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POSTGRAD ORTH Deiary Kader
ACL Injuries
FRCS(Tr&Orth) Revision Course
Professor Deiary Fraidoon Kader
Consultant Orthopaedic & Trauma Surgeon
Knee Surgeon
Newcastle Nuffield
Postgraduate Orthopaedics
FRCS(Tr&Orth) Revision Course
Newcastle Upon Tyne 16-21 March 2015
•
Professor Deiary Kader
Consultant Orthopaedic & Trauma Surgeon
Knee Surgeon
Nuffield Hospital Newcastle
NGMV Charity
POSTGRAD ORTH Deiary Kader
Classification of Knee Stabilisers
Lateral Complex
ITB
LCL
Popliteus
Biceps Femoris
Central Complex
ACL
PCL
Med Menx
Lat Menx
Medial Complex
MCL
Postromedial Capsule
Semi-Memb
Pes anserinus
POSTGRAD ORTH Deiary Kader
Anatomy
 33 mm long, 11 mm in diameter
 Two bundles
 AM bundle – tighten in flexion
 PL bundle – tighten in extension
 Supplied by middle geniculate artery
 90% type I and 10% type III collagen
Anatomy
 (Weber brothers 1836)
 (PL) bundle fibres tighten
rapidly during the early
extension <30º.
POSTGRAD ORTH Deiary Kader
ACL is a primary resister to internal rotation of the tibia at <35º of flexion while the
anterolateral ligament is a stabiliser of internal rotation
in >35º of flexion .
Erin M. Parsons, Albert O. Gee, Charles Spiekerman, and Peter R. Cavanagh
The Biomechanical Function of the Anterolateral Ligament of the Knee
Am. J. Sports Med. Jan 2015
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary KaderPOSTGRAD ORTH Deiary Kader
Immunohistochemical analysis revealed some free nerve endings ( ) and ovoid
Ruffini corpuscles ( * ) are present.
Curtesy of French Arthroscopic Society
Dr Sonnery Cottet
Free nerve endings
Ruffini corpuscles
Proprioception:
“Call for help” from ACL under stress to the
surrounding muscles. The Hamstrings
Type II receptors (Ruffini and Pacini bodies
Anatomy: ACL Mechanoreceptors
POSTGRAD ORTH Deiary Kader
Anatomy
Proprioception:
knee proprioception
returned to normal within
6 months of ACL reconstruction,
Angoules AG, Mavrogenis AF, Dimitriou R, Karzis K, Drakoulakis E, Michos J, et al. Knee proprioception following ACL
reconstruction; a prospective trial comparing hamstrings with bone-patellar tendon-bone autograft. Knee. 2011;18:76–82.
Curtesy of Mr Panos Thomas
POSTGRAD ORTH Deiary Kader
Mechanism of injury
 Low velocity, deceleration and pivotal injury, usually non-contact
 High-energy RTA
 Audible or feeling of “popping”
 Acute haemarthrosis in young 1–2 h, less dramatic in older patient
 20% of ACL injury associated with MCL injury
 80% incidence of lateral meniscal injury with combined ACL–MCL
Valgus + ER
POP
POSTGRAD ORTH Deiary Kader
Causes of Injury
Mechanisms of Injury:
1) “plant-and-cut” manoeuvre
2) Knee Hyperextension (Fall
backwards)
3) Landing on one leg
following a jump
(Olsen et al 2004)
POSTGRAD ORTH Deiary Kader
Clinical presentation
Chronic ACL Deficiency:
1) “Subjective Instability”
2) ‘Pain’
3) Recurrent joint
effusion
4) Locking
5) Quadriceps Atrophy
POSTGRAD ORTH Deiary Kader
McDaniel – Rule of Thirds
 One-third is able to compensate, and can pursue
normal recreational sports
 One-third is able to compensate but will have to
reduce their sporting activities
 One-third does poorly and develop instability with
simple activities daily living
Clinical Examination
Stability Testing:
The Lachman test is the most
Sensitive test in Dx ACL tear
History:
- Noulis test (Georges Noulis Thesis in Paris,
1875)
- Ritchley test (1960)
- Ritchley-Lachman test (Torg et al 1976)
POSTGRAD ORTH Deiary Kader
Curtesy of Mr Panos Thomas
POSTGRAD ORTH Deiary Kader
Clinical Examination
Positive Lachman test with a FIRM ENDPOINT
1. Partial ACL tear
2. Displaced bucket-handle meniscus tear
3. Intra-articular loose bodies
4. OA changes
LFC
PCL
ACL
“Lambda healing” AM bundle heals over PCL
(no subjective instability) (Zantop et al 2007)
An Empty wall sign
POSTGRAD ORTH Deiary Kader
Curtesy of Mr Panos Thomas
Clinical Examination
Pivot Shift Sign:
