The concept of anatomical ACL reconstruction over the last five to seven years

This update follows my previous presentation on Anatomical ACL.

[Published 2011]

Two prominent surgeons, Freddie Fu and Charlie Brown, have been working on the idea of anatomical ACL reconstruction. They would stand up at meetings and say “I’ve done 5,000 ACL reconstructions and looking back at what I was doing I now think that I put 5,000 ACLs in the wrong place because we now know that we have been putting it in the wrong place. Although we can get an excellent clinical result, almost everyone that has an ACL reconstruction will eventually go on to develop osteoarthritis.”

Up to now surgeons were convinced that it is the other damage that you get as a result of the injury – a significant bone bruise, damage to the cartilage and the menisci that occur at the time of the injury or, if you don’t get the knee fixed and it continues to give way you get secondary damage – which causes the knee to go on to develop osteoarthritis. We all still accept that if you damage your knee and you have an ACL rupture and you also damage the joint surface and/or the menisci, then that’s going to cause you problems in the future, but now it has become apparent that a very significant factor to actually developing osteoarthritis is the reconstruction itself.

This is because if you put the ACL in a functional but non-anatomical position it captures the knee and it changes the way the knee moves. So as a result of that you can have an elite athlete playing elite sport, but if this ‘piece of string’ that you put into their knee is not where it is supposed to be – you have not put it in the correct anatomical location – you change the way the knee moves very subtly and the knee reacts to that. Over ten to fifteen years if you don’t take an X-ray – even if an individual hasn’t got any symptoms - you see the beginnings of osteoarthritis.

So this group of prominent surgeons, including several leading Japanese surgeons, looked more carefully at the anatomy and doing a different kind of ACL reconstruction and came up with this concept of ‘double-bundle’ ACL reconstruction, as opposed to a single bundle ACL reconstruction. That is a very anatomical way of doing the surgery as it is re-creating the anatomy by replacing the two ruptured bundles of the original ligament with two new bundles. The problem with that is that it is technically very difficult, and drilling two tunnels in the tibia and two tunnels in the femur is not only technically difficult but revising those patients if there is a problem can be a real challenge. there are so many problems with it that it has been pretty much abandoned and is no longer considered to be a mainstream way of doing ACL surgery.

Last April (2009) a UK surgeon, Tim Spalding, launched his ideas at BASK with an excellent presentation last April (2009) in Oxford where he demonstrated an improved method of locating the real anatomical position for a single bundle procedure – what they are calling the direct measurement technique for ACL surgery. He has now followed that up with a clinical study with high-resolution CT scanning and that article has just been submitted for publication. The new ‘buzz’ way of describing an anatomical ACL reconstruction is called ‘footprint’ ACL surgery or ‘anatomical’ ACL surgery. Tim Spalding and his group have now done a very in-depth study looking at this work over the last year and they have found a very high degree of accuracy between the direct measuring technique that they developed correlated with CT scans to show that they have had a great success in putting the ACL exactly where it should be.

I have been working on a new technique that facilitates the placing of the new ligament in this real anatomical position – doing all the work from the medial side, which is much easier than the old techniques. So you actually look from the medial side and do all the work from the lateral side with some special instruments that go around the corner into the notch and allow you to prepare the femur, mark the femur and then accept this drill bit.

I would like to show you this method which I have illustrated via live surgery in Garmisch, in Southern Germany in 2011 (location of 2011 World Ski Championships) when I was presenting my approach to the German arthroscopic association, and you will find the video below.

This is the view from the patient’s room!

Here are two photos - one showing the surgical staff preparing the patient for surgery while the other shows the recording team seeing to the video and sound equipment.

The next two photos show the surgical team in action looking up at the monitor with the arthroscope on the medial side - you can see how busy it all is with the video crew and the surgical team all in the room together!

Finally, I will show you a video of the new procedure if you click this link - http://www.youtube.com/watch?v=vKVcibPApPU.

The video highlights some new concepts –

• Surgeons are no longer going to have to look from the lateral side. With anatomical ACLR in its current form the whole procedure has to be done medially ie viewing and working through 2 small holes or "portals". This is technically difficult as the arthroscope and tools for working are in very close proximity to one another. This causes "crowding". The good thing is that this anatomical technique allows excellent visualisation by viewing from the medial as opposed to the lateral or outer side of the knee. A good analogy here is that the current technique is like putting your face against the wall and trying to identify a window or something at a distance, whereas with anatomical technique it is like walking comfortably into the middle of the room and looking face on at the wall.
• We have developed a new way of carrying out anatomical or Footprint ACLR which we have called the TransLateral technique. This has been made possible by the development of a series of new instruments that allow all viewing to be done medially (which is good!) and all work or preparation is done from the lateral side. This means that the surgeon can work effectively from both sides of the knee without crowding. This has made what is technically a very difficult operation much more straightforward and reproducible. This will be extremely good for both orthopaedic surgeons and their patients.