Acl Syllabus
Acl Syllabus acl_syllabus acl_syllabus 3 2013 pdf 258413772373414384
2013-02-24
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8/20/2012 Avoiding Complications with the Transtibial Technique Stephen M. Howell, MD 8 min Professor Mechanical Engineering Member of Biomedical Graduate Group University of California at Davis Sacramento, CA Conflict of Interest • Consultant and receive royalties from Biomet Sports Medicine • Co-founder of OtisMed and designer of kinematically aligned TKA • Consultant for Stryker Objective • Share guidelines for placing the tibial and femoral tunnels in the sagittal and coronal plane that avoids complications with the transtibial technique 1 8/20/2012 Placement of Tibial Tunnel in the Sagittal Plane Place Tibial Tunnel ‘Just’ Posterior to Intercondylar Roof in Extended Knee • Applies to both the transtibial and AM portal techniques • • Tibial tunnel must be just posterior to intercondylar roof Anterior placement causes loss of extension and instability from roof impingement Customize the AP Location of the Tibial Tunnel • Applies to both the transtibial and AM portal techniques • An ‘average placement’ results in ‘average results’ and a higher failure rate • Howell, AJSM, 1995 2 8/20/2012 Placement of Tibial Tunnel in the Coronal Plane Place Tibial Tunnel Between Tibial Spines and Through Tip of Lateral Spine • Applies to both the transtibial and AM portal techniques • • Tunnel should be between tibial spines Medial placement causes PCL impingement and loss of flexion and instability Romano, AJSM, 1993 For Transtibial Technique, Set the Tibial Tunnel at an Angle of 60-650 • Places femoral tunnel HALF-WAY down side-wall minimizing loss of flexion and instability from PCL impingement • 60-65 Simmons, Howell, Hull, JBJS, 2003 3 8/20/2012 Consider Using a Tibial Guide That References the Intercondylar Roof • Insert guide • Extend knee • Align rod parallel to QuickTime™ and a Sorenson Photo - JPEG Video decompressor 3 decompressor are needed to see this picture. joint line and perpendicular to tibia, which sets tunnel at 65 degrees Placement of Femoral Tunnel in the Coronal Plane Place the Femoral Tunnel Without PCL Impingement 50% 50% QuickTime™ and a Sorenson Video 3 decompressor are needed to see this picture. View from Transpatellar Tendon Portal 4 8/20/2012 Perform a Wallplasty in Most Knees • • Assess width of notch with a probe that matches width of the ACL graft QuickTime™ QuickTime™and andaa H.264 H.264decompressor decompressor are areneeded neededtotosee seethis thispicture. picture. Remove portion of lateral femoral condyle from apex of notch to bottom View from Transpatellar Tendon Portal Place Femoral Tunnel NO MORE than Half-Way Down Side-Wall • Widen notch & avoid placement close to the PCL • Insert, hook, & rotate 50% 50% QuickTime™ and a Sorenson Photo - JPEG Video decompressor 3 decompressor are needed to see this picture. aimer away from PCL • Moves femoral tunnel down side wall View from Transpatellar Tendon Portal Photograph the ‘Triangle’ Documenting there is No PCL Impingement QuickTime™ and a Sorenson Photo - JPEG Video decompressor 3 decompressor are needed to see this picture. View from Transpatellar Tendon Portal 5 8/20/2012 Placement of Femoral Tunnel in the Sagittal Plane Place the Femoral Tunnel with No More Than a 1 mm Back-Wall • Applies to both the transtibial and AM portal techniques • Consider an overthe-top femoral aimer with an offset no more than 1 mm QuickTime™ and a H.264 decompressor are needed to see this picture. 50% 50% View from Transpatellar Tendon Portal Photograph the 1mm Backwall Documenting the Femoral Tunnel is Posterior QuickTime™ and a Sorenson Photo - JPEG Video decompressor 3 decompressor are needed to see this picture. 