ΑΝΑΘΕΩΡΗΣΗ ΣΥΝΔΕΣΜΟΠΛΑΣΤΙΚΗΣ ΠΡΟΣΘΙΟΥ ΧΙΑΣΤΟΥ...
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- 1. ANATOMIC APPROACH FOR REVISION ACL RECONSTRUCTIONMR ALEVROGIANNIS STAVROS, MD,PhDORTHOPAEDIC SURGEONS. CONSULTANT IN SPORTS INJURIES. ATHENS/GREECE
2. ACL EPIDEMIOLOGY Annual incidence of ~200,000 ACL ruptures per yearwith an estimated 1 in 3,000 pts, in USA 150,000 result in operations costing around two billiondollars a year Females are injured with a higher frequency than malesdue to many factors including slightly different anddisadvantageous joint anatomy, hormonal factors andless 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 inolder 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 3. INCREASE OF PRIMARY ACL RECONSTRUCTION1. increased level of sports activities2. increase of high risk associated activities (contact sports)3. increased awareness4. tendency towards operative treatment 4. FAILURE PRIMARY ACL SURGERY3-10 % fail arthritis and recurrentpain arthrofibrosis or loss ofmotion extensor mechanismdysfunction recurrent patholaxity(Johnson DL, Fu FH. Anterior cruciate ligamnetreconstruction: why do failures occur? InstrCourse Lect 1995: 44: 391-406) 5. CAUSES OF FAILURE traumatic re-injury returning to sports toosoon after surgery inappropriate oroveraggressiverehabilitation technical failures 6. TECHNICAL FAILURES ( 70% OF CASES) Improper graft placement Graft impingement due toinadequate notchplasty Improper graft tensioning Inadequate graft fixation dueto the fixation device ordeficient bone stock Use of a graft of diminishedtensile strength or size Failure to correct associatedligament instabilities 7. INDICATIONS FOR ACL-R1. Subjective feeling of instability during the normal daily and sports activities2. Functional instability with or without pain under weight bearing3. Objective anterior laxity (during the clinical examination) with positive Noulis-Lachman test and significant KT-1000 side-to-side difference 8. TYPICAL PATTERNS OF ACL GRAFT RUPTURE 9. ACL- REVISION ALGORITHM 10. TIPS & PEARLS FORACL REVISION SURGERY ACL ANATOMY CLASSIFICATION SURGICAL METHOD REMOVAL HARDWARE BONE GRAFTS GRAFT CHOICE FIXATION CHOICE DRILLING TUNNELS 11. ANATOMIC ACL-RCRITICAL QUESTIONS: WHAT IS ANATOMIC APPROACH IN ACL-R?(be familiar with anatomical landmarks andfootprints) WHY WE NEED ANATOMIC APPROACH?(24-30% re-rupture of the graft) 12. ACL ANATOMIC FOOTPRINTSFEMUR TIBIA 13. The intact AM and PL bundles of the ACL are shown in (A), and the soft tissueremnant of torn ACL on the femoral side is shown in (B). When the knee is in90 degrees of flexion, the femoral insertion sites of the AM and PL arehorizontally aligned. The white circles on the cadaveric specimen picture (A)and the arthroscopic surgery picture (B) show potential area that the femoraltunnels can be incorrectly placed when a trans-tibial approach and the clockface concept is used, which is seen in most of revision cases. Laser scan (C)and arthroscopic picture (D) show the two bony landmarks on the femoralinsertion sites of the AM and PL bundles when knee is in 90 of flexion 14. Clinical Results after S.B ACLR Greatly improved over the lastyears However, there are many issueswhich should be improved in thefuture: -the normal rate ( 2mm) is only70% -rotatory control is insufficient -normal athletic abilities are notrestored even in the normalkneeRenstrom P.ESSKA 2004) 15. A.M S.B ACLR 16. CONVENTIONAL D.B ACLR 17. ANATOMIC D.B ACLR 18. FEMORAL TUNNELS IN D.B TECHNIQUE 19. ANATOMIC APPROACH S.B TECHNIQUE -FEMORAL DRILLING 20. FEMORAL TUNNEL IN ANATOMIC S.B TECHNIQUEThe femoral tunnel is low and overlaps both the AMand PL anatomical sites 21. TIBIAL DRILLING IN ANATOMIC S.BACLR 22. ACL GRAFT LENGTH 23. 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 significancesuperior (TT technique) vsinferior (AM technique)alignment of femoral tunnelplacement- TT technique produces a moreanterior femoral tunnel and amore vertical ACL graftorientation 24. ACL SAGITTAL ANGLE ACCOUNTS FOR FEMORAL & TIBIAL INSERTIONNormal MRI Anteromedial Technique 25. MRI MEASUREMENT TECHNIQUES ACL angle- Anterior edgeof ACL- Lateral tibialplateau 26. MRI MEASUREMENT TECHNIQUESAT angle-Anterior edgeof ACL-Medial tibialplateau 27. MRI COMPARISON-RESULTSNORMALAM TECHNIQUE TT TECHNIQUE 28. ARTHOSCOPIC PORTALSLP : (lateral portal = incision towards the outside of the knee)MP :(medial portal = incision towards the inside of the knee)AMP : (accessory medial portal = incision even further on the inside of the knee) andCP :(central