old principles versus new perspectives in anterior ... · • m. semimembranosus • m. biceps...

Old principles versus new perspectives in anterior cruciate ligament surgery

Prof. László Hangody M.D., Ph.D., D.Sc.Semmelweis University, Department of Traumatology

Uzsoki Hospital, Department of Orthopaedics & TraumatologyBudapest, Hungary

Old principles versus new perspectives in anterior cruciate ligament surgery

Prof. László Hangody M.D., Ph.D., D.Sc.Semmelweis University, Department of Traumatology

Uzsoki Hospital, Department of Orthopaedics & TraumatologyBudapest, Hungary

ACL

USA - 1998USAUSA -- 19981998

100 000100 000100 000

ACL

Hungary - 2007HungaryHungary -- 20072007

3 0003 0003 000

ACL

•„pes anserinus-group”(semitendinosus, gracilis, sartorius muscles)

• m. semimembranosus• m. biceps femoris• m. soleus, m. popliteus• m. quadriceps femoris

••„„ pes anserinuspes anserinus--groupgroup””(semitendinosus, gracilis, sartorius(semitendinosus, gracilis, sartoriusmusclesmuscles))

•• m. semimembranosusm. semimembranosus

•• m. biceps femorism. biceps femoris

•• m. soleus, m. popliteusm. soleus, m. popliteus

•• m. quadriceps femorism. quadriceps femoris

ACTIVE STABILIZING COMPONENTSACTIVE STABILIZING COMPONENTS ::

Posterior tibial

translation

Anterior tibial

translation

ACL

ACL

according to the type of instability

macroinstability - microinstability

according to the type of instabilityaccording to the type of instability

macroinstabilitymacroinstability -- mmicicroinstabilitroinstabilityy

Surgical approach of knee instabilitiesSurgical approach of knee instabilities

ACL

Curl, W., W. - Krome, J. - Gordon, E., S. et al.: Cartilage injuries: A review of 31,516 knee arthroscopies. The Journal of Arthroscopic and Related Surgery 13: 456-460, 1997

Curl, W., W. - Krome, J. - Gordon, E., S. et al.: Cartilage injuries: A review of 31,516 knee arthroscopies. The Journal of Arthroscopic and Related Surgery 13: 456-460, 1997

Therapeutical viewpointsTherapeutical viewpointsTherapeutical viewpoints

- Time between injury and therapy

- Location of the injury

- Grade of instability

- Age

- Activity level

- Concomitant injuries

- Patient’s compliance

- Objective and subjective conditions

-- Time between injury and therapyTime between injury and therapy

-- Location of the injuryLocation of the injury

-- Grade of instabilityGrade of instability

-- AgeAge

-- Activity levelActivity level

-- Concomitant injuriesConcomitant injuries

-- PatientPatient’’s compliances compliance

-- Objective and subjective conditionsObjective and subjective conditions

Theoretical options

primaprimaryry

reconstructioreconstructionn

delayeddelayed

reconstructionreconstruction

conservativeconservative

treatmenttreatment

ACL

• 70’ – extraarticular techniques

• 80’ – arthroscopic ACL reconstructions; synthetic ligaments

• 90’ – BTB graft, as “gold standard”

• 00’ – preference of semitendinosus graft option

• 05’ – anatomic double-bundle reconstruction

•• 7070’’ –– extraarticular techniquesextraarticular techniques

•• 8080’’ –– arthroscopic ACL reconstructionsarthroscopic ACL reconstructions;; ssyyntnthhetietic ligamentsc ligaments

•• 9090’’ –– BTB graft, as BTB graft, as ““ gold standardgold standard””

•• 0000’’ –– preference of semitendinosus graft optionpreference of semitendinosus graft option

•• 0505’’ –– anatoanatomimic doublec double--bundlebundlereconstructionreconstruction

Development of ACL reconstruction surgery:DevelDeveloopment of ACL reconstruction surgery:pment of ACL reconstruction surgery:

Uzsoki KUzsoki Kóórhrhááz, Ortopz, Ortopéédd--traumattraumatololóógiai Osztgiai Osztáály, Budapestly, Budapest

Primary ACL reconstructionsuccess rate:

Primary ACL reconstructionPrimary ACL reconstructionsuccess rate:success rate:

75 - 93%

(C. H. Brown - F. W. Carson)

75 75 -- 93%93%

((C. H. Brown C. H. Brown -- F. W. Carson)F. W. Carson)

ACL

Uzsoki Hospital, Budapest HUNGARYUzsoki Hospital, Budapest HUNGARYUzsoki Hospital, Budapest HUNGARY

ACL reconstruction:ACL reconstructionACL reconstruction ::

�� TissuesTissues

�� TunnelsTunnels

�� TechniquesTechniques

ACL

Uzsoki Hospital, Budapest HUNGARYUzsoki Hospital, Budapest HUNGARYUzsoki Hospital, Budapest HUNGARY

three Tthree T’’ ss

Graft selection:Graft selectionGraft selection::

•• autograftautograft

•• allograftallograft

•• synthetic ligamentsynthetic ligament

ACL

Uzsoki Hospital, Budapest HUNGARYUzsoki Hospital, Budapest HUNGARYUzsoki Hospital, Budapest HUNGARY

• patellar tendon• quadriceps tendon • hamstring tendons

•• patellar tendonpatellar tendon

•• quadriceps tendon quadriceps tendon

•• hamstring tendonshamstring tendons

Autogenous graft options:Autogenous graft optionsAutogenous graft options::ACL

Uzsoki Hospital, Budapest HUNGARYUzsoki Hospital, Budapest HUNGARYUzsoki Hospital, Budapest HUNGARY

