Case 1. Case Presentation. Interval History 8/10/ year old healthy male

Transcription

1 Case 1 Brian Forsythe, MD Assistant Professor Division of Sports Medicine Head Orthopedic Officer: Chicago Fire Soccer Club Team Physician: Chicago White Sox & Chicago Bulls Midwest Orthopaedics at Rush, Rush University Medical Center Case Presentation 23 year old healthy male Special Education teacher Former D3 collegiate soccer player, assistant varsity coach Collided with an opposing player during a soccer tournament, falling on the lateral aspect of his leg Immediate onset of pain and swelling, no pop Interval History Completed 5 wks of PT Describes his knee as 70% of normal Experiences pain with kicking and passing No improvement w derotational brace Seen by my colleague initially, then referred to me for a 3 rd opinion Symptoms persist over 6 months 1

2 Physical Examination 5 10, 187 lbs. WD/WN, somewhat anxious. Range of motion from degrees 2A Lachman, positive pivot glide exam Alignment neutral Stable to valgus and varus stress No joint line tenderness Negative flexion McMurray Mild asymmetry with single leg hop 5/5 lower extremity strength Radiographs MRI 2

3 MRI MRI Read: Right knee partial ACL tear of posterolateral bundle No anteromedial bundle involvement No lateral or medial meniscus tears No associated posterolateral corner injuries Treatment Options: Considerations Benign Neglect (Expectant management) Physical therapy- plyometrics, neuromuscular training Surgery ACL Reconstruction: BTB Autograft, HS autograft, allograft? IT Band tenodesis ALL reconstruction (Anterolateral ligament) Take him to the operating room and figure it out then Goals Return to soccer, both competitively and as a Coach 3

4 Arthroscopic Pics: 4

5 Thoughts? Examination under anesthesia: 1+ pivot shift, 1-2A Lachman 5

6 Arthroscopy Video Two functional bundles: No impingement 6

7 Postoperative Course 1 week Range of motion from 0 to 90 Has a 30-degree lag on straight leg raise. He has some mild interstitial edema and trace intraarticular effusion. 5 weeks Range of motion is +1 to 120 degrees 20 cc intraarticular effusion Stable 1A Lachman and a stable pivot shift. Postoperative Course 10 weeks Pain-free at baseline and feels 100% of normal w/ ADLs Range of motion is +2 to 135 degrees Stable exam 15 weeks Range of motion of the right knee is +2 to 135 degrees Running without difficulty, progressing with agility training 5 months => Back to soccer AM Bundle Reconstruction Partial ACL reconstruction with preservation of the posterolateral bundle (2012) Orthopaedics & Traumatology: Surgery & Research Sonnery-Cottet et al. (2012) found sig improved scores in patients undergoing AM bundle reconstruction Mean follow-up of 26 months Retrospective, multicenter study of n=168 7

8 PL Bundle Augmentation Posterolateral Bundle Reconstruction With Anteromedial Bundle Remnant Preservation in ACL Tears: Clinical and MRI Evaluation of 39 Patients With 24 Month Follow-up (2013) OJSM 44 patients with HS graft Significant differences in preop and postop clinical results IKDC 44 => 90 MRI: No cyclops lesions No tunnel 2 years follow up Anatomic Technique: Application of anatomic double-bundle reconstruction concept to revision and augmentation ACL surgeries. Shen W, Forsythe B, Fu FH. JBJS, Am Application of double bundle concepts Anatomic Technique: N=11, 27.5 month follow up 10 patients had normal Lachman and pivot shift ROM side-to-side difference of 2.25 degrees in extension and flexion IKDC mean was

9 If you recognize this: Consider ACL Augmentation: Summary: ACL augmentation is a viable treatment for partial thickness ACL tears. Suggested to optimize stability, improve proprioception. Does it facilitate faster rehabilitation vs. complete ACL reconstruction? 9

10 Case 2 Brian Forsythe, MD Assistant Professor Division of Sports Medicine Head Orthopedic Officer: Chicago Fire Soccer Club Team Physician: Chicago White Sox & Chicago Bulls Midwest Orthopaedics at Rush, Rush University Medical Center History: 16 year old healthy female Previous ACL R and LMD, 11/2013, soccer injury, as a 14 year old. Completed a rehabilitation exercise program pre and post-operatively Current History: Right knee buckled during soccer game for U16 team No immediate swelling; however, swelling developed over 24 hrs. Attempted to practice, but knee gave way and swelling recurred. 10

11 Physical Examination Active range of motion from +5 to 140 degrees 2B Lachman, 3+ pivot shift Alignment: approx 3 degrees of valgus Stable to varus, valgus stress 0 and 30 degrees Negative McMurray's exam Trace effusion No joint line tenderness Neurovascular exam intact 5-/5 quad strength Radiographs MRI 11

