Multiligament Knee Injury:Does the ALL Matter? · PDF file4/13/2016 1 Adam Anz, MD Andrews...
Transcript of Multiligament Knee Injury:Does the ALL Matter? · PDF file4/13/2016 1 Adam Anz, MD Andrews...
4/13/2016
1
Adam Anz, MD
Andrews Institute
Gulf Breeze, Florida
Multiligament Knee Injury:Does
the ALL Matter?The Case for ALL
Reconstruction
• Segond Fracture
• 1879
• Synonymous with a tear of the ACL
• Cadaver Study which
demonstrated this fracture pattern
Description of “A pearly, resistant fibrous band” attached to this fracture fragment
History• Dr. Hughston – 1976
• The middle third of the lateral capsular ligament
attaches proximally to the lateral epicondyle and distally to the tibial joint margin
• Anterolateral Rotatory Instability
History
Anterolateral Instability Surgery
Andrews CORR 1983
• 70’s: Restore Rotational Anatomy Lateral-Plasty + ACL Repair
Tenodesis
• 70’s: Restore Rotational Anatomy Lateral-Plasty + ACL Repair
Tenodesis
Andrews AJSM 1985
History
Anterolateral Instability Surgery
• 70’s: Restore Rotational Anatomy Lateral-Plasty + ACL Repair
Tenodesis
• 80‘s: Arthroscopic ACL
History
Anterolateral Instability Surgery
4/13/2016
2
7
• 70’s: Restore Rotational Anatomy Lateral-Plasty + ACL Repair
Tenodesis
• 80‘s: Arthroscopic ACL
• 90‘s: Intra- Articular Double Bundle “A method to better restore rotational stability”
History
Anterolateral Instability Surgery
8
• 70’s: Restore Rotational Anatomy Lateral-Plasty + ACL Repair
Tenodesis
• 80‘s: Arthroscopic ACL
• 90‘s: Intra- Articular Double Bundle “A method to better restore rotational stability”
• 00’s: “Anatomic ACL”
History
Anterolateral Instability Surgery
• 70’s: Restore Rotational Anatomy Lateral-Plasty + ACL Repair
Tenodesis
• 80‘s: Arthroscopic ACL
• 90‘s: Intra- Articular Double Bundle “A method to better restore rotational stability”
• 00’s: “Anatomic ACL”
• 10’s:
Fast Forward to 2014 !!!!
History
Anterolateral Instability Surgery
• 70’s: Restore Rotational Anatomy Lateral-Plasty + ACL Repair
Tenodesis
• 80‘s: Arthroscopic ACL
• 90‘s: Intra- Articular Double Bundle “A method to better restore rotational stability”
• 00’s: “Anatomic ACL”
• 10’s:
Fast Forward to 2014 !!!!
History
Anterolateral Instability Surgery
The Decade of the ALL
11
• 70’s: Restore Rotational Anatomy Lateral-Plasty + ACL Repair
Tenodesis
• 80‘s: Arthroscopic ACL
• 90‘s: Intra- Articular Double Bundle “A method to better restore rotational stability”
• 00’s: “Anatomic ACL”
• 10’s:
Fast Forward to 2014 !!!!
History
Anterolateral Instability Surgery
The Decade of the ALL
“Back to the Future”
The Science
• METHODS-41 Unpaired Human Cadaveric Knees, Dissected and Examined for anatomic attachments of the ALL
• RESULTS-All but 1 specimen (97%) contained an ALL (Anterolateral Ligament)
• CONCLUSION-The ALL was found to be a DISTINCT LIGAMENTOUS
STRUCTURE
4/13/2016
3
Do You Buy It?
