การ ทำ ACL แบบต่างๆ

ในอดีตที่ผ่านมาเรามีการทำ การ ทำ ACL แบบต่างๆผมจะ ลองเอาความรู้เก่าๆมาสอนกันนะครับเผื่อมีประโยชน์สำหรับคนอื่นๆ

เริ่มกันที่ ACL แบบแรกๆที่มีการทำกันในกลุ่ม Surgeon คือ แบบ Fix Post แบบนี้มีข้อเสียคือหากทำการมัดไม้ดีอาจทำให้ ACL ที่ทำแล้วหย่อนได้เทคนิคที่ใช้คือ ใช้ Cancellous Screw ธรรมดาข้อดีคือถูกมาก

ต่อมาเป็น การใช้  Interference Screw  

การใช้ Endobutton

อีกรายการก็เป็น กราฟสังเคราะห์

กราฟประเภทนี้้เป็นกราฟที่ไม่ได้มีความคงทนอนู่ได้ตลอดอายุชีวิตของผู้ป่วยแต่อย่างใด แต่มีอายุการใช้งานค่อนข้างที่จะจำกัดคือขึ้นอยู่กับการ Fixation ด้วยว่าดีหรือไม่หากไม่ดีก็จะไม่สามารถอยู่ได้นานเท่าไร แต่ถ้าทำดีก็จะอยู่ได้ไม่เกิน ๑๐ ปีครับ

Synthetic (Prosthetic) grafts

The appeal of using a synthetic material to replace a torn ACL is undeniable. Perhaps some day the technology will exist to allow surgeons to simply open up a package to obtain a new ACL which we can then safely implant with none of the risks or morbidity associated with other graft choices.

That artificial ACL will then perfectly mimic all the characteristics of a normal ACL in terms of strength, compliance, elasticity, and durability without any side effects. No healing period would be needed once the patient had recovered full function from the surgery itself and patients could return to sports in half the recovery time.

Unfortunately, medicine isn't there yet. Several synthetic ligaments have come and gone but none have met the qualifications needed for a lasting ACL substitute. In the last decade we saw the Gore-Tex graft which was a knitted cable with eyelets on each end. The cable was placed through drill holes similar to the current ACL reconstruction techniques and the end eyelets were then fixed to the bone outside of the tunnels with screws.

Although these grafts allowed rapid return to sports, they were too rigid and gradually began to fragment due to repeated cycling of the knee and probably some chafing at the edges of the bone tunnels. This led to particles of Gore-Tex shedding and distributing throughout the joint, even occasionally spreading into the lymphatic system. The joint became perpetually swollen and eventually most of these grafts failed and had to be removed.

Other materials have been tried such as Dacron and carbon fiber, all with similar results. More recently the Kennedy Ligament Augmentation Device (LAD) was used in an attempt to make a tissue graft more durable. This was essentially a fiber strip looking very much like a white shoelace that was inserted and fixed on top of the ACL tissue graft to further protect the reconstruction. But instead of augmenting the graft, it seems that the device only shielded the graft from normal stress loads that were needed to help the graft heal and mature correctly.

Eventually the LAD would fail because it had different stretch characteristics than the autograft, and the underlying tissue graft was then abruptly exposed to high tensile stresses to which it hadn't yet adapted. The result then was often stretching or failure of the biologic graft itself. These devices are no longer used for ACL reconstructions.

There is still much interest in synthetic grafts and research continues to try and create the perfect ACL replacement. The requirements of a prosthetic ligament are extensive though. It must be strong but have just the right stiffness to match the compliance of a normal ACL. It must have the durability to withstand high tensile loads for millions of cycles without wear. And it must be perfectly tolerable to the host without bone, joint, or systemic reaction. All in all, this is a daunting task.

Several synthetic ligaments are currently being used in Europe and time will tell if they meet these lofty goals. A newer synthetic augmentation graft, Artelon^® - a series of woven polymer fibers with similar mechanical properties to ligaments, is under study. This material is biocompatible and apparently serves as a scaffold to allow native tissue to gradually grow in over 3-4 years. It slowly weakens over time which gives the new biologic tissue a progressive load stimulus that allows it to adapt and strengthen to its ultimate maturity. There are currently, however, no prosthetic ligaments in the U.S. approved by the FDA for ACL reconstruction surgery.

Quadriceps Tendon Graft

ตัวกราฟชนิดนี้ไม่เป็นที่นิยมเนื่องจากมีขนาดใหญ่กว่าที่ต้องการและผลข้างเคียงไม่ดีนัก

Another graft option for ACL reconstruction is the quadriceps tendon. This technique has been popularized by Dr. John Fulkerson in recent years and consists of harvesting a strip of the end of the quadriceps tendon along with a block of bone off the top surface of the patella. This yields a tendon graft with bone on one end (similar to a patellar tendon graft) and soft tissue on the other.