12 MRI MRI Diagnosis Right knee ACL graft tear Menisci intact 12

13 Physical Exam Video Options:? Revision ACL surgery: Hamstring autograft Quad tendon +/- bone block Contralateral BTB autograft Allograft: Achilles, BTB, SemiT, Tib Ant Consider: Osteotomy, ALL reconstruction? Goals Stability, Neuromuscular function, return to sport Arthroscopic Pic: 13

14 Procedure: Revision ACL reconstruction BTB Allograft Extra-articular ligament reconstruction: IT Band rerouting and tenodesis Removal femoral and tibial metal interference screws. Arthroscopy Pic: 14

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17 Revision ACL R, BTB Allograft IT Band Rerouting/Tenodesis: 17

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19 IT Band Rerouting/Tenodesis: 19

20 Postoperative Course 1 week: Pain 3/10, & 60% subjective function Range of motion: 0-90 degrees 20 cc effusion 5 weeks: - Pain 1/10 - ROM +2 (hyperextension) -120 degrees - Trace effusion So far, so good Rehab Progression: Would you slow her down? Timeline for running, agility training, and return to sport? Issues: Use of allograft Extra-articular tenodesis ACL Revisions do worse: Ahn, Lee & Ha (2008) found significant differences in clinical results: Primary reconstruction vs. Revision [IKDC] No difference in stability outcomes [KT-2000] 20

21 Influence of a Lateral Tenodesis Tojani et al (2011) found lateral tenodesis w revision ACLR increased knee stability 80% negative pivot shift vs. 63% without tenodesis Knee Surg Sports Traumatol Arthrosc Aug;20(8): Revision ACL reconstruction: influence of a lateral tenodesis. Trojani C1, Beaufils P, Burdin G, Bussière C, Chassaing V, Djian P, Dubrana F, Ehkirch FP, Franceschi JP, Hulet C, Jouve F, Potel JF, Sbihi A, Neyret P,Colombet P. Effect of Lateral Tenodesis on Internal Rotation Monaco et al (2007) found that single bundle ACL reconstruction with lateral tenodesis significantly reduced internal rotation Knee Surg Sports Traumatol Arthrosc Oct;15(10): Double bundle or single bundle plus extraarticular tenodesis in ACL reconstruction? A CAOS study. Monaco E1, Labianca L, Conteduca F, De Carli A, Ferretti A. Summary: Revision ACL surgeries often suffer from functional stability issues IT band tenodesis can add rotational stability and potentially improve clinical outcomes 21

22 A 34 Year-Old Male with Right Knee Hyperextension Injury Moderator: Brian Forsythe, MD Case Presentation 34 year-old healthy male Hyperextension injury to right knee while playing slow pitch softball Felt a pop Immediate pain and swelling Unable to walk after injury No prior knee pain or injury Described it as a Mariano Rivera injury mechanism Physical Examination Palpable defect in patellar tendon Range of motion 0-70 Unable to perform straight leg raise 2-3+ soft tissue swelling Ligamentous exam limited secondary to pain and swelling Neurovascularly intact with palpable pulses 22

23 Radiographs MRI Coronal Video MRI Sagittal Video 23

24 Diagnoses Patellar tendon rupture ACL tear Grade 2 posterolateral corner injury Lateral meniscus tear (bucket handle displaced into notch) Medial meniscus tear (complex posterior horn) Treatment Planning Goals: Stable knee Intact extensor mechanism Full range of motion Minimize complications Considerations: Timing of surgery? Single versus staged procedure? Exam Under Anesthesia Video 24

25 Arthroscopy Video Thoughts? Meniscus: repair or debride? Should we fix: ACL? Patellar Tendon? Posterolateral Corner? Patellar Tendon Rupture 25

26 Patellar Tendon Repair Patellar Tendon Repair Patellar Tendon Repair 26

27 Postoperative Course WBAT locked in extension in hinged knee brace At 1 week, started CPM 0-30 degrees At 8 weeks, ROM 0-85, straight leg raise without lag At 12 weeks, ROM 0-130, 2A Lachman At 18 weeks, ROM , 2B Lachman Next step? ACL Reconstruction: Allograft Hamstring BTB Autograft? ( ) Lateral meniscus transplant? Surgical Course: Uneventful BTB Allograft Reconstruction No significant cartilage wear in the medial or lateral compartments => no softening, no chondral defects 27

28 Post-op Radiographs ACL reconstruction with BTB allograft At 2 weeks, trace effusion, ROM Weight bearing, brace locked in extension. Kept locked for 2-3 more weeks At 14 weeks, ROM , Lachman 1A, stable valgus, varus At 6 months, , Lachman 1A, quad weakness, steroid injection => Return to sports 7-8 months Combined Patellar Tendon and ACL Injury Rare injury Lack of evidence to guide treatment (case reports) Patellar tendon rupture has 30% rate of associated knee injuries (McKinney et al KSSTA 2008) 28

