Darren L. Johnson, M.D. Professor and Chairman Medical Director of Sports Medicine University of Kentucky School of Medicine

Transcription

1 Revision ACL Surgery Stage it!!!!!!! Darren L. Johnson, M.D. Professor and Chairman Medical Director of Sports Medicine University of Kentucky School of Medicine

2 Disclosure Consultant: Smith-Nephew Endoscopy Institution: Research/Education Smith-Nephew Endoscopy DJ Orthopaedics

3 Staging Indications:< 10% Motion lossparticularly extension Tunnel placement prevents anatomic new tunnel Tunnel lysis(15mm) prevents secure fixation and biology healing of graft

4 Radiographs/CT/MRI Operative Reports/Pictures Tunnel Placement/Location: 3D Secondary Restraints P L A M

5 CT Scan Obtained Tibial Tunnel 18mm Femoral Tunnel

6 Motion Loss

7 FAILED DB ACL/BONE GRAFT

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10 RACL after Bone graft

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12 Revision ACL& Medial Meniscal Allograft

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14 ACL Allograft failure 3X Bone graft

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18 L. C. 23 y/o former collegiate softball player Underwent ACL reconstruction (BPTB) Had total lateral menisectomy Drive through sign laterally!!!!!

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20 My Approach Staged procedure: 1. a. Hardware removal, bonegraft b. Posterolateral corner recon Semi-T: Larson technique c. Lateral meniscus transplant:slot

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22 Outside-In on Femur:All Revisions Drill Outside In!!!! Find a virgin femoral tunnel Avoid previous hardware

23 EF/32F Failed acl with BHMM

24 Case EF

25 Case EF

26 RACL/EF

27 Thank You

28 Pearls Determine Why the Graft Failed Treat other involved Structures Stage if Necessary!!!! Have a contract with patient to follow post op regimen(9-12 months) Use a large GRAFT! Auto if possible

29 Be Prepared Decide on the type of Graft Autograft if possible, Other Leg?? Hardware Removal Sets Have X-ray available Do revision last case, Don t Rush Bone dowels to avoid staging

30 Pt Eval: Physical Exam Patient Size/Bone/BMI Gait Alignment Secondary Restraints Quantify Anterior laxity Quantify Rotatory Laxity

31 Tools Required Kitchen Sink!!! ½ size Drills/Fluted Drills Dilators Flexible Drills Rear-Entry Guide Image

32 ACL Technique Perhaps the most important factor for ACL Reconstruction in 2015 is surgical technique! Anatomic ACL Reconstruction! Forsythe B, Kopf S, Wong A, Martins C, Anderst W, Tashman S, Fu F. J Bone Joint Surg Am. 2010;92:

33 Why I use Large autografts! Lower failure rate in young patients Early incorporation of graft Reduced cost No issues with availability

34 Anatomic ACL Reconstruction 90 Zantop T, Wellman M, Fu FH, Petersen W. Tunnel Positioning of Anteromedial and Posterolateral Bundles in Anatomic Anterior Cruciate Ligament Reconstruction: Anatomic and Radiographic Findings. Am J Sports Med. 2008; 36:65-72.

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36 Why Medial Portal drilling Outside-IN Anatomy: 100% fill of tunnel within native footprint Independent tibial tunnel placement Size of opening is accurate: not oval A M P SB L SB

37 Pitfalls of MP drilling Damage to MFC Short femoral tunnel Posterior blow-out

38 Short femoral tunnel

39 5 years PO Late Failure ACL: Too Vertical

40 Revision Surgery

41 Treat Other Involved Structures Absent medial meniscus lost important stabilizer. Do Medial Meniscal Allograft Arthritis and Mal-alignment: HTO Collateral Capsuloligamentous Involvement: Arthroscopic drive through sign Gait Analysis Varus/Valgus Thrust

42 Medial Gap Test/MCL and POL

43 Medial drive through arthroscopy video

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45 Gapped lateral compartment

46 Positive Lateral Drive-Through

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48 One Stage Tibial Tunnel Stainless Steel is Harder than Titanium Miller MD. Revision Cruciate Ligament Surgery with Retention of Hardware. Arthroscopy 1998; 14(1):

49 NP/RACL/Outside -In

50 Revision ACL Opening Wedge HTO

51 Revision ACL 1 Stage

52 Outside-In on Femur Drill Outside In!!!! Find a virgin femoral tunnel Avoid previous hardware

53 DR/RACL/MM allograft

54 Grand Canyon Size Tunnel Tunnel Lysis TA Allograft High School Female Soccer

55 Staging surgery: Indications Motion problems Anatomic graft placement Secure fixation for immediate rehab

56 Conclusions Etiology of Failure Obtain previous records Large Graft Other Structures Outside in Femur Stage if necessary Anatomic Counsel Patient