ANATOMIC APPROACH FOR REVISION ACL RECONSTRUCTION        MR ALEVROGIANNIS STAVROS, MD,PhD              ORTHOPAEDIC SURGEON...
ACL EPIDEMIOLOGY•   Annual incidence of ~200,000 ACL ruptures per year    with an estimated 1 in 3,000 pts, in USA•   150,...
INCREASE OF PRIMARY               ACL         RECONSTRUCTION1. increased level of sports   activities2. increase of high r...
FAILURE PRIMARY ACL SURGERY3-10 % fail• arthritis and recurrent  pain• arthrofibrosis or loss of  motion• extensor mechani...
CAUSES OF FAILURE• traumatic re-injury• returning to sports too  soon after surgery• inappropriate or  overaggressive  reh...
TECHNICAL FAILURES               ( 70% OF CASES)• Improper graft placement• Graft impingement due to  inadequate notchplas...
INDICATIONS FOR ACL-R1. Subjective feeling of instability during the   normal daily and sports activities2. Functional ins...
TYPICAL PATTERNS OF ACL GRAFT           RUPTURE
ACL- REVISION ALGORITHM
TIPS & PEARLS FOR            ACL REVISION SURGERY•   ACL ANATOMY•   CLASSIFICATION•   SURGICAL METHOD•   REMOVAL HARDWARE•...
ANATOMIC ACL-RCRITICAL QUESTIONS:• WHAT IS ANATOMIC APPROACH IN ACL-R?(be familiar with anatomical landmarks and  footprin...
ACL ANATOMIC FOOTPRINTSFEMUR           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 s...
Clinical Results           after S.B ACLR• Greatly improved over the last  years• However, there are many issues  which sh...
A.M S.B ACLR
CONVENTIONAL D.B ACLR
ANATOMIC D.B ACLR
FEMORAL TUNNELS IN D.B TECHNIQUE
ANATOMIC APPROACH S.B TECHNIQUE -        FEMORAL DRILLING
FEMORAL TUNNEL IN         ANATOMIC S.B TECHNIQUEThe femoral tunnel is low and overlaps both the AMand PL anatomical sites
TIBIAL DRILLING IN ANATOMIC S.B              ACLR
ACL GRAFT LENGTH
FEMORAL TUNNEL POSITION: AN X-RAY COMPARISON OF           DRILLING THROUGH THE TIBIAL TUNNEL vs DRILLING                  ...
ACL SAGITTAL ANGLE ACCOUNTS FOR   FEMORAL & TIBIAL INSERTIONNormal MRI     Anteromedial Technique
MRI MEASUREMENT TECHNIQUES• ACL angle- Anterior edge  of ACL- Lateral tibial  plateau
MRI MEASUREMENT TECHNIQUESAT angle-Anterior edgeof ACL-Medial tibialplateau
MRI COMPARISON-RESULTSNORMAL    AM TECHNIQUE   TT TECHNIQUE
ARTHOSCOPIC PORTALSLP : (lateral portal = incision towards the outside of the knee)MP :(medial portal = incision towards t...
ACL-REVISION GRAFTS• AUTOGRAFTS-BPTB Ipsilateral contralateral-QUADRICERS-QUADRAPLED ST (indirect fixation recommended)-...
JEWEL-ACL        Features and benefits• Is a specialized textile scaffold which is  rendered versatile for ACL reconstruct...
BENEFITS• Can be implanted as a total tissue sparing device,  or with a single hamstring tendon• Manufactured from Polyeth...
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     ...
CLASSIFICATION SYSTEM FOR ACL R.          (H.H. Paessler et al, Wiosna 2002,48-60 New Techniques for ACL                  ...
METHOD•   Mean time between re-rupture of ACL graft and revision surgery 29m ( 9- 39m)•   All cases were type I or II acco...
POST-OP REGIMEN• Immediate knee motion and muscle-  strengthening exercises on the 1st d.p.o• Functional knee brace for 6 ...
COMPLICATIONS• No major complications were found• No joint effusion 2m.p.o• 1 DVT, 15d.p.o was solved uneventfully• 1 supe...
MODIFIED CINCINATTI SCORE                         (0-100)        Excellent (>80), Good (55 to 79), Fair (30 to 54) or Poor...
VISUAL ANALOGUE SCORE                            (0 = good, 10=poor)         10         8         6points         4       ...
PATIENT OUTCOME FUNCTION SCORE    18%   1%                 81%BETTER    SAME         WORSE
PAIN & ACTIVITY                   80%                                                                                     ...
KNEE PERCEPRION                   50%                         46%                   45%                   40%             ...
ACTIVITIES OF DAILY LIVING                   100%                                                                         ...
SPORTS ACTIVITIES                   80%                                                                             80%   ...
LACHMANN-NOULIS TEST                   120%                                                                      98%      ...
PRE-OP IKDC SCORE (%)              KT 1000 LAXITY80                                   71,1706050403020                    ...
PRE-OP PIVOT SHIFT60                             5250403020                   1110                                       7...
POST-OP EVALUATION45                  4240353025                                   no sport               2120            ...
RESULTS                   KT 1000 LIGAMENT EVALUATION                     manual maximum and Telos45                      ...
RESULTS: Pivot Shift        n   80            70            60            50p = 0.001            40                       ...
RESULTS              PIVOT SHIFT70       61605040302010              7                            2        0 0     equal  ...
GLOBAL SCORE IKDC at F.U.                                          5050454035           3230                           24 ...
CONCLUSIONS• Surgical error is the main cause of failure of a primary  reconstruction• Pre-operative planning is crucial t...
ΑΝΑΘΕΩΡΗΣΗ ΣΥΝΔΕΣΜΟΠΛΑΣΤΙΚΗΣ ΠΡΟΣΘΙΟΥ ΧΙΑΣΤΟΥ ΣΥΝΔΕΣΜΟΥ ΓΟΝΑΤΟΣ ΜΕ ΑΝΑΤΟΜΙΚΗ ΤΕΧΝΙΚΗ
ΑΝΑΘΕΩΡΗΣΗ ΣΥΝΔΕΣΜΟΠΛΑΣΤΙΚΗΣ ΠΡΟΣΘΙΟΥ ΧΙΑΣΤΟΥ ΣΥΝΔΕΣΜΟΥ ΓΟΝΑΤΟΣ ΜΕ ΑΝΑΤΟΜΙΚΗ ΤΕΧΝΙΚΗ
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ΑΝΑΘΕΩΡΗΣΗ ΣΥΝΔΕΣΜΟΠΛΑΣΤΙΚΗΣ ΠΡΟΣΘΙΟΥ ΧΙΑΣΤΟΥ ΣΥΝΔΕΣΜΟΥ ΓΟΝΑΤΟΣ ΜΕ ΑΝΑΤΟΜΙΚΗ ΤΕΧΝΙΚΗ

