(Παρουσίαση στο 4ο Διεθνές Συνέδριο Εταιρείας Αρθροσκόπησης & Χειρουργικής Γόνατος της Πολωνίας, RZEZOW 2011). REVISION ACL USING ANATOMICAL SINGLE BUNDLE TECHNIQUE.

1. ANATOMIC APPROACH
FOR REVISION ACL
RECONSTRUCTION
MR ALEVROGIANNIS STAVROS, MD,PhD
ORTHOPAEDIC SURGEON
S. CONSULTANT IN SPORTS INJURIES.
ATHENS/GREECE

2. ACL EPIDEMIOLOGY
• Annual incidence of ~200,000 ACL ruptures per year
with an estimated 1 in 3,000 pts, in USA
• 150,000 result in operations costing around two billion
dollars a year
• Females are injured with a higher frequency than males
due to many factors including slightly different and
disadvantageous joint anatomy, hormonal factors and
less muscle mass
• Incidence highest in population aged 15-45 years old with 1 in 1750 persons
(Brown, 2004)
• Most common injury in football and basketball in younger patients- skiing in
older patients-
• Substantial anterior tibial shear forces stress ACL from quads contraction(esp.
0 – 30 degrees contraction) (Sakane, „97)
• Typically torn in non-contact deceleration results in valgus twisting injury
• Athlete lands on legand pivots in opposite direction
• Average return to full activity is ~ 6 to 8 months

3. INCREASE OF PRIMARY
ACL
RECONSTRUCTION
1. increased level of sports
activities
2. increase of high risk
associated activities
(contact sports)
3. increased awareness
4. tendency towards
operative treatment

4. FAILURE PRIMARY ACL SURGERY
3-10 % fail
• arthritis and recurrent
pain
• arthrofibrosis or loss of
motion
• extensor mechanism
dysfunction
• recurrent patholaxity
(Johnson DL, Fu FH. Anterior cruciate ligamnet
reconstruction: why do failures occur? Instr
Course Lect 1995: 44: 391-406)

5. CAUSES OF FAILURE
• traumatic re-injury
• returning to sports too
soon after surgery
• inappropriate or
overaggressive
rehabilitation
• technical failures

6. TECHNICAL FAILURES
( 70% OF CASES)
• Improper graft placement
• Graft impingement due to
inadequate notchplasty
• Improper graft tensioning
• Inadequate graft fixation due
to the fixation device or
deficient bone stock
• Use of a graft of diminished
tensile strength or size
• Failure to correct associated
ligament instabilities

7. INDICATIONS FOR ACL-R
1. Subjective feeling of instability during the
normal daily and sports activities
2. Functional instability with or without pain under
weight bearing
3. Objective anterior laxity (during the clinical
examination) with positive Noulis-Lachman
test and significant KT-1000 side-to-side
difference

8. TYPICAL PATTERNS OF ACL GRAFT
RUPTURE

9. ACL- REVISION ALGORITHM

10. TIPS & PEARLS FOR
ACL REVISION SURGERY
• ACL ANATOMY
• CLASSIFICATION
• SURGICAL METHOD
• REMOVAL HARDWARE
• BONE GRAFTS
• GRAFT CHOICE
• FIXATION CHOICE
• DRILLING TUNNELS

11. ANATOMIC ACL-R
CRITICAL QUESTIONS:
• WHAT IS ANATOMIC APPROACH IN ACL-R?
(be familiar with anatomical landmarks and
footprints)
• WHY WE NEED ANATOMIC APPROACH?
(24-30% re-rupture of the graft)

12. ACL ANATOMIC FOOTPRINTS
FEMUR TIBIA

13. • The intact AM and PL bundles of the ACL are shown in (A), and the soft tissue
remnant of torn ACL on the femoral side is shown in (B). When the knee is in
90 degrees of flexion, the femoral insertion sites of the AM and PL are
horizontally aligned. The white circles on the cadaveric specimen picture (A)
and the arthroscopic surgery picture (B) show potential area that the femoral
tunnels can be incorrectly placed when a trans-tibial approach and the clock
face concept is used, which is seen in most of revision cases. Laser scan (C)
and arthroscopic picture (D) show the two bony landmarks on the femoral
insertion sites of the AM and PL bundles when knee is in 90° of flexion

