สำหรับงานเวชศาสตร์การกีฬาสัญจร หาดใหญ่ 12-13/12/2017 ครับ

1. Current Management of
Anterior Cruciate Ligament Injury
What's in and What's out?
Ukris Gunadham M.D.
Department of Orthopedics
Trang Regional Hospital
Regional Sports Medicine Meeting 12/12/2017

3. Outlines
 Background
 Anatomy
 Treatment options (non-sx, sb, db)
 Techniques
 Graft types
 Rehabilitation
 Failed ACLR

4. ACL Injuries
 ACL tears account for up to 64% of athletic knee injuries
in cutting and pivoting sports.
 120,000–200,000 ACLRs performed annually in the
United States.
 Acute ACL injuries: joint effusion, altered knee kinematics
and gait, muscle weakness, and reduced functional
performance
 long term sequelae: meniscal tears, chondral lesions, and
posttraumatic osteoarthritis
Stannard JP, Sherman SL, Cook JL. Soft tissues about the knee.
In: Grauer JN, editor.AAOS Orthopaedic Knowledge Update 12. Ch. 36. 1-13. 2017.

5. Anatomy

6. Anatomy
 Double bundle :
 Anteromedial (AM)
 Posterolateral (PL)
 Ribbon-like midsubstance
 Lateral intercondylar ridge
 Lateral bifurcate ridge
Robert Migielski. Ribbonlike Anatomy of the Anterior Cruciate
Ligament from Its Femoral Insertion to the Midsubstance.
ESSKA 2014.

7. Anatomy
 Tibial C-shape insertion runs
from along the medial tibial
spine to the anterior aspect
of the anterior root of LM
 No ACL fibers inserted in
the center of the “C” nor
posterolateral (which was
the place of the bony
attachment of the anterior
root of the LM)
 No PL bundle was found but
posteromedial (PM) fibers
Rainer Siebold.Tibial C-Shaped Insertion of the Anterior
Cruciate LigamentWithout Posterolateral Bundle. ESSKA

8. Treatment options

9. Treatment options
 Non-operative management - poorly tolerated by
both adults and young patients
 Leads to recurrent instability, chondral and meniscal
injuries
 People participating in sports or work related
activities that require a lot of pivoting, cutting, or
jumping may decide to have surgery.
Stannard JP. AAOS Orthopaedic Knowledge Update 12. Ch. 36. 2017
Ajuied A. AJSM 2014

10. Surgical versus conservative
interventions for treating
anterior cruciate ligament injuries
 No differences between surgical management (ACL
reconstruction followed by structured rehabilitation) and
conservative treatment (structured rehabilitation
only) in patient-reported outcomes of knee function at 2-
5 years after injury.
 Many participants with an ACL rupture remained
symptomatic following rehabilitation and later opted for
ACL reconstruction surgery.
2016 Cochrane review

11. ACL reconstruction – Timing
 ACL reconstructions performed beyond 3 weeks post-
injury were at significantly lower risk of developing
arthrofibrosis
Shelbourne et al.AJSM 1991
 ACL reconstruction should preferably be performed
within 6 months from injury to avoid the risk of
additional damage (LM in acute setting and MM as time
elapses)
Kennedy J et al. JBJS Br 2010

12. ACL reconstruction – Timing
 An increase in the number and grade of cartilage lesions
with increasing time from injury is a consistent finding
especially MFC
Tandogan RN, et al. Knee Surg SportsTraumatol Arthrosc 2004
 Skeletally immature patients are at a similar risk of
developing secondary lesions and should be prioritized
for ACL reconstruction with appropriate physeal-sparing
techniques
Dumont GD, et al AJSM 2012

13. Techniques

14. Non-anatomic ACLR
 Traditional ACLRs are placing the graft outside of the
native insertion of the ACL. (clockwise ref.)
 Vertically oriented grafts able to reconstitute stability in
the sagittal plane (anterior-posterior) but fail to provide
adequate rotational stability.
 Non-anatomic tunnel placement can alter the forces
experienced by the graft and is one of the main reasons
grafts fail (continued instability or re-rupture) after ACLR.
Rahnemai-Azar AA, Sabzevari S, Irarrázaval S, ChaoT, Fu FH.Anatomical individualized ACL reconstruction.
Arch Bone Joint Surg 2016;4:291-7

15. Non-anatomic ACLR

16. Non-anatomic ACLR

17. Anatomic ACLR
 attempt to restore the native ACL footprint on
both the tibial and femoral sides of the knee to recreate
the native functional kinematics
 Single bundle reconstruction is indicated for
 tibial insertion sites less than 14 mm in length,
 narrow notches (less than 12 mm in width)
 concomitant ligamentous injuries
 severe bone bruising
 severe arthritic changes (KL3-4)
 in the setting of open physis
van Eck CF, Lesniak BP, SchreiberVM, Fu FH.Anatomic single- and double-bundle anterior
cruciate ligament reconstruction flowchart.Arthroscopy 2010;26:258-68.

