KOCO EATON, M.D.

T A M P A B A Y R A Y S ( 1 9 9 5 – P R E S E N T )

T A M P A B A Y B U C C A N E E R S ( 2 0 1 5 – 2 0 1 6 )

T A M P A B A Y R O W D I E S ( 2 0 1 4 – 2 0 1 7 )

Minimally InvasiveACL Surgery

Knee Anatomy

Anterior Cruciate Ligament Injuries

ACL:

Prevents anterior translation and internal rotation of tibia

Prevents hyperextension

Injuries most common in soccer, football and basketball

ACL Physical Exam

Lachman exam

Patient supine, 20-30 degrees of flexion

Grasp distal femur with one hand, tibia at level of tubercle with the other hand

Pull tibia forward

Positive result indicated by no discernible end point, or increased motion compared to contralateral knee

ACL Physical Exam

Anterior drawer

Patient in a relaxed supine position with knees bent to approximately 90 degrees

Stabilize feet of patient

Place hands around the upper tibia of one leg, while the thumbs of both hands are on the supero-anterior aspect of tibia

Apply posterior-anterior force

Positive result is soft end point, or >6mm of anterior translation

ACL Physical Exam

Pivot shift test

extension to flexion: reduces at 20-30° of flexion

patient must be completely relaxed (easier to elicit under anesthesia)

mimics the actual giving way event

ACL Structure – Double-bundle

Anteromedial bundle

Moderately lax in extension

Tightens in flexion

Primary restraint against anterior tibial translation

Posterolateral bundle

Tight in extension

Relaxes in extension

Stabilizes the knee near full extension, particularly against rotatory loads

ACL Structure – Double-bundle

The ACL – To Repair or Reconstruct?

ACL Repair

Great for acute partial tears, posterolateral bundle

Great option for older patients with lesser activity levels

Less pain, less healing time

ACL Reconstruction

Complete or chronic tears

Younger, high caliber athletes

Contact athletes

ACL Repair Technique

#2 FiberWire is passed in locking fashion through ACL remnant

Microfracture performed within notch at location of anchor placement to create bleeding bone bed

Hole punched/tapped in notch to receive SwiveLockanchor

Suture passed through anchor and inserted

ACL Repair Technique

ACL Repair Technique

ACL Repair – End Result

ACL Repair – My Results

36 ACL repairs performed out of 219 total ACL surgeries since June 2014

16 % of ACL injuries treated effectively with ACL repair surgery

To date, no failures of repairs

Effective treatment of ACL injury in the right patient

Case Report – ACL Repair

81-year old healthy, active female, snowskiing in Colorado sustained knee injury

MRI showed partial ACL tear

Successful ACL repair performed

Great for older patient who wishes to remain active

ACL Reconstruction - Principles

Single vs. double bundle technique

Freddie Fu, M.D. Has been a pioneer in the research of single vs. double-bundle ACL

reconstruction Author of Current Concepts in ACL Reconstruction Winner of Jack Hughston Award

Concludes that anatomic single-bundle reconstruction resulted in less anteroposterior and rotational laxity than conventional single-bundle reconstruction, and the results of the double-bundle group surpassed those of the anatomic single-bundle group for laxity.

Single vs. Double Bundle Technique

ACL Reconstruction – How It’s Done

Femoral drill tunnel is made with a 10 mm reamer, then overdrilled with 4.5 mm reamer

Tibial tunnel drilled with 10 mm reamer over guidepin, outside-in technique

Graft is harvested

Passed through knee joint

Fixation on femoral side with Endobutton

Fixation on tibial side with 6.5 mm screw and washer

Postop X-rays

Graft Options

Middle third of patella tendon is what I use

Can use strip of quad tendon, great for revision

Hamstrings are an option, but graft is much thinner than patella/quad tendon and can result in ongoing knee problems at graft site

Patellar Tendon Graft

Bone-tendon-bone graft is harvested from the middle third of the patellar tendon

Graft is defatted and the bone plugs are contoured to slide into the tibialand femoral tunnels snugly for optimal healing and fixation

Minimally Invasive ACL Surgery

Nobody wants a large incision

Cosmesis is important to most people, particularly females

The smaller the incision, the better

How can an ACL reconstruction with an autologous patellar tendon graft possibly be performed through such a small incision?

Minimally Invasive ACL Surgery

The double knife The bone clampThe towel clip

Minimally Invasive ACL Surgery

Incision is based over medial aspect of patellar tendon

Allows for exposure of tendon for harvesting, and also allows tibialdrill tunnel to be made

Typically 1-1.5 inches is sufficient

Minimally Invasive ACL Surgery

Subcutaneous tissue freed upwith Cobb elevator

Double knife is used to cutvertical borders of graft

Minimally Invasive ACL Surgery

Distal end of graft is cut

with TPS saw

Proximal end of graft is harvested by using towel clip on patella to deliver inferior

pole, cuts are completed

Contouring the Graft

In the olden days of patellar tendon graft harvesting, the bone plugs were shaped with a Rongeur

Passed through a metal sizing tunnel

If it didn’t fit, you whittled some more

Contouring the graft with a Rongeur could take 15 -20 minutes, and it seemed that there must be a more efficient way to get the job done

The Bone Clamp

WHITTLE NO MORE!

Cuts down graft preparation time

Reproducible results

Securely holds graft for suture passing

The Bone Clamp

Idea behind the sizing of the bone plug is based on the Pythagorean Theorem

a² + b² = c²

In order for c to be 10mm, sides a and bare 6 mm and 8 mm respectively

6

810

The Bone Clamp

The Bone Clamp

The bone clamp securely holds the bone plug

A TPS saw blade is passed over the bone plug, removing excess bone

The Bone Clamp

Bone plug is rotated 90˚, tendinous portion turned away, and cut is repeated

Small holes drilled through bone plug while cradled in the bone clamp for passing of suture

Financial Impact

Use of the bone clamp decreases operative time by approximately 15 minutes per case.

Cost of OR time is roughly $600/hour, which breaks down to $10/minute.

Each use of the bone clamp saves approximately $150 in OR time.

Repeat use results in drastic savings to the center.

The Bone Clamp

The bone clamp is a safe and effective surgical instrument for shaping and sizing the bone plugs at

either end of a bone-tendon-bone graft. The results are consistent and reproducible, while use of the bone

clamp decreases operative time.

Citations

Wilk, Kevin E., Michael M. Reinold, and James R. Andrews. "Rehabilitation of the thrower's elbow." Clinics in sports medicine 23.4 (2004): 765-801.

Podesta, Luga, et al. "Treatment of partial ulnar collateral ligament tears in the elbow with platelet-rich plasma." The American journal of sports medicine 41.7 (2013): 1689-1694.

Conway, J. E., et al. "Medial instability of the elbow in throwing athletes. Treatment by repair or reconstruction of the ulnar collateral ligament." J Bone Joint SurgAm 74.1 (1992): 67-83.

Argo, David, et al. "Operative treatment of ulnar collateral ligament insufficiency of the elbow in female athletes." The American journal of sports medicine 34.3 (2006): 431-437.

Savoie, Felix H., et al. "Primary Repair of Ulnar Collateral Ligament Injuries of the Elbow in Young Athletes A Case Series of Injuries to the Proximal and Distal Ends of the Ligament." The American journal of sports medicine 36.6 (2008): 1066-1072.

van Eck, Carola F., et al. "Anatomic single-and double-bundle anterior cruciate ligament reconstruction flowchart." Arthroscopy: The Journal of Arthroscopic & Related Surgery 26.2 (2010): 258-268.