Some say the initial bone bruising from the pivot shift injury damages the cartilage and we need more work in that area. So in summary, large variation in practice globally and even nationally, I suppose you want a good quality graft, whatever you choose. Secure initial fixation in tunnels should allow full range of motion without impingement.
Avoid excessive graft tension. Delay your return to contact sports for 9 to 12 months. Pick a winner. Patients must go through tailored rehab program. It's just as important to the operation. Paper just came out recently at Nottingham, and they put it on the internet freely available before press. A systematic review of all standard techniques and the end result was all standard techniques for comparable, so it doesn't matter what you do as long as done well.
And that's it. Thank you very much. Thank you very much. That was very informative, comprehensive and broken down into small pieces that everyone well, I hope everyone who is listening was able to understand. I have got some questions from the audience if it's OK. So the first one is, do you cycle the knee movement prior to the tibial fixation?
And if you do, why? Yeah, yes, you must you must cycle the knee. And sorry, I didn't mention that, I don't think that's controversial because you put your graft in. You got good femoral fixation, so you flipped. You're in the bottom right from the home run. You need to now work out how isometric your tunnel is. Tells you how well you draw. You drilled your tunnels.
So firstly, I will bend it up and down and just see how far my graft withdraws into the tunnel and particularly on flexion. And we tie to infection. OK, and then you want to get rid of more crepe. So it's all about getting rid of more crepe. There's a viscoelastic. Um, material, I actually threw a question of those question at that one of the MKZ I did, because it's the basic science you might want to do, and that would be a great question, therefore.
Yes because then you could talk about getting rid of creep and you're going to really stretch out if you don't do it and you fix it all as well. That patient may well stretch out just a few millimeters in the early days give you a looser graft. We can talk about the basic science of crimp and collagen fibrils. You guys probably very hot on that.
OK, so what are the tunnel dimensions when you decide between the single or to stage ACL revision surgery? Is there a difference? Yeah, I mean, I just saw a patient with that today and I was actually just thinking that myself. So when I put a question of that in the macoutes said, perhaps we're going to do that. We can talk about it.
I think it's based on experience as well and where you think you can get a tunnel in if you don't think you can get a new tunnel in a good position, you know, near that wide tunnel. It's always safest. It's like a two stage of vision for an infected prosthesis. Your exam answer would be it's quite a tunnel widening. It's probably safe to do a two stage.
Exact measurements are quite hard to find if you can measure she had some way of measuring on your imaging and we can talk about imaging. You do, then that would be great, because that would tell you, I will tell you exactly you might be lucky and you could use that initial tunnel for your second revision if you're lucky. There is some talk about putting in bone dials and drilling through quickly, but you know.
That's a bit risky, but there is talk about it, so I think really, what is too. It's very small. You know, when you can get past it, it's completely the wrong position. You can stay out of the way. And if it's exactly where you are, best to be safe is probably the exam answer, you know? Yes so you didn't mention anything about the primary repair of the ACL.
Yeah yeah, that is controversial. But and actually, that's the better technique. The ba are the one that they do. They come up in the States with pediatricians. That's something I haven't seen anything of that. So much in the UK, where they put a little sponge in between the two ligaments and they allow the ligament, the ligament and to grow into that sponge. I think the sponge is Bears good for pediatrics.
But you know, Gordon McKay up in Scotland, an expert surgeon and ex-professional footballer, has popularized the Arthrex type technique. And I have a friend who's using that technique in Pakistan as well. So there are. It's just like repairing any tendon, more like a rotator cuff. I would say people are using suture anchors, so they are using a scorpion.
You can simply take the anterior stump. So what would my exam answer be? You need to have the appropriate type of tear. So you want a tear from the femoral attachment. So you want to quite a large really want a mid substance repair. You want one that's come off the femoral attachment. Quite healthy, younger patients. You've got to quite quickly and willing to go through that.
There's not really long term data, her present. And then you can simply use as a new scorpion and put strong, high strength, fiber wire through that stump, put it through suture anchors and tap the suture anchors into the femoral insertion. And I've seen that further stabilizes the tightrope, but there are people who say it's devil's work, so. So I'd be careful about. I wouldn't bring that up in the exam as a you, you would get yourself into a lot of trouble because you're not necessarily being examined by a knee surgeon who might know about these things.
I agree. I've got some basic science questions as well. So I've got one about the protocol for weight bearing post-op. Yeah, I mean, I don't brace myself anymore any brace and ACL and restricts weight bearing if I've done a meniscus repair and you should always restrict root reports, but. Um, I normally full way back because you want secure initial fixation, so I'd encourage you to.
Do your egawa before surgery document. It's part of the best consensus document, your pivot, shift your a draw your Lichtman's and the others, and then do it after your fixation. Yeah, when you start off, you might do a gentle Blackman's. You don't want to damage all the work you've done. But as you get more confident, you might try and pivot them again and you can say that there's no you're restricting your weight bearing is not going to stop a fixation of a poorly placed ACL.
So really, get the effusion down, go for a full range of motion. They're going to restrict their weight bearing naturally for a couple of weeks by 6 weeks. Patients might still be on one stick there. It's not like a hip replacement. When they walk in at 6 weeks, always. They're still getting through it. Usually Scars are normally well healed.
Depends if you've done all the work, but full weight bearing, no brace routine for me and I'd I'd recommend that axilo another basic science, which is about graft maturation. What is, what is the latest evidence about the time frame for that to occur? Yeah, that's a really good point. I just say one more point because you said basic science, I don't understand that basic science, you can look up the loads that happen in normal walking, going upstairs there, like in the hundreds of newtons, I believe walking or going upstairs.
So you probably should know that for the exam and you could give them more basic science answer to the rehab. You know, there are. There are Newton's. A magnitude four, walking upstairs and walking along, so maturation, I think it's controversial depending on what you do, because that grass has to neovasc grass and it breaks down.
And it's quite scary if you have to go back into an ACL at six weeks and it doesn't sometimes look like it did when you did it, it might. You know, there are some wispy bits, but you've got the collagen framework, and some say it's about six weeks. I believe that. No, that is weakest. The maturation is it can go on for a long time, so you're forming ligament sensitization.
So that's why I return to sport is a year really for contact sports, because there are histological studies and you want to see those type marks and those basic signs for her ligaments joined to bone. And you've got the complications. I didn't really mention of tunnel widening sign over windscreen wiper effect of the synovial fluid being pushed up and down. So while you don't want to drill short at a smaller diameter tunnels, you really should try and get a tight fit on both sides.
They've got the graph compression tubes from Arthrex to stop expansion with the fluid he put on, and that will improve your maturation. So I suppose the answer would depend on how well the tunnel fit is, you know, the quality of the graph. Let's see, I'd say up to a year, but I haven't looked at that specific point recently. OK so for acute injuries, especially with multiligament injuries, ACL, HPCL PLC.
What would you what would your preferred order be if you have multiligament injury? Yeah, I mean, I mean, don't get the choice, of course. Yeah, I mean, there's a standard, there's a standard framework for that. And I'd I'd urge you guys to look at that. My it's sort of whether you do PCL and ACL and then do the prosthetic corner and you can come back. It depends.
I've got a medial side. You always have to do a medial side. But like major trauma. Those ones say, in my practice, we do a relatively high volume acls, and I think your question, if they say you are the specialist centre, you are because they're not that many of them and you, these are getting concentrated within the facing the major trauma centers, mainly especially centers, you might have had a knee dislocation at the time of injury.