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(Παρουσίαση στο 4ο Διεθνές Συνέδριο Εταιρείας Αρθροσκόπησης & Χειρουργικής Γόνατος της Πολωνίας, RZEZOW 2011).

REVISION ACL USING ANATOMICAL SINGLE BUNDLE TECHNIQUE.

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ΑΝΑΘΕΩΡΗΣΗ ΣΥΝΔΕΣΜΟΠΛΑΣΤΙΚΗΣ ΠΡΟΣΘΙΟΥ ΧΙΑΣΤΟΥ ΣΥΝΔΕΣΜΟΥ ΓΟΝΑΤΟΣ ΜΕ ΑΝΑΤΟΜΙΚΗ ΤΕΧΝΙΚΗ

  1. 1. ANATOMIC APPROACH FOR REVISION ACL RECONSTRUCTION MR ALEVROGIANNIS STAVROS, MD,PhD ORTHOPAEDIC SURGEON S. CONSULTANT IN SPORTS INJURIES. ATHENS/GREECE
  2. 2. 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
  3. 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. 4. 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)
  5. 5. CAUSES OF FAILURE• traumatic re-injury• returning to sports too soon after surgery• inappropriate or overaggressive rehabilitation• technical failures
  6. 6. 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
  7. 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. 8. TYPICAL PATTERNS OF ACL GRAFT RUPTURE
  9. 9. ACL- REVISION ALGORITHM
  10. 10. TIPS & PEARLS FOR ACL REVISION SURGERY• ACL ANATOMY• CLASSIFICATION• SURGICAL METHOD• REMOVAL HARDWARE• BONE GRAFTS• GRAFT CHOICE• FIXATION CHOICE• DRILLING TUNNELS
  11. 11. ANATOMIC ACL-RCRITICAL QUESTIONS:• WHAT IS ANATOMIC APPROACH IN ACL-R?(be familiar with anatomical landmarks and footprints)• WHY WE NEED ANATOMIC APPROACH?(24-30% re-rupture of the graft)
  12. 12. ACL ANATOMIC FOOTPRINTSFEMUR TIBIA
  13. 13. • 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
  14. 14. 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)
  15. 15. A.M S.B ACLR
  16. 16. CONVENTIONAL D.B ACLR
  17. 17. ANATOMIC D.B ACLR
  18. 18. FEMORAL TUNNELS IN D.B TECHNIQUE
  19. 19. ANATOMIC APPROACH S.B TECHNIQUE - FEMORAL DRILLING
  20. 20. FEMORAL TUNNEL IN ANATOMIC S.B TECHNIQUEThe femoral tunnel is low and overlaps both the AMand PL anatomical sites
  21. 21. TIBIAL DRILLING IN ANATOMIC S.B ACLR
  22. 22. ACL GRAFT LENGTH
  23. 23. 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
  24. 24. ACL SAGITTAL ANGLE ACCOUNTS FOR FEMORAL & TIBIAL INSERTIONNormal MRI Anteromedial Technique
  25. 25. MRI MEASUREMENT TECHNIQUES• ACL angle- Anterior edge of ACL- Lateral tibial plateau
  26. 26. MRI MEASUREMENT TECHNIQUESAT angle-Anterior edgeof ACL-Medial tibialplateau
  27. 27. MRI COMPARISON-RESULTSNORMAL AM TECHNIQUE TT TECHNIQUE
  28. 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. 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. 30. 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.
  31. 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 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.
  32. 32. ACLR (JewelAcl-X/O BUTTON) + in elite 25 y. male athlete.
  33. 33. ACLR (JewelAcl-X/O BUTTON) +CHONDROPLASTY MFC(Chondromimetic) in a non-competitive 41 y.female athlete.
