8/10/2016. Revising a Well Done ACL: Concomitant Pathology that Increases Risk. Disclosures. Once is Enough

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1 Revising a Well Done ACL: Concomitant Pathology that Increases Risk 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 Disclosures Arthrex, Inc: Research Support Arthrosurface: Paid presenter or speaker Jace medical: Stock or Stock Options Smith & Nephew: Research support Sonoma: paid consultant; paid presenter or speaker Stryker: research support Once is Enough Revision ACL reconstructions tend to be inferior to primary reconstructions How can we reduce re-injury rate? Who is at higher risk for re-injury? What missed diagnoses contribute to re-injury? 1

2 ACL Reconstruction Re-Injury Risk Factor Age 9% decreased odds per year increase in age Sex Not significant when normalized for activity Activity Level 11% increased odds per increase in Marx activity scale Injury Mechanism Traumatic non-contact 55% Nontraumatic, gradual onset 25% Traumatic, contact 13% Nontraumatic, sudden onset 6% Causes for Failure n= 293 Femoral tunnel malposition 36% New trauma 30% No cause found 15% Impingement 12% Tibial Tunnel malposition 11% Untreated laxity 5% Failure of fixation 5% Hyperlaxity 4% Infection 2% Chen et al 2013 (MARS cohort) Trojani et al Undiagnosed Injuries/Conditions and Associations with ACL re-injury Posterolateral Corner Posterior Tibial Slope Lateral knee Injury and Laxity Meniscal Insufficiency MCL PLC and ACL: Biomechanics PLC is primary restraint: varus forces and posterolateral tibial rotation. PLC is secondary stabilizer: Anterior and Posterior tibial translation Biomechanical Studies ACL graft strain increases w/ PLC sectioning varus & varus/internal rotation (LaPrade et al 1999) DB ACL Reconstruction: will not compensate for sectioned PLC (Bonanzinga et al. 2015) Chahla et al

3 PLC injury History and Physical Mechanism: Hyperextension varus injury, blow to anteromedial knee Examination: - Dial test - Posterolateral drawer - External rotation recurvatum - Reverse pivot - Standing apprehension Dial Test at 30 Ross et al Imaging Studies Radiographs - 51 inch standing alignment - standing anteroposterior - notch view - standing lateral view - varus stress Avulsion of popliteus tendon MRI Sensitivity for detecting lesions LaPrade (2000) Bonadio (2014) FCL (LCL) 94.4% 57.58% Popliteofibular Ligament 68.8% 24% Avulsion of PFL Bonadio compared radiologist report to intra-op Outcomes Dhillon et al 2012 Prospective trial comparing outcomes of ACL tear with concomitant Fenelli grade A or grade B treated conservatively ACL + Grade A PLC do well without PLC reconstruction ACL + Grade B PLC Recommend reconstruction of PLC Fanelli Grade A ER >10, no varus laxity B ER > 10, 5-10 mm varus laxity C ER > 10, > 10 mm varus laxity 3

4 Posterior Tibial Slope Controversial: - Study designs - study populations - females vs males - measurement techniques Measurement technique implemented by Rahnemai-Azar et al PTS Biomechanics => ACL Strain Griffin et al 2004 Anterior osteotomy: increasing PTS by 5 loads similar to clinical exam (low) no sig increase in strain on ACL Fening et al 2008 As above, but with higher loads & more slope 5 mm and 10 mm No sig effect on tibiofemoral translation/acl strain 5 mm wedge 10 mm wedge PTS Biomechanics => ACL Strain Marouane et al 2015 Finite element model to avoid altering joint configuration caused by osteotomy => Found increased force on ACL with increased PTS! 4

5 Clinical Studies assessing ACL Recon & PTS: Re-Injury Webb et al 2013 Prospective case control of 181 patients, 15 yr fol after ACLR. 50 failed (contralateral knee 15/50) Significantly increased slope in re-injury group Odds ratio w/ PTS > 12 = 5.2 Christensen et al 2015 Case control with 35 patients who re-injured after ACLR with 4 yr follow up. Odds reported by increase in slope. 1 = = = = 3.8 Rahnemai-Azar et al 2016 Division I football players => MTS mean 3.1 vs 1.7 & LTS mean 7.7 vs 4.7. Medial tibial slope (MTS) Odds = 1.42 Lateral tibial slope (LTS) odds = 1.43 Treatment for increased PTS Strengthen your hamstrings! Or Sonnery-Cottet et al ACL re-revisions treated with anterior closing wedge osteotomy. 31 month follow up Lysholm 87.8 IKDC scores 79.1 What s going on with the Lateral Knee? Anterior oblique band of fibular collateral ligament? Anterior band of lateral collateral ligament? Capsulo-osseus layer of iliotibial band? Mid-third lateral capsular ligament? Anterolateral Ligament? Anterolateral Capsule? 5