18. SB anatomic ACLR

19. Anatomic ACLR
 Double bundle reconstruction - considered in
patients with
 a large tibial insertion site (anteroposterior length >14 mm)
 large intercondylar notch (length and width >14 mm)
 absence of concomitant ligament injuries
 absence of advanced arthritic changes (KL <3)
 absence of severe bone bruising
 closed physis
van Eck CF, Lesniak BP, SchreiberVM, Fu FH.Anatomic single- and double-bundle anterior
cruciate ligament reconstruction flowchart.Arthroscopy 2010;26:258-68.

20. DB anatomic ACLR
Shino K, Nakata K, Nakamura N et al. (2005) Arthroscopy 21:1402.e1–1402.e5

21. DB anatomic ACLR
Rainer Siebold’s C Type Ribbon Technique
ESSKA 2014

22. SB vs DB ACLR
 DB ACLR is to reconstruct both the AM and PL bundles,
more closely reproducing the native knee
anatomy and kinematics
Paschos NK, Howell SM. EFORT Open Rev 2016
 Biomechanical promise of DB fails to translate into
clinical significance and may predispose the graft to
impingement and excessive tension through the PL
bundle during knee extension, resulting early graft
rupture or attenuation
Rahnemai-Azar AA, Sabzevari S, Irarrázaval S, ChaoT, Fu FH.Anatomical individualized ACL reconstruction.
Arch Bone Joint Surg 2016

23. SB vs DB ACLR
 When patients are individually assigned based on the
size of the ACL native insertion site and the intercondylar
notch width, prospective studies demonstrate no
difference in terms of anteroposterior and rotational
laxity between single or double-bundle reconstruction
techniques
Hussein M, van Eck CF, Cretnik A, Dinevski D, Fu FH. Individualized anterior cruciate ligament surgery:
Am J Sports Med 2012;40:1781-8.

24. SB vs DB ACLR
T. Järvelä and R. Siebold. in Anterior Cruciate Ligament Reconstruction
ESSKA 2014

25. Tunnel Drilling
 Transtibial technique is falling more out of
practice (decreased from 56.4% in 2007 to 17.6% in
2014) as a growing number of surgeons perform an
outside-in technique or use guides placed through the AM
portal (increased from 41.3% in 2007 to 65.1% in 2014)
 Outcome data including fewer persistently positive
Lachman and pivot shift tests, lower KT-1000 scores, and
higher Lysholm scores in the transportal groups further
support this paradigm shift.
Tibor L, Chan PH, FunahashiTT,Wyatt R, Maletis GB, Inacio MC, et al. Surgical technique trends in
primary ACL reconstruction from 2007 to 2014. J Bone Joint Surg Am 2016;98:1079-89.

26. Fixation Types
 no clear consensus on superiority of aperture,
suspensory cortical, or button graft fixation or screw
(metal/biologic) versus button graft fixation.
 Biologic screws can be associated with tunnel
widening, a complication infrequently observed in
metallic screw fixation. However, biologic screws
allow for advanced imaging of the knee
postoperatively without metal artifact.
Tibor L, Chan PH, FunahashiTT,Wyatt R, Maletis GB, Inacio MC, et al. Surgical technique trends in primary
ACL reconstruction from 2007 to 2014. J Bone Joint Surg Am 2016;98:1079-89.

27. Fixation Types
 Decrease in use of first-generation bioabsorbable
screws for graft fixation and a shift toward
biocomposite fixation
 When securing soft tissue grafts, recent studies favor
suspensory fixation which fosters better junctional
bone-tendon healing as well as stronger zero time
fixation
Stannard JP, Sherman SL, Cook JL. Soft tissues about the knee. In: Grauer JN, editor.
AAOS Orthopaedic Knowledge Update 12. Ch. 36. 1-13. 2017.

28. ACL remnant preserving
 Intact remnants played an important role in mechanical
strength in the early postoperative period
 Reservation of the blood supply aid in the healing process
of the graft
 Maintenance of proprioceptive innervation with evident
benefits for the subjective outcome and return to sports
 Optimization of the accuracy of the procedure by
improving the arthroscopic orientation and bone tunnel
placement at the insertion site
Borbon CA, Mouzopoulos G, Siebold R Knee Surg Sports Traumatol Arthrosc 2012.

