G.C. COARI  A. TRIPODO  THE DOUBLE BUNDLE ACL RECONSTRUCTION FROM AM PORTAL “ SAN CAMILLO” PRIVATE HOSPITAL  FORTE DEI MAR...
ARTHROSCOPIC &  PROSTHESYS SURGERY  UNIT “ SAN CAMILLO”  PRIVATE HOSPITAL FORTE DEI MARMI (LU) - TUSCANY - ITALY WWW.SANCA...
OUTCOMES OF SB ACL RECONSTRUCTION? META-ANALYSES OF SUCCESS RATES OF ACL SINGLE-BUNDLE RECON IN 90’S: 69%-95%  (YUNES, ART...
HOW COULD THE 10-30% WORSE RESULTS BE IMPROVED ? THE ANATOMICAL DB ACL RECONSTRUCTION IS  “ AN ENCHANTING HYPOTESIS ” SEAR...
WHY ACL DB RECONSTRUCTION ? <ul><li>MORE ANATOMICAL </li></ul><ul><li>BETTER BIOMECHANICS </li></ul><ul><li>BETTER OUTCOME...
PL AM PL AM ANATOMY
AM PL PL AM Yasuda, Arthroscopy 2004 OTT 7 ANATOMY THE FEMORAL ORIGIN HAS AN OVAL SHAPE WITH THE AM CLOSE TO THE OVER THE ...
ANATOMY AM PL AM PL 8 THE TIBIAL ORIGIN IS AN OVAL SHAPE WITH THE AM CLOSE TO THE ANTERIOR HORN OF THE LATERAL MENISCUS, W...
9 AM PL AM PL AM PL AM PL AM PL AM PL AM PL AM PL AM PL AM PL AM PL AM PL AM PL AM PL AM PL AM PL AM PL AM PL AM PL AM PL ...
WE MAKE ACL SURGERY IN 90°  PL BUNDLE AM BUNDLE EXTENSION FLEXION FEMORAL INSERTION ALIGNMENT CHANGES WITH KNEE FLEXION 10
SURGICAL TECHNIQUE 11
SURGICAL TECHNIQUE 12
PATIENT SETUP 90 o  flexion 120 o  flexion 70 o  flexion A RANGE OF MOTION BETWEEN FULL EXTENSION AND 120° DEGREES OF FLEX...
AM PORTAL Accessory   AM Portal AL PORTAL  SCOPE SWITCHED TO MEDIAL PORTAL
THE ACCESSORY AM PORTAL IS THEN SELECTED USING AN 18 GAUGE SPINAL NEEDLE  THE SITE  IS MEDIAL AND INFERIOR TO THE AM PORTA...
ACCESSORY A.M. PORTAL  PLACEMENT IS CRITICAL: - CORRECT DIRECTION TOWARDS THE FEMUR  SO AS TO AVOID INJURY TO THE M.F.C. S...
VISUALIZATION BY PORTAL SCOPE IN AL SCOPE IN AM
INSERTION SITE MARKING 18
PL FEMORAL TUNNEL 8 mm 5 mm LFC articular cartilage border 19 8 MM FROM THE ANTERIOR AND 5 MM FROM THE INFERIOR L.F.C. CAR...
THE PL FEMORAL TUNNEL IS DRILLED FROM THE ACCESSORY ANTEROMEDIAL PORTAL WITH A 4,5 MM ACORN DRILL.  WE MEASURE THE LENGTH ...
PL FEMORAL TUNNEL
PL TIBIAL TUNNEL AM PL THE PL TIBIAL INSERTION SITE IS LOCATED WITHIN THE TRIANGLE FORMED BY THE AM, THE PCL, AND THE POST...
55° 50° 23
AM TIBIAL TUNNEL AM PL THE ENTRY OF THE AM GUIDE WIRE IS DRILLED MORE ANTERIOR AND PROXIMAL TO THE PL WIRE, AND THERE SHOU...
70° 45° 25
2 GUIDE WIRES AM=70° ° PL=50° 26
PL DRILLING GRACILE TO P.L. (5-6 mm)
AM DRILLING ST  TO A.M. (6-7 mm)
BOTH TIBIAL TUNNELS
AM FEMORAL TUNNEL OTT PL AM
PL TT MP AM FEMORAL TUNNEL THE GUIDE WIRE MAY BE PLACED USING EITHER  A TRANS-TIBIAL OR A ACCESSORY MEDIAL PORTAL APPROACH...
