Post on 02-Nov-2014
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FREE HAND NOVEL ANATOMIC SINGLE BAND TECHNIQUE FOR ACLR
(X/O BUTTON,CONMED,LINVATEC,USA).PRELIMINARY RESULTS.
ALEVROGIANNIS STAVROS,MD,PhDORTHOPAEDIC SURGEON
S. CONSULTANT IN SPORTS INJURIES.ATHENS/GREECE
Rationale
• ACL anatomy • PL Bundle function - ATT control at 20° of flexion • Clinical results • One bundle reconstruction = AM reconstruction • Residual pivot shift (>grade B) > 15% • How to control the rotational stability ? - Lateral tenodesis - Two-bundle reconstruction
ACL EPIDEMIOLOGY
• Annual incidence of ~200,000 ACL ruptures per year with an estimated 1 in 3,000 pts, in USA • 150,000 result in operations costing around two billion dollars a year• Females are injured with a higher frequency than males due to many factors including slightly different and disadvantageous joint anatomy, hormonal factors and less muscle mass• Incidence highest in population aged 15-45 years old with 1 in 1750 persons
(Brown, 2004)• Most common injury in football and basketball in younger patients- skiing in
older patients- • Substantial anterior tibial shear forces stress ACL from quads contraction(esp.
0 – 30 degrees contraction) (Sakane, ‘97) • Typically torn in non-contact deceleration results in valgus twisting injury• Athlete lands on legand pivots in opposite direction • Average return to full activity is ~ 6 to 8 months
SURGICAL TECHNIQUE PEARLS
• ACL ANATOMY
• SURGICAL METHOD
• GRAFT CHOICE
• FIXATION CHOICE
• DRILLING TUNNELS
SURGICAL METHOD
• SINGLE BAND ACLR TT technique high anterior femoral tunnel AM technique damage to the femoral condyle with the drill bit cutting the anterior horn of the medial meniscus incorrect placement of the femoral tunnel due to loss of orientation with hyperflexion
• CONVENTIONAL DOUBLE BAND ACLR
• ANATOMIC DOUBLE BAND ACLR
• ANATOMIC SINGLE BAND ACLR
ACL ANATOMIC FOOTPRINTS
FEMUR TIBIA
The intact AM and PL bundles of the ACL are shown in (A), and the soft tissue remnant of torn ACL on the femoral side is shown in (B). When the knee is in 90 degrees of flexion, the femoral insertion sites of the AM and PL are horizontally aligned. The white circles on the cadaveric specimen picture (A) and the arthroscopic surgery picture (B) show potential area that the femoral tunnels can be incorrectly placed when a trans-tibial approach and the clock face concept is used, which is seen in most of our revision cases. Laser scan (C) and arthroscopic picture (D) show the two bony landmarks on the femoral insertion sites of the AM and PL bundles when knee is in 90° of flexion
Why an anatomic ACLR?
• Every person is different; some people are short, others are tall. Similarly, each person has a different size and shape of the ACL. In order to properly reconstruct the ACL it is important to reproduce each persons individual anatomy.
• The goals of anatomic ACL reconstruction are to:– Restore 80-90% of normal ACL
anatomy – Regain stability and return to pre-
injury activity level– Maintain long term knee health
S.B ACLR
FEMORAL TUNNEL POSITION: AN X-RAY COMPARISON OF DRILLING THROUGH THE TIBIAL TUNNEL vs DRILLING
THROUGH THE MEDIAL PORTALChao D,Pallia C,Young S et al
• 40 ACL recon pts• Results- Statistical significance
superior (TT technique)vs inferior (AM technique) alignment of femoral tunnel placement
- TT technique produces a more anterior femoral tunnel and a more vertical ACL graft orientation
ACL SAGITTAL ANGLE ACCOUNTS FOR FEMORAL & TIBIAL INSERTION
Normal MRI Anteromedial Technique
MRI MEASUREMENT TECHNIQUES
• ACL angle
- Anterior edge of ACL
- Lateral tibial plateau
MRI MEASUREMENT TECHNIQUES
AT angle
-Anterior edge of ACL-Medial tibial plateau
MRI COMPARISON-RESULTS
NORMAL AM TECHNIQUE TT TECHNIQUE
Clinical Results after S.B ACLR
• Greatly improved over the last years
• However, there are many issues which should be improved in the future:
-the normal rate ( 2mm) is only 70%
-rotatory control is insufficient -normal athletic abilities are not
restored even in the “normal” knee
Renstrom P.ESSKA 2004)
CONVENTIONAL D.B ACLR
ANATOMICAL D.B ACLR
FEMORAL TUNNELS IN D.B TECHNIQUE
ANATOMIC D.B SURGICAL TECHNIQUE
CONCLUSIONS FOR D.B ACLR
• The two bundle reconstruction is an effective procedure to reconstruct the ACL
• Needs more than 14mm native ACL tibial width • More rotational stability in almost all clinical papers
in the literature• Time consuming surgical technique• Long learning curve• Difficulty in revision cases
DOUBLE BAND DOUBLE TROUBLE?