1 mm View from Transpatellar Tendon Portal 6 8/20/2012 Summary Findings of Danish ACL Registry • Anteromedial technique has a 2 times greater risk of revision compared to transtibial technique • KSSTA, Star Paper, 2012 Arthroscopically Document Femoral Tunnel is Well-Positioned • • Photograph ‘triangle’ showing no PCL impingement Photograph 1mm back-wall showing posterior femoral tunnel 1 mm 7 8/20/2012 Radiographically Document Tibial and Femoral Tunnels are Well-Positioned • Coronal plane Widen notch Place tibial tunnel through tip of lateral spine Angle 60-650 (TT • • • • technique) Sagittal plane Posterior to intercondylar roof Parallel to intercondylar roof 60-65 • • (TT technique) Thank You! 8 ACL Surgery: Medial Portal Pearls and Pitfalls Darren L. Johnson, M.D. Professor and Chairman Department of Orthopedic Surgery Medical Director of Sports Medicine University of Kentucky School of Medicine Disclosure • Consultant: Smith-Nephew Endoscopy – Royalties: Instrument development • Institution: Research/Education – Smith-Nephew Endoscopy – DJO Orthopaedics Clinical experience • • • • • • 19 years: Academic 100% sports practice KNEE/SHOULDER 450 cases/yr 175-200 ACL/YR 25-30+ REVISION ACL • 20 COMBINED PCL/MCL/FCL • Acute/Chronic • Fellowship:3 fellows Reproducing Anatomy “Whenever you are having your anatomy sessions, pay particular attention, because orthopaedics is all anatomy, plus a little bit of common sense.” J. Hughston ACL Technique Secret of Success • Perhaps the most important factor for ACL Reconstruction in 2012 is surgical technique! – Anatomic ACL Reconstruction! Forsythe B, Kopf S, Wong A, Martins C, Anderst W, Tashman S, Fu F. J Bone Joint Surg Am. 2010;92:1418-1426. Why Medial Portal drilling?? • Anatomy:100% fill of tunnel within native footprint • Independent tibial tunnel placement • Size of opening is accurate: not oval P SB L A M SB Pitfalls of MP drilling • Damage to MFC • Short femoral tunnel • Posterior blow-out Anatomic ACL Reconstruction 90 ° Zantop T, Wellman M, Fu FH, Petersen W. Tunnel Positioning of Anteromedial and Posterolateral Bundles in Anatomic Anterior Cruciate Ligament Reconstruction: Anatomic and Radiographic Findings. Am J Sports Med. 2008; 36:65-72. Patient Setup is Critical • Patient Set up for Hyperflexion in Arthroscopic Leg Holder • Note Flexion of Hip Which Allows Knee Hyperflexion Portal Placement is Critical • MUST Include Accessory Anteromedial Portal For Drilling and Fixation of Femoral Tunnels High “Tight” Anterolateral Low “Tight” Anteromedial Accessory Anteromedial Accessory Far Medial Portal • Create Under Direct Visualization of Spinal Needle • Just Over Medial Meniscus • Horizontal Allows Side-to-Side Movement for Drilling and Pins • Drill is perpendicular to wall: round tunnel not oval! Drilling femoral tunnel • 130º Flexion • Guide Pin and Drilling From Accessory Medial Portal • View From mid portal • Direction determines tunnel length: 32-40mm • Aim proximal to FCL Femoral Tunnel X-ray Anatomic SB Video Clip Future of ACL Surgery We will individualized the surgery/rehab/RTP to the athlete, injury pattern, unique patients anatomy/pathologic kinematics. Not all athletes with an ACL injury will have the same operation/rehabilitation timeline/RTP THANK YOU 8/16/2012 Central Quadriceps Free Tendon Reconstruction of the ACL John P. Fulkerson Orthopedic Associates of Hartford Clinical Professor of Orthopedic Surgery University of Connecticut School of Medicine Farmington, Connecticut • The author is president of the Patellofemoral Foundation that receives undirected grant support from Smith and Nephew and DJO Why use quadriceps