POSTGRAD ORTH Deiary Kader

ACL InjuriesFRCS(Tr&Orth) Revision Course

Professor Deiary Fraidoon KaderConsultant Orthopaedic & Trauma Surgeon

Knee Surgeon

Newcastle Nuffield

Postgraduate OrthopaedicsFRCS(Tr&Orth) Revision Course

Newcastle Upon Tyne 16-21 March 2015

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Professor Deiary KaderConsultant Orthopaedic & Trauma Surgeon

Knee Surgeon

Nuffield Hospital Newcastle

NGMV Charity

POSTGRAD ORTH Deiary Kader

Classification of Knee Stabilisers

Lateral Complex

ITB

LCL

Popliteus

Biceps Femoris

Central Complex

ACLPCL

Med Menx

Lat Menx

Medial Complex

MCL

Postromedial Capsule

Semi-Memb

Pes anserinus

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Anatomy

33 mm long, 11 mm in diameter

Two bundles

AM bundle – tighten in flexion

PL bundle – tighten in extension

Supplied by middle geniculate artery

90% type I and 10% type III collagen

Anatomy (Weber brothers 1836)

(PL) bundle fibres tighten rapidly during the early extension <30º.

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ACL is a primary resister to internal rotation of the tibia at <35º of flexion while the anterolateral ligament is a stabiliser of internal rotation

in >35º of flexion .Erin M. Parsons, Albert O. Gee, Charles Spiekerman, and Peter R. Cavanagh

The Biomechanical Function of the Anterolateral Ligament of the KneeAm. J. Sports Med. Jan 2015

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Immunohistochemical analysis revealed some free nerve endings ( ) and ovoid

Ruffini corpuscles ( * ) are present.Curtesy of French Arthroscopic SocietyDr Sonnery Cottet

Free nerve endings

Ruffini corpuscles

Proprioception:

“Call for help” from ACL under stress to the surrounding muscles. The Hamstrings

Type II receptors (Ruffini and Pacini bodies

Anatomy: ACL MechanoreceptorsPOSTGRAD ORTH Deiary Kader

AnatomyProprioception:

knee proprioception returned to normal within

6 months of ACL reconstruction,

Angoules AG, Mavrogenis AF, Dimitriou R, Karzis K, Drakoulakis E, Michos J, et al. Knee proprioception following ACL reconstruction; a prospective trial comparing hamstrings with bone-patellar tendon-bone autograft. Knee. 2011;18:76–82.

Curtesy of Mr Panos Thomas

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Mechanism of injury

Low velocity, deceleration and pivotal injury, usually non-contact

High-energy RTA

Audible or feeling of “popping”

Acute haemarthrosis in young 1–2 h, less dramatic in older patient

20% of ACL injury associated with MCL injury

80% incidence of lateral meniscal injury with combined ACL–MCL

Valgus + ER

POP

POSTGRAD ORTH Deiary Kader

Causes of InjuryMechanisms of Injury:

1) “plant-and-cut” manoeuvre

2) Knee Hyperextension (Fall backwards)

3) Landing on one leg following a jump

(Olsen et al 2004)

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Clinical presentationChronic ACL Deficiency:1) “Subjective Instability”2) ‘Pain’3) Recurrent joint

effusion4) Locking5) Quadriceps Atrophy

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McDaniel – Rule of Thirds

One-third is able to compensate, and can pursue

normal recreational sports

One-third is able to compensate but will have to

reduce their sporting activities

One-third does poorly and develop instability with

simple activities daily living

Clinical Examination

Stability Testing:The Lachman test is the most

Sensitive test in Dx ACL tear

History:

- Noulis test (Georges Noulis Thesis in Paris, 1875)

- Ritchley test (1960)

- Ritchley-Lachman test (Torg et al 1976)

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Curtesy of Mr Panos Thomas

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Clinical ExaminationPositive Lachman test with a FIRM ENDPOINT

1. Partial ACL tear

2. Displaced bucket-handle meniscus tear

3. Intra-articular loose bodies

4. OA changes

LFC

PCL

ACL

“Lambda healing” AM bundle heals over PCL

(no subjective instability) (Zantop et al 2007)

An Empty wall sign

POSTGRAD ORTH Deiary Kader Curtesy of Mr Panos Thomas

Clinical ExaminationPivot Shift Sign:

Intact Iliotibial tract is required

Lachman tests anterior translation,

Pivot shift tests rotational stability

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Paul F. Segond

a Paris surgeon

1879

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ACL Injury

Diagnosis

Physical Exam

Lachman

Pivot shift (confirmatory)

Plain Radiographs Segond Fracture (<5%)

Standing films for middle-aged athlete (Arthritis)