Intact Iliotibial tract is
required
Lachman tests anterior
translation,
Pivot shift tests rotational
stability
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
Paul F. Segond
a Paris surgeon
1879
POSTGRAD ORTH Deiary Kader
ACL Injury
Diagnosis
 Physical Exam
 Lachman
 Pivot shift (confirmatory)
 Plain Radiographs
 Segond Fracture (<5%)
 Standing films for middle-aged
athlete (Arthritis)
 MRI
MRI
Acute tear:
1. Discontinuity ACL fibres (T1
weight)
2. Signal irregularities in the
ACL course (T2 weight)
3. Empty notch sign (coronal T1
weight)
4. Changes of the ACL angle
5. Partial ACL tear (T2 weight)
Indirect signs:
1. Buckling of PCL
2. Bone bruise (Lat femoral
condyle, lat tibial plateau)
POSTGRAD ORTH Deiary Kader
MRI
Chronic tear:
1) Direct and indirect signs
of ACL tear
2) Subchondral lesions
3) Notch changes
4) Evaluation of articular
cartilage lesions
5) Loose bodies
6) Evaluation of menisci
7) Subchondral oedema
8) Other soft tissue (PCL,
PLC)
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
ACL Evidence-Based Review
Factors affecting results:
Patient Selection
Tunnel placement
Strong graft choices
Solid fixation
Rational rehabilitation
Non-Operative Treatment
 Activity modification
(swimming, bicycling,
jogging on flat ground)
 Muscle Training
(Hamstrings strength)
 Proprioceptive Training
 Bracing (reduce anterior
drawer)
Surgical Treatment
Indications:
1) Subjective instability (non-coper)
2) ACL tear in children and
adolescents
3) Multiligament injury
4) Displaced meniscal tears
5) Instability in OA (positive brace
test)?
Surgical
 Extra-articular reconstruction (Lemaire 1967 & MacIntosh 1972)
Involves tenodesis of the iliotibial tract. Eliminates pivot shift but there is concern
regarding its effectiveness in addressing anterior translation
 Intra-articular reconstruction. Current best practice
 Intra + Extra articular reconstruction
Intra-articular ACL Reconstruction
Techniques of femoral tunnel placement
A. Transtibial technique
B. Medial portal
technique
Transtibial technique
Advantages:
1) Simple technique
2) No graft angulation
Disadvantages:
1) Little ability to adjust
femoral tunnel position
2) Posterior placement of the
tibia tunnel
3) Risk of tibia tunnel
enlargement
4) Need for a notch plasty
5) Irrigating fluid leak from the
tibia tunnel
Curtesy of Mr Panos Thomas
Medial portal technique
Advantages:
1) Independent placement of the
femoral and tibia tunnels
2) No fluid leakage from the tibia
tunnel
3) Anatomic placement of the tibia
tunnel
4) Ability to customise the tunnel
diameters
5) Excellent for revision procedures
Disadvantages:
1) Restricted vision in max flexion
2) Learning curve
Curtesy of Mr Panos Thomas
Hamstring BTB
Grafts / Fixations
Quads
POSTGRAD ORTH Deiary Kader
Curtesy of Dr Sonnery Cottet
Hamstring tendons
Advantages Disadvantages
1. Small incisions
2. Easy graft passage
3. High initial ultimate
load (>4000 N, Woo et al,
1991)
4. Less risk of cyclops
syndrome
5. Variable graft length
1. Exacerbation of medial
instability
2. Prolonged
osseointegration of the
graft 8-12 weeks
3. Weakening of knee deep
flexion (3-4 months)
4. Saphenous nerve injury
 Bone-to-bone healing
 Direct rigid fixation
 Faster biological
integration in 6 weeks
 PFJ Morbidity (Pinczewski)
 Anterior knee pain 30%–50%
 Patellar tendinosis 3%–5%
 Fracture patella, rare
 Patella baja
 Development of late OA
Patellar tendon
Advantages Disadvantages
POSTGRAD ORTH Deiary Kader
Allograft
 Biologically inactive
 Slower incorporation
 Less stability in 6 months
 Risk of disease transmission
 Role in revision surgery
 Weaker after having been irradiated
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
In 1972, D. L. MacIntosh
In 1967,1975, M. Lemaire
Extra-articular reconstruction
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
ANTEROLATERAL LIGAMENT
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
Am J Sports Med. 2015 Jan 2.
