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6 th Annual Wichita Sports Medicine Symposium June 6 th 2009.

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Presentation on theme: "6 th Annual Wichita Sports Medicine Symposium June 6 th 2009."— Presentation transcript:

1 6 th Annual Wichita Sports Medicine Symposium June 6 th 2009

2 KNEE LIGAMENT INJURIES: EXAM AND TREATMENT Daniel J. Prohaska, MD June 6, 2009

3 Talk available:

4 Knee Ligaments Why do we need a knee lecture Why do we need a knee lecture Everything is pretty much sorted out in regard to the knee isn’t it? Everything is pretty much sorted out in regard to the knee isn’t it? Just when you think you have it all down…. Just when you think you have it all down….

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7 Ligament Injury ACL48% MCL29% ACL/MCL13% PCL7% LCL3% Miyasaka, 1989

8 200,000 ACL Injuries Per Year?

9 Different Grafts Biological graft materials: autograft: BPTB, Hamstrings, Quad-tendon allograft: Achilles, BPTB, ACL, peroneal Synthetic graft materials have not been successful Engineered biological ACL scaffolds: still experimental

10 Use of different grafts BPTB 1983-Extraarticular Allografts BPTB-Auto 1992-Hamstrings

11 Who Uses What? Hamstrings + BPTB: equal. 62% use multiple grafts Education of graft choices leads to best graft More than one graft may work for each patient

12 Global Perspective on ACL Reconstruction > 20 different techniques > 5 different grafts > 5 different grafts different rehab protocols different rehab protocols different outcome assessments different outcome assessments

13 How perfect are current operative techniques?

14 20 years ago less knowledge about graft options

15 Advantages BPTB HAMSTRINGS Consistent size and shape Bone to bone healing Consistent fixation Various fixations Tendon-Bone- Healing Graft Comparison Disadvantages Donor site morbidity Greater stiffness No interference with extensor mechanism

16 Advantages Quadriceps tendon Allograft Higher stiffness Bone to bone healing at one side Decrease in tensile strength Prolonged healing response Disease transmission Graft Comparison Disadvantages Donor site morbidity Better cosmesis No donor site morbidity Less postoperative pain

17 Perfect Graft Reproduces insertion and biomechanics Biological incorporation Resumes neuromuscular control

18 Biomechanical research Single bundle ACL (BPTB and hamstrings) AP stability restored rotational stability not restored Pivot shift not restored

19 Where we are: Development of Reconstructive Knee Surgery has made advancements largely due to the use of the arthroscope. 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. Patients and physicians now take for granted that procedures can be done with arthroscopic assist.

20 Literature Suggests it is possible to obtain stability 90-95% with variety of graft sources Suggests it is possible to obtain stability 90-95% with variety of graft sources Not all surgeons can obtain this level of stability with single tunnel technique Not all surgeons can obtain this level of stability with single tunnel technique Doing a double bundle does not make the procedure technically easier and may in fact lead to further instability ? Doing 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 patients Changes in ACL surgery/rehab need to focus on where we are failing patients Are we failing with the single tunnel technique? Are 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- term Recent studies have found that patients with ACL reconstruction have a high incidence of arthritic changes in the long- term We want to prevent arthritic changes, but do we really know why they occur? We 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? Is it the meniscus, bone bruise, the cartilage, the graft? Do we need double bundles? Do we need double bundles? The theory is that arthritic changes are occuring because adequate stability is not being achieved with single-bundle 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 changes ACL deficient knee alone does not cause arthritic changes It is the meniscus tears and chondral damage that occurs with additional giving way episodes that causes the problem It is the meniscus tears and chondral damage that occurs with additional giving way episodes that causes the problem If a person with an ACL-deficient knee can prevent instability, arthritic changes may not occur If 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 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 “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 for Goals of ACL surgery is to obtain knee symmetry for Stability Stability ROM ROM Strength Strength FUNCTION FUNCTION

27 Don’t change into a technicians We seem to always seek a surgical answer to problems We seem to always seek a surgical answer to problems Most solvable problems are related to rehabilitation, not surgery Most solvable problems are related to rehabilitation, not surgery Cannot control meniscus tears or chondral damage Cannot control meniscus tears or chondral damage

28 Changing Surgical Technique Why “fix” a problem that we have not really found Why “fix” a problem that we have not really found Why Ignore other big problems, ie chondral and meniscus damage Why Ignore other big problems, ie chondral and meniscus damage

29 Biomechanical Research need for need for in situ forces in situ forces in vivo data in vivo data For ACL and PCL ! For ACL and PCL !

