1. NEW ADVANCEMENTS in ORTHOPAEDIC SPORTS MEDICINE
Prof. Berkes, I.

2. PRIORITIES in SPORTS MEDICINE
Antidoping
Prevention
Safe and effective surgeries
Minimal invasivity
Autografts
Solid fixation
Early and accelerated rehabilitation

3. DISTRIBUTION of SPORTS INJURIES
Lower extremity 61 %
Upper extremity 22 %
Spine-trunk 17 %

4. ANTERIOR CRUCIATE LIGAMENT
(ACL)

5. ACL RECONSTRUCTION USA 75.000 -100.000 / year Hungary 7.000 / year
85 % of orthopedic surgeons perform less than 10 ACLR / year

6. ACL RECONSTRUCTION 75 - 90 % success rates 10 % pain and instability
Revision surgery
Faulty surgical technique
Improper tibial and femoral bone tunnel placement
Osteoarthritis 35 %

7. PREVENTION Consensus Good & balanced muscular strength
Eccentric and concentric resistance training
Muscle flexibility
Stretching
Good proprioceptive function
Proprioceptive training
Good aerobic & anaerobic stamina
Controlled endurance training

8. PREVENTION Challenges Introduction is often difficult
Resistance from club and coaches
Most methods: well-defined effective doses, BUT does the schedule allow to apply them?
They prevent non-contact injuries effectively, BUT what about contact injuries?
Acute knee ligament injuries will keep on happen…

9. DIAGNOSIS Consensus Good history taking Physical examination
Injury mechanism
Physical examination

10. HEMARTHROSIS Calls for differentiated approach
„Diagnostic arthroscopy” - Has any therapeutic benefit?
„Morphologic diagnosis by arthroscopy”
Carries several potential risks!

11. INDICATIONS Activity and occupational level
Associated lesions (i.e. repairable menisci)
Age
Combined ligamentous injuries
Instability producing functional disability
Ability of a patient to comply with a rehab program

12. ACL RECONSTRUCTION > 20 different techniques
> 5 different grafts
Different rehabilitation protocols
Different outcome assessments

13. AFFECTING FACTORS Preoperative rehabilitation
Surgeons’s skills and experience
Graft material
Graft placement
Initial graft tension

14. AFFECTING FACTORS Graft fixation Concomitant injuries Rehabilitation
Graft healing
Insertion site healing

15. PREOP REHABILITATION Preop rehabilitation is benefitial !
Increase in ROM
Muscle build-up +
Patient’s involvement and confidentiality
Learning new motor controls
Learning new skills
Preop rehabilitation is benefitial !

16. GRAFT SELECTION Biological graft materials:
Autograft: BPTB, Hamstrings, Quad-tendon
Allograft: Achilles, BPTB, ACL
Synthetic graft materials have not been successful.
Engineered biological ACL scaffolds: still experimental.

17. TENDON-to-BONE HEALING
Single collagen fibers
attaching to bone –
„Sharpey’s fibers”

18. BONE-to-BONE HEALING Schiavone et al., 1993.
Knee Surg. Sports Traumatol. Arthros.
Rabbit study
Incorporations months
Normal insertion 6-9 months
Hidas et al., 2005.

19. ARE RESULTS GRAFT- DEPENDENT?
Aglietti et al. Am J Sports Med 1994;22(2):211
„…no significant overwhelming differences between BPTB and hamstring implantation…“
Denti et al. Knee Surg Sports Traumatol Arthrosc Jan 10:1-4
„…no statistical differences in the clinical and instrumental evaluations of stability after 1 and 2 years (Lachman and Jerk test, KT1000) between BPTB and hamstring…“

20. approach to RHB according to graft selection
HOWEVER
„…delayed TENDON-BONE healing (soft grafts) with potential risk of graft stretch out in bony cannal is presumeble…“
Meister K, Huegel M, Indelicato PA, et al. Current concepts in the
recognition and treatment of knee injuries. APTA SPTS HSC-00: Lacrosse, WI; 2000.
Slightly different
approach to RHB according to graft selection

21. OUR GRAFT SELECTION Hamstrings (ST and / or GR)
Most primary indications, less active, older patients, PF problems, less demanding activities, some revisions
BPTB
Professional athletes, some revisions
Allograft
Some revisions, PF and hamstrings problem

22. USE of DIFFERENT GRAFTS
60 % HS
35 % BPTB
5 % Allografts

23. GRAFT PLACEMENT

24. GRAFT FIXATION

25. GRAFT FIXATION

26. GRAFT TUNNEL MOTION

27. TUNNEL WIDENING Universal problem in Hamstrings and BPTB
in auto- and allografts
Etiology?
Clinical significance?

28. BIOMECHANICAL RESEARCH
Single bundle ACL reconstruction
(BPTB and Hamstrings)
AP stability restored
Rotational stability not restored
Pivot shift not restored

29. ACL RECONSTRUCTION
Single bundle ACL reconstruction - procedure of choice for instability in the past decade
Clinical and biomechanical studies: SB ACL reconstruction restored the sagittal stability but not the rotational stability
Anatomical reconstruction of the two functional bundles of the ACL is necessary?

