MacIntosh Procedure




- lateral border femur

- 15 cm proximal to knee joint

- curve anteriorly across patella tendon


Harvest ITB

- expose ITB

- width and length depend on patient size

- usually central 3 cm

- take 25 - 30 cm in length

- tubularise end and leave threads long to pass tendon


Lateral dissection

- expose and elevate LCL

BPTB Allograft

Graft Preparation


BPTB Allograft Initial



- in 2 litres normal saline

- can add vancomycin powder


Choose which part of graft to use

- usually central third

- can take either side

- try to leave sufficient graft in case of disasters

- i.e. dropping or rupturing graft



IncidenceRevision ACL Ruptured Graft MRI BPTB Allograft


Up to 8% patients with ACL reconstruction will have recurrent instability and graft failure

- increased with surgical inexperience


Graft can


1.  Be inadequate from the start

- inadequate tension

- poor tunnel placement



Concept Accelerated Rehabilitation


Shelbourne 1995

- noticed patients noncompliant with their rehab protocol were doing much better

- looked at what noncompliant patients were doing

- what they were doing was advancing activities as tolerated


Reviewed results of accelerated rehabilitation

- fewer ruptures with better ROM


Major recommendations


Management Options



Natural History of ACL deficient knee is variable

- functional instability 15% - 90%

- progression to OA is variable


Depends on level of patient demands / activity


1.  Late meniscal injury in ACL deficient knee




2.  Function


Daniels Am J Sports Med 1994

- 292 ACL defecients knees



ACL Normal ArthroscopyACL Normal Arthroscopy




Developmental Anatomy


Knee joint first appears as a mesenchymal cleft at 8 weeks gestation

- ACL and PCL separate entities by week 10