MRI

MRIAcute tear:1. Discontinuity ACL fibres (T1

weight)2. Signal irregularities in the

ACL course (T2 weight)3. Empty notch sign (coronal T1

weight)4. Changes of the ACL angle5. Partial ACL tear (T2 weight)Indirect signs:1. Buckling of PCL 2. Bone bruise (Lat femoral

condyle, lat tibial plateau)

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MRIChronic tear:1) Direct and indirect signs

of ACL tear2) Subchondral lesions3) Notch changes4) Evaluation of articular

cartilage lesions5) Loose bodies6) Evaluation of menisci7) Subchondral oedema8) Other soft tissue (PCL,

PLC)

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ACL Evidence-Based Review

Factors affecting results:

Patient Selection

Tunnel placement

Strong graft choices

Solid fixation

Rational rehabilitation

Non-Operative Treatment Activity modification

(swimming, bicycling, jogging on flat ground)

Muscle Training (Hamstrings strength)

Proprioceptive Training

Bracing (reduce anterior drawer)

Surgical TreatmentIndications:1) Subjective instability (non-coper)2) ACL tear in children and

adolescents3) Multiligament injury4) Displaced meniscal tears5) Instability in OA (positive brace

test)?

Surgical Extra-articular reconstruction (Lemaire 1967 & MacIntosh 1972)

Involves tenodesis of the iliotibial tract. Eliminates pivot shift but there is concern

regarding its effectiveness in addressing anterior translation

Intra-articular reconstruction. Current best practice

Intra + Extra articular reconstruction

Intra-articular ACL Reconstruction

Techniques of femoral tunnel placement

A. Transtibial technique

B. Medial portal technique

Transtibial techniqueAdvantages:1) Simple technique2) No graft angulationDisadvantages:1) Little ability to adjust

femoral tunnel position2) Posterior placement of the

tibia tunnel3) Risk of tibia tunnel

enlargement4) Need for a notch plasty5) Irrigating fluid leak from the

tibia tunnel

Curtesy of Mr Panos Thomas

Medial portal techniqueAdvantages:1) Independent placement of the

femoral and tibia tunnels2) No fluid leakage from the tibia

tunnel3) Anatomic placement of the tibia

tunnel4) Ability to customise the tunnel

diameters5) Excellent for revision procedures

Disadvantages:1) Restricted vision in max flexion2) Learning curve

Curtesy of Mr Panos Thomas

Hamstring BTB

Grafts / Fixations

Quads

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Curtesy of Dr Sonnery Cottet

Hamstring tendonsAdvantages Disadvantages

1. Small incisions

2. Easy graft passage

3. High initial ultimate load (>4000 N, Woo et al, 1991)

4. Less risk of cyclops syndrome

5. Variable graft length

1. Exacerbation of medial instability

2. Prolonged osseointegration of the graft 8-12 weeks

3. Weakening of knee deepflexion (3-4 months)

4. Saphenous nerve injury

Bone-to-bone healing

Direct rigid fixation

Faster biological

integration in 6 weeks

PFJ Morbidity (Pinczewski)

Anterior knee pain 30%–50%

Patellar tendinosis 3%–5%

Fracture patella, rare

Patella baja

Development of late OA

Patellar tendon

Advantages Disadvantages

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Allograft

Biologically inactive

Slower incorporation

Less stability in 6 months

Risk of disease transmission

Role in revision surgery

Weaker after having been irradiated

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In 1972, D. L. MacIntoshIn 1967,1975, M. Lemaire

Extra-articular reconstruction

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ANTEROLATERAL LIGAMENT

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Am J Sports Med. 2015 Jan 2.The Biomechanical Function of the

Anterolateral Ligament of the Knee.

Damage to the ALL of the knee could result in knee instability at high angles of flexion.

It is possible that a positive pivot-shift sign may be observed in some patients with an intact ACL but with damage to the

ALL.

This work may have implications for extra-articular reconstruction in patients with chronic anterolateral

instability.

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The effect of femoral tunnel placement on ACL graft orientation and length during in vivo knee flexion. J Biomech 2011Abebe ES, Kim JP, Utturkar GM, Taylor DC, Spritzer CE, Moorman CT, Garrett WE, DeFrate LE.

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Anatomic Single bundle recon

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5mm +

Comparison of 2 femoral tunnel locations in anatomic single-bundle anterior cruciate ligament reconstruction: a biomechanical study. Arthroscopy 2012;

Driscoll MD, Isabell GP, Conditt MA, Ismaily SK, Jupiter DC, Noble PC, Lowe WR

Centre AM Bundle vs centre of femoral foot print

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Single or Double bundle technique?