That's probably more important. What I'd want to know first, that the first answer I'd expect is this is a serious injury. This is high energy. This patient obsessively assessed bas status protocol. That knee, which may look reduced now or may have dedicated time. You should know the risk of internal tear from the artery, so you should check your pulses to neovasc examination.
C.t. angiogram is quite common. Never be a wrong answer. If and doing implies doing Doppler. Make sure you haven't got that. I've seen it a few times and I've seen those patients have multiple ligaments being put in braces and Amy and actually, you know, they had an internal tear. But you know, when you've seen them, they've got sort of vascular symptoms, so stabilize the knee.
It depends on your local expertise. And there are I've seen I've seen variations of things. It's difficult to give a framework about one, but I've seen, you know, you don't have to do all of them. It's quite common to the ACL and then the collaterals you need to repair collaterals. Now it depends how bad your collaterals are, because if you look at your guidelines from medial to lateral injury and lateral collateral injury or the medial collateral that has grades, you should know your grades when we do collateral.
If it's, you know, a pull off again from the insertion site, that may heal with the brace if it's mid substance, say, of the superficial MCL, just like a knee replacement, that is a very important ligament. You might want to repair that directly and reinforce that with a hamstring. And then do an ACL as well. You've got to be thinking about your graft choice so you might use hamstrings or think.
For one, say the ACL, you might use a large ligament for the PCL. You might need to have that on the side. And then for the posterolateral corner and LCL, I tend to think of the last approach we drove through the fibular head and just do a single, a single screw in the lateral epicondyle. There is an appropriate approach, which is more complicated because everything by the prod is more complicated.
But yeah, again, it's not something I've dealt with for a while, but that's what I'd be thinking. Just exclude the serious knee dislocation. Look at the MRI, think logically and restore AP and collateral stability. I think what I think what you said, Mr. About multiligament sentries coming up in the exam, it's not about your order of fixation, it's going to be about recognizing this as a high energy injury.
And yeah, I think so to do, I'd suggest that if you got to the point of how you're going to go about fixing it, you're doing really well in your question as opposed to the basic part of your pass fail type question. And I wouldn't push to go to discussing the order of fixation in the exam because it's never going to go that way at the first two parts, the first three minutes or so, it's all about managing the patient in terms of ATMs and recognizing that there could be neurovascular injury associated with this.
If there is, I think we should leave the questions for now and go on to the MSK portion of this presentation. If Hanna, if you don't mind putting them up. Thank you. So everyone, if you could answer the questions really quickly, this is our way of gauging. First of all, how our presentation is going, but also it gives you an idea of the type of questions that can be asked as an MSC in the exam.
While you're answering the question, I'll remind everyone that our UK is a charity that focuses on orthopedic research, but also education. Please visit their website if for further courses and webinars. If our mentor group is known for is again, a charity organization, we don't get money for what we're doing, but we do raise money by doing a couple of things.
First, the courses that we do Viva courses and the money on that goes to maintaining our ability to present these talks every Wednesday. Also, we published a book concise orthopedics. Please do at least browser to see if it suits you, but we believe it's a very good book for preparing for the exam. All proceeds of that again, go to maintaining this ability to provide these Wednesday sessions and maintaining the cost of the Zoom programming.
The mentors give their time free, as does our UK lecturers like Mr. panwar. We do appreciate that. And reminder that our UK also publishes quite a few books for of exam, please do look at them as well in terms of a middle aged person or a younger person with an ACL injury. Do you do an osteotomy or. OK it's a classic question, and they probably do it just from the medial egawa point of view.
And they might give you a young laborer 45 miles. And then if you do really well, you might get to the ACL rupture and things like that. So yeah, your classic young laborers with various knees and medial medial away. You can talk about how tuberosity sometimes because it's not going to wear out and they can load those properly because you can't reload a pulse blasting.
Now, if you're talking about an older patient, you might want to talk about a uni metal knee replacement and then they might throw that curveball in off your ACL being ruptured. And so the options are there that you can do a uni with an ACL reconstruction again as rare as hen's teeth. You'd be doing very well towards the end unless they showed you a picture of that.
It's not something I'd mentioned sort of thing. If you were in Oxford doing an exam, they might do that. The only interesting thing is in the Oxford or a uni, they might want you to know that an ACL rupture is a contraindication to a medial or lateral medial uni knee replacement, and they might talk about four bar linkage, you know, which is quite one of my favorite questions of their forces from the Oxford sort of textbook with fixed bearing unis.
Actually, they say you can have a bit of ACL fraying, a bit of ACL rupturing, but that's again is another topic for another day. And I'm glad, happy to talk about that. Another point bringing you back to talk about uni condolences for those who want to go, look this up. This is actually on our YouTube channel. And with arthroplasty. And one of the options we've discussed was unique names as part of are fantastic, but we would love to have you back, Mr Palmer, if you wish to give a talk on that topic.
I really enjoyed it. OK, so we'll close the polling. I'm very disappointed in you guys. Only 44 of you have answered, but. And that's less than 50% of the people here. But anyway, let's move on. Mr Palmer, if you want to, please go ahead. Yeah, I mean, I just put that one in because when I'm doing an ACL, all the mask goes out of my head, usually at that point.
So planning. Planning is really important because it may be a bit typekit at stage. It's essentially your desired graft length plus 10 for your classic button. So perhaps I'm showing my age and the buttons used quite commonly used. You need 10 turning space, really. I have argued this 6 millimeters might do, but technically it's 10 millimeters will get you through.
So it was C 35 millimeters. So it's really from a tunnel. It's 40. 25 millimeters is a design graft insertion length that's sort of an accepted amount of graft. It's putting the femur. I didn't talk about that as controversial, but a minimum is 15 for some people in France and 20s. OK so then you need a 15 millimeter and a button because 25 plus 15 is 40.
However, you need to pull that metal button up lengthwise clear the whole button so you've got to pull your hamstring graft up 10 more millimeters, then 25 to 35 millimeters, your metal button will reliably pass flip and you get that lovely toggle sensation. So and it's in the Smith and nephew optech, which if you just look up ACL technique, you'll find it in there with a nice picture grasslands plus 10.
So the risk factor for ACL failure. So very good low posterior tibial slope is not a risk factor. Hi tibial slope would be a risk factor. Hi tibial slope is beneficial for PCL injuries because your femur sits back more, but it's bad for ACL. So people talk about slope reducing or Stratasys. And as I said, the femur and tibia was just to reinforce.
It's accepted to put your femoral tunnel quite far back as far back as you dare. Really? and your typical tunnel not more than 50% So you don't want the less to be down to the more than 50% You'll be vertical if you do that and you might get more notch impingement even to wear impinging on the PCL. The last one?
Well, I was clearly grasping for basic science. And you clearly you're very good at that. You need to know the properties of scholastic materials, hysteresis, crepe time dependent stress strain behavior. My favorite example is hammering in an unscented femoral stem because that's when you're going to get your fractures, and that might be a question that asked and strain hardening. I'm sure you guys will tell me more than I would know is to do with metals and when they pass their yield point.
But it did sound quite viscous elastic, so I thought somebody might fall for it. Clearly not so. Very well done. OK, thank you. Thank you, everybody. These are good questions. They will come up. They I suspect some form of this type of mk would come up in the FRCS.