free tendon for ACL reconstruction? • Easy Access, low morbidity harvest • Less pain and quicker rehab than other autografts (Joseph et al) • Preserve hamstrings-no loss of power in flexion • No added risk of patella fracture • Strong graft • Possible simultaneous harvest • No evidence of anterior knee pain at long term follow up (DeAngelis, Cote and Fulkerson) 1 8/16/2012 Original Descriptions-Quad tendon with bone Marshall, Blauth, Staubli • Quad tendon in continuity with patellar tendon: Clin Orthop 143: 97-106, 1979. • Quad tendon with bone: Unfallheilkunde 87: 45-51, 1984 First published description of quad tendon without bone for ACLR 1998 • Isolated Quad tendon without bone: Techniques in Orthopedics 13(4): 367-374, 1998. • Op Tech Sports Med 7:195-200, 1999. Quad tendon strength • The Central Quad Tendon is thicker than the patellar tendon • 9 vs 4.8 mm thick • Staubli has shown comparable strength • Partial thickness (7mm) harvest is preferable • No rupture or problem with quad tendon in 17 year experience using CQT for ACLR 2 8/16/2012 Quad tendon is stronger after CQFT harvest than PT before harvest(Mazzocca) 4000 3500 Newtons to failure 3000 2500 2000 3-D Column 3 1500 1000 500 0 Intact PT Intact QT harvestPT harvestQT Release under direct vision • Pull tendon distally and release • At least 7 cm from distal end • Then whip stitch the second end 3 8/16/2012 CQFT GRAFT • 2-2.5 cm in each tunnel • Bone disk option on femoral end to meet screw tip • #5 nonabsorbable suture whip stitches • 7 cm long graft or longer 4 8/16/2012 The endobutton works well with CQFT • Our experience with endobutton fixation has been very successful. • With four strands of ultrabraid or fiberwire, fixation is extremely secure. • Short tunnel with anatomic femoral fixation and “bungee cord” effect has not been noted Preparation • # 5 whip stitches (4 strands) each end. Currently use Ultrabraid • Endo button •Play Video 5 8/16/2012 MTS Testing of CQFT Fixation using biointerference screw • With Compression and Anchor fixation, using bioabsorbable screw in a”stuffed”tunnel one size smaller than the screw, there is <1mm of slippage after 2500 cyclical loads of 150 Newtons (Nagarkatti, Jan/Feb 2001 AJSM) Load to failure-soft tissue screw with button anchor • Note graft tearing beyond screw (density matched foam bone) • Button reduces slippage to very low level • Illustration courtesy of Patrick Kwok, M.D. This is an option, but I do not currently use this technique 6 8/16/2012 CQFT advanced into femoral socket • Graft should be snug in the socket such that passage will require a firm pull and probe assistance • Ultrabraid, #5 ethibond or fiberwire sutures My preference • Endobutton with Ultrabraid (4 strands) whip stitched on femoral end • With or without biointerference screw femoral side • Recessed biointerference screw or button on the tibial side We can say with confidence that you do not need to take a bone block from the patella any more than you need to take bone with a hamstring graft 7 8/16/2012 Double bundle options with quad free tendon Quad tendon has intermedius and rectus components Post operative pain medication after ACLR comparing BTB, hamstrings, and CQFT Days to zero pain meds by graft types 60 Meds(days) • Perhaps most striking of all is the consistently diminished pain medication requirements of CQFT reconstructed patients (Joseph, 2000) 40 20 0 n=25 B TB n=21 n=18 Hamstrng Quad Td n Graft type Restoration of ROM after CQFT ACLR compared to BTB and hamstring Weeks to full extension by graft types 10 .0 Weeks to 120 P-Flex by graft types 9 Full Ext 7.5 5.0 2.5 n=25 B TB 120 Flex 7 5 3 n=25 B TB n=21 n=18 Hamstrng Quad Td n n=21 n=18 Hamstrng Quad Td n Graft type • Mick Joseph (independent PT) studied BTB, hamstring, and CQFT ACLR prospectively and found more rapid return of ROM in CQFT patients Graft type 8 8/16/2012 CQFT data >2 years • DeAngelis et al. Clinics in Sports Med 26(4), October 2007. 