Kennedy Laprade AJSM 2015
• Femoral Insertion
- Area 67.7 mm2
- 2.7 mm proximal to FCL
- 2.8 mm posterior to FCL
• Tibial Insertion
- Area 64.9 mm2
Anatomy:
Kennedy Laprade AJSM 2015
• Femoral Insertion
- Area 67.7 mm2
- 2.7 mm proximal to FCL
- 2.8 mm posterior to FCL
• Tibial Insertion
- Area 64.9 mm2
- 24.7 mm Posterior to Gerdy
- 26.1 mm Anterior to Fibula
- 9.5 mm Distal to the Joint
Anatomy:
4/13/2016
4
Anatomy:
Branch Anz OJSM 2015
• Femoral Insertion
- Area 67.7 mm2
- 2.7 mm proximal to FCL
- 2.8 mm posterior to FCL
• Tibial Insertion
- Area 64.9 mm2
- 24.7 mm posterior to Gerdy
- 26.1 mm Anterior to Fibula
- 9.5 mm Distal to the Joint
- Intimate with Tibial Band of BF
- Intimate with Iliotibial Band
20Branch Anz OJSM 2015
Anatomy:
• Femoral Insertion
- Area 67.7 mm2
- 2.7 mm proximal to FCL
- 2.8 mm posterior to FCL
• Tibial Insertion
- Area 64.9 mm2
- 24.7 mm posterior to Gerdy
- 26.1 mm Anterior to Fibula
- 9.5 mm Distal to the Joint
- Intimate with Tibial Band of BF
- Intimate with Iliotibial Band
21Branch Anz OJSM 2015
Anatomy:
• Femoral Insertion
- Area 67.7 mm2
- 2.7 mm proximal to FCL
- 2.8 mm posterior to FCL
• Tibial Insertion
- Area 64.9 mm2
- 24.7 mm posterior to Gerdy
- 26.1 mm Anterior to Fibula
- 9.5 mm Distal to the Joint
- Intimate with Tibial Band of BF
- Intimate with Iliotibial Band
Anatomy:
• Simple Biomechanics
- Failure Load: 175 N
- Stiffness: 20 N/mm
- Segond Fracture: 30%
• Simple Biomechanics
- Failure Load: 175 N
- Stiffness: 20 N/mm
- Segond Fracture: 30%
• Complex Biomechanics
Anatomy:
• Simple Biomechanics
- Failure Load: 175 N
- Stiffness: 20 N/mm
- Segond Fracture: 30%
• Complex Biomechanics
-Does It Do Anything?
Anatomy:
4/13/2016
5
• Simple Biomechanics
- Failure Load: 175 N
- Stiffness: 20 N/mm
- Segond Fracture: 30%
• Complex Biomechanics
-Does It Do Anything?
Anatomy:
Kittl Amis AJSM 2016• Simple Biomechanics
- Failure Load: 175 N
- Stiffness: 20 N/mm
- Segond Fracture: 30%
• Complex Biomechanics
-Does It Do Anything?
Anatomy:
Kittl Amis AJSM 2016
• Simple Biomechanics
- Failure Load: 175 N
- Stiffness: 20 N/mm
- Segond Fracture: 30%
• Complex Biomechanics
-Does It Do Anything?
Anatomy:
Kittl Amis AJSM 2016• Simple Biomechanics
- Failure Load: 175 N
- Stiffness: 20 N/mm
- Segond Fracture: 30%
• Complex Biomechanics
-Does It Do Anything?
-No
Anatomy:
Kittl Amis AJSM 2016
• Simple Biomechanics
- Failure Load: 175 N
- Stiffness: 20 N/mm
- Segond Fracture: 30%
• Complex Biomechanics
-Does It Do Anything?
-No
Anatomy:
Rasmussen Laprade AJSM 2016
• Simple Biomechanics
- Failure Load: 175 N
- Stiffness: 20 N/mm
- Segond Fracture: 30%
• Complex Biomechanics
-Does It Do Anything?
-No
Anatomy:
Rasmussen Laprade AJSM 2016
ACL Deficient Alone
4/13/2016
6
• Simple Biomechanics
- Failure Load: 175 N
- Stiffness: 20 N/mm
- Segond Fracture: 30%
• Complex Biomechanics
-Does It Do Anything?
-No
Anatomy:
Rasmussen Laprade AJSM 2016
ACL + ALL Deficient
• Simple Biomechanics
- Failure Load: 175 N
- Stiffness: 20 N/mm
- Segond Fracture: 30%
• Complex Biomechanics
-Does It Do Anything?
-No
-Yes
Anatomy:
Rasmussen Laprade AJSM 2016
ACL + ALL Deficient
• Simple Biomechanics
- Failure Load: 175 N
- Stiffness: 20 N/mm
- Segond Fracture: 30%
• Complex Biomechanics
-Does It Do Anything?
-No
-Yes
Anatomy:
Rasmussen Laprade AJSM 2016
ACL + ALL Deficient
Whose Right? • Complex Biomechanics
-Does It Do Anything?
-No
-Yes
Anatomy:
Whose Right?
• Complex Biomechanics
-Does It Do Anything?
