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(Παρουσίαση σε Διεθνές Συνέδριο Εταιρείας Αρθροσκόπησης & Χειρουργικής Γόνατος της Πολωνίας, POZNAN 2011). FREE HAND NOVEL ANATOMIC SINGLE BAND TECHNIQUE FOR ACLR (X/O BUTTON,CONMED,LINVATEC,USA).PRELIMINARY RESULTS. (POZNAN 2011)

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  • 1. FREE HAND NOVEL ANATOMIC SINGLE BAND TECHNIQUE FOR ACLR(X/O BUTTON,CONMED,LINVATEC,USA). PRELIMINARY RESULTS. ALEVROGIANNIS STAVROS,MD,PhD ORTHOPAEDIC SURGEON S. CONSULTANT IN SPORTS INJURIES. ATHENS/GREECE

2. 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

3. 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 ma n y 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 f ootball and basketball in younger patients- skiing in older patients-
  • Substantial anterior tibial shear forces stressACLfrom 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

4. SURGICAL TECHNIQUE PEARLS

  • ACL ANATOMY
  • SURGICAL METHOD
  • GRAFT CHOICE
  • FIXATION CHOICE
  • DRILLING TUNNELS

5. SURGICAL METHOD

  • SINGLE BAND ACLR
  • TT techniquehigh anterior femoral tunnel
  • AM technique damage to the femoral condyle with the drillbit
  • 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

6. ACL ANATOMIC FOOTPRINTS

  • FEMURTIBIA

7.

  • 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

8. 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

9. S.B ACLR 10. FEMORAL TUNNEL POSITION: AN X-RAY COMPARISON OF DRILLING THROUGH THE TIBIAL TUNNEL vs DRILLING THROUGH THE MEDIAL PORTAL Chao 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

11. ACL SAGITTAL ANGLE ACCOUNTS FOR FEMORAL & TIBIAL INSERTION

  • Normal MRIAnteromedial Technique

12. MRI MEASUREMENT TECHNIQUES

  • ACL angle
  • Anterior edge of ACL
  • Lateral tibial plateau

13. MRI MEASUREMENT TECHNIQUES AT angle -Anterior edge ofACL -Medial tibial plateau 14. MRI COMPARISON-RESULTS

  • NORMALAM TECHNIQUETT TECHNIQUE

15. Clinical Results afterS.BACL R

  • 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)

16. CONVENTIONAL D.B ACLR 17. ANATOMICAL D.B ACLR 18. FEMORAL TUNNELS IN D.B TECHNIQUE 19. ANATOMIC D.B SURGICAL TECHNIQUE 20. 21. 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 BANDDOUBLE TROUBLE?

LEADS TO 22. 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.

23. 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)

24. SURGICAL PROCEDURE-FEMUR

  • STEP 1
  • STEP 2
  • STEP 3

25. ANATOMICAL POINTS FOR FEMORAL DRILLING 26. SURGICAL PROCEDURE-FEMUR

  • STEP 4
  • STEP 5
  • STEP 6

27. 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.
  • 1590mm depth marks for easy identification of bone tunnel depth
  • Sterile, single use

28. ACL GRAFT LENGTH 29. SURGICAL PROCEDURE-FEMUR

  • STEP 7
  • STEP 8
  • STEP 9

30. FEMORAL TUNNEL IN ANATOMICAL S.B TECHNIQUE The femoral tunnel is low and overlaps both the AM and PL anatomical sites 31. SURGICAL PROCEDURE-TIBIA

  • STEP 10
  • STEP 11
  • STEP 12

32. TIBIAL DRILLING IN ANATOMIC S.B ACLR 33. SURGICAL PROCEDURE-TIBIA

  • STEP 13
  • STEP 14
  • STEP 15

34. GRAFT SPIPPAGE & FIXATION 35. 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

36. MATERIAL 37. PRE-OP IKDC PASSIVE MOTION DEFICIT 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 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)

51. 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