CU Sports Medicine Symposium Oct 2, 2015

Transcription

1 Revision ACL Surgery: Technical Pearls to Maximize Outcomes Robert Hunter MD Director, Orthopedic Sports Medicine Center Salida, Colorado CU Sports Medicine Symposium Oct 2, 2015

2 Conflict of Interest Statement Paid Consultant: Smith & Nephew Biomet Royalties: Biomet Institutional/Program Support: Smith & Nephew DJO Biomet Synthes AANA: Committee Chairman, Board of Directors, Executive Committee

3 'Yea, Though I Fly Through the Valley of the Shadow of Death, I Shall Fear No Evil, for I am at 80,000 Feet and Climbing.' - Sign over SR-71 Wing

4 ACL Reconstructions In U.S.A. >200,000/year

5 Success Rate ~ 85% 30,000 Failures/Year If You Do Knee Surgery, You Will See This. (And At Least Some Of Them Will Be Your Failures.)

6 Recurrent Instability

7 Causes of Failure Recurrent Instability Uncorrected Laxities Biologic Failure Technical Errors Uncorrected Malalignment Re-Rupture

8 Technical Failures Should be the first thing on the list non-ideal graft placement (>50%) controversial in the age of anatomic ACL vertical grafts don t control pivot anterior grafts are anisometric high PLB failure rate on 2 look Wahl 13

9 Femoral Tunnel Malposition in ACL Revision Reconstruction MARS Group 87 Surgeons and 460 Revision Surgeries 60% Had Technical Error As Cause of Failure Femoral Tunnel Malposition Most Common Reason Cited for Graft Failure Femoral Tunnel Malposition a Cause 48% Femoral Tunnel Malposition the Cause 25% Too Vertical 36% Too Anterior 30% Too Vertical and Anterior 27% Revision With Entirely New Femoral Hole 82% Morgan et al 12

10 Tunnel Errors: The Transtibial Technique Anterior Femoral Hole Vertical Femoral Hole Anterior Tibial Hole Vertical Tibial Hole

11 Tip #1 Don t Make Your Femoral Hole Dependent on Your Tibial Hole.

12 APM: Flexion 120 As Low As Possible and Clear Tibia As Medial As Possible and Clear Medial Femur

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15 Creating a Femoral Socket Using OI Technique 60 In Coronal Plane 20 In Axial Plane Best Replication of ACL Footprint Lubowitz et al 13

16 The Femoral Tunnel AMP: Reproducible Anatomic Position Tends to Produce a Low/Posterior Exit Must Hyperflex the Knee 120% Can Be Hard to See

17 The Femoral Tunnel Outside-In: Reproduces Anatomic Position Produces a Longer Hole Than AMP Produces an Oval Hole at the Footprint Produces a High/Anterior Exit Can Be Done at 90% Flexion Requires a Drill Guide My Choice

18 Tip #2 Get a Good View!

19 Get a Good View MP With the Scope Looking Anterior

20 OI: Knee at 90 Flexion Lubowitz Lines

21 Tip #3 Look For and Correct Other Laxities and Malalignment.

22 Technical Failures: Diagnostic Omissions Posterolateral Corner Instablilty 10-15% Chronic ACL Injured Knees (Gersoff 1988) Up to 70% of Multiply Revised ACL Knees (O Brien) Unaddressed LCL/PLC or MCL Laxity Increase ACL Strain Address if More Than 8- to 10-mm Opening/Instability at 0 Prone Dial Test >10 More Than Opposite Side Asymmetric Varus Alignment

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24 Instability My Target

25 Tip #4 Tibial Fixation Is the Weak Link. Make It Strong.

26 Fixation The Weak Link Is the Tibia I Prefer Interference Fit Drill To: 1.0 mm Smaller Than New Graft For 2.0 mm Smaller Than New Graft For Dilate (Compress) To The Size of the Graft Insert A Screw 1.0 mm Larger Than the Graft In Revision Cases, I Always Back Up Intraosseous Interference Fixation With Backup Suture Fixation Over a Post.

27 Tip #5 Be Ready and Have a Strategy for Enlarged Femoral and/or Tibial Holes

28 X-Ray/MRI Both X-Ray and MRI Overestimate the Size and Severity of Lytic Lesions or Tunnel Expansion Be Ready To Deal With A Widened Tunnel But Most the Time You Won t Have To. Bone Graft (Two Stage) Allograft Bone Tendon (Achilles, BTB) Large Screws

29 Imaging Prior to Revision ACL X-rays, MRI femoral/tibial tunnel widening

30 Tools & Techniques: Bone Loss Prepare the Patient For a Staged Approach Does the Bone Affect Where Holes Will Go? No. Yes stage. Allograft/Bone Putty In A 7mm Flexible Cannula Inserted Using the Cannula Trocar Inserted in a Dry Joint Maybe? stage.

31 Revision ACL Problem 32 Y/O S/P BTB ACL Physical Exam MJL Pain ROM- full Stability Med. 30 /0 1/1 Lat. 30 /0 1/1 Pivot 3 Lachman s 3 Post. Drawer 1 Posterolateral 1

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38 Thank You