Graft selection:Graft selection:Graft selection:

patellar tendon patellar tendon

ACL

Uzsoki Hospital, Budapest HUNGARYUzsoki Hospital, Budapest HUNGARYUzsoki Hospital, Budapest HUNGARY

Graft selection:Graft selection:Graft selection:

•• good tensile propertiesgood tensile properties

•• smaller diameter than PTsmaller diameter than PT

hamstring tendonshamstring tendonshamstring tendons

ACL

Uzsoki Hospital, Budapest HUNGARYUzsoki Hospital, Budapest HUNGARYUzsoki Hospital, Budapest HUNGARY

• Less donor site morbidity• Less arthrofibrosis complications• Better rotational stability• Less scar problems• Stronger than BTB• Survival of tendocytes⇒ Johnson L., L.: The outcome of a

free autogenous semitendinosus tendon autograft in human anterior cruciate reconstructive surgery. A histological study. Arthroscopy 9; 2: 131-142, 1993

•• Less donor site morbidityLess donor site morbidity•• Less arthrofibrosis complicationsLess arthrofibrosis complications•• Better rotational stabilityBetter rotational stability•• Less scar problemsLess scar problems•• Stronger than BTBStronger than BTB•• Survival of tendocytesSurvival of tendocytes⇒⇒ Johnson LJohnson L., ., L.L.:: The outcome of a The outcome of a

free autogenous semitendinosus tendon autograft in human free autogenous semitendinosus tendon autograft in human anterior cruciate reconstructive surgery. A histological anterior cruciate reconstructive surgery. A histological study. Arthroscstudy. Arthroscopyopy 9; 2: 1319; 2: 131--142, 1993142, 1993

Advantages of hamstring grafts:AAdvantages of hamstring graftsdvantages of hamstring grafts::ACL

• „isometric points”• 10/14 is better than 11/13• tibial tunnel is determining:

- don’t damage the pes anserinus tendons- AM portal in case of difficult femoral positioning

• lateral directioning of femoral tunnel

•• „„ isometric pointsisometric points””

•• 10/14 is better than 11/1310/14 is better than 11/13

•• tibial tunnel is determining:tibial tunnel is determining:

-- dondon’’ t damage the pes anserinus tendonst damage the pes anserinus tendons

-- AM portal in case of difficult femoral positioningAM portal in case of difficult femoral positioning

•• lateral directioning of femoral tunnellateral directioning of femoral tunnel

Tunnel positioning:Tunnel positioningTunnel positioning::ACL

Uzsoki Hospital, Budapest HUNGARYUzsoki Hospital, Budapest HUNGARYUzsoki Hospital, Budapest HUNGARY

• cortical layer is more reliable, than cancellous bone• optimal fixation is near to the end of the graft • avoid bungee effect• titanium is advantageous in follow up MRI• biodegradable materials may cause cystic formation• no hardware – press-fit techniques

•• cortical layer is more reliable, than cancellous bonecortical layer is more reliable, than cancellous bone

•• optimal fixation is near to the end of the graft optimal fixation is near to the end of the graft

•• avoid bungee effectavoid bungee effect

•• titanium is advantageous in follow up MRItitanium is advantageous in follow up MRI

•• biodegradable materials may cause cystic formationbiodegradable materials may cause cystic formation

•• no hardware no hardware –– presspress--fit techniquesfit techniques

Fixation considerations:Fixation considerationsFixation considerations::ACL

Uzsoki Hospital, Budapest HUNGARYUzsoki Hospital, Budapest HUNGARYUzsoki Hospital, Budapest HUNGARY

Uzsoki KUzsoki Kóórhrhááz, Ortopz, Ortopéédd--traumattraumatololóógiai Osztgiai Osztáály, Budapestly, Budapest

• not sufficient rotational stability• persisting pivot shift in spite of good stability• different stability values in different flexion angle

•• not sufficient rotational stabilitynot sufficient rotational stability

•• persisting ppersisting pivot shiftivot shift in spite of good stabilityin spite of good stability

•• different stability values in differentdifferent stability values in different flexion angleflexion angle

Possible disadvantages in case of “successful ACL reconstruction”:Possible disadvantages in case of Possible disadvantages in case of ““ successful ACL reconstructionsuccessful ACL reconstruction”” ::

ACL

Uzsoki Hospital, Budapest HUNGARYUzsoki Hospital, Budapest HUNGARYUzsoki Hospital, Budapest HUNGARY

New trends – anatomic approach:Double-bundle, four-tunnel

ACL reconstruction:

New trends New trends –– anatomic approachanatomic approach::DoubleDouble--bundle, fourbundle, four--tunneltunnel

ACL reconstructionACL reconstruction::

Uzsoki KUzsoki Kóórhrhááz, Ortopz, Ortopéédd--traumattraumatololóógiai Osztgiai Osztáály, Budapestly, Budapest

Anatomy:AAnatomynatomy::

• Anteromedial bundle:tension in flexion

• Posterolateral bundle:tension in extension

Duthon et al., ESSKA 2004

•• AnteromedialAnteromedialbundle:bundle:tension in flexiontension in flexion

•• PosterolateralPosterolateralbundle:bundle:tension in extensiontension in extension

Duthon Duthon et al., ESSKA 2004et al., ESSKA 2004

Uzsoki KUzsoki Kóórhrhááz, Ortopz, Ortopéédd--traumattraumatololóógiai Osztgiai Osztáály, Budapestly, Budapest

ACL reconstructionprobably the most successful concomitant procedure

ACL reconstructionACL reconstructionprobably the most successful concomitant procedureprobably the most successful concomitant procedure

Thank you for your attention!Thank Thank you for your attention!you for your attention!