THE ADDITIONAL LATERAL TENODESIS OF THE KNEE : EARLY RESULTS IN SOCCER PLAYERS

1. THE ADDITIONAL LATERAL TENODESIS OF THE KNEE : EARLY RESULTS IN SOCCER PLAYERS Karachalios G.G. , Tamviskos A. , Krinas G. , Pavlides E. , Milionis G. Arthroscopic Surgery and Sports Injury dpt Metropolitan Hospital , Piraeus , Hellas Laertion Rehabilitation Center , Piraeus , Hellas

2. R . T . P. after ACL reconstruction 1986 : only 30% active 3 years post.op. – none 7 years post.op.Roos 2011 : 94% return to normal training 10 months - 89% to elite level competition 12 ms post.op.Walden Usual range 60 – 85% amateurs professionals

4. Which factors can explain these differences ?

5. RTP FUNCTIONAL STABILITY ROTATIONAL STABILITY pivot shift ? OSTEOARTHRITIS

6. Recent studies correlate residual rotatory instability with decreased patient satisfaction , increase functional instability , chondromalacia and the development of osteoarthritis . . . Ayeni Tanaka positive pivot sign after ACL reconstruction is prognostic of o/a in the future . . . Jonsson restoring rotational kinematics during dynamic pivoting activities after ACL reconstruction is predictive of functional outcome . . . Zampeli , Pappas , Giotis , Hantes , Georgoulis 2012

7. But . . . ACL reconstruction , with graft either hamstrings or BTB , and with the recent techniques , can notrestore the rotation of the tibiato the previous physiological levels during activities with increased rotational loading of the knee , although the abnormal anteroposterior tanslation of the tibia has been restablished Prof An. Georgoulis

8. Improved techniques ?

9. “ posterolateralization ” ? amorehorizontal placementof the femoral tunnel,close to 10 o΄clock , which is anatomically closer to the insertion of thep/lbundle, can improve rotational stability , without full restoration Lucchetti

10. Double – bundle technique ? the anatomical double-bundle reconstruction can decrease the translation and rotation of the tibia during pivot-shiftZaffagnini there are no studies showing any major clinical advantages in terms of using the double-bundle surgical technique Meredick , Sammuelson technically demanding dependent on individual anatomical factors revision ?

11. Lateral tenodesis ? . . .The addition of a lateral extra-articular reconstruction to a standard single bundle ACL reconstruction with hamstrings tendons graft , is more effective in reducing the IR of the tibia at 30o of knee flexion , as compared with a standard single bundleACL reconstruction and with an anatomic double bundle reconstruction . . . Monaco 2007

13. Results • Isolated extra-articular tenodesis : only 50% of patients reported good to excellent results is no longer recommended • ACL reconstruction and extra-articular tenodesis : 80-90% good to excellent results Dodds ( review )

14. THE AIM OF THIS STUDY IS . . . . . . To present our experience with this combined procedure regarding . . . The procedure itself The time of return to play The special issues ( if any ) during rehabilitation The stability of the knee and An early follow-up

15. MATERIAL • 37 male soccer players • Recent ( < 30 days ) ACL rupture • 2014 : at least 12months follow-up ( 12 – 21 ) • 16 – 34 years old • Level : 3 first division 16 second/third division 18 amateurs

16. CONCOMITANT INJURIES • 20 meniscal injury 14 lateral 6 medial • 8 chondral injuries 7 ICRS < II 1 ICRS III

17. INCLUSION CRITERIA / INDICATIONS • High demanding players • Age < 20 • Findings of anterolateral instability ( 34 pts ) pivot shift lateral compartment bone edema ( MRI )

18. SURGICAL TECHNIQUE : • 4- strand autologus ST/G tendon graft • Retain and pull-out the torn ligament’s remnants • Notchplasty • “ monoloop ” lateral tenodesis knee in 20-30o fl ( initially 90o ) and ex.rot. of the tibia • 8 meniscal repair , 7 trimming and 5 partialmeniscectomies . • No any special treatment for the chondral injuries

20. Mark of anatomical structures • 4-5 cm incision centered on the lateral femoral epicondyle • Retaining of the thread suture of the intrarticular graft

21. A strip of 10 -12 mm width and of 5 cm. length . • We don΄t go all the way to Gerdy΄s tubercle . • Just posterior to the epicondyle , as to do not overtight the patella .