14. Clinical Results
after S.B ACLR
• Greatly improved over the last
years
• However, there are many issues
which should be improved in the
future:
-the normal rate ( 2mm) is only
70%
-rotatory control is insufficient
-normal athletic abilities are not
restored even in the “normal”
knee
Renstrom P.ESSKA 2004)

15. A.M S.B ACLR

16. CONVENTIONAL D.B ACLR

17. ANATOMIC D.B ACLR

18. FEMORAL TUNNELS IN D.B TECHNIQUE

20. ANATOMIC APPROACH S.B TECHNIQUE -
FEMORAL DRILLING

21. FEMORAL TUNNEL IN
ANATOMIC S.B TECHNIQUE
The femoral tunnel is low and overlaps both the AM
and PL anatomical sites

22. TIBIAL DRILLING IN ANATOMIC S.B
ACLR

23. ACL GRAFT LENGTH

24. FEMORAL TUNNEL POSITION: AN X-RAY COMPARISON OF
DRILLING THROUGH THE TIBIAL TUNNEL vs DRILLING
THROUGH THE MEDIAL PORTAL
Chao D,Pallia C,Young S et al
• 40 ACL recon pts
• Results
- Statistical significance
superior (TT technique) vs
inferior (AM technique)
alignment of femoral tunnel
placement
- TT technique produces a more
anterior femoral tunnel and a
more vertical ACL graft
orientation

25. ACL SAGITTAL ANGLE ACCOUNTS FOR
FEMORAL & TIBIAL INSERTION
Normal MRI Anteromedial Technique

26. MRI MEASUREMENT TECHNIQUES
• ACL angle
- Anterior edge
of ACL
- Lateral tibial
plateau

27. MRI MEASUREMENT TECHNIQUES
AT angle
-Anterior edge
of ACL
-Medial tibial
plateau

28. MRI COMPARISON-RESULTS
NORMAL AM TECHNIQUE TT TECHNIQUE

29. ARTHOSCOPIC PORTALS
LP : (lateral portal = incision towards the outside of the knee)
MP :(medial portal = incision towards the inside of the knee)
AMP : (accessory medial portal = incision even further on the
inside of the knee) and
CP :(central portal= incision towards medial one third of patellar
ligament)

30. ACL-REVISION GRAFTS
• AUTOGRAFTS
-BPTB
 Ipsilateral
 contralateral
-QUADRICERS
-QUADRAPLED ST (indirect fixation recommended)
-DOUBLED STG ( more fixation options,
internal rotation weakness)
• ALLOGRAFTS
 Achilles tendon
 Posterior tibialis
• XENOGRAFTS (new generation)
 JewelAcl (NeoLigaments)

31. JEWEL-ACL
Features and benefits
• Is a specialized textile scaffold which is
rendered versatile for ACL reconstruction
by various structural features. The scaffold
is treated with a proprietary gas plasma
treatment process that increases its surface
energy and renders it hydrophilic
• The continuous tubular form can accommodate a
hamstring tendon
• The open weave sections have appropriate spacing to
encourage tissue ingrowth into the scaffold.
• The densely woven sections have superior handling
properties.
• The JewelACL is a bio-enhanced prosthesis for the ACL
reconstruction.
• The JewelACL can be secured to the bone with currently
available fixation devices.

32. BENEFITS
• Can be implanted as a total tissue sparing device,
or with a single hamstring tendon
• Manufactured from Polyethylene Terephthalate (polyester)
• Allows early rehabilitation (parallel longitudinal polyester fibres
provide high strength of 3000N)
• Implanted using standard modern ACL guide-wire systems
• Stiffness is matched to the semitendinosus tendon to permit load
transfer and encourage cell growth due to plasma-spray.
more than four times as many cells were found on the plasma-treated ligament
surfaces after 14 days incubation compared to non plasma-treated polyester surfaces.