The Biomechanical Function of the
Anterolateral Ligament of the Knee.
Damage to the ALL of the knee could result in knee instability
at high angles of flexion.
It is possible that a positive pivot-shift sign may be observed in
some patients with an intact ACL but with damage to the
ALL.
This work may have implications for extra-articular
reconstruction in patients with chronic anterolateral
instability.
POSTGRAD ORTH Deiary Kader
The effect of femoral tunnel placement on ACL graft orientation and
length during in vivo knee flexion. J Biomech 2011
Abebe ES, Kim JP, Utturkar GM, Taylor DC, Spritzer CE, Moorman CT, Garrett WE, DeFrate LE.
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary KaderPOSTGRAD ORTH Deiary Kader
Anatomic Single bundle recon
POSTGRAD ORTH Deiary Kader
5mm +
Comparison of 2 femoral tunnel locations in anatomic single-bundle
anterior cruciate ligament reconstruction: a biomechanical
study. Arthroscopy 2012;
Driscoll MD, Isabell GP, Conditt MA, Ismaily SK, Jupiter DC, Noble PC, Lowe WR
Centre AM Bundle vs centre of femoral foot print
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
Single or Double bundle technique?
Anatomical Single-Bundle
Technique Double-Bundle Technique
Advantages:
1) Simplicity
2) Broad spectrum of grafts
3) Simpler graft passage
4) Lower cost
Disadvantages:
1) Inadequate rotational
stability
Advantages:
1) ?Better rotational stability
2) Allowance for individual
variables
Disadvantages:
1) Anatomic or not? (Numerous
double bundle techniques)
2) Technically demanding
3) Longer operating time
4) Limited graft selection
Cochrane Database Rev. 2012
Double-bundle versus single-bundle reconstruction for anterior
cruciate ligament rupture in adults
There is insufficient evidence to determine the relative effectiveness of double-
bundle and single-bundle reconstruction for anterior cruciate ligament rupture in
adults, although there is limited evidence that double-bundle ACL reconstruction
has some superior results in objective measurements of knee stability and
protection against repeat ACL rupture or a new meniscal injury.
Curtesy of Dr Sonnery Cottet
45°, Curve, QuickPass Lassos
POSTGRAD ORTH Deiary Kader
Curtesy of Dr Sonnery Cottet
HIDDEN LESION and Ramp tear
POSTGRAD ORTH Deiary Kader
Curtesy of Dr Sonnery Cottet
ACLR Clinical Questions?? Evidence
What is the risk of infection after ACLR 0.8% (LOE1)
Menx Repair Not on tech 94% success
What are the risk of ACLR graft failure at
2 years
3% (LOE1)
What are the risk of ACL tear in the
normal contra lateral knee at 2 years
3-6%
What is the risk of future OA
(radiographic) after ACL tear/ACLR?
Isolated ACL tear:0-13%
ACL+Menx tear: 21-48%
(LOE2)
POSTGRAD ORTH Deiary Kader
ACLR Clinical Questions Evidence
What is the best graft autograft or
allograft
No difference from meta-analysis but does
not address the young active or elite
athlete (LOE3)
Bioabsorbable or metal Screws No difference
Only knee effusion is higher in Bio!