Thank you very much for this brilliant talk. And while the ACL controversies ACL is a standard bread and butter operation in orthopedics, you're expected to have seen it as part of your training. And so therefore it's expected that you would be able to answer a question on ACL. The trick in these questions is talking about the controversies around it. What are the pros and cons of different ways?
And as demonstrated, as long as you do an operation correctly and do it well, the patient will have good results. But I can foresee a lot of those type of questions being coached into the exam very easily, including the discussion about whether you should give VTE prophylaxis or not. I think that one is something to watch out for potentially later on. Is there?
If there is no burning questions, Abdullah will stop recording here and move on to our vyver session. Once again, thank you, Mr pointe-noire. Really excellent talk. I know I benefited from it listening to it, and I'm very sure our people are preparing for the exam well. And if you want to go over this talk again, it will be on the YouTube first mentor YouTube channel and on our UK website as well.
Thank you, everybody. Thank you. Thanks for.
Segment:0 .
Good evening, everybody, welcome to our usual Wednesday slot. Today, where it's a combination of the FRCS mentor group and ORUK. We are very proud to bring you Mr Shah Punwar.
He's a consultant, knee surgeon based in University Hospital Lewisham in South London. His main areas of expertise are knee and hip replacement surgery, as well as soft tissue sports injuries and soft tissue knee injuries. His particular interest is in partial knee replacements, case arthroplasty and ACL reconstruction. He's a member of the British Association of knee surgery and is committed to medical education.
In 2013, he undertook a fellowship year in complex sports injury training in Perth, Western Australia, and before returning to the UK, had been appointed as a consultant in orthopedic surgery in Lewisham. He we are very pleased with his talk today, which is going to be quite important for the FRC exam controversies in ACL reconstruction. Before before I introduce Mr. panmure, I just want to remind everyone that if you have any questions, please do type in the chat and we will ask the questions at the end.
Also, people who wish to participate in the Viva please do let heiney know you can send them a message or raise your hand in the chat group. And without further ado, Mr. Anwar. It's a real pleasure to hear your talk today. Thank you very much. Thank you. Thank you, swan. Thank you for that introduction.
Thank you to you or ACC. And the FSS mentor group is a topic close to my heart, but hopefully I didn't bite off too much. So let's get on with it. Controversies in reconstruction. I don't have any disclosures I currently use Smith nephew products. We will have one of the longest history in ACL reconstruction work, and there's images here from various sources.
No patient identifiable images, right? What's my object is today? What are the main controversies, graft choices, tunnel placement, mainly on the federal side, to be honest. Fixation choices. The additional procedures you might want to do. And just some small print stuff. Timing of surgery and rehabilitation.
So bone, patellar, tendon, bone. Traditionally, this was the go to graft, easy to harness front of the knee. Is it still the gold standard? Hamstrings certainly were popular during my training and no donor site morbidity, and I would say 90% of the ACL reconstructions you'll see will be hamstrings. Clothes 10 plus or minus telephone block is fairly new, and the Americans seem to be very keen on it.
There are minimal grafting donor harvesting techniques, but time, I think, will tell whether this is a superior graft. Other smaller options are allograft, so donated cadaveric tendon tends to be radiated in slightly weaker than your own tendons or synthetic graft, which was very popular in Australia in the 90s. Such as loss, and there's certainly been a move away from that.
So, you know, what are we looking for looking for a strong graft? Now, your native ACL has a load to failure strength around 2000 newtons. A 10 millimeter bone patellar tendon bone graft has more than that about 3,000 newtons. You're going to get direct bone to bone healing, so that's very strong for strained hamstring graft. About 3,000 to 4000, depending on what you read.
And that's slightly more than the actual bone patellar tendon graft itself. Quad tendon similar allograft range from 24,000. But as you can see, we're all in the region of over 2000. These are very strong. That's not really going to be your initial weakness. This is probably going to be your fixation, particularly when the graph is, you know, bending in so big beating TBE bone cells in the bone.
Popular for heavy mouths, but there is an increased risk of anterior knee pain, patella fracture, patellar tendon contracture. But you get this solid bone to bone healing. Your hamstrings need to be at least 7.5 to eight. Now, if you've got a short, typically short female, you have to just be concerned that you might have quite short tendons. There is a risk of softness, nerve injury, and you can lose the end kick of sprinting.
But largely there's very little donor mobility from taking hamstrings allograft. So donated tendon sort of thing Michael Owen had back in the day, really for professional straight line athletes only. So sprinters or rowers, there's a high rupture rate, but it might be just right to get those people through their careers in some studies, a four times higher rupture rate.
I haven't really talked about return to sport at the level that people were at, but it's something you should send people for because I think it is quite difficult for professional athletes to get back to the same level of sport that they were at. The synthetic grass will eventually fail. It can cause sinusitis and bone cysts. It was very popular in Australia following an Aussie football's football rules player at a large graph and got back to playing very quickly.
But since then, there have been lots of failures, and there's now a position statement from Australia saying don't use them. So what's the reality we'll grow if you're going to choose? It's like anything, it's based on your training, your fellowship and perhaps current trends will influence you. Lots of training opportunities.
Now, as a consultant to go to soft tissue labs and even abroad when we're allowed to travel and keep an eye on what's happening. But I do think the training and your fellowship really does affect what you use. You want low donor site morbidity. Acls tend to be j-k surgery, so you want me to manage pain and hamstring tendons are very versatile. The quadriceps, tendons, relatively new, something I'm looking into and I'm sure those of you younger knee surgeons coming through will be looking into.
And as I said before, your technique, initial fixation is more important when you graft choice. The weak point is tibial fixation. It's a question you might get asked in the fast. Yes, there's greater shear forces. And again, remember the metaphyseal bone on the tibia can be weaker, particularly these patients are deconditioned.
Well, preparation. There is some controversy about tensioning, but it makes sense it's a ligament. It removes creep. If you put on your graft, you can't put on a patellar tendon graft, but for hamstrings useful detention, the vancomycin swab is not really controversial anymore in the papers about using that on your graft. It does reduce infection.
I use it. It's really easy to do. One gram of vancomycin is saline and just soak a swab, prepare your graft and a graft master and wrap it in your hamstrings. There's lots of different configurations. I've just put a diagram of some of the things you can do if you want to make your graft stronger. The classic is the 1 over on the right side.
They're just a quadruple semi tee and bas status graft over usually suspension fixation. There's an interference screw in the tibia. You can triple your semi tenodesis, put the groceries over the top to make a five ton graft. You can if you have 30 centimeters long, both tendons stitch them both together and triple them to make a six strand graft. Hamstrings should be over 7.5 diameter, really eight.
And you want I'm looking for 10 centimeters long. Really for a standard suspension fixation on the FEMA and its evil interference group. So that's going to be about 4 centimeters. And FEMA about 1 and 1/2 centimeters within the joint and about four 4.5 centimeters on the tibia. And you can adjust your tunnel drilling if you have a slightly shorter graft. You need a shorter graft if you're using suspension fixation on both sides.
It's becoming more popular, such as the Office groveling, but doesn't come without its own. Possible complications. So more tunnel placement, probably the most highly debated thing in ACL reconstruction. You need to know your terminology might make something that might come up in the exam instead of proximal distal anterior posterior. We tend to use high, low, deep and shallow deep being posterior, shallow being anterior.
