Acl Syllabus

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8/20/2012

8 min

Avoiding Complications

with the Transtibial

Technique

Stephen M. Howell, MD

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

•Share guidelines for placing the tibial

and femoral tunnels in the sagittal and

coronal plane that avoids

complications with the transtibial

technique

Objective

8/20/2012

Placement of Tibial Tunnel

in the Sagittal Plane

•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

Place Tibial Tunnel ‘Just’ Posterior to

Intercondylar Roof in Extended Knee

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

8/20/2012

Placement of Tibial

Tunnel in the Coronal

Plane

•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

Place Tibial Tunnel Between Tibial

Spines and Through Tip of Lateral Spine

Romano, AJSM, 1993

•Places femoral

tunnel HALF-WAY

down side-wall

minimizing loss of

flexion and instability

from PCL

impingement

For Transtibial Technique, Set the

Tibial Tunnel at an Angle of 60-650

•Simmons, Howell, Hull, JBJS, 2003

60-65

8/20/2012

QuickTime™ and a

Sorens on Video 3 decompres sor

are needed to see this picture.

QuickTime™ and a

Photo - JPEG decompressor

are needed to see this picture.

Consider Using a Tibial Guide That

References the Intercondylar Roof

•Insert guide

•Extend knee

•Align rod parallel to

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

QuickTime™ and a

Sorens on Video 3 decompres sor

are needed to see this picture.

50%

View from Transpatellar Tendon Portal

8/20/2012

QuickTime™ and a

H.264 decompressor

are needed to see this picture.

Perform a Wallplasty in Most Knees

•Assess width of

notch with a probe

that matches width of

the ACL graft

•Remove portion of

lateral femoral

condyle from apex of

notch to bottom

QuickTime™ and a

H.264 decompressor

are needed to see this picture.

View from Transpatellar Tendon Portal

QuickTime™ and a

Sorens on Video 3 decompres sor

are needed to see this picture.

QuickTime™ and a

Photo - JPEG decompressor

are needed to see this picture.

Place Femoral Tunnel NO MORE

than Half-Way Down Side-Wall

•Widen notch & avoid

placement close to

the PCL

•Insert, hook, & rotate

aimer away from PCL

•Moves femoral

tunnel down side

wall

50%

View from Transpatellar Tendon Portal

QuickTime™ and a

Sorens on Video 3 decom pressor

are needed to see this picture.

QuickTime™ and a

Photo - JPEG decompressor

are needed to see this picture.

Photograph the ‘Triangle’ Documenting

there is No PCL Impingement

View from Transpatellar Tendon Portal

8/20/2012

Placement of Femoral

Tunnel

in the Sagittal Plane

•Applies to both the

transtibial and AM

portal techniques

•Consider an over-

the-top femoral

aimer with an

offset no more

than 1 mm

Place the Femoral Tunnel with No More

Than a 1 mm Back-Wall

QuickTime™ and a

H.264 decompressor

are needed to see this picture.

View from Transpatellar Tendon Portal

50%

QuickTime™ and a

Sorens on Video 3 decom pressor

are needed to see this picture.

QuickTime™ and a

Photo - JPEG decompressor

are needed to see this picture.

Photograph the 1mm Backwall

Documenting the Femoral Tunnel is

Posterior

View from Transpatellar Tendon Portal

1 mm

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

1 mm

Arthroscopically Document Femoral

Tunnel is Well-Positioned

•Photograph ‘triangle’

showing no PCL

impingement

•Photograph 1mm

back-wall showing

posterior femoral

tunnel

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 (TT

technique)

60-65

Thank You!

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

Pitfalls of MP drilling

•Damage to MFC

•Short femoral tunnel

•Posterior blow-out

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.

Anatomic ACL Reconstruction

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)

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

8/16/2012

Quad tendon is stronger after CQFT

harvest than PT before

harvest(Mazzocca)

500

1000

1500

2000

2500

3000

3500

4000

Intact PT Intact QT harvestPT harvestQT

3-D Column 3

Newtons to failure

Release under direct vision

•Pull tendon distally and release

•At least 7 cm from distal end

•Then whip stitch the second end

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

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

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

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

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

•Perhaps most

striking of all is the

consistently

diminished pain

medication

requirements of

CQFT reconstructed

patients (Joseph,

2000)

Days to zero pain meds by graft types

BT B Hamstrng Quad Td n

Graft type

Meds(days)



n=25 n=21 n=18

Restoration of ROM after CQFT ACLR

compared to BTB and hamstring

Weeks to full extension by graft types

BTB Hamst rng QuadTd n

Graft type

2.5

5.0

7.5

10.0

Full Ext





n=25 n=21 n=18

•Mick Joseph

(independent PT)

studied BTB,

hamstring, and

CQFT ACLR

prospectively and

found more rapid

return of ROM in

CQFT patients

Weeks to 120 P-Flex by graft types

BTB Hamst rng QuadT dn

Graft type

120 Flex



n=25 n=21 n=18

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 ACLR-

lacrosse (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

Revision ACL Reconstruction

-Causes-

VuMedi Webinar

Avoiding Complications and

Revision ACL Reconstruction

Dr. 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

Anatomic ACL Reconstruction is the

functional restoration of the ACL to its

native dimensions, collagen

orientation, and insertion sites.