AM FEMORAL TUNNEL THE TRANS-TIBIAL TECHNIQUE OFTEN MISSES THE FEMORAL ANATOMICAL INSERCTION Clancy  JBJSA 1982 Steiner AJS...
AM FEMORAL TUNNEL 7/8 mm 1/2 mm PL IS THE LANDMARK
BOTH FEMORAL TUNNELS AL PORTAL AM PORTAL
35 DRAGGING THREADS
INTRA-ARTICULAR PL BUNDLE PASSAGE
INTRA-ARTICULAR AM BUNDLE PASSAGE
BOTH BUNDLES 38
TENSIONING AND TIBIAL FIXATION LENGHT/STRAIN PATTERNS OF NORMAL AMB AND PLB P.L. BUNDLE TIGHT NEAR EXTENSION AND RELAXED D...
WE APPLY SIMULTANEOUSLY A  30-40N LOAD TO EACH BUNDLE AT 10 DEGREES OF KNEE FLEXION 40
IT’S THE RIGHT WAY TO IMPROVE OUR OUTOCOMES ? 41 WE NEED PROSPECTIVE RANDOMIZED CLINICAL STUDY BETWEEN SB AND DB TECNIQUE ...
DOUBLE BUNDLE VS SINGLE BUNDLE PROSPECTIVE CONTROLLED RANDOMIZED CLINICAL STUDY 42 AIM OF THE STUDY: TO COMPARE THE CLINIC...
60 PATIENTS (2009 SEPT - UP TO NOW) 20 SB ANATHOMICAL WITH INDIPENDENT TUNNELS 20 DB 20 SB TRANSTIBIAL <ul><li>NO ASSOCIAT...
PATIENTS EVALUATION <ul><li>3 Months:  6 Months:  KT-2000  +  IKDC +   LYSHOLM  12 and 24 Months:  MRI  KT-2000  +  IKDC +...
UP TO NOW ONLY 40% OF PATIENTS HAVE REACHED A 6 MONTHS FOLLOW-UP 45 WE STILL HAVE TO WAIT TO GET COMPLETE OUTCOMES
OUT-IN TECNIQUE
THANK YOU [email_address]
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Coari tripodo db esska oslo 2010

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  • Up to now we’ve been performing ACL reconstruction using SB surgery. .....showed us a high rate of success ranging from 70 to 95 %.... in the remaning percentage a persist........has been observed In long term f-up patients had degenr.......... and only the 47% of.......
  • WITH DB MORE.....WE’VE BEEN REGISTERING BETTER OUTCOMES STILL WAITING FOR CONFIRMATION IN THE LONG RUN
  • CHANGES ACCORDING TO EX....WHERE THE DB ARE VERTICAL AND FLEX.....WHERE THEY ARE ORIZZ....
  • the table is in its full length/we use the whole table BUT EVEN if you use the hanging table
  • THE ANTEROLATERAL AND ANTEROMEDIAL PORTALS ARE ESTABLISHED ADIACENT TO THE LATERAL AND MEDIAL PATELLAR TENDON BORDERS AT THE LEVEL OF THE INFERIOR POLE OF THE PATELLA.
  • IF WE COMPARE THE VIEWS WITH AL AND AM SCOPE WE CAN SEE THAT IN THE LATTER ONE WE GET A BETTER VIEW OF THE CFL
  • WE NOW MARK THE ENTRY AND EXIT POINTS OF THE ORIGINAL ACL ON FEMUR AND TIBIA
  • Coari tripodo db esska oslo 2010

    1. 1. G.C. COARI A. TRIPODO THE DOUBLE BUNDLE ACL RECONSTRUCTION FROM AM PORTAL “ SAN CAMILLO” PRIVATE HOSPITAL FORTE DEI MARMI (LUCCA) - ITALY