-No
-Yes
Anatomy:
Whose Right? • Complex Biomechanics
-Does It Do Anything?
-No
-Yes
Anatomy:
Whose Right?
4/13/2016
7
• Complex Biomechanics
-Does It Do Anything?
-No
-Yes
Anatomy:
Whose Right? • Complex Biomechanics
-Does It Do Anything?
-No
-Yes
Anatomy:
Whose Right?
• Complex Biomechanics
-Does It Do Anything?
-No
-Yes
Anatomy:
Whose Right? • Complex Biomechanics
-Does It Do Anything?
-No
-Yes
Anatomy:
Whose Right?
• Complex Biomechanics
-Does It Do Anything?
-No
-Yes
Anatomy:
Whose Right? • Complex Biomechanics
-Does It Do Anything?
-No
-Yes
Anatomy:
Whose Right?
4/13/2016
8
• Complex Biomechanics
-Does It Do Anything?
-No
-Yes
Anatomy:
Whose Right? • Complex Biomechanics
-Does It Do Anything?
-No
-Yes
Anatomy:
Whose Right?
TextProbably Cut Elements of BF and ITB
• Complex Biomechanics
-Does It Do Anything?
-No
-Yes
Anatomy:
Whose Right?
Text
Both Right
Probably Cut Elements of BF and ITB
• Complex Biomechanics
-Does It Do Anything?
-No
-Yes
Anatomy:
Whose Right?
Text
Both Right
Intimate Confluence of ITB, BF, and ALL
Probably Cut Elements of BF and ITB
Technique:• Femoral Footprint- Guide Pin
• 2.7 mm proximal to FCL’s Femoral Insertion
• 2.8 mm posterior to FCL’s femoral Insertion
Technique:• Femoral Footprint- Guide Pin
• 2.7 mm proximal to FCL’s Femoral Insertion
• 2.8 mm posterior to FCL’s femoral Insertion
Kennedy Laprade AJSM 2015
4/13/2016
9
Technique:• Femoral Footprint- Guide Pin
• 2.7 mm proximal to FCL’s Femoral Insertion
• 2.8 mm posterior to FCL’s femoral Insertion
Technique:• Femoral Footprint- Guide Pin
• 2.7 mm proximal to FCL’s Femoral Insertion
• 2.8 mm posterior to FCL’s femoral Insertion
Technique:• Femoral Footprint- Guide Pin
• 2.7 mm proximal to FCL’s Femoral Insertion
• 2.8 mm posterior to FCL’s femoral Insertion
- Aim Distal and Anterior
Technique:• Femoral Footprint- Guide Pin
• 2.7 mm proximal to FCL’s Femoral Insertion
• 2.8 mm posterior to FCL’s femoral Insertion
- Aim Distal and Anterior
• Tibial Footprint- Guide Pin
• 24.7 mm posterior to the center Gerdy’s
• 26.1 mm proximal to anterior margin of fibular head
• 9.5 mm distal to the joint line
- Aim Straight In
• Graft- Allograft SemiT or Gracilis
- 6mm or 7mm
• Fixation- Line to Line
Technique:• Femoral Footprint- Guide Pin
• 2.7 mm proximal to FCL’s Femoral Insertion
• 2.8 mm posterior to FCL’s femoral Insertion
- Aim Distal and Anterior
• Tibial Footprint- Guide Pin
• 24.7 mm posterior to the center Gerdy’s
• 26.1 mm proximal to anterior margin of fibular head
• 9.5 mm distal to the joint line
- Aim Straight In
• Graft- Allograft SemiT or Gracilis
- 6mm or 7mm
• Fixation- Line to Line
Steven Claes, MD:ALL Surgical Technique
4/13/2016
10
Steven Claes, MD:ALL Surgical Technique
1. Guide Pin for the 4.75 mm SwiveLock
2. Aim Anterior and Distal
3. Split the Iliotibial band
Steven Claes, MD:ALL Surgical Technique
1. Guide Pin for the 4.75 mm SwiveLock
2. Aim Anterior and Distal
3. Split the Iliotibial band
Steven Claes, MD:ALL Surgical Technique
4. 4.5 mm Drill to drill to a depth of 24 mm.