(LOE1)
What is the best Autograft choice HG or
PTB
No difference (LOE1)
Should I use a brace after ACLR? No Evidence in isolated ACLR (LOE1)
POSTGRAD ORTH Deiary Kader
What are the
complications after ACL
reconstruction?
POSTGRAD ORTH Deiary Kader
Complications
 Infection
 DVT and PE
 Osteoarthritis
 Cyclops lesion residual tissue anterior to the ACL
blocks extension
POSTGRAD ORTH Deiary Kader
Complications
 Failure of Fixation
 Anterior placement of the femoral tunnel limits
flexion
 Anterior placement of the tibial tunnel limits
extension
 Flexion contracture and arthrofibrosis
 Graft rupture from impingement
Tibial Eminence Fracture
Meyers and McKeever classification (1959)
 Type I: non displaced
 Type II: partially displaced or hinged
 Type III: completely displaced (Type III)
 Type IIIA (Zifko) involves the ACL insertion only
 Type IIIB (Zifko) includes the entire intercondylar eminence.
 Type IV (Zaricznyj 1977): comminution of the fracture fragment.
Treatment
 Casting in extension for type I
 Open reduction and internal fixation.
 Arthroscopic reduction and fixation
 Rarely ACL reconstruction is necessary
Postgraduate Orthopaedics
FRCS(Tr&Orth) Revision Course
Professor Deiary Kader
Consultant Orthopaedic & Trauma Surgeon
Knee Surgeon
Newcastle Nuffield
MCL
Medial Collateral Ligament Injury
 Incidence >> LCL Injury
 Mechanism of injury
Direct blow laterally, valgus stress,
forced external rotation
POSTGRAD ORTH Deiary Kader
Medial Collateral Ligament Exam
 Opening @ 30o only
 Isolated MCL Injury
 Opening @ 0o
 Injury to Posteromedial
Capsule
 Usually with ACL +/or PCL
injury
25-30° of flexion, the MCL
provides 80% of the support
to valgus stress
POSTGRAD ORTH Deiary Kader
Classification
I Localised tenderness, no instability, or laxity on testing
II localised swelling, possibly mild laxity, no instability
III definite clinical laxity ..Instability symptom . (80% MLI)
< 5 mm, 5-10 mm, > 10 mm
MCL
MCL
MCL
4 mm proximal
4 mm posterior to the medial epicondyle
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
MCL tear arising from the tibial insertion May lead to
STENER type lesion
POSTGRAD ORTH Deiary Kader
Treatment
Acute isolated MCL tear
I Simple rest, ice, compression bandage, early physiotherapy. 2 Wks
II Hinged brace for symptom improves, WBAA, 1-2weeks
III Hinged brace 30-90/ Surgical 3-4 wks
Operative treatment depend on site and patient
Chronic isolated MCL tear – simple reapproximation – tend to elongate and stretch
therefore needs Augmentation with semitendinosis
Combined injury ACL and MCL→Reconstruction ACL and non-operative
treatment MCL I-II but surgical for III
MCL
MCL Reconstruction
with AT
+
Revision ACLR
Chronic MCL Injury
POSTGRAD ORTH Deiary Kader
THANK YOU

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Updated ACL and MCL Injuries for Postgraduate Orthopaedic Course in Newcastle March 2015

  • 1. POSTGRAD ORTH Deiary Kader ACL Injuries FRCS(Tr&Orth) Revision Course Professor Deiary Fraidoon Kader Consultant Orthopaedic & Trauma Surgeon Knee Surgeon Newcastle Nuffield
  • 2. Postgraduate Orthopaedics FRCS(Tr&Orth) Revision Course Newcastle Upon Tyne 16-21 March 2015 • Professor Deiary Kader Consultant Orthopaedic & Trauma Surgeon Knee Surgeon Nuffield Hospital Newcastle NGMV Charity
  • 3. POSTGRAD ORTH Deiary Kader Classification of Knee Stabilisers Lateral Complex ITB LCL Popliteus Biceps Femoris Central Complex ACL PCL Med Menx Lat Menx Medial Complex MCL Postromedial Capsule Semi-Memb Pes anserinus
