Lecture given by Dr Saithna, Orthopedic Surgeon, Overland Park, Kansas on his latest research related to knee and shoulder injuries, including: Anterior cruciate ligament (ACL), ACL repair, ACL reconstruction, ACL rehabilitation, Rotator cuff and Long head of biceps injuries

1. Orthopedic Sports Medicine: What's new in 2019?
Dr Adnan Saithna
King James IV Professor, Royal College of Surgeons of Edinburgh
Honorary Professor, School of Science and Technology, Nottingham, UK
Adjunct Clinical Faculty, KCUMB

2. About me…
Medical School and Residency in UK
Two years of fellowship training at internationally recognized centers of excellence
in Sports Medicine:
• Royal Orthopaedic Hospital, UK
• Pan Am Clinic, Canada
In Practice since 2014, Knee and Shoulder, Sports Medicine
>150 publications

6. • Return to pre injury level of sport 61-83% in elite athletes
Lai et al. BJSM 2017, Read et al, AJSM 2017
• Graft rupture rate in a elite population = 5.2% to 18%
Lai et al. BJSM 2017, Jordan et al, OAJSM 2017
• Significantly shorter career length
Arundael et al. AJSM 2018, Mai et al, AJSM 2017
• Persistent instability & re-operation rates
ACLR Clinical Results in Elite Athletes
Published in 2017/2018

7.  Neither double bundle nor independent femoral tunnel
drilling have resulted in expected change in outcomes
 Meredick RB et al. Outcome of single-bundle versus double-bundle reconstruction of the ACL: a meta-
analysis. AJSM 2008
 Riboh JC et al. Transtibial vs Independent drilling techniques for ACL. A systematic review, meta-
analysis and meta-regression. AJSM 2013

8. ALL Reconstruction
 LET procedures share load with the ACL graft
 The effect of an iliotibial tenodesis on intraarticular graft forces and knee joint motion. Engebretsen L
et al. AJSM 1990
 Restore normal kinematics where an isolated ACLR does not
 Nitri M et al. and Inderhaug et al AJSM 2016/7

9. Consensus statement 1:
“The anterolateral ligament exists”

10. Clinical Effectiveness of ACL+ALLR
Winner of AANA 2017 Richard J O’Connor Award
June 2017

11. Surgical Technique
Combined Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction.
Saithna et al . JBJS EST. 2018
A
Courtesy Dr Claes

12. Quadrupled HT: 10.8%
BPTB: 16.8%
HT+ALL: 4.1%
Graft rupture rates at mean f/up 38 months

13. Comparison
Surgeries
Hazard Ratio (Multivariate) CI (95%) Significant
4HG/ BPTB 1,204 0.555 , 2.66 No
4HG/ HG+ALL 0.327 0.13, 0.758 Yes
BPTB/HG+ALL 0.393 0.153 , 0.953 Yes
Hazard Ratio multi variate
Survival Analysis
x3
x2,5
Prospective Comparative Study

14. 3D MRI Classification

15. MRI Classification

17. The basis for these improved results compared to historically
poor outcomes:
ALL Less Invasive & More Anatomic

18. – Protects repaired medial meniscus: Two fold reduction in re-
operation for MM repair failure in patients with ACLR+ALLR
compared to patients with isolated ACLR (hazard ratio, 0.443;
95% CI, 0.218-0.866).
ALL Protects MM repair
May 2018

19. Persistent instability after ACLR occurs in up to 30% and it
etiology is multifactorial
Expanding the indications – Persistent instability

20. 37 year old professional dancer
ACL injury and reconstruction 4HT (8mm). No secondary
restraint lesions
Persistent instability and unable to return to sport despite
two years intensive physiotherapy
OJSM Case Report

21. Diagnostic arthroscopy
- graft, no concerns
- no new meniscus/chondral lesion
Gracilis allograft ALL reconstruction
4 months after ALLR back to pre-injury level of dance
(after 2 years of being unable to participate following
isolated ACLR)
Single case report – emerging series
Case Report

23. Cory Edgar, Robert Arciero et al. AAOS 2015
JM Stephen, A Williams, A Amis. AJSM 2016
A Peltier, T Lording, S Lustig. KSSTA 2015
Biomechanics of Ramp Lesions

24. Biomechanics of Ramp
= Postero-medial Instability

25. Hidden lesions of the Posterior Horn of the medial meniscus:
A systematic arthroscopic exploration of the concealed portion of the knee
Sonnery-Cottet et al. Am J Sport Med 2014
How to identify Ramp Lesions on Arthroscopy
302 ACL reconstruction
= 125 medial meniscal tears
• Step 1 = 75 tears identified
• Step 2 = 29 tears identified
• Step 3 = 21 tears identified
40%

27. Surgical Technique = Bankart Repair

28. 23.9% rate of ramp
lesions

29. Epidemiological Evaluation of Meniscal Ramp Lesions in 3214 ACL injured knee From the SANTI Study Group Database
Sonnery-Cottet et al. Am J Sport Med in Press
Male sex,
Patients aged < 30 years,
Revision ACLR,
Chronic injuries,
Preoperative side-to-side laxity >6 mm,
Concomitant lateral meniscal tears
RAMP : Risk Factors

30. Secondary Medial Meniscectomy
after PM repair: 10,8% (Mean FU 45.6 months (range, 24.2-66.2 months)
ALL Reconstruction Protects the Repaired Medial Meniscus: A Comparative Study of 383 ACL reconstruction with a Minimum FU of 2 Years
Sonnery-Cottet et al. Am J Sport Med 2018
Epidemiological Evaluation of Meniscal Ramp Lesions in 3214 ACL injured knee From the SANTI Study Group Database
Sonnery-Cottet et al. Am J Sport Med in Press
215 193 187 116 63 15
250 219 206 160 107 50
0 1 2 3 4 5
Time to 2nd meniscectomy or censoring
0.5
0.6
0.7
0.8
0.9
1.0
SurvivalProbability
1
2
2: Isolated ACL1: ACL + External plastySurgical procedure
Product-Limit Survival Estimates
With Number of Subjects at Risk and 95% Confidence Limits
215 193 187 116 63 15
250 219 206 160 107 50
0 1 2 3 4 5
Time to 2nd meniscectomy or censoring
0.5
0.6
0.7
0.8
0.9
1.0
SurvivalProbability
1
2
2: Isolated ACL1: ACL + External plastySurgical procedure
+ Censored
Product-Limit Survival Estimates
With Number of Subjects at Risk and 95% Confidence Limits
ACL + ALL R : 6,66%
ACL R : 14,82 %
The combined procedure
was associated with
a > 2-fold reduction in the
failure rate of ramp repair
(P =.021)

32. Tagging of LHB

33. Excursion with hook and re-
tagging

34. Excursion with grasper and re-
tagging

41. Thank you!
All my research can be found at ResearchGate:
https://www.researchgate.net/profile/Adnan_Saithna
Twitter: kc_ortho
Linkedin: https://www.linkedin.com/in/adnan-saithna-544944b8