33. ACLR (JewelAcl-X/O BUTTON) +
in elite 25 y. male athlete.

34. ACLR (JewelAcl-X/O BUTTON) +
CHONDROPLASTY MFC(Chondromimetic) in a
non-competitive 41 y.female athlete.

35. MATERIAL
(AUG. 2010- FEB.2011)
PRE-OP EVALUATION
• Sex ratio : 48 males, 22 females
• Side : 41 left, 29 right
Mean age : 29 years (range 16-48)
no sport
sport from time to time
frequent sport
40 competition
30 38
22
20
10 8
2
0
report activity prior to ACL
re-rupture

36. CLASSIFICATION SYSTEM FOR ACL R.
(H.H. Paessler et al, Wiosna 2002,48-60 New Techniques for ACL
revision surgery)
• GRADE I :
a) Narrow femoral and tibial
tunnels in correct position
b) Femoral tibial tunnel far
away from correct position
• GRADE II: Large tibial
tunnel + small femoral
tunnel or previous tunnel
closed by bone block of
initial graft
• GRADE III : Large femoral +
tibial tunnel
• GRADE IV : GRADE
III+additional lesions of
secondary restraints
osteoarthritis PCL

37. METHOD
• Mean time between re-rupture of ACL graft and revision surgery 29m ( 9- 39m)
• All cases were type I or II according to H.H Paessler Classification system
• All cases performed by one senior surgeon in one stage procedure
• Diagnostic arthroscopy first
• All ACL graft remnants were removed
• 29 meniscal tears ( 18 part.debrided-11 repaired)
• 22 cartilage lesions ( 15/III,7/IV),16 debrided, 4 Chondromimetic, 2 ACT3D ( 2
procedures)
• 52 cases using the anatomical approach, remaining 18 the modified one
• No notchplasty!!!!
• 2 had an OWHTO due to varus mal-alignment prior to ACLR (single varus)
• 3 had reconstruction of the posterolateral ligament structures
• Interference screw was not removed in misplaced femoral tunnel
• ST tendon ( ipsilateral or contralateral) with JewelAcl augmentation was used in all
cases
• 3 doses of gentamycin was given i.v
• Prophylactic anti-coagulants for 20 d.p.o
• Functional brace

38. POST-OP REGIMEN
• Immediate knee motion and muscle-
strengthening exercises on the 1st d.p.o
• Functional knee brace for 6 w.p.o
• Full R.O.M from the 1st d.p.o
• P.w.b from the 2nd w.p.o f.w.b 6th w.p.o
• Physio- protocol was modified if concomitant
procedure was performed
• Running program 6th m.p.o
• Pivoting+ contact sports 9th-12 m.p.o

39. COMPLICATIONS
• No major complications were found
• No joint effusion 2m.p.o
• 1 DVT, 15d.p.o was solved uneventfully
• 1 superficial infection ( oral antibiotics)
• 2 arthrofibrosis ( 1 required MUA 7w.p.o-
the other arthroscopic lysis of adhesions
and scar tissue 10w.p.o)
• No re-re-rupture of the graft (JewelAcl?)

40. MODIFIED CINCINATTI SCORE
(0-100)
Excellent (>80), Good (55 to 79), Fair (30 to 54) or Poor(<30)
Pain
80
Swelling
70
Giving way
60 68,2 72,5
Overall activity level 50 PRE.OP
Walking 40 6M.P.O
41,5
Stairs 30 1Y.P.O
Running activity 20
10
Jumping or twisting
activities 0