30. ACL From anterior and central tibia
to posterior and medial aspect of LFC
Primary restraint to anterior tibial translation
Controls pivot shift phenomenon

31. Anteromedial bundle
Posterolateral
bundle
2 major bundles: Anteromedial
Posterolateral

32. KINEMATICS
Different tension patterns and elongation behaviors of different fiber bundles with knee flexion

33. Nomenclature of the bundles related to their tibial insertionAM PL
Nomenclature of the bundles
related to their tibial insertion

34. AM: anterior and proximal PL: posterior and distal
Femoral insertion
AM: anterior and proximal
PL: posterior and distal

35. ACL Reconstruction No ACL remnants in chronic lesions
Need to know arthroscopic anatomy

36. Femoral Insertion
Arthroscopic Nomenclature 12 6 3 9
30°

37. Less important for ACL graft kinematics
Tibial Tunnel Position
Less important for ACL graft kinematics
Muneta, Am J Sports Med, 1993
Hefzy, Am J Sports Med, 1994

38. Avoid impingement !
Howell & Taylor, JBJS, 1993

39. Femoral Tunnel Position60 40
Graft tension (Newton)
shallow 20
isometric 20 50 80
110
Knee flexion (°)
Strongly affects graft tension and knee kinematics
Position close to AM bundle insertion more isometric
Zavras & Amis, KSSTA, 2001

40. Double bundle (anatomic) reconstruction12 6 3 9

41. OUR RATIONALE 1) To adopt a reproducible surgical technique
2) Based on cadaveric validations

42. Comparative Study Single bundle 1 tibial, 2 femoral

43. CONCLUSIONS
ACL insertions show a high variability both in location and dimension
Often in ACL injuries no femoral footprint remnants can be visualized at arthroscopy
Need for precise landmarks and reproducibility

44. CONCLUSIONS
Single bundle ACL reconstruction is effective in limiting anterior translation but does not control pivot-shift
Double bundle sounds promising, but clinical results are necessary to confirm lab results

45. ARTHROSCOPIC MENISCUS SURGERY
To preserve as much healty meniscus tissue as possible

46. MENISCAL HEALING
The peripheral blood supply can produce a reparative response
Fibrovascular scar tissue by 10 weeks

47. HEALING ENCHANCEMENT Fibrin glue Fibrin clot insertion
Vascular access channels
Synovial abrasion
Modulators of healing

48. CLASSIFICATION

49. TREATMENT OPTIONS
Leave alone
Benign neglect
Puncture
Resect
Repair

50. IDEAL TEAR FOR REPAIR Traumatic Vertical longitudinal Peripheral 3 mm
1 - 4 cm
No damage to the meniscal body

51. CONTRAINDICATIONS Complex geometry Flap tears Complete radial tears
Recovery time?

52. MENISCUS REPAIR

53. MENISCUS-REPAIR

54. REFIXATION IMPLANTS DART (ARTHREX) FASTENER (MITEK) STAPLE (ARTHROTEK)
CLEARFIX SCREW ( MITEK )
T – FIX (SMITH + NEPHEW )

55. REHABILITATION Depends on repair! Weight - bearing Range of motion
Bracing
Squatting >120 degree
Return to sports

56. REHABILITATION 6 WKS - WEIGHT-BEARING RESTRICTION
3 MO - LOW IMPACT SPORTS
6 MO - RETURN TO PREVIOUS LEVEL OF
ACTIVITY
DeHAVEN

57. REHABILITATION 0 - 2 wks – wbat
2 - 4 wks – closed kinetic chain resistance
4 - 8 wks – sports specific functional progression
SHELBOURNE

58. HANGODY’s MOSAICPLASTY

59. STEADMAN’s MICROFRACTURE

60. REHABILITATION Depends on graft fixation slow rehabilitation fast
Must be accelerated and not aggressive!

61. TODAY Immediate mobilization Gradual increase in ROM
Graft dependent
Progressive weight-bearing
Proprioception restoration

62. GRAFT DIFFERENCE Hamstrings BPTB Allograft
Hamstrings strenghtening from 5 ws
Running 12 ws, jumping ws
Full sports 6 ms
BPTB
Full hamstrings strenghtening from beginnig
Running ws
Full sports 6-9 ms
Allograft
Program focused more on prevention of arthrofibrosis

63. INSERTION SITE HEALING
Tendon-to-Bone healing
Growth-Factors
Near
future?

64. ANATOMY
ROBOTICS
BIOMECHANICS
SCAFFOLD
MUSCLE BIOPSY
STEM CELLS
GROWTH-FACTOR

65. Year 2020 CT-scan Fetal cord cells Gene transfer ligament scaffold
enhanced with autologous cells
Gene transfer

66. TAKE-HOME MESSAGE
„Attention to detail
is the key to success!”