ANATOMIC SINGLE BAND ACLR
MAJOR INDICATIONS:• The patient has a very small native ACL size, usually
less than 14 mm. This can be estimated on MRI, but can only be confirmed at the time of surgery.
• The patient is still growing and his or her growth plate is not closed.
• The patient has severe arthritis of the knee. • The patient has multiple knee ligament injuries or a
knee dislocation and multiple other ligaments need to be reconstructed at the same time.
• The patient has bone that is severely bruised. • The patient has a small “notch”.
ARTHOSCOPIC PORTALS
LP (lateral portal = incision towards the outside of the knee) MP (medial portal = incision towards the inside of the knee) and AMP (accessory medial portal = incision even further on the inside of the knee)
SURGICAL PROCEDURE-FEMUR
STEP 1
STEP 2
STEP 3
ANATOMICAL POINTS FOR FEMORAL DRILLING
SURGICAL PROCEDURE-FEMUR
STEP 4
STEP 5
STEP 6
SENTINEL: Eccentric mono-fluted Drill-Bit
• Rounded side designed to protect cartilage and soft tissue prior to drilling
• This unique drill bit features an eccentric mono-fluted cutting edge for drilling bone tunnels in ACL and PCL reconstruction procedures.
• Cannulated for use with a 2.4mm High Strength Guide Pin.
• Eccentric mono-fluted cutting edge. • 15–90mm depth marks for easy
identification of bone tunnel depth • Sterile, single use
ACL GRAFT LENGTH
SURGICAL PROCEDURE-FEMUR
STEP 7
STEP 8
STEP 9
FEMORAL TUNNEL IN ANATOMICAL S.B TECHNIQUE
The femoral tunnel is low and overlaps both the AM and PL anatomical sites
SURGICAL PROCEDURE-TIBIA
STEP 10
STEP 11
STEP 12
TIBIAL DRILLING IN ANATOMIC S.B ACLR
SURGICAL PROCEDURE-TIBIA
STEP 13 STEP 14
STEP 15
GRAFT SPIPPAGE & FIXATION
Postoperative regime
• Splint in full extension
• Priority to full extension recovery
• Partial weight bearing 6 weeks
• Closed kinetic chain during 4 months
• Non pivot training at 3 months
• Pivot activities at 6 months
MATERIAL
8
38
22
20
10
20
30
40
report activity prior to ACL tear
PRE-OP EVALUATION• Sex ratio : 48 males, 22 females
• Side : 41 left, 29 right Mean age : 29 years (range 16-48)
no sportsport from time to timefrequent sportcompetition
PRE-OP IKDC PASSIVE MOTION DEFICIT
91
6,62,4 0
0
20
40
60
80
100
A B C D
Lack of extension
PRE-OP IKDC SCORE (%) PASSIVE MOTION DEFICIT
88,6
6,82,2 2,4
0
10
20
30
40
50
60
70
80
90
A B C D
Lack of flexion
PRE-OP IKDC SCORE (%) PASSIVE MOTION DEFICIT
3,411,1 14,4
71,1
01020304050607080
A B C D
C + D > 85%
PRE-OP IKDC SCORE (%)KT 1000 LAXITY
0
11
52
7
0
10
20
30
40
50
60
equal +glide ++ clunk +++ gross
PRE-OP PIVOT SHIFT
212 14,4
71,6
01020304050607080
A B C D
C + D = 86%
GLOBAL IKDC PRE-OP SCORE (%)
2
21
42
5
0
5
10
15
20
25
30
35
40
45
no sportsport fromtime totime
frequentsport
competition
1 year follow-up sport activity
POST-OP EVALUATION
no sport
sport from time to time
frequent sport
competition
68
2 0 00
10
2030
4050
60
70
A B C D
Lack of extension
RESULTS •70 patients, 1 year follow-up
•Passive motion deficit
65
3 2 00
10
20
30
40
50
60
70
A B C D
Lack of flexion
RESULTS •70 patients, 1 year follow-up
•Passive motion deficit
1
45
18
51
0
5
10
15
20
25
30
35
40
45
-3 to -1 mm -1 to 2 mm 3 to 5 mm 6 to 10 mm > 10 mm
RESULTS KT 1000 LIGAMENT EVALUATION
manual maximum and Telos
84%
13%
3 0
0
10
20
30
40
50
60
70
80n
A equal B glide C clunk D gross
p = 0.001
RESULTS: Pivot Shift
Preop
Postop
61
72 00
10
20
30
40
50
60
70
equal +glide ++ clunk +++ gross
RESULTS
PIVOT SHIFT
2
41
12
38
14,420
71,6
10
10
20
30
40
50
60
70
80
P = 0.003A
A B C D
A + B = 79%
RESULTS: GLOBAL IKDC SCORE (%) Subjective score IKDC: 92 ±4.6 (75-100)
(Pre-op : 60,3)
Pre-op
Post-op
2,2
32,7
41,3
47,843,5
13 13
6,5
0
5
10
15
20
25
30
35
40
45
50
A B C D
SCORE IKDC GLOBAL POST OP %
pré-op
post-op
76
13
1 00
10
20
30
40
50
60
70
80
A none B mild C moderate D severe
RESULTS : harvest site pathology
2
32
8
24
1012
50
2
0
5
10
15
20
25
30
35
40
45
50
A B C D
GLOBAL SCORE IKDC at F.U.