Remember, the knee will be flexed, usually at 90 degrees when you're doing your femoral tunnel and then high for proximal and low for distal. Now, the initial ACL reconstructions were open. I'm not going to talk about those. They violated the fact pad and much more painful procedures. I think I saw one very my first registrar drop back in 2007. The transtibial technique is also.
Not used that often these days, they're still in quite widespread use where you would bend the knees 90, drill through the tibia using over the top guide to put through the tibia, hook over the back of the femoral notch and then you can drill your femoral tunnel. Now, clearly, you'll be constrained by where you've put your tibial tunnel, so you tend to get quite a high graft, really high and vertical, and that doesn't really give you very good.
Rotary control might give you some control, but didn't give you very good rotator control. So we've got a diagram on the right and medial drilling, which I'm sure almost you've seen gives you a greater obliquity, but you do need to Hyper flex the knee. Otherwise, you can get short, shorter tunnels and. There's also the risk of estrogenic damage to the medial epicondyle, particularly if you're drilling a large craft.
But the great obliquity leads to greater territory control. So what's the evolution of affirmative replacement? Now, most of you will have heard of the clock method, say for a right knee, you could use 2300 quite the old fashioned high position and you could use PM for a left knee. Now the disadvantage of the clock face is that that's a 2D description and obviously is 3D the notch.
So it doesn't give you any idea about depth, but it's still useful as aim and I think. We found the time replacement you want to use lots of different things. The ridges are quite commonly used now. There's the luxury into the ridge, so-called residence ridge because you don't want to go above it. With difficult ridge, which is meant to separate the two bundles.
I haven't discussed axilo anatomy. I'm sure most of you are aware of ample and remedial bundle and posterolateral bundle and will actually perhaps challenge that classic description of axilo anatomy in a bit. So from the clock face. Um, we went down to anatomic reconstruction. Now, if you didn't anatomic reconstruction, you can either do a double bundle through to an adult anatomic.
So try and announce a media bundle at the back post that's for the front. Or you can do a single bundle anatomic at the midpoint thermal footprint, and I'll show you some diagrams later. Or you can perhaps go to more higher and deeper position at the back of the knee in the center than to media bundle. Now we've gone from the higher initial graphs, quite vertical going more and more anatomic, and I think there is now a trend to go back to a slightly higher and deeper position.
So instead of PM sort of 1030 on the right, 1 30 on the left, and we'll explain why that might make biomechanical and anatomical sense. The rich technique the image on the right is from one of my cases. You can see an empty lateral wall to get a PC on the side here. We don't tend to not blast these so much in the UK. I think if you do have a very narrow v-shaped notch, maybe in a lady you're going to get impingement against either the side of the notch or the PCL.
You might want to consider some form of notch blasting. But you can often see these ridges and you can see the remnants of the femoral insertion. So I always look and look for elections coverage. And then you can look for coverage. Often the remnants will help you decide where these are. If you don't do anatomic placement, you want to go in the midpoint of the federal footprint, which is quite low, I think.
So there are different ways of doing it. You can measure with no scoppi ruler and often you have to change portals for that because you need to measure on the lateral side. And then you can go in the midpoint of your measurement. So you can measure and go in the midpoint. You can also use the bundles. If you can see the typekit ridge, you could just make a mark there.
And this is a double bundle technique of a single bundle center. The footprint double bundle was popularized by Fred, few in America, but I think it really has fallen out of favor. You've got inadequate graft size. You're going to get graft impingement, tunnel placement problems and that revision you're dealing with for tunnels.
So I think anatomic reconstruction is still definitely a thing, but I think people will tend to go more for a center footprint on the ridge with a single bundle rather than go for a double bundle technique. There are other ways of working out with your ephemeral tunnel is that I don't use. There are grids, there's a Bernard and Hertel grid. You can use operatively Roscoe.
I think you can always use navigation, and these are ways that you can look at your time replacement following surgery, perhaps on a CT scan. I don't use philosophy, but you can take true lateral x-rays, we use it for other knee surgery, such as ampofo reconstruction, and you can use standard percentages that I'll show you later to work out exactly where you want to go.
So the anatomy of the knee has been revisited several times, this classical teaching of entry, medial and lateral bundles has been challenged. There's a recent concept of the ACL being more flat, and ribbon like tends to be coming from this paper by smiggle from Poland, but working with very well known London knee surgeon Andrew Williams. The recent concept is that it's more flat and ribbon like, and there are two different types of fiber attachment direct fibers which appear to be carrying more load both historically and I think microscopically.
And they're attached high and deep within the region of tenotomy to bundle and then indirect fibers, which have a weaker attachment and take less of a load. This is the paper, it's freely available on the internet, and I'd recommend you have a look at it. So this is source in the paper. This is the posterior femoral cortex. This is the back of the notch.
This red line is the direct fibers, which seem to have a very double tight mark has been described, seem to have a very strong attachment to the back of the knee and look how far back it is. You really want to go as far back as you dare, and this yellow one is indirect fibers in the region of the posterolateral bundle, the so-called posterior bundle not quite as distinct. So they propose that we should put icons in the region of the direct fiber insertion.
Now this agrees with another concept from Stephen Howell Perla McAllister called the ideal federal location. And this session Zimmer Biomet website, though it's come from lots of different research with the lovely, lovely bits on the website and even gets you to choose where you'd put your own tunnel. So ideal stands for isometric. We want the potential relationship similar to Native ACL ACL.
We want it really to stay the same length throughout a range of motion as best as possible. The D stands for Direct fibers, as we discussed before. An eccentric means it doesn't have to be in the center of the footprint. They're saying go higher in the footprint and in the middle portion, which agrees with that smiggle paper, and they're completely separate concepts from different parts of the world.
Equidistant so halfway, the top and bottom the notch, which is the good interrogative check. And in real life, you're going to be using your experience in intraoperative checks. So I clear the notch at the back and I do look for the top and the bottom, the notch. I look for the articular cartilage, and it does tend to be in the middle because remember, if you're drilling, say, an 8 millimeter graft tunnel by the time you've marked your tunnel, it's going to be 4 millimeters bigger forward and 4 millimeter backwards, so you have to take that into account.
The a stands for anatomic and the L stands for low tension. The anatomic, I think, stands for. You know, in the media bundle, they're not going for a central footprint position. And there's a diagram, which is on that website. And the green part, they're sort of shows the confluence of where they think all these things coincide. So it's where all these circles overlap in this sort of position, which I agree is high in deep in the region of the direct fiber insertion.
So where do I put it? I put it in the sense of ventromedial tunnel. So behind the typekit ridge, just slightly knowing that by the time I've drilled, it'll be say I'm drilling an 8 millimeter tunnel. Most commonly, it'll be 4 millimeters behind the 4 minutes in front, but always behind the Buffalo Ridge and just under the lt-col ridge. Now clap worthy at now, also with Andy Williams, and the Danish registry has shown a higher failure rate of 3.5% times in the slap worthy study, using an anatomic tunnel placement that's more the low, more shallow placement.
So, you know, I would go for that. And medial bundle and I would leave at least 2 millimeters of posterior wall. So if it goes to the back, there is a risk of blowout. That's not always a bad thing if you're using suspension fixation, but you need to know that you've done it. So I show you a picture later, and I always check the posterior walls intact.
