So, I am going to talk to you about ACL and PCL graft options and preparation. I am going to concentrate on GraftLink, touch a little bit on TriLink and how we prepare that, and also introduce the idea of graft reinforcement, and if we do have a short graft how we can extend that. Then, like Jim, I am going to finish with some of my own results and those of some other surgeons that have presented.
So in terms of our graft choice, all-inside gives us a great option of being soft tissue preserving and bone preserving because we are using a single semi-T and as we’ve heard we can do that through a very small minimally invasive approach through the posterior harvesting technique. Now we preserve the gracilis and this gives us stability, strength and proprioception but also allows us to do other reconstructions which are becoming more and more important to us such as the anterolateral ligament, or we can do a Larson, a lateral collateral ligament or in rare cases other reconstructions such as the MPFL. We can combine a semi-T and a gracilis to make an 8 strand GraftLink where we need, and if we need to use allograft we only need to use one, and that’s a huge cost saving - they’re £2000 in the UK - and just using one for an ACL saves a lot of money. The semi-T allografts can come pre-prepared from Arthrex and we frequently use peroneus longus and tibialis anterior in my practice.
There’s this fantastic new technique now for minimally invasive harvesting for a quads tendon and there are some great instruments to do this. This is a very good option which I suggest you look at.
So how do we make the GraftLink in 2014? Here we have our semi-T, we bring the ends together; there are some very nice 2 FibreWire double-needled sutures now that make it even easier. So we can tie the knot together, we invert this knot into the central aspect of the GraftLink to make it low profile, and then using the straight needles we can control the graft with one hand and then run the needle through with the other. By leaving the needles attached - we don’t even need to detach these needles we simply leave them attached - and then make our second pass.
So here I’ve done my first cerclage and I am now going to do my second locking suture. We do 2 on the femoral side and we can do 1 or 2 on the tibial side depending on your preference; I just do 1. So here I am coming through to complete on the femoral side, and then I repeat this on the tibial side.So for PCL GraftLink we can use a semi-T - it is enough. In a big patient I would often use a peroneus longus or a tibialis anterior and several authors have now published on this including myself with very good results.
We can combine the gracilis and a semi-T to make an 8 strand graft, and we can do this where we have a small semi-T. In our series the average size has been 8.6 – obviously a very nice size – but occasionally in a small female this may come out a little small and I use this for revision procedures.So, the TriLink: This is actually a very easy graft to make. Jim touched on it in his earlier talk. So, 0 FibreWire just to bring the ends together, 2 RT TightRopes, and a third, and then we simply fold the graft in 2 and then we can play with the length of this to make a very slightly longer AM and a very slightly shorter PL, and it’s just a simple matter of locking the tibial end in the standard way to make our TriGraft.
We have used this successfully in the PCL, I think this will be where it is adopted first, you get fantastic femoral fill-in. So here I am coming in with my AL, and this is a peroneus longus allograft, and the nice thing about this is the ease with which you can pass on the tibial side using the all-inside technique.
So my results which we are hoping to publish very soon: Our 2 year results, 237 patients, we have 164 with more than a year and we are coming up now for 100 at 2 years.Like Jim, I’m very happy. These are the best ACLs that I’ve done to date: very good in terms of the Koos, the Lysholm, and the Tegner, and very few failures – 4% - and of those patients virtually all of them went back to sport a little early and had further significant trauma. We have had one PE recently but the complication rate has been very favourable.
Jim has already shown these: Other surgeons have now presented through the SOS system combining their data to show comparable to the BTB gold standard, the Womac, the SF-12 and the pain scores.And we have just heard about this study from Philippe who’s recently presented this; 46 patients, and they looked at one month at their results, they had a better position using FlipCutter on the tibia, a better range of motion, better stability with the rolimeter, but the principle finding was significantly less pain with it all-inside vs their traditional hamstring group.
So, in summary, all-inside preserves the gracilis, it preserves it for stability, strength and proprioception; we can use this for other ligament reconstructions. We have graft reinforcement for small grafts for extra articular procedures and for multiligament reconstruction, we can lengthen grafts and I am presenting some really good results for my GraftLink series at 2 years. Thank you very much.