66 month mean f/u (24-105). Five patients with known graft failure out of 154 patients >2 years. Using Noyes’ criteria of arthrometric success up to 5 mm side-side, 94% success at > 1 year (86% <3mm). Single leg hop quotient 0.96 • >90% return to pre-injury athletic activity • Two NCAA national champions after CQFT ACLRlacrosse (Univ of Virginia) and gymnastics (Univ of Michigan) • No anterior knee pain or motion loss >2 yrs (Cote) • Walter Shelton is reporting similar results with quad free tendon ACL reconstruction (Arthroscopy, 2010). No anterior knee pain or loss of motion at follow up >2 years! \ Conclusions regarding CQFT • Very favorable results at average f/u>5 years (DeAngelis, 2007) • No ROM loss or anterior knee pain in our f/u. • Residual strength of quad tendon after harvest is greater than patella tendon before harvest. • Well suited for double bundle ACLR • Less post op pain and risk than other autografts • Least morbid of the autograft alternatives with comparable long term results. Therefore, quad tendon without bone is our first choice autograft for all ACLR patients 9 VuMedi Webinar Avoiding Complications and Revision ACL Reconstruction Revision ACL Reconstruction -CausesDr. Freddie H. Fu Distinguished Service Professor David Silver Professor and Chairman Department of Orthopaedic Surgery University of Pittsburgh Head Team Physician University of Pittsburgh Athletic Department Individualized Anatomic ACL Reconstruction Anatomic ACL Reconstruction is the functional restoration of the ACL to its native dimensions, collagen orientation, and insertion sites. http://www.vumedi.com van Eck, Fu et al. Arthroscopy, 2010 Instability 33 y/o male Rotational Instability 8° <33˚=Non-Anatomic Illingworth, Fu et al. AJSM 2011 Left: Uninjured knee Right: Post Primary Surgery 77.8° 45.3° Non-Anatomic PL AM Old Tunnel PL Post Anatomic Revision Old Tunnel New Tunnel 49° Evaluation with MRI Left: Uninjured knee Right: Post Anatomic Revision 46 ° 45.3° Marchant, Noyes et al. AJSM Oct. 2010 122 patients: failed ACL revision surgery 88% of operated knees: non-anatomic tunnels However; Many Non-Anatomic Grafts Survive Non-Anatomic Single bundle ACL-R >15 yrs Stable Knee Non-anatomic Non-anatomic 10° Office exam: stable knee 90 ° AM PL PL AM PL AM arthritic changes Office visit after rescope, stable knee Under anesthesia: unstable knee Non-Anatomic Transtibial BPTB allograft, 1989 20 yrs follow-up 11 yrs of professional NFL career Stable knee, occasional discomfort Non-anatomic position PL AM 90º 33º PL Arthritic changes Post-OP 1989 Left:ROM: 4° Varus AM Right: 8.5°7Varus Right (operative): to 137 Left: -2 to 142 Why Do Non-Anatomic Grafts Survive? Notch NotchHeight Size Variation Variation Notch Height (10-28mm) 11mm 25mm 25mm 11mm FailedNotch 11mm Width (9-21mm) Intact 25mm 11mm 10mm Captured Knee 27 y/o, male 20 2008: ACL-R Pain 10o extension lag Miserable No instability Intact Graft 72° Average 43˚ - 57˚ Non-Anatomic Intact Graft Non-Anatomic 5 Days Post Op Relieved Patient Increased Extension 17 53 We Have To Eliminate Non-Anatomic ACL Reconstruction as a Risk Factor For Osteoarthritis What Did We Tell Our Patients? 