So family time, a drilling technique is also controversial. We talked about Sean's debut. I don't think many of you will be doing that anymore. You tend to view from what I tend to view, mainly for the lateral portal and ready to view from the medial portal. If I can't get around the corner and I can't get a good view, and if you are viewing from an intermediate portal, you drill from an accessory and media portal.
Most tunnels are drilled inside out, but outside in came in, mainly through Arthrex. There's the flip cutter, which you make a hole laterally on the FEMA. You put in the FlipCutter device and then you can drill from the lateral flow inwards, open the little clip cutter and then drill your socket backwards that way so you can get socket rather than a tunnel.
If you do that on both sides, you can sometimes have graft socket mismatch as you can have patellar tendon socket mismatch. And so sometimes people just drill an outside wind tunnel in the FEMA and a whole tibial tunnel from outside in as normal because you don't want to have more problems. But it is an attractive technique. The graph link hotfix technique flexible versus rigid dreamers. I think there's a lot to be said for rigid, flexible dreamers.
You can probably get less than an oblique tunnel and you can get around the medial epicondyle, but there are many in use. Stryker have them, and certainly I haven't used any as of yet. Just beware your short tunnels aren't familiar drilling. There's three stages to a straightforward and no button drill. First, it's a 2.5 millimeter beef pin. If if you can measure that and it doesn't feel right, you can readjust.
By the time we drilled a 4.5 Indo button drill, you get a good measurement. It can be difficult to change because you get tunnel convergence. You can still change at that stage. But once you drill the big acorn reamer, then it is quite difficult to change. So need to Hyper flex? Be careful where your hand is.
I tend to go about 30 degrees from the midline out to the side when I'm drilling for the unfamiliar portal and I get my hands slightly. And once you do quite a few, you know where your pinch should come out and you're looking for a tunnel about 40 to 4 to 5. It's quite consistent. If you've got it right. So these are the different views.
You can get, this one in the middle was viewing from a standard lateral portal. You get a slightly better view than that. But if you say you've got to be like this and you weren't quite happy that you could see properly the back of the notch, you could change to a high entry media portal and then you could drill through an accessibility media portal and you get more face on. I tend to put my sister into media portal a little bit more in to avoid the medial epicondyle, and depending where you put your hand, you can change because of the tunnel.
Some people like very short tunnels. Obviously, if you've got a short graft or you're using a quadruple semi tee, you might want to purposely draw short tunnels. The typical tunnel is less controversial, really. I tend to use anatomical landmarks, the posterior border of the anterior horn or the lateral meniscus, such anterior horn lateral meniscus.
No, you don't have that knee replacements. You can see that the ACL starts very anteriorly, you want to go in the middle, really if you go to a be tight inflection. So I find the posterior border of the anterior horn tends to be slightly red, obviously seen. And then you triangulate with the PC out of the back, and the medial tibial spine is also into eminence in front of the PCL, and you use a 55 degree tip of Elmer elbow.
I tend to prefer a tip am so that I know exactly where the y is going to come out. If you increase your angle, you're get a sight longer tunnel. And conversely, if you decrease your angle in a shorter tunnel, which might be useful. Again, that paper, which talked about the ribbon attachment, there's some nice anatomical specimens showing that the tibia attachment is more C shaped than two discrete bundles.
They actually say the bundle theory might be more of an illusion as the ribbon wraps around itself. And if you look closely where the posterior lateral bundle is meant to be on the tibia, it's actually in the area of the Anshul root attachment or to natural meniscus. So, you know, I'm not, you know, I do think there might be a sea change in ACL anatomy. Certainly, this is not what I was taught when I finished training, but you can find lots of things about this in the literature now.
This is just a picture from a recent case. How I actually do it. You're clear the notch use a shaver, get to the back a 45 degree, or it's quite useful because you can hook the back of the notch and then you can just come forward. You know, it's 5 millimeters from the tip of the oil to that Black mark, so I can measure that to be at least 5 millimeters to the back.
And then I put it in using the clock face and the ridges and where the anteromedial bundle I think was before. And you can see I made sure I've got a posterior wall. So clear all the swoff with your shaver and make sure you've got a posterior wall and you can actually look up the tunnel. For the typical tunnel, this is actually a one, tenodesis. It's quite red and then. It will pass your graft check, there's no impingement in extension, so you straight up the graph.
And that's sort of a standard picture I expect to see. How do you evaluate your time? Replacement should get some imaging following surgery, ideally before the patient leaves or at least the next clinical appointment. Plain x-rays are fine. My colleague prefers to do, and that is very accurate and there is a CT protocol within our trust. So you can closely monitor the tunnel placement and adjust your practice, and you could use those grids as before.
You can't really do a talk on ACLs without mentioning Lipinski and the Sydney experience. And I often refer back to this poster because it tells you where what you should be looking for on a plane. Post-operative X-ray of an ACL reconstruction and essentially femoral tunnel should really be as far back as possible. So about 86% along blue line and the tibial tunnel should be no more than 50% along the lateral tibial plateau.
But I find that quite useful way of assessing the presence of results tunnel placement. But you do need good quality x-rays, particularly the lateral. And in this paper and study, they found a higher failure rate. So 17% compared to seven percent, which was significant if your tibial tunnel was over 50% posterior. So the typical tunnel placement in the app plane does appear to be a crucial.
Fixation, how are you going to fix your graft? There's two main types. Interference or cortical suspension, permettendo bone grafts. Usually fix of screws. Lipinski, I think, developed the reverse $30 eye screw, which is a niche thing you might get asked in an exam used for thermal fixation the right knee to stop your graft being twisted.
You want to ideally put in front of your bone block, so that's just a niche thing. The reverse side screw soft tissue grafts you tend to use called suspension on the FEMA. You can use fix loops or adjustable loops. Now the popular ones are the Arthrex tie rope. It's also the pull up, and Smith nephew also have an adjustable one now screw on the tibia. It can be metal, a stainless steel nonrenewable peak, which is not a global but doesn't show up an X-ray or an observable screw.
Suspension on both sides are becoming more popular because you can use shorter grass, but you've got to be careful. About the strength of your tibial bone. Some people worry about using tight suspension and buttons on tibia because, you can crumple the cortex there and certainly you can crumple the cortex with the staple. The reports of tissue reaction insists and breakage usually bioresorbable screws, so I don't use those anymore.
And with the other screws in the revision scenario, you can remove them. Some people use a secondary fixation, a stapler or a screw to prevent shear. You might have unobservable which stitches where you will have on the tibial side, and you can tie those around a post on the tibia. You usually increase this freedom to by 1 millimeter might be something you're asked.
Femoral bone tends to be very hard to be using a screw up there. You, you don't tend to be lying to line, and you can use a screw in the femur for soft tissue grafts. There are other methods which I haven't mentioned the transfix where you can drill through the femoral or lateral cortex, and put two sort of pins in, and there's a special jig for that which is popular in the transtibial technique.
But though I've seen that used, it's not something I think you'll might see in very modern practice. Where you fix the graph is a little bit controversial. You should check our high symmetric it is by looking at how far the graph moves up and down. Typical tunnel when you go through a range of motion tend to fix and tenths degrees of flexion push down to the tibia.
If you fix too tight, it'll stretch out. You might limit flexion. But again, you don't want to fix things too loose. There were tension devices. Some people use them. There are a bit fiddly, particularly if they want all four strands to be separated. So I tend to just pull very hard. OK, your assisted to pull very hard.