29 Less gap formation & higher ultimate failure loads with anchors: Cohort study, level 3 8 immediate MAT; 10 delayed MAT 35 months (range 9-92); 14 meniscetomy Follow-up 4-6 years Results: VAS and IKDC favor immediate over delayed Isokinetic muscle strength favors immediate Immediate had less degeneration on x-ray and MRI (Kellgren-Lawrence score and Yulish score) Small sample size No power analysis Comparison group Not randomized No matching of comparison group (age, sex, compartment, concomitant procedure, preop duration of symptoms) Immediate versus delayed group differences 21 month average shorter follow-up for immediate MAT Age 23 for immediate MAT versus 28 for delayed) 29

30 THANK YOU! Anterior Cruciate Ligament Reconstruction: A Review of Rehabilitation Outcome Measurements and Factors Governing Return to Play Brian Forsythe, MD Assistant Professor Division of Sports Medicine Team Physician Chicago White Sox, Chicago Bulls, & Chicago Fire Midwest Orthopaedics at Rush Rush University Medical Center Introduction High yield of anterior cruciate ligament (ACL) tears 125,000 reconstructions performed annually (Kim et al, 2011) Regain of function usually 6-9 months after Variability in Return to Play (RTP) protocols Inconsistency in RTP guidelines between different practices Lack of uniformity in evaluation of readiness for RTP Optimization of RTP allows strategic, efficient, and appropriate decision making 30

31 The Problem Limited validated reliable consensus guidelines with objective criteria to facilitate the return to play process AAOS 2015 Substantial questions remain What specific criteria and tests are we currently using? What tests should we be using? Can we come to consensus regarding RTP guidelines? 31

32 Purpose To assess orthopedic surgeon and other providers (PT, research, ATC) views on RTP protocols following ACL reconstruction To compare what different practices view as optimal criteria for engaging in RTP Methods Electronic survey distributed to 89 potential participants Asked to evaluate importance of variables to initiate RTP (time of surgery, pain, effusion ) Asked to rank outcome surveys in RTP decision making Asked for RTP management preferences and opinions Data analyzed to compare responses between surgeons and other respondents Reached out to different practices for RTP protocols Created by Taskforce Founders Vetted by small panel of experts Mayo Clinic Tim Hewett University of Pittsburgh Jim Irrgang Santa Monica Sport Medicine Foundation Holly Silver Rush University Brian Cole and team University of Missouri Patrick Smith 32

33 U.S. Multicenter ACL RTP Taskforce Initiated in 2015 Seth L. Sherman, MD (University of Missouri) Jo Hannafin, MD PhD (HSS) Tim Hosea, MD (Rutgers) Deceased Brian Forsythe, MD (Rush University) 8/10/ Participants: 17 academic medical centers 40 surgeons 18 non-surgeons (i.e. PhD, ATC, PT, PA) U.S. Multicenter ACL RTP Taskforce Goals of Taskforce: Phase 1: Understand variation in current RTP guidelines A) Review and analyze existing protocols from each center B) Create and implement survey on ACL RTP C) Compare/contrast findings with existing RTP literature Phase 2: Validate and test uniform RTP protocol following ACL reconstruction 33

34 Results 48 survey responses 35 orthopedic surgeons 8 physical therapists 3 researchers 2 athletic trainers RTP protocols obtained from 12 practices Results- Decision to Initiate RTP Top 5 variables affecting RTP decision Threshold of 75% of respondents, ROM, gait, and effusion most important Outcome surveys not considered very important to surgeons except for psych readiness Results- Decision to Initiate RTP Influence of prior surgical history Threshold of 75% of respondents, ROM, gait, and effusion most important Optimal time to initiate RTP 6-8 months (47%) 4-6 months (38%) 8-12 months (16%) 34

35 Results- Functional Testing Surgeon vs. non-surgeon opinion of functional tests Non-surgeons considered crossover hop test, drop vertical jump test, and 6m timed hop test as very important Results- Functional Testing and RTP Assessment of performance ability, symmetry, pain and movement quality in functional tests Results- RTP Protocols Functional tests deemed as very important in surveys inconsistently appear on RTP protocols Of 12 protocols, separate RTP testing only in 58% 35

36 Discussion ROM, gait, and presence of an effusion were very important factors for over 75% of respondents RTP protocols do not fully reflect what providers view as important No agreement on time interval to begin RTP testing Inconsistencies in the evaluation of individual functional tests and the RTP protocols remain There is need for objective guidelines that can be feasibly incorporated into any orthopedic practice THANK YOU! 36