    2. 2. ARTHROSCOPIC & PROSTHESYS SURGERY UNIT “ SAN CAMILLO” PRIVATE HOSPITAL FORTE DEI MARMI (LU) - TUSCANY - ITALY WWW.SANCAMILLOFORTE.IT ORTOPEDIA@SANCAMILLO.NET 2 CHIEFS: G.C. COARI - A. MONTANO ORTHOPEDIC STAFF: A. TRIPODO - P. RIGHI F. MIELE - F. TROIANI S. CAPPATO - A. DAGNINO A. PERA - A. BIAGI
    3. 3. OUTCOMES OF SB ACL RECONSTRUCTION? META-ANALYSES OF SUCCESS RATES OF ACL SINGLE-BUNDLE RECON IN 90’S: 69%-95% (YUNES, ARTHROSCOPY 2001, FREEDMAN AJSM 2003) PERSISTENT ROTATIONAL INSTABILITY AT THE FUNCTIONAL TESTS 3 <ul><li>DEGENERATIVE RADIOGRAPHIC CHANGES IN 90% OF PATIENTS 7 YEARS AFTER ACL SINGLE-BUNDLE RECONSTRUCTION </li></ul><ul><li>47% OF PATIENTS RETURNED TO PREVIOUS ACTIVITY LEVEL </li></ul>17%-18% PIVOT SHIFT GLIDE WITH BTB AND HS Aglietti et al. Isakos 2003
    4. 4. HOW COULD THE 10-30% WORSE RESULTS BE IMPROVED ? THE ANATOMICAL DB ACL RECONSTRUCTION IS “ AN ENCHANTING HYPOTESIS ” SEARCHING TO RECREATE THE COMPLEX ACL ANATOMY AND FUNCTION
    5. 5. WHY ACL DB RECONSTRUCTION ? <ul><li>MORE ANATOMICAL </li></ul><ul><li>BETTER BIOMECHANICS </li></ul><ul><li>BETTER OUTCOMES ? </li></ul>
    6. 6. PL AM PL AM ANATOMY
    7. 7. AM PL PL AM Yasuda, Arthroscopy 2004 OTT 7 ANATOMY THE FEMORAL ORIGIN HAS AN OVAL SHAPE WITH THE AM CLOSE TO THE OVER THE TOP POSITION AND THE PL 10mm MORE DISTAL, CLOSE TO THE ANTERIOR (8mm) AND INFERIOR (5mm) CARTILAGE BORDER
    8. 8. ANATOMY AM PL AM PL 8 THE TIBIAL ORIGIN IS AN OVAL SHAPE WITH THE AM CLOSE TO THE ANTERIOR HORN OF THE LATERAL MENISCUS, WHILE THE PL IS BETWEEN THE TWO TIBIAL SPINES, ABOUT 8mm POSTERIOR AND LATERAL FROM THE AM BUNDLE
    9. 9. 9 AM PL AM PL AM PL AM PL AM PL AM PL AM PL AM PL AM PL AM PL AM PL AM PL AM PL AM PL AM PL AM PL AM PL AM PL AM PL AM PL AM PL Giron, Arthroscopy, 2007 21 NORMALIZED: HIGH VARIETY IN SHAPE AND SIZE
    10. 10. WE MAKE ACL SURGERY IN 90° PL BUNDLE AM BUNDLE EXTENSION FLEXION FEMORAL INSERTION ALIGNMENT CHANGES WITH KNEE FLEXION 10
    11. 11. SURGICAL TECHNIQUE 11
    12. 12. SURGICAL TECHNIQUE 12
    13. 13. PATIENT SETUP 90 o flexion 120 o flexion 70 o flexion A RANGE OF MOTION BETWEEN FULL EXTENSION AND 120° DEGREES OF FLEXION INTRA-OPERATIVELY IS ESSENTIAL
    14. 14. AM PORTAL Accessory AM Portal AL PORTAL SCOPE SWITCHED TO MEDIAL PORTAL
    15. 15. THE ACCESSORY AM PORTAL IS THEN SELECTED USING AN 18 GAUGE SPINAL NEEDLE THE SITE IS MEDIAL AND INFERIOR TO THE AM PORTAL Accessory AM Portal
    16. 16. ACCESSORY A.M. PORTAL PLACEMENT IS CRITICAL: - CORRECT DIRECTION TOWARDS THE FEMUR SO AS TO AVOID INJURY TO THE M.F.C. SURFACE AND M.M.