95% Success Rate Back to Activity in 6 Months Criteria to Return to Sports Full Range of Motion Quadriceps-Strength Graft-Healing? Return to Sports 6 Months Post-op: Went Back to Practice MRI: Immature Graft Early Return to Activity Graft Re-Rupture AM PL 4 yr post ACL-R Re-rupture Healed Graft 4 months post ACL reconstruction Unhealed Graft Graft Healing Time Zero 6 months 24 months Miyawaki, Fu et al. Ongoing Study Return to Sports 6 Months: MRI 9 Months Autograft 12 Months Allograft van Eck, Fu et al. AJSM 2012 How Do We Measure Success? Survey amongst 215 surgeons • Subjective Return to Sports 83 14 2 Patient feels stable and satisfied Negative pivot shift on exam 1 KT-1000 < 3mm Follow-up observation difference • Objective Orthopaedics Today, 2011 • • • 3T MRI 3D CT Biomarkers RSA Definition of Failure? Re-rupture ROM Subjective/ Objective Instability Pain, Miserable Revision ACL Surgery Surgical Technique Mechanism of Failure Trauma Graft Incorporation/ Biological Harner, Fu et al. AAOS 1994 Failure of Graft Incorporation after NonAnatomic Tunnel Placement High AM 90° 90º AM PL PL AM AM PL 90º Tunnel mismatch Conclusions Anatomical Individualize Understand Healing Be Critical on Outcome Measurements Thank You! Revision ACL Reconstruction David R. McAllister, MD Associate Team Physician UCLA Athletic Department Chief, Sports Medicine Service Professor Department of Orthopaedic Surgery David Geffen School of Medicine at UCLA Los Angeles, CA USA 1 Disclosure Member of Medical Board of Trustees and Consultant to MTF 2 Outline Epidemiology Causes of Failure Pre-operative evaluation Surgical considerations Clinical Results 3 1 Demographics 250,000 ACL reconstructions per year performed in United States Annual incidence of ACL tears in the US is 1 in 3000 Americans Average age: 26 70% occur as result of indirect contact Annual Cost is > 2 Billion dollars Graft failure rate is ~8% 4 Goals of Revision ACL Surgery Provide stable joint Preserve Meniscus Maintain full ROM Return to sport, work, daily activities ? Chondroprotective ? Prevent osteoarthritis 5 Success Functional stability Relief of Symptoms Return to pre-injury level of activity Objective outcomes: Lachman, anterior drawer, pivot shift tests, KT 1000 Kocher et al. AJSM 2004 Pivot shift is the only test shown to correlate with subjective satisfaction 6 2 Recurrent Instability Early failure (<6months) Surgical technical error Failure of graft incorporation Diagnostic error Incorrect or aggressive rehab Premature return to sport Late failure ( > 1 year ) Significant re-injury Delayed return to sport 7 MARS Study 460 patients (57% men; median age, 26 years). Mode of failure as deemed by the revising surgeon: traumatic (32%) technical (24%-majority femoral tunnel malposition) biologic (7%) combination (37%) infection (<1%) Graft choice for revision ACL reconstruction was 45% autograft, 54% allograft, and more than 1% both allograft and autograft. Meniscus and/or chondral damage was found in 90% of patients. Wright et al, AJSM 2010 8 Surgical Technique Most avoidable cause of graft failure Technical Errors: Non-anatomic tunnel placement Inadequate notchplasty Inadequate graft fixation Improper graft tensioning Improper graft selection Failure to address secondary stabilizers 9 3 Anatomic Tunnel Placement Many ACL graft failures are caused by tunnel malposition Aberrant tunnel placement can lead to: Loss of knee ROM Graft impingement Stretch-out and Laxity 10 Femoral Tunnel Placement Oblique Vertical 12 Femoral Tunnel 12 9 9 11 Femoral Tunnel Placement Too Anterior A common error Tight in flexion Lax in extension Loss of flexion or stetchout of graft Too Vertical May not provide enough rotational stability 12 4 Aberrent Tibial Tunnel Placement Too Anterior Notch impingement Too Posterior PCL impingement 13 Inadequate Notchplasty ACL graft often larger than native ACL Need clearance between graft and roof of notch Notch large enough to accommodate full ROM Inadequate