Anterior Cruciate reconstruction: TLS technique (FH Orthopaedics)
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ACL injuries are a common injury, often associated with meniscal or other ligament injuries. Chondral injuries are less common, but left untreated ACL deficient knees will acquire meniscal or chondral injuries at a rate of 0.6 – 1% per month (Brambilla et al 2015). The chondral injuries are thought to occur as secondary damage when the knee has episodes of instability. Thus by 4 years (a 48% chance) approaching a one in two chance of meniscal or chondral injury which is known have significant long-term degenerative consequences on the knee.
The decision on whether to reconstruct an ACL rupture needs to be tailored to the patient, based on their future planned activity and their age (and thus their risk of subsequent secondary injury) or resultant instability after a trial of non-operative management. In relatively sedentary and/or older patients non-operative management may be appropriate if stability can be achieved.
In younger, more active patients or with ongoing instability Anterior Cruciate Ligament Reconstruction (ACLR) may be necessary. This is described in the Panther group (an expert consensus symposium) output statement in 2020 by Diermeier et al: in young patients wanting to return to direction change activity then early ACLR reconstruction is advised, whereas those patients with no direction change may be treated non-operatively. If there is subjective instability after non-operative maximisation then ACLR is also indicated.
The tape locking screw (TLS) system demonstrated in this technique was developed in 2003 by FH Orthopaedics and over 100,000 cases having been performed. It is based on three principles:
- one hamstring tendon only is harvested, prepared into a short 50-60mm, 4 to 5 strand closed loop, with a diameter of 8 to 10mm and a 500N pre-load applied
- short tunnels, 10 or 15mm, are created in a retrograde manner to match the diameter of each end of the graft (press-fit)
- femoral and tibial fixation is provided by polyethylene terephthalate tape strips that pass through each end of the closed tendon loop and attach to bone with a dedicated interference screw.
The TLS system demonstrated here is one of many that have been proven to work well.
The technique concentrates on the unique steps for the TLS and this should be read in conjunction with the other ACL reconstruction techniques on the Orthoracle platform:
ACL reconstruction with 6 strand hamstring allograft and Smith and Nephew Endobutton and RCI screw
Patella tendon harvest for ACL reconstruction
Anatomic ACL reconstruction using hamstring tendons ( Linvatec graft tensioner)
Anterior cruciate ligament reconstruction using a double-stranded hamstring graft
Arthroscopic medial menisectomy and chondroplasy of knee
Knee arthroscopy and partial medial menisectomy
(With thanks to Jonathan Miles FRCS (Tr & Orth) whose case is demonstrated in this Instructional technique).
Author: James Donaldson FRCS (Tr & Orth)
Institution: The Royal National Orthopaedic Hospital, Stanmore, London, UK.
Clinicians should seek clarification on whether any implant demonstrated is licensed for use in their own country.
In the USA contact: fda.gov
In the UK contact: gov.uk
In the EU contact: ema.europa.eu