22. Find the lateral colateral ligament

23. Create a tunnel underneath the ligament

24. Suturing of the end of the strip .

25. Krackow f-9 point • Proximal and posterior to the insertion of the LCL , where the lateral intramuscular septum ends up .

26. Looking for the intraarticular graft button to don΄t violate its fixation .

27. Prepare the K f9 with an osteotome

28. The strand is pulled underneath the LCL .

29. Fixation of the strip with a tendon staple. • Knee in 30o and external rotation . • Check .

30. POSTOPERATIVELY : • 5 days Knee brace in full extension No Meniscal injury or Meniscectomy • Full ROM • Knee brace 4 weeks Meniscal repair • 5 – 21 days knee brace 0-60o light touch • 21 – 42 days knee brace 0 - 90o

31. Phase 1 0 – 4 w. purpose : • Graft fixation protection • Control & reduction of inflammation • Full extension • Flexion 90% • Patellar mobilization • Partial wb • Control of muscle contraction • Gradual retraining of proprioception ( both legs ) • NO CPM

32. Phase 2 4-8 w . purpose : • Phase 1 + • Flexion 120o • Weaning of crutches and brace • Gradual muscle strengthening • Static bike

33. Phase 3 8- 12 w . purpose : • Phase 3 + • Flexion > 120o • Swimming pool • Walking and slow skipping on traboline • Run retraining • Single leg step up

34. Phase 4 12-16 w . purpose : • Phase 3 + • Improving the confidence of the knee • Avoid stresses and excesses in cutting and pivoting • Start running

35. Phase 5 16 w . + purpose : Gradual return to sports activities • Criteria for progress in 5 phase : • Painfree ROM • No irritation at the PF joint • Enough muscle strength and proprioception

37. RTP criteria : • Advanced specialized exercises ( focused on the soccer ) • LSI strength > 90% on knee extensor as well as knee flexor strength • LSI hop performance 90% on two maximum as well as one endurable Roland Thomee et al 2011

39. EARLY RESULTS : • 35 pts returned to unrestricted training < 7 ms • 20 pts lack of flexion < 10o • 5 pts minimal lack of extension without anterior knee pain • One reoperation due to symptomatic extension deficit • Transient restriction of patellar motion • 3 pts disappointed with the scar

40. 12 – 21 months : • 2 pts Lachman test 2- 5 mm • 6 pts anterior drawer test 2- 5 mm • None pivot sign positive • None subjective instability

41. 12 – 21 months : • No rerupture • No meniscal repair failure • No secondary chondral injury • 21 footballers same team • 11 same division • 5 lower division

42. One pt with pivoting episode without rerupture on MRI ( pivot + ) One medial meniscus tear Two dropped level ( winter 2015 – 2016 ) Last assessment :

43. In summary our EARLY results showed : • Improved stability ( mainly in the last degrees of extension ) and protection of the knee • Without elongation of the recovery time • Slight delay in achieving full ROM • Without any special demands Particularly for athletes with high demanding pivot and cutting activities ( such as footballers ) , the addition of lateral tenodesis provides a more stable knee and offers an unrestricted return to play

44. Thank you and have a nice day

45. phase 3 purpose 4-6 • Phase 2 + • Flexion 90-120o • Weaning of crutches and brace • Static bike

46. Phase 5 8-12 • Phase 4 + • Gradual run retraining • Slow skipping on the trampoline • Single leg step up

47. … tibial rotation is not restored after ACL reconstruction with a hamstring allograft . . . Georgoulis et al . 2007

48. Tanaka 2012

49. Anatomical structure Paul Segond 1879 “ Segond ” fracture . . . Terry and LaPrade 1996 capsulo-osseous layers LaPrade 2000 midthird lateral capsular lig. Campos 2001 lateral capsular lig. Vieira 2007 anterolateral ligament Vincent 2012 anterolateral ligament ( ΑLL ) 100% of the knees Claes 2013 97% of the knees

50. Biomechanical and anatomical reconstruction