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This presentation is the intellectual property of the author. Contact them at [email protected] for permission to reprint and/or distribute.
STATE OF THE ART OF ACL SURGERY
(Advancements that have had an impact)David Drez, Jr., M.D.
Clinical Professor of OrthopaedicsLSU School of Medicine
Financial Disclosure
Dr. David Drez has no relevant financial relationships with commercial interests to disclose.
Biggest Impact on ACL SurgeryBetter defining ACL Anatomy
This presentation is the intellectual property of the author. Contact them at [email protected] for permission to reprint and/or distribute.
Bundles are named for their attachment on tibia“Anterior medial bundle” – attaches on anterior
and medial aspect of tibia (tightest in flexion)“Posterior lateral bundle" – attaches on posterior
and lateral aspect of tibia (tightest in extension)
Tight in extension
Tight in flexion
PL
AM
Controls rotation of tibia on femur
Controls forward motion of tibia on femur
(Resident’s ridge)
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Intermeniscal ligament. Meniscomeniscal
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This presentation is the intellectual property of the author. Contact them at [email protected] for permission to reprint and/or distribute.
Reconstructionof
Anterior Cruciate Ligament
Single Bundle Anatomic ACL Reconstruction
Double BundleAnatomic
ACL Reconstruction
PL bundle
“Accessory Medial Portal” to gain better access to anatomic ACL attachment on femur
LFC
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Outside in Reconstruction
Flip cutter
Drill out to in
Create socket with flip cutter
targetTunnel for graft
Same on tibia
“All inside” ACL Reconstruction
Femoral socket
Tibial socket
ACL Reconstruction in child with open growth plates
Transphyseal Physeal sparing IT band – over the top
Must use soft tissue grafts
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Meniscus Repair
Inside out repair with sutures
Outer 1/3 vascular
Meniscus suturing device
Excellent graftIncorporates faster than soft tissue grafts– bone into boneGreater chance of anterior knee pain
bone
bone
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Hamstring harvest in popliteal fossa
Closed end stripper
Open ended stripper
Must be >8mm in diameter
Hamstring GraftsLonger time to incorporate in tunnelsLess stiffness than BPBSlightly more laxity than BPBHigher failure rates in females –
esp. if have valgus alignmentVariable size of tendons
Evaluation of Muscle Size and Fatty Infiltration with MRI 9‐11 Years Following Hamstring Harvest for ACL Reconstruction
JBJS 20:94:1274‐823
Gracilis & Semitendinosus muscles showed atrophy & fatty infiltration Variable tendon regenerationPersistent quadriceps atrophyCompensatory hypertrophy of long head of biceps
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Distal Quadriceps Tendon Graft
Scar is largerNew harvesting device is being made
Graft MorbidityNerveInjury
PF pain Weakness Tendon rupture
Patellar Fx Hematoma Problemwith size of grafts
Quad 0 0 0 0 0 + 0
PT + + + + + 0 +
Ham + 0 + 0 0 0 +
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ALLOGRAFT FOR ACL RECONSTRUCTION IN PATIENTS
UNDER THE AGE OF 2520% required revision
62% were classified as failures (+ Lachman & pivot shift)
Recent StudyArthroscopy‐Dec. 2012
• Comparison of Autograft BPB and Allograft BPB ACL reconstruction in patients under 25 with closed growth plates
• Failure rates• Autografts – 3%• Allografts – 11%
“Like shoe strings – they eventually break”
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Graft stiffnessStiffer the structure – more force needed to lengthen itLess stiff – the less force needed to lengthenIn order for graft to function properly, a force must be applied to it to reduce slack that will result when loadedQuestion is how much force is needed to reduce the laxity that may result when the graft is loaded?
Pretensioning of grafts
“Theoretically” will reduce the laxity in the knee when one uses grafts that have reduced
stiffness
Methods to pretensionGraft tensioning board
Tensioning device
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“Simple” way of pretensioning
Fix femoral attachment first•Surgeon pulls on tibial end of graft• Flex and extend knee 10‐20 times before fixing tibial attachmentAverage force exerted with a single hand pull
by a surgeon is 99N (approx. 25lbs.)
WHAT ARE SYMPTOMS ?
POP – FELT OR HEARD BY PATIENT OR BYSTANDERFELT LIKE JOINT SEPARATEDSEVERE PAINSWELLING WITHIN 30 MINUTES TO 2 HOURSINABILITY TO CONTINUE PARTICIPATION
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Same with a patellar dislocation or osteochondral fx.
When aspirate look for fat in aspirate
Clinical tests for ACL tearLateral Pivot Shift
My preferred testReference –JBJS 60A #8Dec. 1978pp. 105-1030
Dr. LoseeEnnis, Montana93 years old
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ACL – X-rays & MRISegond Fracture
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Determining Return to Play(There is no literature to determine the appropriate time when an athlete
can return to full unrestricted activity)1. Patient perception 2. Physician perspective 3. Isokinetic testing +/‐4. Functional tests
should be about 85%‐90% of normalside – I/N =%
Determination of healing and maturation of graft by MRI
(Univ. of Pitt.)Signal intensity of ACL graft should be same as PCLMRI can be used as an adjunct to functional testing
ACL Tear ACL graft 6 at mo ACL Graft at 2 years Mature graft should have same signal as PCL
“Non scientific” determination of graft maturation & healing
“When the color of the skin incisions become the same color as the normal
skin”
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PRPPlatelets contain the bioactive factorsNot all PRP systems are the same Many studies using different systemsWhich system is the best????No proven benefit in ACL surgeryPromotion tool
SummaryMost important “state of art” development has been better defining ACL anatomy Many techniques are out there – so for none have been proven to be “the best” by long term follow up – esp. true for anatomic double bundle vs. anatomic single bundleBest ACL graft is still not determinedFemales with valgus knees have higher failure rates
if use hamstring graftsMakes little difference which graft one uses if a
non‐anatomic reconstruction is done !!!!!
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Overall retear rates of ACL grafts ‐ about 10% ‐ same for opposite knee (approx. 25% in younger patients who return to sport)
Allografts in young patients have a high failure rateAllografts that are irradiated and chemically treated show
higher failure rates (fresh frozen are best)If meniscus excision done when ACL reconstructed – increased
risk of arthritis Repair if possibleMeniscus transplant ???
Value of PRP in ACL surgery ????
Nothing ruins good results like follow up
Don’t be swayed by the media and unfounded advertisement
Thanks for your attention
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