Individualized Anatomic

ACL Reconstruction

http://www.vumedi.com

van Eck, Fu et al. Arthroscopy, 2010

33 y/o male

Rotational

Instability

8°

Illingworth, Fu et al. AJSM 2011

<33˚=Non-Anatomic

Right: Post Primary Surgery

77.8°

45.3°

Left: Uninjured knee

Non-Anatomic

Old

Tunnel

Post Anatomic Revision

49°

New Tunnel

Old Tunnel

Evaluation with MRI

Left: Uninjured knee Right: Post Anatomic Revision

46 °

45.3°

122 patients: failed ACL  revision surgery

88% of operated knees: non-anatomic tunnels

Marchant, Noyes et al. AJSM Oct. 2010

However; Many Non-Anatomic

Grafts Survive

Non-anatomic

Office exam: stable knee

Under anesthesia:

unstable knee

Single bundle ACL-R >15 yrs

Stable Knee

10°

arthritic changes

Non-anatomic

PL 90

Office visit after rescope, stable knee

Non-Anatomic

Transtibial BPTB allograft, 1989

20 yrs follow-up

11 yrs of professional NFL career

Stable knee, occasional discomfort

Post-OP 1989

ROM:

Right (operative): 7 to 137

Left: -2 to 142

Non-anatomic position

90º

33º

Arthritic changes Left: 4° Varus

Right: 8.5° Varus

Non-Anatomic

Why Do

Non-Anatomic

Grafts Survive?

Notch Size Variation Notch Height Variation

10mm

11mm

25mm

Notch Width (9-21mm)

Notch Height (10-28mm)

11mm

25mm

11mm 25mm

Failed Intact

27 y/o, male

2008: ACL-R

Pain

10o extension lag

Miserable

No instability

Captured Knee

20

72°

Average

43˚ - 57˚

Intact Graft

Non-Anatomic

Intact Graft Non-Anatomic

5 Days Post Op

17

53

Relieved Patient

Increased Extension

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

4 yr post ACL-R

Healed Graft

Graft Re-Rupture

Re-rupture

4 months post ACL reconstruction

Unhealed Graft

Miyawaki, Fu et al. Ongoing Study

Time Zero 24 months

Graft Healing

6 months

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

Orthopaedics Today, 2011

Patient feels stable

and satisfied Negative pivot shift

on exam KT-1000 < 3mm

difference Follow-up observation

Objective

14 2 1

•3T MRI

•3D CT

•Biomarkers

•RSA

•Return to Sports

Subjective

Definition of Failure?

 Re-rupture

 ROM

 Subjective/ Objective Instability

 Pain, Miserable

Graft Incorporation/

Biological

Trauma

Surgical Technique

Mechanism of

Failure

Revision ACL Surgery

Harner, Fu et al. AAOS 1994

AM PL

90°

High AM

Tunnel mismatch

Failure of Graft Incorporation after Non-

Anatomic Tunnel Placement

90º

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

Disclosure

Member of Medical Board of Trustees and

Consultant to MTF

Outline

Epidemiology

Causes of Failure

Pre-operative evaluation

Surgical considerations

Clinical Results

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%

Goals of Revision ACL Surgery

Provide stable joint

Preserve Meniscus

Maintain full ROM

Return to sport, work, daily

activities

? Chondroprotective

? Prevent osteoarthritis

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

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

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

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

Anatomic Tunnel Placement

Many ACL graft failures are

caused by tunnel mal-

position

Aberrant tunnel placement

can lead to:

Loss of knee ROM

Graft impingement

Stretch-out and Laxity

Femoral Tunnel 12

Femoral Tunnel Placement

Oblique Vertical

Femoral Tunnel Placement

Too Anterior

A common error

Tight in flexion

Lax in extension

Loss of flexion or stetch-

out of graft

Too Vertical

May not provide enough

rotational stability

Aberrent Tibial Tunnel Placement

Too Anterior

Notch impingement

Too Posterior

PCL impingement

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

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

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

Pre-operative Evaluation

Etiology of failure

Is there symptomatic

instability?

Whether or not a patient

is a candidate for revision

Radiographs

X-rays: AP, lateral, 45° PA weight

bearing view

Arthritis

Size and position of previous tunnels

Previous hardware

Notch architecture

Alignment

CT

Bone tunnel enlargement

MRI

Bone tunnel enlargement

Graft integrity

Associated injuries

Surgical Considerations

Staging

Graft selection

Hardware removal

Notchplasty

Bone tunnel placement

Graft fixation

Rehabilitation

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

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

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

Tunnel Placement

The most important and

challenging hurdle

Anatomic vs non-

anatomic

Tunnel widening or no

tunnel widening

Tunnel Placement

Non anatomic tunnels

Drill new anatomic tunnels

Leave old hardware in place

Tunnel Placement

Anatomic or near anatomic

Remove old hardware

Redirect anatomic tunnel

Two incision technique, AM

portal, etc.

Tunnel Placement

Tunnel widening

Staged bone grafting

Stacked interference screws

Larger bone plugs

Bone Dowels

Graft Fixation

Secure graft fixation is

critical

May re-enforce primary

fixation

Post and washer

Staple

Endobutton

Stacked interference

screws

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

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

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

Thank You

Acl Syllabus

Acl Syllabus acl_syllabus acl_syllabus 3 2013 pdf 258413772373414384

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