notchplasty Impingement in extension loss of extension Can lead to graft attrition Formation of “cyclops” lesion 14 Graft Fixation Tibial fixation is weak point Less bone density Dual Photon Absorptometry (DEXA) of the tibial metaphysis less bone density than femoral metaphysis. Angle of force Line of force on graft directly in line with tibial tunnel Line of force on graft oblique to femoral tunnel in WB 15 5 Graft Incorporation Biologic failure may occur from: Loosening within tunnel before bony ingrowth Delayed remodeling of allografts Avascularity caused by over tensioning of graft Avascularity from allografts Allograft immunologic response Infection 16 Pre-operative Evaluation Etiology of failure Is there symptomatic instability? Whether or not a patient is a candidate for revision 17 Radiographs X-rays: AP, lateral, 45° PA weight bearing view CT Arthritis Size and position of previous tunnels Previous hardware Notch architecture Alignment Bone tunnel enlargement MRI Bone tunnel enlargement Graft integrity Associated injuries 18 6 Surgical Considerations Staging Graft selection Hardware removal Notchplasty Bone tunnel placement Graft fixation Rehabilitation 19 Staging Tunnel expansion Bone grafting as a separate procedure required less than 10% of cases in MARS series Wright et al, AJSM 2010 Loss of motion Limb mal-alignment 20 Graft Selection Auto vs Allograft Allograft Advantages Shorter operative time Smaller incisions Avoid donor site morbidity No size limitation (for large tunnel diameters can use a large bone plug) Disadvantages May play role in failure Longer incorporation times Immunologic reaction Higher cost Disease transmission Radiation kills viruses but required dosage alters graft integrity 21 7 Surgical Considerations Hardware removal Remove only when necessary Commercially available revision set may be helpful Use fluoroscopy, if necessary Avoid stripping screw head Knee flexion angle should be the same as when screw was inserted Notchplasty As necessary 22 Tunnel Placement The most important and challenging hurdle Anatomic vs nonanatomic Tunnel widening or no tunnel widening 23 Tunnel Placement Non anatomic tunnels Drill new anatomic tunnels Leave old hardware in place 24 8 Tunnel Placement Anatomic or near anatomic Remove old hardware Redirect anatomic tunnel Two incision technique, AM portal, etc. 25 Tunnel Placement Tunnel widening Staged bone grafting Stacked interference screws Larger bone plugs Bone Dowels 26 Graft Fixation Secure graft fixation is critical May re-enforce primary fixation Post and washer Staple Endobutton Stacked interference screws 27 9 Revision ACL results Diamantopoulos et al. AJSM 2008 107 pt with 73 month f/u Avg Lysholm score was 88.5 62/107 had normal or near normal results on IKDC Battaglia et al. AJSM 2007 63 pt with 72 month f/u 71% good to excellent results 59% returned to sports 25% required additional surgery O’Neil et al. AJSM 2004 48 revision ACL with f/u of 90 months 73% had normal or near normal scores on IKDC 6% failure rate 225 primary ACL 92% had normal or near normal scores on IKDC 7% failure rate 28 Comparative Studies Ahn et al. AJSM 2008 56 revision vs 117 primary reconstructions Variety of grafts used (hamstring autografts, BTB allograft, Achilles allograft) No difference in laxity Lysholm score 63 vs 93 IKDC score 85% A/B vs 95% A/B No differences between grafts used 29 Summary Revision ACL reconstruction will continue to be a growing problem Identify the cause of failure Identify the appropriate candidate for reconstructions Need meticulous pre-operative planning Inform patients on appropriate expectations 30 10 Thank You 31 11
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