I use an end button, the FEMA. At present, I have used other fixation methods. The most common one is a 15 millimeter. They still stock everything from 10 to about 30, probably in your hospitals. It's a fixed loop. It's got the longest track record. The disadvantage is you have to ream a slightly longer socket.
Your big socket or tunnel then necessary in order to flip the button. And any of you struggle to flip it, and the button will know that it's important not to shortchange yourself and try and be careful when you're pulling those grafts through and protect your fingers. It's quite easy to pull the wires to cut, cut through into and just cut your fingers.
It's a badge of honor. So I use a bias or screw made of peek. It's not resolvable, it's MRI compatible. If I need to scan people again, particularly within a meniscus repair. Occasionally, minuscule repairs might be symptomatic. They may fail. You may want an MRI. I usually use about 35 millimeter screw tunnel tenotomy 40 to 40 five, and I don't want to go into the joint, but I want to get as much sort of boundary fixation on the tibia as I can.
I whip with fiber while others use bond. You could use Velcro, but I want to protect the graft, particularly from the screw. I'll just check time. Seven already. So interference groups and police continue. Everybody is OK, I'll continue. Fringe groups. You've got to be aware of screw divergence.
So where you put your guideline is really important. So I take a little guidewire and I put it into the typical tunnel. And I like to see it coming out in front of the graph. Ideally, if it's in the middle of the graph, then you could damage your screw going. Your graph going in. It could take a little bit of work to make sure you know what our guide wire is.
The length is controversial. Some want as long as possible to get a picture fixation. But you don't, especially when you're using metal screws, you don't want to protrude into the joint. So I think 35 millimeters fine. I don't use screw and sheet types. They're a bit fiddly. You may see it. We've mentioned the reverse thread.
You a feminist collegians, when you see them in ACL reconstructions. Actually, we're getting a lot of people coming through very late, especially with covid, and you still have to assess normal meniscal lesions to see whether I repairable, but that's a different, different talk. I just want to mention the slap lesion, which doesn't actually stand for anything.
It just stands, I think, like a ramp, but it's a posterior meniscus to tear, which I have seen. You can hook it. It probably heals by itself. In the majority of cases, because a good healing environment, once you've done an ACL, but burn Bertrand egawa test, another big name French name in acls, he's popularizing posture, medial portals and a little spiral hook to repair properly.
You can try and repair them from the front. I've done that, but it's worth trying to get possibly the porcelain, perhaps in a kind of a first Latter tenodesis that's come back into Vogue the international ligament around for a long time. In fact, the early ACL reconstruction were actually articular. But since 2013, in this class study, it's got a resurgence in interest, and it might explain the second fracture, something that might come up in the exam.
Maybe that lateral capsule evolution is the actual ligament, and in revisions and hyper extenders marked laxity. Very high performance people. You might want to do it at the same time as your ACL reconstruction. You can just take a strip of white band. There's a Macintosh and La Mer method. They're quite similar, just different insertion points.
I tend to go just posterior and proximal to the lateral control epicondyle. So you take a straight pointy bend feed on the ACL back to your tibia tibia. You can fix it with anchors at that point, just posterior to the lateral epicondyle or a staple, you can get convergence with the ACL tunnels. You normally go more anterior and proximal with that tunnel and then get good out there.
They've got some big studies coming out now. They've shown decrease failure rates. If you use it with primaries, which stands to reason, it's a greater fixation. You could over constrain the lateral compartment, so don't pull too hard. You're not meant to pull much on it. And some say the ban is a Main Street to internal rotation and tibia.
So you're going to reduce your pivot shift. So you've got hyperextended that explosive pivot shift. You might want to do a left tenodesis. There are other methods you can use. Hamstrings, as well as an elegant method of using a semitendinosus for the ACL and the gosselaar for your Allen, but it's fairly straightforward.
Apart from the capsule can be quite thin underneath the LCL and you've got to cut the IT band over the LCL, so mark it carefully. Make sure you've got a good length about 12 centimeters you need. You're going to flip it over and then carefully dissect under the ACL LCL. Sorry to pass your graft. Uh, it'd be good to look at the mask based guidelines now if you're going for the exam, as it's good to look at all the bombast guidelines.
They've got a consensus statement on ACL injuries. There's some controversial areas such as DVT prophylaxis, and I follow my trust protocol. If it's an operation lower limb over 60 minutes of combined anesthetic surgical time, you should consider chemical prophylaxis. So I give a week of click Sign. They say there's no need, there's no risk factors. Interestingly, they say you can perform meniscal repair.
If you've got an acute, you lock knee and it's not ready for an ACL because you haven't got the expertise or the knees. Not quiet, but ideally performing at the same time. I recommend you have a look at that timing of surgery. Generally, you wait until the knees quiet. There's a risk of fibrosis. You start too early, but elite athletes might be ready quicker.
They've got game ready, they've got ice baths. The very motivated everybody gets pre habilitation these days, and it's safe to operate as soon as the knee has full active extension and is bending freely to over 90 with minimal swelling. So if you've got somebody motivated, you could operate within three weeks. It doesn't happen. Usually on the NHS, particularly during this COVID time rehab.
Now you may well know about open and closed chain, and traditionally there were two phases to ACL rehab. First, graft protection for six weeks, then graft strengthening. Now it's controversial as to when your grass at the weakest, your grass being neovasc rise. They might be the weakest at six weeks, so I often think we should slow down around then. But there's lots of protocols.
Now where they're combining open and closed chain and our biomechanical studies showing you can have increased forces on the knee with closed chain. So just like, say, Achilles tendon injuries got accelerated rehab, and what remains the same is initial focus reducing effusion, regaining a range of motion six weeks. You want to see full extension because hard to get that back then you work on flexion and allow jogging at three months.
Return to contact sports is 9 months to a year, particularly football. The slap slope is beyond the scope of this talk. There's a greater failure rate with higher TB, a slope, so revision cases, you might want to do a slope changing osteotomy and osteotomy again, an old technique coming back into Vogue. And you know, something you may see a lot of. So come towards the end.
Now there are some unanswered questions, which patients do well with, you know, not management. You can certainly try not open sedentary patients, and that makes sense unless they've got symptomatic instability and those over 40 willing to try the approach. I know people have done very well. No, not. The risk of egawa in the ACL deficiency has not been proven yet, you would say an unstable joint is more at risk of arthritis, but it's not been proven.
And osteoarthritis itself is contraindicated in ACL reconstruction. So I think it's still a controversial area. Some say the initial bone bruising from the pivot shift injury damages the cartilage and we need more work in that area. So in summary, large variation in practice globally and even nationally, I suppose you want a good quality graft, whatever you choose. Secure initial fixation in tunnels should allow full range of motion without impingement.
Avoid excessive graft tension. Delay your return to contact sports for 9 to 12 months. Pick a winner. Patients must go through tailored rehab program. It's just as important to the operation. Paper just came out recently at Nottingham, and they put it on the internet freely available before press. A systematic review of all standard techniques and the end result was all standard techniques for comparable, so it doesn't matter what you do as long as done well.
And that's it. Thank you very much. Thank you very much. That was very informative, comprehensive and broken down into small pieces that everyone well, I hope everyone who is listening was able to understand. I have got some questions from the audience if it's OK. So the first one is, do you cycle the knee movement prior to the tibial fixation?
