Evolution of Technique: 90 s

Transcription

1 Anterior Medial and Accessory Portal Techniques: ACL Reconstruction Charles A. Bush Joseph, MD Rush University Medical Center Chicago, IL Evolution of Technique: 80 s Open and 2 incision methods produced a femoral tunnel low and horizontal in orientation (Bach AJSM 1994) Surgical morbidity high 8 12% flexion contracture Most revision procedures were for stiffness and arthritis Evolution of Technique: 90 s Bach, Bush Joseph AJSM 1998 Decreased morbidity Motion problems nearly eliminated 91% with negative pivot 95% satisfied knees were not as tight 1

2 Evolution of Technique: mid 90 s Single incision trans tibial over the top guides moved the tunnel posterior but led to the femoral tunnel being more vertical or onto the roof Evolution of Technique: By simplifying technique did we lose our way? Vertical tunnels lead to a stable Lachman but residual rotatory instability I am afraid we may have trained a generations of surgeons improper technique (Frank Noyes, MD 2008) Re establishing Goals: Anatomic femoral tunnel placement Anterior medial portal drilling (Steiner 2007) Trans tibial drilling at oblique angle (Bach 2008) 2 incision rear entry technique Flexible reamers (Clancy, S&N) Image guided or navigation systems 2

3 2 Incision Technique: Pro s Anatomic position Low risk of posterior blow out Best for revision surgery Con s Lateral incision Quadriceps/IT band issues Flexion contractures? $$$ Expense of percutanous devices 2 Incision Technique: 2 Incision Technique: Medial portal viewing Mini C arm verification 3

4 2 Incision Technique: Graft passage femur to tibia Small tibial tunnel/socket needed Lateral cortical fixation Transtibial: Pro s Technical simplicity Patient comfort Excellent track record Con s Non anatomic tunnels? Vertical femoral Posterior tibial tunnel Graft tunnel mismatch due to short tibial tunnel Transtibial: Tibial entrance point key element Half fluted reamers to avoid tibial tunnel expansion 4

5 Transtibial: Anterior Medial Technique: Pro s Anatomic tunnel Avoid lateral incision Co linear interference screw placement No graft tunnel mismatch Con s Technical complexity MFC scuffing Difficult with narrow notch $$$ with flexible reaming systems Interference screw divergence risk Anterior Medial Technique: 5

6 Anterior Medial Transtibial Anterior Medial: Flexible Reamer Accurate tunnel location with routine position Lower risk of cartilage scuffing Higher disposable expense Orientation of interference screw fixation can lead to screw divergence Surgical Technique Trends Tibor et al, JBJS 2016 Kaiser ACL registry data, 9.5 million lives 33 hospitals, 246 surgeons 21,686 ACL procedures 72% sports trained fellowship surgeons 6

7 Surgical Technique Trends Tibor et al, JBJS Transtibial 56% AM portal 41% 2 incision 2% 2014 Transtibial 17% AM portal 65% 2 incision 17% Surgical Technique Trends Tibor et al, JBJS : No change Graft type utilization Allograft utilization Suspensory/interference fixation Graft failure revision rate AM/Transtibial Drilling: Clinical Outcomes Biomechanical/location better with AM drilling Small improvement in Lysholm with AM drilling No difference in IKDC or Tegner scores 7

8 AM Transtibial Drilling: Revision Rates? Danish Registry AJSM 2014: AM > TT Too tight overconstrained? MOON Data JBJS 2013: TT > AM Too loose functional instability? Peter MacDonald/Herodicus 2016, RCT with 90 patients: TT = AM Too small sample size? Key Points: Proper tunnel location key to success Be prepared to deal with varying anatomy Familiarity with varying techniques My current approach: Young athletic patients AM drilling with PT or hamstring autograft Low level recreational Transtibial drilling with hamstring or allograft Revision Surgery AM drilling or 2 incision technique Questions? 8