Carlos Eduardo Franciozi Rogério T. De Carvalho Yasuo Itami Michelle McGarry Sheila Ingham Rene Abdalla James Tibone Thay Q. Lee

Transcription

1 Bicruciate lesion biomechanics Treatment using a simultaneous tensioning protocol: ACL fixa;on first is be<er than PCL fixa;on first to restore ;biofemoral orienta;on Carlos Eduardo Franciozi Rogério T. De Carvalho Yasuo Itami Michelle McGarry Sheila Ingham Rene Abdalla James Tibone Thay Q. Lee

2 DISCLOSURES Carlos Eduardo Franciozi and Rene Jorge Abdalla received fees for speaking or for organizing an educa:onal program and fee for consul:ng from Smith & Nephew in the past five years, not related to this study. James Eugene Tibone acts as consultant for Arthrex, but do not receive any money from them. The remaining authors declare no conflict of interest.

3 Introduc:on Bicruciate Lesion (PCL + ACL) Surgial Treatment: Two stages: PCL first 3-6months followed by Manual knee reduc:on to the normal step-off posi:on ACL Levy et al., 2009 Fanelli et al Schenck et al., 2014 OR One stage: PCL fixa:on at flexion Manual knee reduc:on to the normal step-off posi:on ACL fixa:on at extension Zhao et al., 2006 Strobel et al., 2006 Hirschmann et al., 2010 Piontek et al., 2013 Denti et al., 2015 Panigrahi et al., 2016 Moatshe et al., 2018

4 Introduc:on Bicruciate Lesion (PCL + ACL) Surgial Treatment: One stage: PCL fixa:on at flexion Manual knee reduc:on to the normal step-off posi:on Posterior subluxa:on ACL fixa:on at extension RISK OF OVERCORRECTION Posterior drawer Manual reduc:on Overcorrec:on

5 Introduc:on Simultaneous Tensioning: Simultaneous tensioning for :bial reduc:on: checkrein to avoid overcorrec:on PCL fixa:on first at flexion OR ACL fixa:on first at extension ACL at extension Wascher et al., 1999 Mariani et al., 2001 Hayashi et al., 2008 PCL at flexion Kim et al., 2014 Knee at extension is more stable than at flexion stability Screw home posi:on Tensioned capsule De Carvalho et al., 2018

6 Objec:ve To compare :biofemoral biomechanics between ACL graz fixa:on first and PCL graz fixa:on first in a simultaneous tensioning protocol for bicruciate ligament reconstruc:on.

7 Methods Experimental therapeu:c study (Level V) Twelve cadaveric knees (six matched pairs) Data acquisi:on: 3D digi:zing system - Microscribe 3DLX Custom tes:ng system: 6 degrees of freedom Sample size: power 0.8; alpha 0.05 Microscribe

8 Methods Evalua:on at 0, 30, 60 e 90 flexion Parameters: Neutral Tibial Posi:on, AP transla:on, Varus/Valgus, External Rota:on/Internal Rota:on Normal Knee (n=12) T Bicruciate Lesion (n=12) T Bicruciate Reconstruction (n=12) T T PCL Fixation First (n=6) ACL Fixation First (n=6) T: Biomechanical tests

9 Methods ACL: quadruple hamstrings fixa:on always at extension PCL: quadriceps fixa:on always at 90o (single bundle) Fixa:on: Interference Screw (post and washer added for PCL) PCL Fixation First with Simultaneous Tensioning ACL Fixation First with Simultaneous Tensioning

10 Results Statistical significant difference at 90 o favoring ACL First CLINICALLY significant (around 5mm)

11 Results Statistical significant difference at 30 o NOT CLINICALLY significant (1-2mm) No differences: Varus/ Valgus; External / Internal Rotation

12 Conclusion Bicruciate ligament reconstruction using a simultaneous tensioning protocol with ACL fixation first, at full extension, resulted in a closer to normal tibiofemoral orientation. This protocol may lead to superior results in comparison to the gold-standard PCL fixation first tightening sequence in the clinical setting.

