9 Different Grafts Biological graft materials: autograft: BPTB, Hamstrings, Quad-tendonallograft: Achilles, BPTB, ACL, peronealSynthetic graft materials have not been successfulEngineered biological ACL scaffolds:still experimental
10 Use of different grafts BPTB1983- ExtraarticularAllograftsBPTB-Auto1992- Hamstrings
11 Who Uses What? Hamstrings + BPTB: equal. 62% use multiple grafts Education of graft choices leads to best graftMore than one graft may work for each patient
12 Global Perspective on ACL Reconstruction > 20 different techniques> 5 different graftsdifferent rehab protocolsdifferent outcome assessmentsoverall clinical / functional resultsare good or excellent
13 How perfect are current operative techniques?Need for improvement?
14 20 years ago less knowledge about graft options
15 Graft Comparison Advantages Disadvantages BPTB Consistent size and shapeBone to bone healingConsistent fixationDonor site morbidityHAMSTRINGSVarious fixationsTendon-Bone-HealingGreater stiffnessNo interference with extensor mechanism
16 Graft Comparison Advantages Disadvantages Quadriceps tendon Higher stiffnessBone to bone healing at one sideDonor site morbidityAllograftDecrease in tensile strengthProlonged healing responseDisease transmissionBetter cosmesisNo donor site morbidityLess postoperative pain
17 Does not yet exist Perfect Graft Reproduces insertion and biomechanics Biological incorporationResumes neuromuscular controlDoes not yet exist
18 Biomechanical research Single bundle ACL (BPTB and hamstrings)AP stability restoredrotational stability not restoredPivot shift not restored
19 Where we are:Development of Reconstructive Knee Surgery has made advancements largely due to the use of the arthroscope.Patients and physicians now take for granted that procedures can be done with arthroscopic assist.
20 LiteratureSuggests it is possible to obtain stability 90-95% with variety of graft sourcesNot all surgeons can obtain this level of stability with single tunnel techniqueDoing a double bundle does not make the procedure technically easier and may in fact lead to further instability ?
21 Are WeFailing Our patients Changes in ACL surgery/rehab need to focus on where we are failing patientsAre we failing with the single tunnel technique?
22 Where are we failing?Recent studies have found that patients with ACL reconstruction have a high incidence of arthritic changes in the long-termWe want to prevent arthritic changes, but do we really know why they occur?
23 Where are we failing?Is it the meniscus, bone bruise, the cartilage, the graft?Do we need double bundles?The theory is that arthritic changes are occuring because adequate stability is not being achieved with single-bundle
24 Where are we failing?ACL deficient knee alone does not cause arthritic changesIt is the meniscus tears and chondral damage that occurs with additional giving way episodes that causes the problemIf a person with an ACL-deficient knee can prevent instability, arthritic changes may not occur
25 Where are we failing?Patients who have some knee laxity with full ROM are better off long-term than patients with stability and less than full ROM“Stable” knees may be bad knees in the future if we don’t also consider all factors that make knees symmetrical
26 Where are we failing?Goals of ACL surgery is to obtain knee symmetry forStabilityROMStrengthFUNCTION
27 Don’t change into a technicians We seem to always seek a surgical answer to problemsMost solvable problems are related to rehabilitation, not surgeryCannot control meniscus tears or chondral damage
28 Changing Surgical Technique Why “fix” a problem that we have not really foundWhy Ignore other big problems, ie chondral and meniscus damage
29 Biomechanical Research need forin situ forcesin vivo dataFor ACL and PCL !
30 ACL Single bundle ACL currently the gold standard 10-35% poor results based on continued pain and instabilityLong term follow-up (7 years) shows indicates a high proportion of patients develop DJDBiau, Corr, 2007Freedman et al.,AJSM, 2003Fithian DC et al, AJSM 2005
31 Single Bundle ACLSingle bundle ACL reconstruction does not recreate the normal knee kinematicsEvidence points to double bundle recreating kinematicsDoes it matter?
32 ACL AnatomyPL and AM parallel in extensionBoth bundles have tension
33 ACL AnatomyIn flexion AM stays tight, PL loosens
55 Fixation with bioscrew But ...Weiler et al. 1998
56 Fixation - Failures single side fixation FAILED HEALING ? ACL reconstruction with hamstrings,fixation with PLLA interference screw15 mo after ACL surgerysingle side fixationFAILED HEALING ?
57 Fixation - Failures New Bio-Screws with TCP to incorporate faster Allograft Screws: $$$$Two screws more than surgeon reimbursement for procedureBilled to insurance as allograft: ethics of this practice?
58 Biological Incorporation No graft can completely reproduce insertion sites!Improve healing?Improve remodeling?
60 Immobilization Not the answer to gain graft incorporation. Graft incorporation enhanced by stress loads below the threshold of fixation
61 Problems with Motion Post Op Some reasons patients have problems with extension post op could be cyclops lesion, scar tissue, or malposition of graft. Surgeon needs to be sure of graft placement and check motion before secures the graft in place
62 Scar tissueScar tissue around the patella femoral joint will severely limit flexion. This needs to be addressed early in PT with aggressive treatment for patellar mobilization.Stiffness rate should not exceed 3-5%.
65 Why Improve? Too Much Morbidity from injuries and the surgery! Preventive Training unable to prevent injury.
66 What can we do to become better? Understand anatomyRecreate anatomy as closely as possibleUse of technology?Need for more accurate way to measure reproducibly rotational control achieved with ACL reconstructions