29. Graft Types

30. Allograft vs Autograft
 Selection should be based on patient factors
(patient age, skeletal maturity, and activity level)
 2.6x higher rate of failure when using allograft vs
autograft in patients <25 years
 Allograft - acceptable outcome in middle-aged or
recreational athlete
 Allograft – need longer time for graft ligamentization
Stannard JP, Sherman SL, Cook JL. Soft tissues about the knee.
AAOS Orthopaedic Knowledge Update 12. 2017

31. Graft Types
 HT - equivalent functional outcomes and less donor-
site morbidity, but increased risk of failure/revision,
persistently positive pivot shift test, diminished return
to preinjury levels of activity, and higher rates of
infection
 BPTB - strong stiff graft, secure fixation, bone-to-bone
healing, and low failure rates, but higher incidence of
anterior knee pain and kneeling pain
GifstadT, Foss OA, Engebretsen L, Lind M, Forssblad M,Albrektsen G, et al.
A registry study based on 45,998 primary ACL reconstructions in Scandinavia.Am J Sports Med 2014.

32. Graft Types
 QT - good strength, low donor-site morbidity, and
reliable long term outcomes
 Quadriceps is an ACL antagonist, slightly impaired
function of this muscle may protect the ACL graft
against the quadriceps anteriorly directed force
Fischer F, et al. Knee Surg SportsTraumatol Arthrosc. 2017
 Biomechanical studies demonstrate that the residual
strength of the QT after graft harvest is higher than
that of the intact PT.
Kim SJ, Kumar P, Oh KS.Arthroscopy 2009

33. Rehabilitation

34. Rehabilitation
 Pre-op rehabilitation – preserve Q strength and knee
ROM
 Post-op rehabilitation
 Acute phase - restore ROM ,maintain Q strength, reduce
inflammation (0-3 wks.)
 Recovery phase - improve lower limb muscle strength and
functional stability (3-6 wks.)
 Functional phase - return to previous level of activity and
reduce risk of re-injury (6+ wks.)

35. Rehabilitation
 Little consensus regarding rehab protocol
 Early return to play – increased risk of graft failure
and injury to contralateral native ACL
 Return to play when:
 Time from surgery 8-12 months
 Absence of pain and effusion
 ROM comparable to contralateral knee
 Negative Lachman / Pivot shift test
 One leg hop test >85-90% of contralateral
 Drop vertical jump without dynamic valgus
Ellman MB et al. JAAOS 2015

36. Return to Sports after ACLR
 In the first 2 years after ACL reconstruction, 30 % of
people who returned to level I sports sustained a
reinjury compared to 8 % of those who participated in
lower level sports.
 For every month that return to sport was delayed, until 9
months after ACL reconstruction, the rate of knee reinjury
was reduced by 51%.
 More symmetrical quadriceps strength prior to
return to sport significantly reduced the knee reinjury rate.
 Only 5.6 % of patients who passed RTS criteria before
returning to level I sports suffered reinjuries compared to
37.5 % of those who didn’t pass
Grindem et al (BJSM 2016)

37. Failed ACL Reconstruction

38. Failed ACL Reconstruction
 10-25% failure
 0.7-8% recurrent instability
 Caused of failure
 Atraumatic
 Technical errors (24%) most common
 Biological (fail of graft incorporation) (7%)
 Traumatic: early or late (32%)
Multicenter ACL Revision Study (MARS) AJSM 2010

39. Technical Cause of Failure
Cause %
Femoral tunnel malposition
Tibial tunnel malposition
Malalignment
Femoral fixation
Tibial fixation
Autograft source
Allograft source
Posteromedial laxity
Posterolateral laxity
Other
80
37
4
6
1
1
7
2
1
4
Multicenter ACL Revision Study (MARS) AJSM 2010

40. Controversial Subjects
 ACL Repair
 Internal Bracing
 Synthetic grafts
 ALL reconstruction
 Biologic agent in ACLR

41. Take home message
 The treatment of ACL injury is dynamic and evolving
 Strategies changes from:
 better understanding of the native knee kinematics
 basic science of ligament healing
 improved surgical techniques
 rehabilitation programs
 better recognition of major causes of ACL surgical failure
 Important to reflect on where we have been and where
we are going
 Learn from the success and failure of those who came
before us

42. ATOS Klinik Heidelberg 2015