ΑΝΑΘΕΩΡΗΣΗ ΣΥΝΔΕΣΜΟΠΛΑΣΤΙΚΗΣ ΠΡΟΣΘΙΟΥ ΧΙΑΣΤΟΥ ΣΥΝΔΕΣΜΟΥ ΓΟΝΑΤΟΣ ΜΕ ΑΝΑΤΟΜΙΚΗ ΤΕΧΝΙΚΗ
ANATOMIC APPROACH FOR REVISION ACL RECONSTRUCTION MR ALEVROGIANNIS STAVROS, MD,PhD ORTHOPAEDIC SURGEON S. CONSULTANT IN SPORTS INJURIES. ATHENS/GREECE
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
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
FAILURE PRIMARY ACL SURGERY3-10 % fail• arthritis and recurrent pain• arthrofibrosis or loss of motion• extensor mechanism dysfunction• recurrent patholaxity(Johnson DL, Fu FH. Anterior cruciate ligamnet reconstruction: why do failures occur? Instr Course Lect 1995: 44: 391-406)
CAUSES OF FAILURE• traumatic re-injury• returning to sports too soon after surgery• inappropriate or overaggressive rehabilitation• technical failures
TECHNICAL FAILURES ( 70% OF CASES)• Improper graft placement• Graft impingement due to inadequate notchplasty• Improper graft tensioning• Inadequate graft fixation due to the fixation device or deficient bone stock• Use of a graft of diminished tensile strength or size• Failure to correct associated ligament instabilities
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
• 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 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
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)
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
MRI COMPARISON-RESULTSNORMAL AM TECHNIQUE TT TECHNIQUE
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)
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)
JEWEL-ACL Features 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 guide-wire 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.
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.
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 sport sport from time to time frequent sport40 competition30 38 222010 8 2 0report activity prior to ACL re-rupture
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 position• GRADE II: Large tibial tunnel + small femoral tunnel or previous tunnel closed by bone block of initial graft• GRADE III : Large femoral + tibial tunnel• GRADE IV : GRADE III+additional lesions of secondary restraints osteoarthritis PCL
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 ( 2 procedures)• 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 all cases• 3 doses of gentamycin was given i.v• Prophylactic anti-coagulants for 20 d.p.o• Functional brace
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 concomitant procedure was performed• Running program 6th m.p.o• Pivoting+ contact sports 9th-12 m.p.o
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 adhesions and scar tissue 10w.p.o)• No re-re-rupture of the graft (JewelAcl?)
MODIFIED CINCINATTI SCORE (0-100) Excellent (>80), Good (55 to 79), Fair (30 to 54) or Poor(<30)Pain 80Swelling 70Giving way 60 68,2 72,5Overall activity level 50 PRE.OPWalking 40 6M.P.O 41,5Stairs 30 1Y.P.ORunning activity 20 10Jumping or twisting activities 0
POST-OP EVALUATION45 4240353025 no sport 2120 sport from time to time15 frequent sport10 5 competition5 20 no sport from competition sport frequent time to sport time 1 year follow-up sport activity
RESULTS KT 1000 LIGAMENT EVALUATION manual maximum and Telos45 454035302520 1815105 5 1 10 -3 to -1 mm -1 to 2 mm 3 to 5 mm 6 to 10 mm > 10 mm
RESULTS: Pivot Shift n 80 70 60 50p = 0.001 40 Preop 84 Postop 30 % 20 10 13 3 0 % 0 A equal B glide C clunk D gross
GLOBAL SCORE IKDC at F.U. 5050454035 3230 24 pre-op25 F-U2015 12 1010 85 2 20 A B C D
CONCLUSIONS• Surgical error is the main cause of failure of a primary reconstruction• Pre-operative planning is crucial to carefully access the factors that may have been related to the prior failure• Revision ACL surgery is technically demanding- requires theoretical and clinical experience• Anatomic approach for revision ACL is a very attractive surgical method• No re-failure of the graft yet! (24-30% in the literature)• Primary results of ACL-R graft augmentation with JewelAcl, seems to be more than encouraging• Further mid-term results are needed• Patients should be well informed about the less favorable outcome of a revision (unrealistic expectations !!!!)