    17. 17. VISUALIZATION BY PORTAL SCOPE IN AL SCOPE IN AM
    18. 18. INSERTION SITE MARKING 18
    19. 19. PL FEMORAL TUNNEL 8 mm 5 mm LFC articular cartilage border 19 8 MM FROM THE ANTERIOR AND 5 MM FROM THE INFERIOR L.F.C. CARTILAGE THE KNEE IS FLEXED TO 120° TO AVOID THE PERONEAL NERVE AND TO ENSURE ADEQUATE TUNNEL LENGTH
    20. 20. THE PL FEMORAL TUNNEL IS DRILLED FROM THE ACCESSORY ANTEROMEDIAL PORTAL WITH A 4,5 MM ACORN DRILL. WE MEASURE THE LENGTH AND THEN CHOOSE A FIXATION (EB FAMILY) 20
    21. 21. PL FEMORAL TUNNEL
    22. 22. PL TIBIAL TUNNEL AM PL THE PL TIBIAL INSERTION SITE IS LOCATED WITHIN THE TRIANGLE FORMED BY THE AM, THE PCL, AND THE POSTERIOR ROOT OF THE LATERAL MENISCUS
    23. 23. 55° 50° 23
    24. 24. AM TIBIAL TUNNEL AM PL THE ENTRY OF THE AM GUIDE WIRE IS DRILLED MORE ANTERIOR AND PROXIMAL TO THE PL WIRE, AND THERE SHOULD BE A BONE BRIDGE OF AT LEAST 1 CM BETWEEN THE TWO TUNNELS
    25. 25. 70° 45° 25
    26. 26. 2 GUIDE WIRES AM=70° ° PL=50° 26
    27. 27. PL DRILLING GRACILE TO P.L. (5-6 mm)
    28. 28. AM DRILLING ST TO A.M. (6-7 mm)
    29. 29. BOTH TIBIAL TUNNELS
    30. 30. AM FEMORAL TUNNEL OTT PL AM
    31. 31. PL TT MP AM FEMORAL TUNNEL THE GUIDE WIRE MAY BE PLACED USING EITHER A TRANS-TIBIAL OR A ACCESSORY MEDIAL PORTAL APPROACH TRANS-TIB VS. MED PORTAL
    32. 32. AM FEMORAL TUNNEL THE TRANS-TIBIAL TECHNIQUE OFTEN MISSES THE FEMORAL ANATOMICAL INSERCTION Clancy JBJSA 1982 Steiner AJSM 2008 Woo JBJSA 2002 Yamamoto AJSM 2004
    33. 33. AM FEMORAL TUNNEL 7/8 mm 1/2 mm PL IS THE LANDMARK
    34. 34. BOTH FEMORAL TUNNELS AL PORTAL AM PORTAL
    35. 35. 35 DRAGGING THREADS
    36. 36. INTRA-ARTICULAR PL BUNDLE PASSAGE
    37. 37. INTRA-ARTICULAR AM BUNDLE PASSAGE
    38. 38. BOTH BUNDLES 38
    39. 39. TENSIONING AND TIBIAL FIXATION LENGHT/STRAIN PATTERNS OF NORMAL AMB AND PLB P.L. BUNDLE TIGHT NEAR EXTENSION AND RELAXED DURING FLEXION A.M. BUNDLE TIGHT NEAR EXTENSION, MOST RELAXED AT 30°- 60° AND TIGHT AGAIN OVER 90° ONLY NEAR EXTENSION WE GET EQUAL STRAIN OF THE TWO BUNDLES Yasuda ISAKOS 2005
    40. 40. WE APPLY SIMULTANEOUSLY A 30-40N LOAD TO EACH BUNDLE AT 10 DEGREES OF KNEE FLEXION 40
    41. 41. IT’S THE RIGHT WAY TO IMPROVE OUR OUTOCOMES ? 41 WE NEED PROSPECTIVE RANDOMIZED CLINICAL STUDY BETWEEN SB AND DB TECNIQUE WITH 10 YS FOLLOW-UP MINIMUN
    42. 42. DOUBLE BUNDLE VS SINGLE BUNDLE PROSPECTIVE CONTROLLED RANDOMIZED CLINICAL STUDY 42 AIM OF THE STUDY: TO COMPARE THE CLINICAL OUTCOMES OF PATIENTS TREATED EITHER WITH AN ANATOMICAL SB (AM PORTAL), WITH TRANSTIBIAL SB (HOWELL) AND WITH A DB (AM PORTAL) TECHNIQUE
    43. 43. 60 PATIENTS (2009 SEPT - UP TO NOW) 20 SB ANATHOMICAL WITH INDIPENDENT TUNNELS 20 DB 20 SB TRANSTIBIAL <ul><li>NO ASSOCIATED LESIONS </li></ul><ul><li>NO MALALIGNEMENT </li></ul>INCLUSION CRITERIA:
    44. 44. PATIENTS EVALUATION <ul><li>3 Months: 6 Months: KT-2000 + IKDC + LYSHOLM 12 and 24 Months: MRI KT-2000 + IKDC + LYSHOLM </li></ul>
    45. 45. UP TO NOW ONLY 40% OF PATIENTS HAVE REACHED A 6 MONTHS FOLLOW-UP 45 WE STILL HAVE TO WAIT TO GET COMPLETE OUTCOMES
    46. 46. OUT-IN TECNIQUE
    47. 47. THANK YOU [email_address]

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