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Many anterior cruciate ligament ruptures are treated by reconstruction of the ligament usually using one of the patients own tendons. The most common procedures performed currently are the bone patellar tendon bone graft and the hamstring graft. In the former, a small fragment of the distal pole of the patella attached to the central third of the patellar tendon and a portion of bone of the tibial tuberosity is harvested and transferred to replace the torn anterior cruciate ligament. In the hamstring graft, a length of hamstring tendon is harvested and folded into a double or more commonly four stranded graft. The procedure itself involves the drilling of tunnels through the proximal tibia and distal femur, threading the graft and attaching it proximally and distally by one of a number of methods. The most common method employed is to use so called retention screws which compress the end of the ligament or bone against the side wall of the drilled tunnel hoping that healing will result in a firm attachment proximally and distally. In some instances, a clip is used to secure the proximal (femoral) end rather than a retention screw. The procedure is carried out in patients with unstable anterior cruciate ligament rupture in the hope to prevent the onset of secondary meniscal or cartilage injury. Immediate post operative complications include fracture and infection but it is the more long term sequelae that imaging is more commonly used to assess. The assessment of the patient with anterior cruciate ligament reconstruction involves a review of: Isomerism Integrity Impingement
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The position of the graft tunnels is important to ensure that the graft functions as the native ligament. Reproducing the complex function of the native graft is difficult particularly as the two separate bundles (the anteromedial and the posterolateral) are at different tensions throughout the range of flexion and extension. In order to reproduce this function as closely as possible, the position of the tibial and femoral tunnels is crucial. Typically the graft is placed using a carefully designed jig which is attached to the knee and the incidence of misplacement of the tunnels is reduced. The position of the tibial tunnels can be assessed on both plain radiography and MRI. Typically the distal end of the femoral tunnel lies at the superior extent of Blumensaat’s line on the lateral view. The tibial tunnel should emerge into the joint in the central third of the tibia also on the lateral view A too anterior position of the tibial tunnel will force the graft to impinge against the intercondylar roof and as a consequence repetitive flexion and extension may lead to rupture.
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