  • 4. POSTGRAD ORTH Deiary Kader Anatomy  33 mm long, 11 mm in diameter  Two bundles  AM bundle – tighten in flexion  PL bundle – tighten in extension  Supplied by middle geniculate artery  90% type I and 10% type III collagen
  • 5. Anatomy  (Weber brothers 1836)  (PL) bundle fibres tighten rapidly during the early extension <30º. POSTGRAD ORTH Deiary Kader
  • 6. ACL is a primary resister to internal rotation of the tibia at <35º of flexion while the anterolateral ligament is a stabiliser of internal rotation in >35º of flexion . Erin M. Parsons, Albert O. Gee, Charles Spiekerman, and Peter R. Cavanagh The Biomechanical Function of the Anterolateral Ligament of the Knee Am. J. Sports Med. Jan 2015 POSTGRAD ORTH Deiary Kader
  • 7. POSTGRAD ORTH Deiary KaderPOSTGRAD ORTH Deiary Kader
  • 8. Immunohistochemical analysis revealed some free nerve endings ( ) and ovoid Ruffini corpuscles ( * ) are present. Curtesy of French Arthroscopic Society Dr Sonnery Cottet Free nerve endings Ruffini corpuscles Proprioception: “Call for help” from ACL under stress to the surrounding muscles. The Hamstrings Type II receptors (Ruffini and Pacini bodies Anatomy: ACL Mechanoreceptors POSTGRAD ORTH Deiary Kader
  • 9. Anatomy Proprioception: knee proprioception returned to normal within 6 months of ACL reconstruction, Angoules AG, Mavrogenis AF, Dimitriou R, Karzis K, Drakoulakis E, Michos J, et al. Knee proprioception following ACL reconstruction; a prospective trial comparing hamstrings with bone-patellar tendon-bone autograft. Knee. 2011;18:76–82. Curtesy of Mr Panos Thomas
  • 10. POSTGRAD ORTH Deiary Kader Mechanism of injury  Low velocity, deceleration and pivotal injury, usually non-contact  High-energy RTA  Audible or feeling of “popping”  Acute haemarthrosis in young 1–2 h, less dramatic in older patient  20% of ACL injury associated with MCL injury  80% incidence of lateral meniscal injury with combined ACL–MCL
  • 11. Valgus + ER POP POSTGRAD ORTH Deiary Kader
  • 12. Causes of Injury Mechanisms of Injury: 1) “plant-and-cut” manoeuvre 2) Knee Hyperextension (Fall backwards) 3) Landing on one leg following a jump (Olsen et al 2004) POSTGRAD ORTH Deiary Kader
  • 13. Clinical presentation Chronic ACL Deficiency: 1) “Subjective Instability” 2) ‘Pain’ 3) Recurrent joint effusion 4) Locking 5) Quadriceps Atrophy POSTGRAD ORTH Deiary Kader
  • 14. McDaniel – Rule of Thirds  One-third is able to compensate, and can pursue normal recreational sports  One-third is able to compensate but will have to reduce their sporting activities  One-third does poorly and develop instability with simple activities daily living
  • 15. Clinical Examination Stability Testing: The Lachman test is the most Sensitive test in Dx ACL tear History: - Noulis test (Georges Noulis Thesis in Paris, 1875) - Ritchley test (1960) - Ritchley-Lachman test (Torg et al 1976) POSTGRAD ORTH Deiary Kader Curtesy of Mr Panos Thomas
  • 17. Clinical Examination Positive Lachman test with a FIRM ENDPOINT 1. Partial ACL tear 2. Displaced bucket-handle meniscus tear 3. Intra-articular loose bodies 4. OA changes
  • 18. LFC PCL ACL “Lambda healing” AM bundle heals over PCL (no subjective instability) (Zantop et al 2007) An Empty wall sign POSTGRAD ORTH Deiary Kader Curtesy of Mr Panos Thomas
  • 19. Clinical Examination Pivot Shift Sign: Intact Iliotibial tract is required Lachman tests anterior translation, Pivot shift tests rotational stability POSTGRAD ORTH Deiary Kader
  • 20. POSTGRAD ORTH Deiary Kader Paul F. Segond a Paris surgeon 1879
