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6 th Annual Wichita Sports Medicine Symposium

6 th Annual Wichita Sports Medicine Symposium. June 6 th 2009. KNEE LIGAMENT INJURIES: EXAM AND TREATMENT. Daniel J. Prohaska, MD www.drprohaska.com danprohaska@gmail.com June 6, 2009. Talk available:. www.drprohaska.com. Knee Ligaments. Why do we need a knee lecture

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6 th Annual Wichita Sports Medicine Symposium

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  1. 6th Annual Wichita Sports Medicine Symposium June 6th 2009

  2. KNEE LIGAMENT INJURIES: EXAM AND TREATMENT Daniel J. Prohaska, MD www.drprohaska.com danprohaska@gmail.com June 6, 2009

  3. Talk available: www.drprohaska.com

  4. Knee Ligaments • Why do we need a knee lecture • Everything is pretty much sorted out in regard to the knee isn’t it? • Just when you think you have it all down….

  5. It's not just the ACL

  6. Cartilage Insertion site Graft healing Meniscus Neurovascular ingrowth bone It's the whole knee Muscle

  7. Ligament Injury ACL 48% MCL 29% ACL/MCL 13% PCL 7% LCL 3% Miyasaka, 1989

  8. 200,000 ACL Injuries Per Year?

  9. Synthetic graft materials have not been successful Engineered biological ACL scaffolds: still experimental Different Grafts Biological graft materials: autograft: BPTB, Hamstrings, Quad-tendon allograft: Achilles, BPTB, ACL, peroneal

  10. Use of different grafts 1980- BPTB 1983- Extraarticular 1985- Allografts BPTB-Auto 1992- Hamstrings

  11. Who Uses What? • Hamstrings + BPTB: equal. 62% use multiple grafts • Education of graft choices leads to best graft • More than one graft may work for each patient

  12. overall clinical / functional results are good or excellent Global Perspective on ACL Reconstruction • > 20 different techniques • > 5 different grafts • different rehab protocols • different outcome assessments

  13. How perfect are current operative techniques? Need for improvement?

  14. 20 years ago less knowledge about graft options

  15. Graft Comparison Advantages Disadvantages BPTB • Consistent size and shape • Bone to bone healing • Consistent fixation • Donor site morbidity HAMSTRINGS • Various fixations • Tendon-Bone-Healing • Greater stiffness • No interference with extensor mechanism

  16. Graft Comparison Advantages Disadvantages Quadriceps tendon • Higher stiffness • Bone to bone healing at one side • Donor site morbidity Allograft • Decrease in tensile strength • Prolonged healing response • Disease transmission • Better cosmesis • No donor site morbidity • Less postoperative pain

  17. Perfect Graft • Reproduces insertion and biomechanics • Biological incorporation • Resumes neuromuscular control Does not yet exist

  18. AP stability restored rotational stability not restored Pivot shift not restored Biomechanical research Single bundle ACL (BPTB and hamstrings)

  19. Where we are: • Development of Reconstructive Knee Surgery has made advancements largely due to the use of the arthroscope. • Patients and physicians now take for granted that procedures can be done with arthroscopic assist.

  20. Literature • Suggests it is possible to obtain stability 90-95% with variety of graft sources • Not all surgeons can obtain this level of stability with single tunnel technique • Doing a double bundle does not make the procedure technically easier and may in fact lead to further instability ?

  21. Are WeFailing Our patients • Changes in ACL surgery/rehab need to focus on where we are failing patients • Are we failing with the single tunnel technique?

  22. Where are we failing? • Recent studies have found that patients with ACL reconstruction have a high incidence of arthritic changes in the long-term • We want to prevent arthritic changes, but do we really know why they occur?

  23. Where are we failing? • Is it the meniscus, bone bruise, the cartilage, the graft? • Do we need double bundles? • The theory is that arthritic changes are occuring because adequate stability is not being achieved with single-bundle

  24. Where are we failing? • ACL deficient knee alone does not cause arthritic changes • It is the meniscus tears and chondral damage that occurs with additional giving way episodes that causes the problem • If a person with an ACL-deficient knee can prevent instability, arthritic changes may not occur

  25. Where are we failing? • Patients who have some knee laxity with full ROM are better off long-term than patients with stability and less than full ROM • “Stable” knees may be bad knees in the future if we don’t also consider all factors that make knees symmetrical

  26. Where are we failing? • Goals of ACL surgery is to obtain knee symmetry for • Stability • ROM • Strength • FUNCTION

  27. Don’t change into a technicians • We seem to always seek a surgical answer to problems • Most solvable problems are related to rehabilitation, not surgery • Cannot control meniscus tears or chondral damage

  28. Changing Surgical Technique • Why “fix” a problem that we have not really found • Why Ignore other big problems, iechondral and meniscus damage

  29. Biomechanical Research • need for • in situ forces • in vivo data • For ACL and PCL !

  30. ACL • Single bundle ACL currently the gold standard • 10-35% poor results based on continued pain and instability • Long term follow-up (7 years) shows indicates a high proportion of patients develop DJD • Biau, Corr, 2007 • Freedman et al.,AJSM, 2003 • Fithian DC et al, AJSM 2005

  31. Single Bundle ACL • Single bundle ACL reconstruction does not recreate the normal knee kinematics • Evidence points to double bundle recreating kinematics • Does it matter?

  32. ACL Anatomy • PL and AM parallel in extension • Both bundles have tension

  33. ACL Anatomy • In flexion AM stays tight, PL loosens

  34. ACL • Histologically the insertions are distinct

  35. ACL • Right knee • Standard lateral portal • Only bifurcate ridge and part of posterolateral bundle insertion are visualized

  36. ACL Anatomy • Right Knee • Viewing through medial portal

  37. ACL Anatomy

  38. 3-D ACL reconstruction Tunnel

  39. 3-D ACL reconstruction Tunnel

  40. $ ACL Factory?

  41. ACL double-bundle ? ACL graft: 2 bundles What does it take to do double?

  42. treatment controversial conservative treatment for isolated injuries ? clinical results of PCL reconstruction: 80% satisfaction PCL injuries

  43. PCL Anatomy - Components • anterolateral (AL) • taut in flexion • posteromedial (PM) • taut in extension • meniscofemoral (MFL)

  44. PCL Biomechanics • Tensile testing: AL - stiffer, stronger than PM and MFL • Function of different bundles of PCL can not be restored with single drill hole replacement

  45. PCL Reconstruction 1999 • Current approaches • tunnel placement: AL • graft fixation / tension: knee in flexion • Newer considerations • double bundle

  46. PCL Reconstruction – 2009 Double Bundle • 1. AL • 10 mm Achilles tendon • Fix at 90° with anterior drawer • 2. PM • 7-8 mm doubled ST • Fix at full extension

  47. AL PM PCL Reconstruction Double-bundle technique

  48. PCL Reconstruction Tibial Onlay technique

  49. GRAFT HEALING • Goal is to reproduce the insertion site of the native ACL • Different healing for different grafts

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