RETURN TO PLAY AFTER ACL PRIMARYREPAIR WITH INTERNAL BRACING ANDMEDIAL MENISCUS REPAIRThein R1,2, Burstein G1, Tenenbaum Sl

lDepartment of Orthopedic Surgery, Chaim Sheba Medical Center, Tel Hashomer,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv;

2Hapoel Tel-Aviv Football Club, Israeli Premier League, Tel-Aviv, Israel

Recently, good results of arthroscopic primary Anterior Cruciate Ligament (ACL) repair in selected cases ofproximal tears have been reported (1).We present a case report of an 18-year-old, professional male football defender who was invited for the firsttime to a pre-season training camp of a Premier League team. The young player had a non-contact pivotingknee injury on the last day of the camp. He was examined by the team physiotherapist and a meniscal injurywas suspected. He was admitted to our outpatient clinic five days after the injUry. The X-ray findings were neg­ative. Clinical examination revealed effusion, limited Range Of Motion (ROM) with 100 lag of extension and 900

of flexion in the knee joint. Lachman test was positive with no firm end point, meniscal tests were positive formedial meniscus. The Magnetic Resonance Imaging (MRI) was administered, and it confirmed an ACL femoralinsertion tear and displaced bucket handle tear of the medial meniscus (Figure 1).

Figure 1. Magnetic Resonance Imaging (MRI) demon­strate Double Posterior Cruciate ligament (PCl) signwhich confirm displaced bucket handle tear of themedial meniscus

Three days later, the patient underwent an arthroscopic procedure. The knee was examined under anaesthesia,and Lachman test was positive. Diagnostic arthroscopy revealed ACL femoral insertion tear with good remain­ing ligament and displaced medial meniscus bucket handle tear. An anatomic reduction of the meniscus wasachieved and five sutures were used to secure the meniscus. ACL primary repair with internal bracing was done.In brief, the surgery was performed under general anesthesia. During the arthroscopic procedure, the medialmeniscus was redLiced, the area of the meniscal tear was rasped and the meniscus was sutured by the folloWingtechnique. Two inside out Polydioxanone (PDS) 0 sutures were placed on the anterior horn and the anteriorpart of the meniscal body. One outside in PDS 0 suture was placed on the posterior part of the meniscal bodyand two Fast-Fix 360 meniscal repair system (Smith & Nephew Endoscopy, Andover, USA) were placed on theposterior horn of the medial meniscus.

364 XXVI INTERNATIONAl. CoNFERENCE ON SPoRTS REHABILITATION AND TRAUMATDLOGY

----~-----IThe meniscus stability was tested by probing which proved the meniscus to be stable. The ACL remnantwas whip stitched using an arthroscopic suture passing instrument developed for shoulder surgery (ScorpionFastPass, Arthrex, Naples, Florida). Two whip stitch were passed around the proximal part of the ACL. Theproximal end of the ACL was then re-approximated against the medial wall of the lateral femoral condyle, in ananatomical position to the center of the footprint. This was done by suturing the fiber wires to the TightRope(Arthrex, Naples, Florida) on the femur. The bone on the femoral condyle at the anatomical insertion point wasfreshened with drilling.The repair was then protected using the Internal Brace Ligament Augmentation Repair device, a 2.5 mm poly-ethylene tape bridging from tibia to femur. The Internal Brace bridges the anatomical attachments of the ACLin the mid-bundle position on both femur and tibia, protecting the repair. Tensioning of the Internal Brace wascarried out with the knee in full extension. 3.5 mm tunnels were drilled in the tibia and femur to facilitate therepair and for the Internal Brace fixation. Fixation of the repair stitch and Internal Brace proximally was carriedout with the ACL TightRope (Arthrex, Naples, Florida) whilst distal fixation of the Internal Brace was carried outwith the SwiveLock Suture Anchor (Arthrex, Naples, Florida).The knee was immobilized with the brace in full extension with immediate full weight bearing as tolerated.After three days, isometric exercises were initiated, and ROM was increased up but not more than 900 of flexionin six weeks to protect the meniscal repair. After six weeks ROM steadily increased to reach full range in eightweeks. The standard Antero-Posterior and Lateral radiograph was performed eight weeks after surgery andshowed good position of the implant.Five months' post-op clinical examination revealed knee with full ROM, there was no tenderness on the joint lineor around the knee, anterior posterior and mediolateral stability were good with no clinical difference betweenthe two knees. Negative Lachman, anterior drawer and pivot shift tests were recorded.Follow up MRI was done showing that the ACL was reattached to the femur with no evidence of tear and themedial meniscus was shown to be in anatomical position with no signs of re-tear. In addition, an isokinetic testwas done showing no more than 10% difference between the ipsilateral and contralateral knees' flexors orextensors muscle strengths (Table 1).

Injured Un-injured Injured vs Un-injured

Extensors Flexors F/E Extensors Flexors F/E a Extensors a Flexors

Torque at 60'/s (Nm) 186.8 145.7 78% 179.1 140.3 78% 4% 4%

Torque at 120'/s (Nm) 140.0 124.8 140.9 112.3 -1% 10%

Table 1. Isokinetic Test five months post-op. F/E: ratio Flexors/extensors. a: Delta.

Five months after surgery the patient was allowed to return to sports.

References

1. Difelice GS, Villegas C, Taylor S. Anterior cruciate ligament preservation: early results of a novel arthroscopictechnique for suture anchor primary anterior cruciate ligament repair. Arthroscopy 2015; 31(11): 2162-2171

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