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ΣΥΝΔΕΣΜΟΠΛΑΣΤΙΚΗ ΠΡΟΣΘΙΟΥ ΧΙΑΣΤΟΥ ΣΥΝΔΕΣΜΟΥ ΜΕ ΜΟΝΗ ΔΕΣΜΗ ΣΕ ΑΝΑΤΟΜΙΚΗ ΘΕΣΗ. ΠΕΡΙΓΡΑΦΗ ΤΕΧΝΙΚΗΣ
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ΣΥΝΔΕΣΜΟΠΛΑΣΤΙΚΗ ΠΡΟΣΘΙΟΥ ΧΙΑΣΤΟΥ ΣΥΝΔΕΣΜΟΥ ΜΕ ΜΟΝΗ ΔΕΣΜΗ ΣΕ ΑΝΑΤΟΜΙΚΗ ΘΕΣΗ. ΠΕΡΙΓΡΑΦΗ ΤΕΧΝΙΚΗΣ

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(Παρουσίαση σε Διεθνές Συνέδριο Εταιρείας Αρθροσκόπησης & Χειρουργικής Γόνατος της Πολωνίας, POZNAN 2011). …

(Παρουσίαση σε Διεθνές Συνέδριο Εταιρείας Αρθροσκόπησης & Χειρουργικής Γόνατος της Πολωνίας, POZNAN 2011).

FREE HAND NOVEL ANATOMIC SINGLE BAND TECHNIQUE FOR ACLR
(X/O BUTTON,CONMED,LINVATEC,USA).PRELIMINARY RESULTS.
(POZNAN 2011)

Published in Health & Medicine , Technology
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  • Place the guide at the center of the ACL Footprint. Advance the Pin a few millimeters to notch the bone. Then check to ensure that the pin correlates to the mark made earlier. Use a twisting motion to remove the Femoral Footprint Guide.
  • Insert the mono-fluted Sentinel Drill Bit over the guide pin through the accessory anteromedial portal with the cutting edge facing away from the femoral condyle and advance the Drill Bit to the femoral ACL footprint. Using a piston-like back and forth motion, drill the femoral socket to the desired depth cautiously to prevent blow out of the lateral femoral cortex. Keeping the hand off of the trigger, slide the Sentinel Drill Bit past the medial femoral condyle and out of the portal, making sure to keep the blade oriented away from the condylar surface.
  • Use the XO Button Drill Bit to drill the femoral channel. Advance the drill bit through the lateral cortex. Using the XO Button Drill Bit as you would use a standard depth gauge, manually pull back on the bit to hook the head of the drill bit on the external femoral cortex to confirm the aperture to cortex length. Remove the XO Button Drill Bit leaving the graft passing guide pin in place. Place the two free ends of the #2 passing suture through the eyelet of the guide pin. Then, pull the guide pin through the femur laterally, making sure to keep a finger in the suture loop to prevent it from being pulled into the knee joint. Once the suture ends are retrieved laterally, pull the looped end of the suture all the way to the entrance of the femoral tunnel.
  • Set the angle of the Pinn-ACL Guide to 55 degrees. Insert the tip into the anteromedial portal, placing the tip of the guide into the center of the tibial ACL footprint. Next, advance the external guide sleeve flush to the anterior tibial cortex. Using the ConMed Linvatec M-Power 2 handpiece and pin-driver attachment, advance the guide pin until it meets the point of the guide arm. Then, depress the Pinn-ACL drill guide lever to remove the sleeve. Remove the Pinn-ACL guide from the guide pin and joint. Place a curette over the point of the guide pin to protect against inadvertent advancement when drilling. Use the appropriate size Badger or Sentinel Drill Bit to drill the tibial tunnel.
  • Using the appropriate size SE Graft Tensioner Drill/Guide, place the guide in the tibial tunnel and position two Breakaway pins and then remove the guide Retrieve the loop through the tibial tunnel using Suture Retrieval Forceps. With the suture loop exposed externally, load the suture strands of the XO Button loaded graft into the passing suture loop and pull them through the femoral tunnel, making sure to keep the graft construct outside of the tibia. Tying the appropriate bundle strands to the left and right tensioner wheels allows the bundles to be individually and accurately tensioned. Apply the desired graft tension and then cycle the knee to alleviate laxity. Hold the knee at fifteen degrees and set the desired final tension.