portal= incision towards medial one third of patellar ligament) 29. ACL-REVISION GRAFTS AUTOGRAFTS-BPTB Ipsilateral contralateral-QUADRICERS-QUADRAPLED ST (indirect fixation recommended)-DOUBLED STG ( more fixation options,internal rotation weakness) ALLOGRAFTS Achilles tendon Posterior tibialis XENOGRAFTS (new generation) JewelAcl (NeoLigaments) 30. JEWEL-ACLFeatures and benefits Is a specialized textile scaffold which isrendered versatile for ACL reconstructionby various structural features. The scaffoldis treated with a proprietary gas plasmatreatment process that increases its surfaceenergy and renders it hydrophilic The continuous tubular form can accommodate ahamstring tendon The open weave sections have appropriate spacing toencourage tissue ingrowth into the scaffold. The densely woven sections have superior handlingproperties. The JewelACL is a bio-enhanced prosthesis for the ACLreconstruction. The JewelACL can be secured to the bone with currentlyavailable fixation devices. 31. 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 fibresprovide high strength of 3000N) Implanted using standard modern ACL guide-wire systems Stiffness is matched to the semitendinosus tendon to permit loadtransfer 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. 32. ACLR (JewelAcl-X/O BUTTON) +in elite 25 y. male athlete. 33. ACLR (JewelAcl-X/O BUTTON) +CHONDROPLASTY MFC(Chondromimetic) in a non-competitive 41 y.female athlete. 34. MATERIAL (AUG. 2010- FEB.2011) 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 sport40competition3038 222010 8 2 0report activity prior to ACLre-rupture 35. CLASSIFICATION SYSTEM FOR ACL R.(H.H. Paessler et al, Wiosna 2002,48-60 New Techniques for ACL revision surgery)GRADE I :a) Narrow femoral and tibial tunnels in correct positionb) Femoral tibial tunnel far away from correct positionGRADE II: Large tibial tunnel + small femoral tunnel or previous tunnel closed by bone block of initial graftGRADE III : Large femoral + tibial tunnelGRADE IV : GRADE III+additional lesions of secondary restraints osteoarthritis PCL 36. METHOD Mean time between re-rupture of ACL graft and revision surgery 29m ( 9- 39m) All cases were type I or II according to H.H Paessler Classification system All cases performed by one senior surgeon in one stage procedure Diagnostic arthroscopy first All ACL graft remnants were removed 29 meniscal tears ( 18 part.debrided-11 repaired) 22 cartilage lesions ( 15/III,7/IV),16 debrided, 4 Chondromimetic, 2 ACT3D ( 2procedures) 52 cases using the anatomical approach, remaining 18 the modified one No notchplasty!!!! 2 had an OWHTO due to varus mal-alignment prior to ACLR (single varus) 3 had reconstruction of the posterolateral ligament structures Interference screw was not removed in misplaced femoral tunnel ST tendon ( ipsilateral or contralateral) with JewelAcl augmentation was used in allcases 3 doses of gentamycin was given i.v Prophylactic anti-coagulants for 20 d.p.o Functional brace 37. POST-OP REGIMEN Immediate knee motion and muscle-strengthening exercises on the 1st d.p.o Functional knee brace for 6 w.p.o Full R.O.M from the 1st d.p.o P.w.b from the 2nd w.p.o f.w.b 6th w.p.o Physio- protocol was modified if concomitantprocedure was performed Running program 6th m.p.o Pivoting+ contact sports 9th-12 m.p.o 38. COMPLICATIONS No major complications were found No joint effusion 2m.p.o 1 DVT, 15d.p.o was solved uneventfully 1 superficial infection ( oral antibiotics) 2 arthrofibrosis ( 1 required MUA 7w.p.o-the other arthroscopic lysis of adhesionsand scar tissue 10w.p.o) No re-re-rupture of the graft (JewelAcl?) 39. MODIFIED CINCINATTI SCORE (0-100)Excellent (>80), Good (55 to 79), Fair (30 to 54) or Poor( 85% 48. PRE-OP PIVOT SHIFT60 5250403020 1110 7 00 equal +glide ++ clunk +++ gross 49. POST-OP EVALUATION454240353025 no sport 2120 sport from time to time15 frequent sport105competition5 20no sport from competition sport frequent time to sport time 1 year follow-up sport activity 50. RESULTS KT 1000 LIGAMENT EVALUATION manual maximum and Telos45454035302520 18151055110 -3 to -1 mm-1 to 2 mm 3 to 5 mm 6 to 10 mm > 10 mm 51. RESULTS: Pivot Shiftn 80706050p = 0.00140 Preop84 Postop30%201013 30%0 A equal B glide C clunk D gross 52. RESULTSPIVOT SHIFT70 61605040302010720 0 equal +glide ++ clunk +++ gross 53. GLOBAL SCORE IKDC at F.U.5050454035 3230 24pre-op25 F-U2015 121010852 20 A B C D 54. CONCLUSIONS Surgical error is the main cause of failure of a primaryreconstruction Pre-operative planning is crucial to carefully acc