5. Whipstitched Gracilis Graft
6. 4.75 mm SwivelLock
Steven Claes, MD:ALL Surgical Technique
7. Insert and Secure the Graft
Steven Claes, MD:ALL Surgical Technique
8. Create a plane underneath the iliotibial band
9. Passing suture from distal to proximal with the hemostat.
10. Pass the graft to the tibial side. 11. Guide Pin between Gerdy’s Tubercle and Fibular Head.
Steven Claes, MD:ALL Surgical Technique
4/13/2016
11
11. Guide Pin between Gerdy’s Tubercle and Fibular Head.
Steven Claes, MD:ALL Surgical Technique
12. Check isometry: Should be isometric between 30-90 degrees of flexion.
Steven Claes, MD:ALL Surgical Technique
Steven Claes, MD:ALL Surgical Technique
13. Drill to a depth of 20 mm with the 7 mm drill.
Steven Claes, MD:ALL Surgical Technique
14. Secure with a 7 mm Tenodesis screw over the graft.
15. Push the graft end into the tunnel and adjust tension by pulling on the
graft.
16. Do Not Over constrain
Steven Claes, MD:ALL Surgical Technique
17. Secure in 30˚ of flexion and neutral tibial rotation.
18. Cut the excess graft exiting the tibial socket.
How Do Reconstructions
Perform:
• Biomechanically
- Laprade: Epub AJSM 2016
• Pretty GoodACL Recon Alone
4/13/2016
12
How Do Reconstructions
Perform:
• Biomechanically
- Laprade Epub AJSM 2016
• Pretty GoodACL + ALL Recon
How Do Reconstructions
Perform:
• Biomechanically
- Laprade Epub AJSM 2016
• Pretty GoodACL + ALL Recon
Tension at 30 Degrees
How Do Reconstructions
Perform:
• Biomechanically
- Laprade Epub AJSM 2016
• Pretty GoodACL + ALL Recon
You Can Over Constrain
How Do Reconstructions
Perform:
• Biomechanically
- Laprade Epub AJSM 2016
• Pretty GoodACL + ALL Recon
You Can Over Constrain
ACL + ALL Recon
Use Collagen
How Do Reconstructions
Perform:
• Clinically
-Zaffagnini: KSSTA 2006
• Prospective RCT
• Better Subjective Outcome Scores
• Sooner Return to Sports
Maracci Combined Intra/Extra-Articular
How Do Reconstructions
Perform:
• Clinically
-Zaffagnini: KSSTA 2006
• Prospective RCT
• Better Subjective Outcome Scores
• Sooner Return to Sports
- Vadala: Int Orthop 2013
•Modified MacIntosh + Hamstring
•Prospective RCT
•Significant Reduction in Rotational Instability
4/13/2016
13
How Do Reconstructions
Perform:
• Clinically
-Zaffagnini: KSSTA 2006
• Prospective RCT
• Better Subjective Outcome Scores
• Sooner Return to Sports
- Vadala: Int Orthop 2013
•Modified MacIntosh + Hamstring
•Prospective RCT
•Significant Reduction in Rotational Instability
- Sonnery-Cottet: AJSM 2015
• 91.6% without a Pivot at Minimum of 2 Years
Surgical Indications:
• Sonnery-Cottet: AJSM 2015
- Patients with Grade 2 or 3 Pivots
- Segond Fracture Accompanying ACL
- Chronic ACL Injury
- High Level of Sporting Activity
- Participation in Pivoting Sports
- Lateral Femoral Notch Sign
• Ferretti
- Severe Rotational Instability with Pivot Shift Exam
- Women
-High Level Athletes
- Revision Cases
• Further Clinical Outcome Data is Necessary
Where Do We Go
• Biomechanical Comparison
Where Do We Go
• Biomechanical Comparison
- Graft Reconstruction
Where Do We Go
• Biomechanical Comparison
- Graft Reconstruction
- IT Band Tenodesis
Where Do We Go
• Biomechanical Comparison
- Graft Reconstruction
- IT Band Tenodesis
- Combined Procedures
vs
4/13/2016
14
Where Do We Go
• Biomechanical Comparison
- Graft Reconstruction
- IT Band Tenodesis
- Combined Procedures
vs vs
Where Do We Go
• Biomechanical Comparison
- Graft Reconstruction
- IT Band Tenodesis
- Combined Procedures
vs vs
• Clinical Outcome Studies
81
QuickTime™ and aH.264 decompressor
are needed to see this picture.
QuickTime™ and aH.264 decompressor
are needed to see this picture.
QuickTime™ and aH.264 decompressor
are needed to see this picture.
Case Example22 yo Male
7 months out from Failed
Hamstring ACL
Thank You!