Transcript

  • 1. FREE HAND NOVEL ANATOMIC SINGLE BAND TECHNIQUE FOR ACLR (X/O BUTTON,CONMED,LINVATEC,USA). PRELIMINARY RESULTS. ALEVROGIANNIS STAVROS,MD,PhD ORTHOPAEDIC SURGEON S. CONSULTANT IN SPORTS INJURIES. ATHENS/GREECE
  • 2. 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
  • 3. 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 ma n y 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 f ootball 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
  • 4. SURGICAL TECHNIQUE PEARLS
    • ACL ANATOMY
    • SURGICAL METHOD
    • GRAFT CHOICE
    • FIXATION CHOICE
    • DRILLING TUNNELS
  • 5. 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
  • 6. ACL ANATOMIC FOOTPRINTS
    • FEMUR TIBIA
  • 7.
    • 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
  • 8. 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
  • 9. S.B ACLR
  • 10. 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
  • 11. ACL SAGITTAL ANGLE ACCOUNTS FOR FEMORAL & TIBIAL INSERTION
    • Normal MRI Anteromedial Technique
  • 12. MRI MEASUREMENT TECHNIQUES
    • ACL angle
    • Anterior edge of ACL
    • Lateral tibial plateau
  • 13. MRI MEASUREMENT TECHNIQUES AT angle -Anterior edge of ACL -Medial tibial plateau
  • 14. MRI COMPARISON-RESULTS
    • NORMAL AM TECHNIQUE TT TECHNIQUE
  • 15. Clinical Results after S.B ACL R
    • 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)
  • 16. CONVENTIONAL D.B ACLR
  • 17. ANATOMICAL D.B ACLR
  • 18. FEMORAL TUNNELS IN D.B TECHNIQUE
  • 19. ANATOMIC D.B SURGICAL TECHNIQUE
  • 20.  
  • 21. 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?
    LEADS TO
  • 22. 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”.
  • 23. 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)
  • 24. SURGICAL PROCEDURE-FEMUR
    • STEP 1
    • STEP 2
    • STEP 3
  • 25. ANATOMICAL POINTS FOR FEMORAL DRILLING
  • 26. SURGICAL PROCEDURE-FEMUR
    • STEP 4
    • STEP 5
    • STEP 6
  • 27. 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
  • 28. ACL GRAFT LENGTH
  • 29. SURGICAL PROCEDURE-FEMUR
    • STEP 7
    • STEP 8
    • STEP 9
  • 30. FEMORAL TUNNEL IN ANATOMICAL S.B TECHNIQUE The femoral tunnel is low and overlaps both the AM and PL anatomical sites
  • 31. SURGICAL PROCEDURE-TIBIA
    • STEP 10
    • STEP 11
    • STEP 12
  • 32. TIBIAL DRILLING IN ANATOMIC S.B ACLR
  • 33. SURGICAL PROCEDURE-TIBIA
    • STEP 13
    • STEP 14
    • STEP 15
  • 34. GRAFT SPIPPAGE & FIXATION
  • 35. 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
  • 36. MATERIAL
  • 37. PRE-OP IKDC PASSIVE MOTION DEFICIT
  • 38.  
  • 39.  
  • 40.  
  • 41.  
  • 42.  
  • 43.  
  • 44.  
  • 45.  
  • 46.  
  • 47.  
  • 48.  
  • 49.  
  • 50. 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)
  • 51. 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
    ... there are no guidelines as to how many hamstring are really needed!
  • 52. JEWEL-ACL Features and benefits
    • I s 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.
  • 53. BENEFITS BENEFITS
    • Can be implanted as a total tissue sparing device ,
    • or with a single hamstring tendon
    • Manufactured from Polyethylene Terephthalate
    • (polyester)
    • Allows early rehabilitation (p arallel 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.
  • 54. TENSILE LOAD OF HUMAN ACL
    • Intact ACL : 2160±154
    • Bone-patellar tendon-bone : 2376 ±151
    • Single-strand semitendinosus : 1216±50
    • Quadruple d hamstring : 4108±200
    • Quadriceps tendon (10mm) : 2352±495
  • 55. FASTLOK
    • I s recommended for secure fatigue resistant fixation of JewelAcl directly to bone
    • C onsists 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
  • 56. ACLR (JewelAcl-X/O BUTTON) + in elite 25 y. male athlete.
  • 57. ACLR (JewelAcl-X/O BUTTON) + CHONDROPLASTY MFC(Chondromimetic) in a non-competitive 41 y.female athlete.
  • 58. 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
  • 59. 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
  • 60. Thank you!