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