  • 21. POSTGRAD ORTH Deiary Kader ACL Injury Diagnosis  Physical Exam  Lachman  Pivot shift (confirmatory)  Plain Radiographs  Segond Fracture (<5%)  Standing films for middle-aged athlete (Arthritis)  MRI
  • 22. MRI Acute tear: 1. Discontinuity ACL fibres (T1 weight) 2. Signal irregularities in the ACL course (T2 weight) 3. Empty notch sign (coronal T1 weight) 4. Changes of the ACL angle 5. Partial ACL tear (T2 weight) Indirect signs: 1. Buckling of PCL 2. Bone bruise (Lat femoral condyle, lat tibial plateau) POSTGRAD ORTH Deiary Kader
  • 23. MRI Chronic tear: 1) Direct and indirect signs of ACL tear 2) Subchondral lesions 3) Notch changes 4) Evaluation of articular cartilage lesions 5) Loose bodies 6) Evaluation of menisci 7) Subchondral oedema 8) Other soft tissue (PCL, PLC) POSTGRAD ORTH Deiary Kader
  • 24. POSTGRAD ORTH Deiary Kader ACL Evidence-Based Review Factors affecting results: Patient Selection Tunnel placement Strong graft choices Solid fixation Rational rehabilitation
  • 25. Non-Operative Treatment  Activity modification (swimming, bicycling, jogging on flat ground)  Muscle Training (Hamstrings strength)  Proprioceptive Training  Bracing (reduce anterior drawer)
  • 26. Surgical Treatment Indications: 1) Subjective instability (non-coper) 2) ACL tear in children and adolescents 3) Multiligament injury 4) Displaced meniscal tears 5) Instability in OA (positive brace test)?
  • 27. Surgical  Extra-articular reconstruction (Lemaire 1967 & MacIntosh 1972) Involves tenodesis of the iliotibial tract. Eliminates pivot shift but there is concern regarding its effectiveness in addressing anterior translation  Intra-articular reconstruction. Current best practice  Intra + Extra articular reconstruction
  • 29. Techniques of femoral tunnel placement A. Transtibial technique B. Medial portal technique
  • 30. Transtibial technique Advantages: 1) Simple technique 2) No graft angulation Disadvantages: 1) Little ability to adjust femoral tunnel position 2) Posterior placement of the tibia tunnel 3) Risk of tibia tunnel enlargement 4) Need for a notch plasty 5) Irrigating fluid leak from the tibia tunnel Curtesy of Mr Panos Thomas
  • 31. Medial portal technique Advantages: 1) Independent placement of the femoral and tibia tunnels 2) No fluid leakage from the tibia tunnel 3) Anatomic placement of the tibia tunnel 4) Ability to customise the tunnel diameters 5) Excellent for revision procedures Disadvantages: 1) Restricted vision in max flexion 2) Learning curve Curtesy of Mr Panos Thomas
  • 32. Hamstring BTB Grafts / Fixations Quads POSTGRAD ORTH Deiary Kader Curtesy of Dr Sonnery Cottet
  • 33. Hamstring tendons Advantages Disadvantages 1. Small incisions 2. Easy graft passage 3. High initial ultimate load (>4000 N, Woo et al, 1991) 4. Less risk of cyclops syndrome 5. Variable graft length 1. Exacerbation of medial instability 2. Prolonged osseointegration of the graft 8-12 weeks 3. Weakening of knee deep flexion (3-4 months) 4. Saphenous nerve injury
  • 34.  Bone-to-bone healing  Direct rigid fixation  Faster biological integration in 6 weeks  PFJ Morbidity (Pinczewski)  Anterior knee pain 30%–50%  Patellar tendinosis 3%–5%  Fracture patella, rare  Patella baja  Development of late OA Patellar tendon Advantages Disadvantages POSTGRAD ORTH Deiary Kader
  • 35. Allograft  Biologically inactive  Slower incorporation  Less stability in 6 months  Risk of disease transmission  Role in revision surgery  Weaker after having been irradiated POSTGRAD ORTH Deiary Kader