pre-op
F-U
ACLR GRAFTS
• AUTOGRAFTS-BPTB Ipsilateral contralateral-QUADRICERS-QUADRAPLED ST (indirect fixation recom.)-DOUBLED STG (more fixation options, internal
rotation weakness)• ALLOGRAFTS Achilles tendon Posterior tibialis• XENOGRAFTS (new generation) JewelAcl (NeoLigaments)
DO WE REALLY NEED BOTH ST & G FOR ACLR
– Segawa H., Omori G., Koga Y., Kameo T., Iida S., Tanaka M.• Rotational muscle strength of the limb after ACL
reconstruction using Semitendinosus and gracilis tendon. Arthroscopy 18,(2) 177-182. 2002
– Armour T, Forwell L., Kirkley A, Litchfield R, Fowler P.• Isokinetic evaluation of internal / external tibial rotation
strength following the use of hamstring tendons for ACL reconstruction. ISAKOS 2003
– Ohkoshi Y.,Inoue C.,Yamane S. Hashimoto T.,Ishida R.• Changes in muscle strength properties caused by harvesting
of autogenous semitendinosus tendon for reconstruction of contralateral ACL Arthroscopy 14,(6) 1998 580-584
– Gobbi A., Domzalski M., Pascual J., Zanazzo M.• Hamstring ACL Reconstruction.Is it Necessary to Sacrifice
the Gracilis? Arthroscopy 2004
JEWEL-ACLFeatures and benefits
• Is a specialized textile scaffold which is rendered versatile for ACL reconstruction by various structural features. The scaffold is treated with a proprietary gas plasma treatment process that increases its surface energy and renders it hydrophilic • The continuous tubular form can accommodate a
hamstring tendon• The open weave sections have appropriate spacing to
encourage tissue ingrowth into the scaffold. • The densely woven sections have superior handling
properties. • The JewelACL is a bio-enhanced prosthesis for the ACL
reconstruction. • The JewelACL can be secured to the bone with currently
available fixation devices.
BENEFITS
• Can be implanted as a total tissue sparing device, or with a single hamstring tendon • Manufactured from Polyethylene Terephthalate (polyester) • Allows early rehabilitation (parallel longitudinal polyester fibres
provide high strength of 3000N) • Implanted using standard modern ACL guidewire systems • Stiffness is matched to the semitendinosus tendon to permit load
transfer and encourage cell growth due to plasma-spray.
more than four times as many cells were found on the plasma-treated ligament surfaces after 14 days’ incubation compared to non plasma-treated polyester surfaces.
BENEFITS
TENSILE LOAD OF HUMAN ACL
• Intact ACL: 2160±154
• Bone-patellar tendon-bone: 2376 ±151
• Single-strand semitendinosus: 1216±50
• Quadrupled hamstring: 4108±200
• Quadriceps tendon (10mm) : 2352±495
FASTLOK
• Is recommended for secure fatigue resistant fixation of JewelAcl directly to bone
• Consists of a titanium alloy staple and buckle providing a unique triple clamping action to minimize slippage under repeated loading
• Staples firmly gripped by impactor so easy to use for insertion and removal from bone
• Designed for easy application through small incisions
• Sliding hammer attaches to
impactor to help remove staples
ACLR (JewelAcl-X/O BUTTON) +in elite 25 y. male athlete.
ACLR (JewelAcl-X/O BUTTON) +CHONDROPLASTY MFC(Chondromimetic) in a
non-competitive 41 y.female athlete.
LIMITATIONS OF ANATOMIC S.B ACLR
• Anatomic free hand single-bundle ACLR has some limitations when compared to anatomic double-bundle reconstruction. – It cannot recreate the two functional bundles (AM
and PL) of the ACL. – It can cover less of the size of the normal ACL,
typically 65-85% of the ACL insertion site recreated, vs. 80-90% in double-bundle reconstruction.
– Prospective, randomized trial and long term f.up needed
CONCLUSIONS FOR ANATOMIC S.B ACLR
• Lower pivot shift rate in comparison with S.B ACLR, almost similar to anatomic D.B
• Very short lurning curve• Not time consuming technique• Can be executed with new generation of
xenografts for more aggressive rehab protocol.
• Need controlled prospective randomized trial studies and long term f.up