And if you do, why? Yeah, yes, you must you must cycle the knee. And sorry, I didn't mention that, I don't think that's controversial because you put your graft in. You got good femoral fixation, so you flipped. You're in the bottom right from the home run. You need to now work out how isometric your tunnel is. Tells you how well you draw. You drilled your tunnels.
So firstly, I will bend it up and down and just see how far my graft withdraws into the tunnel and particularly on flexion. And we tie to infection. OK, and then you want to get rid of more crepe. So it's all about getting rid of more crepe. There's a viscoelastic. Um, material, I actually threw a question of those question at that one of the MKZ I did, because it's the basic science you might want to do, and that would be a great question, therefore.
Yes because then you could talk about getting rid of creep and you're going to really stretch out if you don't do it and you fix it all as well. That patient may well stretch out just a few millimeters in the early days give you a looser graft. We can talk about the basic science of crimp and collagen fibrils. You guys probably very hot on that.
OK, so what are the tunnel dimensions when you decide between the single or to stage ACL revision surgery? Is there a difference? Yeah, I mean, I just saw a patient with that today and I was actually just thinking that myself. So when I put a question of that in the macoutes said, perhaps we're going to do that. We can talk about it.
I think it's based on experience as well and where you think you can get a tunnel in if you don't think you can get a new tunnel in a good position, you know, near that wide tunnel. It's always safest. It's like a two stage of vision for an infected prosthesis. Your exam answer would be it's quite a tunnel widening. It's probably safe to do a two stage.
Exact measurements are quite hard to find if you can measure she had some way of measuring on your imaging and we can talk about imaging. You do, then that would be great, because that would tell you, I will tell you exactly you might be lucky and you could use that initial tunnel for your second revision if you're lucky. There is some talk about putting in bone dials and drilling through quickly, but you know.
That's a bit risky, but there is talk about it, so I think really, what is too. It's very small. You know, when you can get past it, it's completely the wrong position. You can stay out of the way. And if it's exactly where you are, best to be safe is probably the exam answer, you know? Yes so you didn't mention anything about the primary repair of the ACL.
Yeah yeah, that is controversial. But and actually, that's the better technique. The ba are the one that they do. They come up in the States with pediatricians. That's something I haven't seen anything of that. So much in the UK, where they put a little sponge in between the two ligaments and they allow the ligament, the ligament and to grow into that sponge. I think the sponge is Bears good for pediatrics.
But you know, Gordon McKay up in Scotland, an expert surgeon and ex-professional footballer, has popularized the Arthrex type technique. And I have a friend who's using that technique in Pakistan as well. So there are. It's just like repairing any tendon, more like a rotator cuff. I would say people are using suture anchors, so they are using a scorpion.
You can simply take the anterior stump. So what would my exam answer be? You need to have the appropriate type of tear. So you want a tear from the femoral attachment. So you want to quite a large really want a mid substance repair. You want one that's come off the femoral attachment. Quite healthy, younger patients. You've got to quite quickly and willing to go through that.
There's not really long term data, her present. And then you can simply use as a new scorpion and put strong, high strength, fiber wire through that stump, put it through suture anchors and tap the suture anchors into the femoral insertion. And I've seen that further stabilizes the tightrope, but there are people who say it's devil's work, so. So I'd be careful about. I wouldn't bring that up in the exam as a you, you would get yourself into a lot of trouble because you're not necessarily being examined by a knee surgeon who might know about these things.
I agree. I've got some basic science questions as well. So I've got one about the protocol for weight bearing post-op. Yeah, I mean, I don't brace myself anymore any brace and ACL and restricts weight bearing if I've done a meniscus repair and you should always restrict root reports, but. Um, I normally full way back because you want secure initial fixation, so I'd encourage you to.
Do your egawa before surgery document. It's part of the best consensus document, your pivot, shift your a draw your Lichtman's and the others, and then do it after your fixation. Yeah, when you start off, you might do a gentle Blackman's. You don't want to damage all the work you've done. But as you get more confident, you might try and pivot them again and you can say that there's no you're restricting your weight bearing is not going to stop a fixation of a poorly placed ACL.
So really, get the effusion down, go for a full range of motion. They're going to restrict their weight bearing naturally for a couple of weeks by 6 weeks. Patients might still be on one stick there. It's not like a hip replacement. When they walk in at 6 weeks, always. They're still getting through it. Usually Scars are normally well healed.
Depends if you've done all the work, but full weight bearing, no brace routine for me and I'd I'd recommend that axilo another basic science, which is about graft maturation. What is, what is the latest evidence about the time frame for that to occur? Yeah, that's a really good point. I just say one more point because you said basic science, I don't understand that basic science, you can look up the loads that happen in normal walking, going upstairs there, like in the hundreds of newtons, I believe walking or going upstairs.
So you probably should know that for the exam and you could give them more basic science answer to the rehab. You know, there are. There are Newton's. A magnitude four, walking upstairs and walking along, so maturation, I think it's controversial depending on what you do, because that grass has to neovasc grass and it breaks down.
And it's quite scary if you have to go back into an ACL at six weeks and it doesn't sometimes look like it did when you did it, it might. You know, there are some wispy bits, but you've got the collagen framework, and some say it's about six weeks. I believe that. No, that is weakest. The maturation is it can go on for a long time, so you're forming ligament sensitization.
So that's why I return to sport is a year really for contact sports, because there are histological studies and you want to see those type marks and those basic signs for her ligaments joined to bone. And you've got the complications. I didn't really mention of tunnel widening sign over windscreen wiper effect of the synovial fluid being pushed up and down. So while you don't want to drill short at a smaller diameter tunnels, you really should try and get a tight fit on both sides.
They've got the graph compression tubes from Arthrex to stop expansion with the fluid he put on, and that will improve your maturation. So I suppose the answer would depend on how well the tunnel fit is, you know, the quality of the graph. Let's see, I'd say up to a year, but I haven't looked at that specific point recently. OK so for acute injuries, especially with multiligament injuries, ACL, HPCL PLC.
What would you what would your preferred order be if you have multiligament injury? Yeah, I mean, I mean, don't get the choice, of course. Yeah, I mean, there's a standard, there's a standard framework for that. And I'd I'd urge you guys to look at that. My it's sort of whether you do PCL and ACL and then do the prosthetic corner and you can come back. It depends.
I've got a medial side. You always have to do a medial side. But like major trauma. Those ones say, in my practice, we do a relatively high volume acls, and I think your question, if they say you are the specialist centre, you are because they're not that many of them and you, these are getting concentrated within the facing the major trauma centers, mainly especially centers, you might have had a knee dislocation at the time of injury.
That's probably more important. What I'd want to know first, that the first answer I'd expect is this is a serious injury. This is high energy. This patient obsessively assessed bas status protocol. That knee, which may look reduced now or may have dedicated time. You should know the risk of internal tear from the artery, so you should check your pulses to neovasc examination.
C.t. angiogram is quite common. Never be a wrong answer. If and doing implies doing Doppler. Make sure you haven't got that. I've seen it a few times and I've seen those patients have multiple ligaments being put in braces and Amy and actually, you know, they had an internal tear. But you know, when you've seen them, they've got sort of vascular symptoms, so stabilize the knee.
It depends on your local expertise. And there are I've seen I've seen variations of things. It's difficult to give a framework about one, but I've seen, you know, you don't have to do all of them. It's quite common to the ACL and then the collaterals you need to repair collaterals. Now it depends how bad your collaterals are, because if you look at your guidelines from medial to lateral injury and lateral collateral injury or the medial collateral that has grades, you should know your grades when we do collateral.