  34. 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 sport sport from time to time frequent sport40 competition30 38 222010 8 2 0report activity prior to ACL re-rupture
  35. 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 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
  36. 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 ( 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
  37. 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 concomitant procedure was performed• Running program 6th m.p.o• Pivoting+ contact sports 9th-12 m.p.o
  38. 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 adhesions and scar tissue 10w.p.o)• No re-re-rupture of the graft (JewelAcl?)
  39. 39. 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
  40. 40. VISUAL ANALOGUE SCORE (0 = good, 10=poor) 10 8 6points 4 2 0 0 6 12 months
  41. 41. PATIENT OUTCOME FUNCTION SCORE 18% 1% 81%BETTER SAME WORSE
  42. 42. PAIN & ACTIVITY 80% 69% 70% 60%Percent of Knees 50% 45% 38% Pre-Op 40% Post-Op 30% 25% 20% 13% 10% 4% 6% 0% 0% Severe with Daily Moderate with Daily Activities Only None with Sports Activities Daily Activities Activities Pain Symptoms Related to Activity
  43. 43. KNEE PERCEPRION 50% 46% 45% 40% 37% 35% 35% 33%Percent of Knees 30% Pre-Op 25% Post-Op 20% 15% 15% 15% 9% 10% 6% 5% 2% 0% 0% Poor Fair Good Very Normal Good Patient Perception of the Knee Condition
  44. 44. ACTIVITIES OF DAILY LIVING 100% 80% 75% 90% 90% 70% 80% 60% Percent of KneesPercent of Knees 70% 60% 50% Pre-Op 40% Pre-Op 50% 44% 40% 35% Post-Op Post-Op 40% 30% 31% 21% 30% 17% 20% 20% 15% 10% 8% 6% 10% 2% 10% 2% 2% 2% 0% 0% 0 20 30 40 0 20 30 40 Walking Stair Climbing
  45. 45. SPORTS ACTIVITIES 80% 80% 75% 70% 67% 70% 60% 60% Percent of KneesPercent of Knees 50% 50% Pre-Op 37% Pre-Op 40% 40% 31% Post-Op 33% Post-Op 29% 29% 30% 30% 20% 20% 17% 13% 13% 13% 10% 11% 10% 10% 10% 10% 2% 0% 0% 40 60 80 100 40 60 80 100 Running Twisting/ Turning
  46. 46. LACHMANN-NOULIS TEST 120% 98% 100%Percent of Knees 80% 64% Pre-Op 60% Post-Op 40% 21% 20% 15% 0% 2% 0% <3 3-5.5 > 5.5 Antero-posterior Displacement
  47. 47. PRE-OP IKDC SCORE (%) KT 1000 LAXITY80 71,1706050403020 14,4 11,110 3,4 0 A B C D C + D > 85%
  48. 48. PRE-OP PIVOT SHIFT60 5250403020 1110 7 00 equal +glide ++ clunk +++ gross
  49. 49. 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
  50. 50. 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
  51. 51. 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
  52. 52. RESULTS PIVOT SHIFT70 61605040302010 7 2 0 0 equal +glide ++ clunk +++ gross
  53. 53. GLOBAL SCORE IKDC at F.U. 5050454035 3230 24 pre-op25 F-U2015 12 1010 85 2 20 A B C D
  54. 54. 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 !!!!)

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