Anatomical Single-Bundle Technique Double-Bundle Technique

Advantages:

1) Simplicity

2) Broad spectrum of grafts

3) Simpler graft passage

4) Lower cost

Disadvantages:

1) Inadequate rotational stability

Advantages:

1) ?Better rotational stability

2) Allowance for individual variables

Disadvantages:

1) Anatomic or not? (Numerous double bundle techniques)

2) Technically demanding

3) Longer operating time

4) Limited graft selection

Cochrane Database Rev. 2012 Double-bundle versus single-bundle reconstruction for anterior cruciate ligament rupture in adults

There is insufficient evidence to determine the relative effectiveness of double-bundle and single-bundle reconstruction for anterior cruciate ligament rupture in adults, although there is limited evidence that double-bundle ACL reconstruction has some superior results in objective measurements of knee stability and protection against repeat ACL rupture or a new meniscal injury.

Curtesy of Dr Sonnery Cottet

45°, Curve, QuickPass Lassos

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Curtesy of Dr Sonnery Cottet

HIDDEN LESION and Ramp tear

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Curtesy of Dr Sonnery Cottet

ACLR Clinical Questions?? Evidence

What is the risk of infection after ACLR 0.8% (LOE1)

Menx Repair Not on tech 94% success

What are the risk of ACLR graft failure at

2 years

3% (LOE1)

What are the risk of ACL tear in the

normal contra lateral knee at 2 years

3-6%

What is the risk of future OA

(radiographic) after ACL tear/ACLR?

Isolated ACL tear:0-13%

ACL+Menx tear: 21-48%

(LOE2)

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ACLR Clinical Questions Evidence

What is the best graft autograft or

allograft

No difference from meta-analysis but does

not address the young active or elite

athlete (LOE3)

Bioabsorbable or metal Screws No difference

Only knee effusion is higher in Bio!

(LOE1)

What is the best Autograft choice HG or

PTB

No difference (LOE1)

Should I use a brace after ACLR? No Evidence in isolated ACLR (LOE1)

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What are the complications after ACL

reconstruction?

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Complications

Infection

DVT and PE

Osteoarthritis

Cyclops lesion residual tissue anterior to the ACL

blocks extension

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Complications

Failure of Fixation

Anterior placement of the femoral tunnel limits

flexion

Anterior placement of the tibial tunnel limits

extension

Flexion contracture and arthrofibrosis

Graft rupture from impingement

Tibial Eminence Fracture

Meyers and McKeever classification (1959)

Type I: non displaced

Type II: partially displaced or hinged

Type III: completely displaced (Type III)

Type IIIA (Zifko) involves the ACL insertion only

Type IIIB (Zifko) includes the entire intercondylar eminence.

Type IV (Zaricznyj 1977): comminution of the fracture fragment.

Treatment

Casting in extension for type I

Open reduction and internal fixation.

Arthroscopic reduction and fixation

Rarely ACL reconstruction is necessary

Postgraduate OrthopaedicsFRCS(Tr&Orth) Revision Course

Professor Deiary KaderConsultant Orthopaedic & Trauma Surgeon

Knee Surgeon

Newcastle Nuffield

MCL

Medial Collateral Ligament Injury

Incidence >> LCL Injury

Mechanism of injury

Direct blow laterally, valgus stress, forced external rotation

POSTGRAD ORTH Deiary Kader

Medial Collateral Ligament Exam

Opening @ 30o only Isolated MCL Injury

Opening @ 0o

Injury to Posteromedial Capsule

Usually with ACL +/or PCL injury

25-30° of flexion, the MCL

provides 80% of the support

to valgus stress

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Classification

I Localised tenderness, no instability, or laxity on testing

II localised swelling, possibly mild laxity, no instability

III definite clinical laxity ..Instability symptom . (80% MLI)

< 5 mm, 5-10 mm, > 10 mm

MCL

MCL

MCL4 mm proximal

4 mm posterior to the medial epicondyle

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MCL tear arising from the tibial insertion May lead to

STENER type lesion

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TreatmentAcute isolated MCL tear

I Simple rest, ice, compression bandage, early physiotherapy. 2 Wks

II Hinged brace for symptom improves, WBAA, 1-2weeks

III Hinged brace 30-90/ Surgical 3-4 wks

Operative treatment depend on site and patient

Chronic isolated MCL tear – simple reapproximation – tend to elongate and stretch

therefore needs Augmentation with semitendinosis

Combined injury ACL and MCL→Reconstruction ACL and non-operative

treatment MCL I-II but surgical for III

MCL

MCL Reconstruction with AT

+

Revision ACLR

Chronic MCL Injury

POSTGRAD ORTH Deiary Kader

THANK YOU