41. VISUAL ANALOGUE SCORE
(0 = good, 10=poor)
10
8
6
points
4
2
0
0 6 12
months

42. PATIENT OUTCOME
FUNCTION SCORE
18% 1%
81%
BETTER SAME WORSE

43. PAIN & ACTIVITY
80%
69%
70%
60%
Percent of Knees
50% 45%
38% Pre-Op
40%
Post-Op
30% 25%
20% 13%
10% 4% 6%
0%
0%
Severe with Daily Moderate with Daily Activities Only None with Sports
Activities Daily Activities Activities
Pain Symptoms Related to Activity

44. KNEE PERCEPRION
50%
46%
45%
40% 37%
35%
35% 33%
Percent of Knees
30%
Pre-Op
25%
Post-Op
20%
15% 15%
15%
9%
10%
6%
5% 2%
0%
0%
Poor Fair Good Very Normal
Good
Patient Perception of the Knee Condition

45. ACTIVITIES OF DAILY LIVING
100% 80% 75%
90%
90%
70%
80%
60%
Percent of Knees
Percent of Knees
70%
60% 50%
Pre-Op 40% Pre-Op
50% 44% 40% 35%
Post-Op Post-Op
40% 30%
31% 21%
30% 17%
20%
20% 15%
10% 8%
6% 10% 2%
10% 2%
2% 2%
0% 0%
0 20 30 40 0 20 30 40
Walking Stair Climbing

46. SPORTS ACTIVITIES
80% 80% 75%
70% 67% 70%
60% 60%
Percent of Knees
Percent of Knees
50% 50%
Pre-Op 37% Pre-Op
40% 40%
31% Post-Op 33% Post-Op
29% 29%
30% 30%
20% 20% 17%
13% 13% 13%
10% 11% 10% 10%
10% 10%
2%
0% 0%
40 60 80 100 40 60 80 100
Running Twisting/ Turning

47. LACHMANN-NOULIS TEST
120%
98%
100%
Percent of Knees
80%
64%
Pre-Op
60%
Post-Op
40%
21%
20% 15%
0% 2%
0%
<3 3-5.5 > 5.5
Antero-posterior Displacement

48. PRE-OP IKDC SCORE (%)
KT 1000 LAXITY
80
71,1
70
60
50
40
30
20 14,4
11,1
10 3,4
0
A B C D
C + D > 85%

49. PRE-OP PIVOT SHIFT
60
52
50
40
30
20
11
10 7
0
0
equal +glide ++ clunk +++ gross

50. POST-OP EVALUATION
45 42
40
35
30
25 no sport
21
20 sport from time to time
15
frequent sport
10
5 competition
5 2
0
no sport from competition
sport frequent
time to sport
time
1 year follow-up sport
activity

51. RESULTS
KT 1000 LIGAMENT EVALUATION
manual maximum and Telos
45 45
40
35
30
25
20 18
15
10
5
5
1 1
0
-3 to -1 mm -1 to 2 mm 3 to 5 mm 6 to 10 mm > 10 mm

52. RESULTS: Pivot Shift
n 80
70
60
50
p = 0.001
40 Preop
84 Postop
30 %
20
10 13 3
0
%
0
A equal B glide C clunk D gross

53. RESULTS
PIVOT SHIFT
70
61
60
50
40
30
20
10 7
2 0
0
equal +glide ++ clunk +++ gross

54. GLOBAL SCORE IKDC at F.U.
50
50
45
40
35 32
30
24 pre-op
25
F-U
20
15 12
10
10 8
5 2 2
0
A B C D

55. CONCLUSIONS
• Surgical error is the main cause of failure of a primary
reconstruction
• Pre-operative planning is crucial to carefully access the
factors that may have been related to the prior failure
• Revision ACL surgery is technically demanding- requires
theoretical and clinical experience
• Anatomic approach for revision ACL is a very attractive
surgical method
• No re-failure of the graft yet! (24-30% in the literature)
• Primary results of ACL-R graft augmentation with JewelAcl,
seems to be more than encouraging
• Further mid-term results are needed
• Patients should be well informed about the less favorable
outcome of a revision (unrealistic expectations !!!!)