6 Anatomy Inconsistencies Van der watt et al 2015 Schon et al 2016 Dodds et al 2014 Zlotnicki et al 2016 Helito et al 2013 Claes et al 2013 Anterolateral Ligament: Origin: lateral femoral epicondyle region Insertion: proximal tibia, between Gerty s and fibular head Function: In theory, provides anterolateral knee stability Reconstruction Technique History Segond 1879 described avulsion fracture at anterolateral tibia associated with ACL rupture - Lemaire (1967) - MacIntosh (1976) - Losee (1978) - Ellison (1979) - Arnold and Coker (1979) - Wilson and Scranton (1979) - Zarins and Rowe (1980) - Andrews (1982) - Benum (1982) - Muller (1983) - Marcacci & Zaffagnini (1998) Slette et al

7 Biomechanical Controversy- Optimists Parsons et al 2015 ALL important stabilizer of internal rotation at flexion angles greater than 35 Ruiz et al 2016 Anterolateral structures are an important stabilizer to internal rotation of the knee in conjunction with the ACL Spencer et al 2015 ALL role in controlling anterolateral laxity. Biomechanical Controversy- Pessimists Suero et al 2013 Increase in magnitude of pivot shift and Lachman was observed when constraint of IT band removed Kittl et al 2016 Found the ITB to be primary restraint to internal tibial rotation for ACL intact and deficient knees. Did not suggest significant restraining role for ALL Thein et al 2016 ALL engages only during pathologic ranges of tibial translation. Limited need for reconstruction in well functioning ACL reconstructed knee Clinical Outcomes: Lateral Sided Tenodesis No differences in clinical outcomes, but improved laxity - Systematic review by Hewison et al 2015 pre-op What about increasing OA risk? O Brien et al evidence for OA Monacco et al No evidence at 10 yrs Clinical benefit of improved laxity? MOON cohort increased odds of revision (1.87) with high grade prereconstruction laxity No difference in clinical outcome scores 12 yrs 7

8 Role in Revisions Lateral tenodesis decreased forces on ACL graft by 15% - Engebretsen et al Biomechanical Study Lateral tenodesis significantly decreases pivot shift in revisions at 2 yr follow up - Trojani et al Important structural augmentation in revisions - Mascarenhas et al Lateral Extra-articular Tenodesis Key Points Do not over-constrain joint Long term studies to evaluate risk of OA are not available No role as a routine procedure, rather specific situations Consider in select cases with significant pivot shift Consider with residual internal rotation and laxity despite ACLR No superior technique Further studies needed to determine clear indications and clinical benefit Menisci and ACL Injury : Biomechanics Total resection of medial meniscus increases force on ACL graft 33-50% - Papageorgiou et al 2001 Medial meniscus important stabilizer of anterior and lateral tibial translations. Should be preserved in setting of ACLR Seon et al 2009 Lateral meniscus important restraint to anterior tibial translation during valgus and rotatory loads of pivoting Musahl et al

9 Menisci and ACL Injury : Biomechanics Repair of medial meniscus leads to significant reduction of anterior tibial translation Lorbach et al 2015 * Biomechanical properties demonstrate significant role in stabilization, thus protection of ACL graft after reconstruction ACL & Meniscal Injuries Concomitant meniscal injury in 15-40% of ACL injuries Levy et al Repair it or remove it? -Lyman et al found 1.23 odd of revision in 1 yr with concomitant meniscectomy -Norwegian Knee registry showed no difference in outcomes at two years -Melton et al reported significant difference at 12 yrs Melton et al 2011 What to do with concomitant meniscal tear? Paucity of data on risk of ACL re-injury with meniscectomy vs repair vs in situ. MOON cohort reports on meniscal re-operation: 14% repair failure at 6 yrs Nomogram for deciding whether or not to leave the meniscus tear in situ 9

10 ACL & Grade III MCL Controversial Key points to consider: Allow MCL to heal prior to reconstruction Varus/valgus instability can compromise graft Restore ROM prior to undertaking ACL reconstruction Establish patient goals and individualize treatment ACL & Grade III MCL Controversies: Delayed vs. early ACL reconstruction Operative vs. non-operative MCL treatment Halinen et al. JBJS 2009 Early ACLR < 3weeks 23 operative MCL, 24 non-op Similar results Millett et al. J Knee Surg 2004 Early ACLR < 3weeks 19 Grade III non-op MCL 1 arthrofibrosis Minimal loss of motion Peterson and Laprell early reconstruction < 3 weeks 37 delayed reconstruction >10 weeks Delayed group had less loss of motion and greater Lysholm scores ACL & Grade III MCL Proximal MCL Injury: Leave alone! (Heterotopic Ossification) Mid-substance MCL: Posterior Oblique Ligament advancement Distal MCL Avulsion: Repair primarily 10

11 Conclusion Good Luck! 11