  • 36. POSTGRAD ORTH Deiary Kader POSTGRAD ORTH Deiary Kader
  • 37. In 1972, D. L. MacIntosh In 1967,1975, M. Lemaire Extra-articular reconstruction POSTGRAD ORTH Deiary Kader
  • 38. POSTGRAD ORTH Deiary Kader ANTEROLATERAL LIGAMENT POSTGRAD ORTH Deiary Kader
  • 40. Am J Sports Med. 2015 Jan 2. The Biomechanical Function of the Anterolateral Ligament of the Knee. Damage to the ALL of the knee could result in knee instability at high angles of flexion. It is possible that a positive pivot-shift sign may be observed in some patients with an intact ACL but with damage to the ALL. This work may have implications for extra-articular reconstruction in patients with chronic anterolateral instability. POSTGRAD ORTH Deiary Kader
  • 41. The effect of femoral tunnel placement on ACL graft orientation and length during in vivo knee flexion. J Biomech 2011 Abebe ES, Kim JP, Utturkar GM, Taylor DC, Spritzer CE, Moorman CT, Garrett WE, DeFrate LE. POSTGRAD ORTH Deiary Kader
  • 42. POSTGRAD ORTH Deiary KaderPOSTGRAD ORTH Deiary Kader
  • 43. Anatomic Single bundle recon POSTGRAD ORTH Deiary Kader
  • 44. 5mm +
  • 45. Comparison of 2 femoral tunnel locations in anatomic single-bundle anterior cruciate ligament reconstruction: a biomechanical study. Arthroscopy 2012; Driscoll MD, Isabell GP, Conditt MA, Ismaily SK, Jupiter DC, Noble PC, Lowe WR Centre AM Bundle vs centre of femoral foot print POSTGRAD ORTH Deiary Kader
  • 47. Single or Double bundle technique? Anatomical Single-Bundle Technique Double-Bundle Technique Advantages: 1) Simplicity 2) Broad spectrum of grafts 3) Simpler graft passage 4) Lower cost Disadvantages: 1) Inadequate rotational stability Advantages: 1) ?Better rotational stability 2) Allowance for individual variables Disadvantages: 1) Anatomic or not? (Numerous double bundle techniques) 2) Technically demanding 3) Longer operating time 4) Limited graft selection
  • 48. Cochrane Database Rev. 2012 Double-bundle versus single-bundle reconstruction for anterior cruciate ligament rupture in adults There is insufficient evidence to determine the relative effectiveness of double- bundle and single-bundle reconstruction for anterior cruciate ligament rupture in adults, although there is limited evidence that double-bundle ACL reconstruction has some superior results in objective measurements of knee stability and protection against repeat ACL rupture or a new meniscal injury.
  • 49. Curtesy of Dr Sonnery Cottet
  • 50. 45°, Curve, QuickPass Lassos POSTGRAD ORTH Deiary Kader Curtesy of Dr Sonnery Cottet
  • 51. HIDDEN LESION and Ramp tear POSTGRAD ORTH Deiary Kader Curtesy of Dr Sonnery Cottet
  • 52. ACLR Clinical Questions?? Evidence What is the risk of infection after ACLR 0.8% (LOE1) Menx Repair Not on tech 94% success What are the risk of ACLR graft failure at 2 years 3% (LOE1) What are the risk of ACL tear in the normal contra lateral knee at 2 years 3-6% What is the risk of future OA (radiographic) after ACL tear/ACLR? Isolated ACL tear:0-13% ACL+Menx tear: 21-48% (LOE2) POSTGRAD ORTH Deiary Kader
  • 53. ACLR Clinical Questions Evidence What is the best graft autograft or allograft No difference from meta-analysis but does not address the young active or elite athlete (LOE3) Bioabsorbable or metal Screws No difference Only knee effusion is higher in Bio! (LOE1) What is the best Autograft choice HG or PTB No difference (LOE1) Should I use a brace after ACLR? No Evidence in isolated ACLR (LOE1) POSTGRAD ORTH Deiary Kader
  • 54. What are the complications after ACL reconstruction?