If it's, you know, a pull off again from the insertion site, that may heal with the brace if it's mid substance, say, of the superficial MCL, just like a knee replacement, that is a very important ligament. You might want to repair that directly and reinforce that with a hamstring. And then do an ACL as well. You've got to be thinking about your graft choice so you might use hamstrings or think.
For one, say the ACL, you might use a large ligament for the PCL. You might need to have that on the side. And then for the posterolateral corner and LCL, I tend to think of the last approach we drove through the fibular head and just do a single, a single screw in the lateral epicondyle. There is an appropriate approach, which is more complicated because everything by the prod is more complicated.
But yeah, again, it's not something I've dealt with for a while, but that's what I'd be thinking. Just exclude the serious knee dislocation. Look at the MRI, think logically and restore AP and collateral stability. I think what I think what you said, Mr. About multiligament sentries coming up in the exam, it's not about your order of fixation, it's going to be about recognizing this as a high energy injury.
And yeah, I think so to do, I'd suggest that if you got to the point of how you're going to go about fixing it, you're doing really well in your question as opposed to the basic part of your pass fail type question. And I wouldn't push to go to discussing the order of fixation in the exam because it's never going to go that way at the first two parts, the first three minutes or so, it's all about managing the patient in terms of ATMs and recognizing that there could be neurovascular injury associated with this.
If there is, I think we should leave the questions for now and go on to the MSK portion of this presentation. If Hanna, if you don't mind putting them up. Thank you. So everyone, if you could answer the questions really quickly, this is our way of gauging. First of all, how our presentation is going, but also it gives you an idea of the type of questions that can be asked as an MSC in the exam.
While you're answering the question, I'll remind everyone that our UK is a charity that focuses on orthopedic research, but also education. Please visit their website if for further courses and webinars. If our mentor group is known for is again, a charity organization, we don't get money for what we're doing, but we do raise money by doing a couple of things.
First, the courses that we do Viva courses and the money on that goes to maintaining our ability to present these talks every Wednesday. Also, we published a book concise orthopedics. Please do at least browser to see if it suits you, but we believe it's a very good book for preparing for the exam. All proceeds of that again, go to maintaining this ability to provide these Wednesday sessions and maintaining the cost of the Zoom programming.
The mentors give their time free, as does our UK lecturers like Mr. panwar. We do appreciate that. And reminder that our UK also publishes quite a few books for of exam, please do look at them as well in terms of a middle aged person or a younger person with an ACL injury. Do you do an osteotomy or. OK it's a classic question, and they probably do it just from the medial egawa point of view.
And they might give you a young laborer 45 miles. And then if you do really well, you might get to the ACL rupture and things like that. So yeah, your classic young laborers with various knees and medial medial away. You can talk about how tuberosity sometimes because it's not going to wear out and they can load those properly because you can't reload a pulse blasting.
Now, if you're talking about an older patient, you might want to talk about a uni metal knee replacement and then they might throw that curveball in off your ACL being ruptured. And so the options are there that you can do a uni with an ACL reconstruction again as rare as hen's teeth. You'd be doing very well towards the end unless they showed you a picture of that.
It's not something I'd mentioned sort of thing. If you were in Oxford doing an exam, they might do that. The only interesting thing is in the Oxford or a uni, they might want you to know that an ACL rupture is a contraindication to a medial or lateral medial uni knee replacement, and they might talk about four bar linkage, you know, which is quite one of my favorite questions of their forces from the Oxford sort of textbook with fixed bearing unis.
Actually, they say you can have a bit of ACL fraying, a bit of ACL rupturing, but that's again is another topic for another day. And I'm glad, happy to talk about that. Another point bringing you back to talk about uni condolences for those who want to go, look this up. This is actually on our YouTube channel. And with arthroplasty. And one of the options we've discussed was unique names as part of are fantastic, but we would love to have you back, Mr Palmer, if you wish to give a talk on that topic.
I really enjoyed it. OK, so we'll close the polling. I'm very disappointed in you guys. Only 44 of you have answered, but. And that's less than 50% of the people here. But anyway, let's move on. Mr Palmer, if you want to, please go ahead. Yeah, I mean, I just put that one in because when I'm doing an ACL, all the mask goes out of my head, usually at that point.
So planning. Planning is really important because it may be a bit typekit at stage. It's essentially your desired graft length plus 10 for your classic button. So perhaps I'm showing my age and the buttons used quite commonly used. You need 10 turning space, really. I have argued this 6 millimeters might do, but technically it's 10 millimeters will get you through.
So it was C 35 millimeters. So it's really from a tunnel. It's 40. 25 millimeters is a design graft insertion length that's sort of an accepted amount of graft. It's putting the femur. I didn't talk about that as controversial, but a minimum is 15 for some people in France and 20s. OK so then you need a 15 millimeter and a button because 25 plus 15 is 40.
However, you need to pull that metal button up lengthwise clear the whole button so you've got to pull your hamstring graft up 10 more millimeters, then 25 to 35 millimeters, your metal button will reliably pass flip and you get that lovely toggle sensation. So and it's in the Smith and nephew optech, which if you just look up ACL technique, you'll find it in there with a nice picture grasslands plus 10.
So the risk factor for ACL failure. So very good low posterior tibial slope is not a risk factor. Hi tibial slope would be a risk factor. Hi tibial slope is beneficial for PCL injuries because your femur sits back more, but it's bad for ACL. So people talk about slope reducing or Stratasys. And as I said, the femur and tibia was just to reinforce.
It's accepted to put your femoral tunnel quite far back as far back as you dare. Really? and your typical tunnel not more than 50% So you don't want the less to be down to the more than 50% You'll be vertical if you do that and you might get more notch impingement even to wear impinging on the PCL. The last one?
Well, I was clearly grasping for basic science. And you clearly you're very good at that. You need to know the properties of scholastic materials, hysteresis, crepe time dependent stress strain behavior. My favorite example is hammering in an unscented femoral stem because that's when you're going to get your fractures, and that might be a question that asked and strain hardening. I'm sure you guys will tell me more than I would know is to do with metals and when they pass their yield point.
But it did sound quite viscous elastic, so I thought somebody might fall for it. Clearly not so. Very well done. OK, thank you. Thank you, everybody. These are good questions. They will come up. They I suspect some form of this type of mk would come up in the FRCS.
Thank you very much for this brilliant talk. And while the ACL controversies ACL is a standard bread and butter operation in orthopedics, you're expected to have seen it as part of your training. And so therefore it's expected that you would be able to answer a question on ACL. The trick in these questions is talking about the controversies around it. What are the pros and cons of different ways?
And as demonstrated, as long as you do an operation correctly and do it well, the patient will have good results. But I can foresee a lot of those type of questions being coached into the exam very easily, including the discussion about whether you should give VTE prophylaxis or not. I think that one is something to watch out for potentially later on. Is there?
If there is no burning questions, Abdullah will stop recording here and move on to our vyver session. Once again, thank you, Mr pointe-noire. Really excellent talk. I know I benefited from it listening to it, and I'm very sure our people are preparing for the exam well. And if you want to go over this talk again, it will be on the YouTube first mentor YouTube channel and on our UK website as well.
Thank you, everybody. Thank you. Thanks for.
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