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