13 References - de Carvalho, R. T., C. E. Franciozi, Y. Itami, M. H. McGarry, S. J. M. Ingham, R. J. Abdalla, J. E. Tibone, and T. Q. Lee 'Bicruciate lesion biomechanics, Part 1- Diagnosis: translations over 15 mm at 90 degrees of knee flexion are indicative of a complete tear', Knee Surg Sports Traumatol Arthrosc. - Denti, M., D. Tornese, G. Melegati, H. Schonhuber, A. Quaglia, and P. Volpi 'Combined chronic anterior cruciate ligament and posterior cruciate ligament reconstruction: functional and clinical results', Knee Surg Sports Traumatol Arthrosc, 23: Franciozi, C. E., L. J. Albertoni, F. N. Ribeiro, A. C. Moscon, A. Munhoz Mde, R. Krause, and R. J. Abdalla 'A simple method to minimize vascular lesion of the popliteal artery by guidewire during transtibial posterior cruciate ligament reconstruction: a cadaveric study', Arthroscopy, 30: Hayashi, R., N. Kitamura, E. Kondo, Y. Anaguchi, H. Tohyama, and K. Yasuda 'Simultaneous anterior and posterior cruciate ligament reconstruction in chronic knee instabilities: surgical concepts and clinical outcome', Knee Surg Sports Traumatol Arthrosc, 16: Hefti, F., W. Muller, R. P. Jakob, and H. U. Staubli 'Evaluation of knee ligament injuries with the IKDC form', Knee Surg Sports Traumatol Arthrosc, 1: Hirschmann, M. T., F. Iranpour, W. Muller, and N. F. Friederich 'Surgical treatment of complex bicruciate knee ligament injuries in elite athletes: what long-term outcome can we expect?', Am J Sports Med, 38: Kim, S. J., S. H. Kim, M. Jung, J. M. Kim, and S. W. Lee 'Does sequence of graft tensioning affect outcomes in combined anterior and posterior cruciate ligament reconstructions?', Clin Orthop Relat Res, 473: Mariani, P. P., F. Margheritini, and G. Camillieri 'One-stage arthroscopically assisted anterior and posterior cruciate ligament reconstruction', Arthroscopy, 17: Moatshe, G., J. Chahla, A. W. Brady, G. J. Dornan, K. J. Muckenhirn, B. M. Kruckeberg, M. E. Cinque, T. L. Turnbull, L. Engebretsen, and R. F. LaPrade 'The Influence of Graft Tensioning Sequence on Tibiofemoral Orientation During Bicruciate and Posterolateral Corner Knee Ligament Reconstruction: A Biomechanical Study', Am J Sports Med, 46: Panigrahi, R., A. Kumari Mahapatra, A. Priyadarshi, D. Singha Das, N. Palo, and M. Ranjan Biswal 'Outcome of Simultaneous Arthroscopic Anterior Cruciate Ligament and Posterior Cruciate Ligament Reconstruction With Hamstring Tendon Autograft: A Multicenter Prospective Study', Asian J Sports Med, 7: e Piontek, T., K. Ciemniewska-Gorzela, A. Szulc, J. Naczk, M. Wardak, T. Trzaska, W. Dudzinski, and M. Grygorowicz 'Arthroscopically assisted combined anterior and posterior cruciate ligament reconstruction with autologous hamstring grafts-isokinetic assessment with control group', PLoS One, 8: e Strobel, M. J., M. S. Schulz, W. J. Petersen, and H. J. Eichhorn 'Combined anterior cruciate ligament, posterior cruciate ligament, and posterolateral corner reconstruction with autogenous hamstring grafts in chronic instabilities', Arthroscopy, 22: Wascher, D. C., J. R. Becker, J. G. Dexter, and F. T. Blevins 'Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation. Results using freshfrozen nonirradiated allografts', Am J Sports Med, 27: Zhao, J., Y. He, and J. Wang 'Simultaneous arthroscopic reconstruction of the anterior and posterior cruciate ligaments with autogenous hamstring tendons', Arthroscopy, 22: PUBLISHED AS: Franciozi CE, de Carvalho RT, Itami Y, McGarry MH, Ingham SJM, Abdalla RJ, Tibone JE, Lee TQ. Bicruciate lesion biomechanics, Part 2-treatment using a simultaneous tensioning protocol: ACL fixation first is better than PCL fixation first to restore tibiofemoral orientation. Knee Surg Sports Traumatol Arthrosc Sep 28. doi: /s y.