  • 55. POSTGRAD ORTH Deiary Kader Complications  Infection  DVT and PE  Osteoarthritis  Cyclops lesion residual tissue anterior to the ACL blocks extension
  • 56. POSTGRAD ORTH Deiary Kader Complications  Failure of Fixation  Anterior placement of the femoral tunnel limits flexion  Anterior placement of the tibial tunnel limits extension  Flexion contracture and arthrofibrosis  Graft rupture from impingement
  • 57. Tibial Eminence Fracture Meyers and McKeever classification (1959)  Type I: non displaced  Type II: partially displaced or hinged  Type III: completely displaced (Type III)  Type IIIA (Zifko) involves the ACL insertion only  Type IIIB (Zifko) includes the entire intercondylar eminence.  Type IV (Zaricznyj 1977): comminution of the fracture fragment.
  • 58.
  • 59. Treatment  Casting in extension for type I  Open reduction and internal fixation.  Arthroscopic reduction and fixation  Rarely ACL reconstruction is necessary
  • 60. Postgraduate Orthopaedics FRCS(Tr&Orth) Revision Course Professor Deiary Kader Consultant Orthopaedic & Trauma Surgeon Knee Surgeon Newcastle Nuffield MCL
  • 61. Medial Collateral Ligament Injury  Incidence >> LCL Injury  Mechanism of injury Direct blow laterally, valgus stress, forced external rotation POSTGRAD ORTH Deiary Kader
  • 62. Medial Collateral Ligament Exam  Opening @ 30o only  Isolated MCL Injury  Opening @ 0o  Injury to Posteromedial Capsule  Usually with ACL +/or PCL injury
  • 63. 25-30° of flexion, the MCL provides 80% of the support to valgus stress POSTGRAD ORTH Deiary Kader
  • 64. Classification I Localised tenderness, no instability, or laxity on testing II localised swelling, possibly mild laxity, no instability III definite clinical laxity ..Instability symptom . (80% MLI) < 5 mm, 5-10 mm, > 10 mm MCL
  • 65. MCL
  • 66.
  • 67.
  • 68. MCL 4 mm proximal 4 mm posterior to the medial epicondyle POSTGRAD ORTH Deiary Kader
  • 72. MCL tear arising from the tibial insertion May lead to STENER type lesion POSTGRAD ORTH Deiary Kader
  • 73. Treatment Acute isolated MCL tear I Simple rest, ice, compression bandage, early physiotherapy. 2 Wks II Hinged brace for symptom improves, WBAA, 1-2weeks III Hinged brace 30-90/ Surgical 3-4 wks Operative treatment depend on site and patient Chronic isolated MCL tear – simple reapproximation – tend to elongate and stretch therefore needs Augmentation with semitendinosis Combined injury ACL and MCL→Reconstruction ACL and non-operative treatment MCL I-II but surgical for III MCL
  • 74. MCL Reconstruction with AT + Revision ACLR Chronic MCL Injury POSTGRAD ORTH Deiary Kader

Editor's Notes

  1. Good after My name is Banaszkiewicz For this first section I will be taking you through examination of the hip I have no disclosures to make
  2. Good after My name is Banaszkiewicz For this first section I will be taking you through examination of the hip I have no disclosures to make
  3. We have known that the ….
  4. knee proprioception returned to normal within 6 months of ACL reconstruction, without statistically significant differences between types of autograft used.
  5. Single best test we have for diagnosing ACL rupture
  6. Le probl actuel de la reconstruction monobrin reste le contrôle des rotations. Effectivement nos reconstructions permettent un bon contrôle antero post en extension mais insuffisante en rotation ce qui explique que l’on retrouve a long terme dans les methanalyse environ 15% de ressaut rotatoire
  7. Good after My name is Banaszkiewicz For this first section I will be taking you through examination of the hip I have no disclosures to make