30 ACL Single bundle ACL currently the gold standard Single bundle ACL currently the gold standard 10-35% poor results based on continued pain and instability 10-35% poor results based on continued pain and instability Long term follow-up (7 years) shows indicates a high proportion of patients develop DJD Long term follow-up (7 years) shows indicates a high proportion of patients develop DJD Biau, Corr, 2007 Biau, Corr, 2007 Freedman et al.,AJSM, 2003 Freedman et al.,AJSM, 2003 Fithian DC et al, AJSM 2005 Fithian DC et al, AJSM 2005

31 Single Bundle ACL Single bundle ACL reconstruction does not recreate the normal knee kinematics Single bundle ACL reconstruction does not recreate the normal knee kinematics Evidence points to double bundle recreating kinematics Evidence points to double bundle recreating kinematics Does it matter? Does it matter?

32 ACL Anatomy PL and AM parallel in extension PL and AM parallel in extension Both bundles have tension Both bundles have tension

33 ACL Anatomy In flexion AM stays tight, PL loosens In flexion AM stays tight, PL loosens

34 ACL Histologically the insertions are distinct Histologically the insertions are distinct

35 ACL Right knee Right knee Standard lateral portal Standard lateral portal Only bifurcate ridge and part of posterolateral bundle insertion are visualized Only bifurcate ridge and part of posterolateral bundle insertion are visualized

36 ACL Anatomy Right Knee Right Knee Viewing through medial portal Viewing through medial portal

37 ACL Anatomy

38 3-D ACL reconstruction Tunnel

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41 ACL Factory?

42 ACL double-bundle ACL graft: 2 bundles What does it take to do double?

43 PCL injuries treatment controversial conservative treatment for isolated injuries ? clinical results of PCL reconstruction: 80% satisfaction

44 PCL Anatomy - Components anterolateral (AL) taut in flexion posteromedial (PM) taut in extension meniscofemoral (MFL)

45 PCL Biomechanics Tensile testing: AL - stiffer, stronger than PM and MFLTensile testing: AL - stiffer, stronger than PM and MFL Function of different bundles of PCL can not be restored with single drill hole replacementFunction of different bundles of PCL can not be restored with single drill hole replacement

46 PCL Reconstruction 1999 Current approaches tunnel placement: AL graft fixation / tension: knee in flexion Newer considerations double bundle

47 PCL Reconstruction – 2009 Double Bundle 1. AL 10 mm Achilles tendon Fix at 90° with anterior drawer 2. PM 7-8 mm doubled ST Fix at full extension

48 Double-bundle technique PCL Reconstruction AL PM

49 Tibial Onlay technique PCL Reconstruction

50 GRAFT HEALING Goal is to reproduce the insertion site of the native ACL Goal is to reproduce the insertion site of the native ACL Different healing for different grafts Different healing for different grafts

51 ACL insertion subchondral bone mineralized cartilage non-mineralized cartilage ligament “tide mark” mineralized cartilage non-mineralized cartilage bone ligament

52 Animal studies for tendon to bone fixation (hamstring) Extra-articular model Intra-articular model Rodeo et al, 1993 Grana et al Single collagen fibers attaching to bone attaching to bone

53 Factor of Rehabilitation Tailor Made ! Rehab depending on graft fixation slow rehabilitation fast

54 Different Fixations

55 Weiler et al Fixation with bioscrew

56 Fixation - Failures 15 mo after ACL surgery single side fixation FAILED HEALING ? ACL reconstruction with hamstrings, fixation with PLLA interference screw

57 Fixation - Failures New Bio-Screws with TCP to incorporate faster New Bio-Screws with TCP to incorporate faster Allograft Screws: $$$$ Allograft Screws: $$$$ Two screws more than surgeon reimbursement for procedure Two screws more than surgeon reimbursement for procedure Billed to insurance as allograft: ethics of this practice? Billed to insurance as allograft: ethics of this practice?

58 Biological Incorporation èNo graft can completely reproduce insertion sites! èImprove healing? èImprove remodeling?

59 IGF-1 bFGF Decorin BMP-2 Biological solutions

60 Immobilization Not the answer to gain graft incorporation. Not the answer to gain graft incorporation. Graft incorporation enhanced by stress loads below the threshold of fixation 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 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 tissue Scar tissue around the patella femoral joint will severely limit flexion. This needs to be addressed early in PT with aggressive treatment for patellar mobilization. Scar 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%. Stiffness rate should not exceed 3-5%.

63 Biological solutions Cell therapy Gene therapy Tissue engineering

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65 Why Improve? Too Much Morbidity from injuries and the surgery! Too Much Morbidity from injuries and the surgery! Preventive Training unable to prevent injury. Preventive Training unable to prevent injury.

66 What can we do to become better? Understand anatomy Understand anatomy Recreate anatomy as closely as possible Recreate anatomy as closely as possible Use of technology? Use of technology? Need for more accurate way to measure reproducibly rotational control achieved with ACL reconstructions Need for more accurate way to measure reproducibly rotational control achieved with ACL reconstructions

67 Thank You!!


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