Outcome of a combined ACL and ALL reconstruction with a minimum 2-years follow-up.

Transcription

1 Outcome of a combined ACL and ALL reconstruction with a minimum 2-years follow-up. Bertrand Sonnery-Cottet Centre orthopédique Santy, Lyon France FIFA Medical Centre of Excellence

2 Centre Orthopédique Santy LYON Since 2003 with G. WALCH & P. CHAMBAT Sports Medecine 600 ACL / year

3 Biomechanics Normal ACL Rotational Axis ACL Rupture Amis AA et al. Biomechanics of rotational instability and anatomic ACL reconstruction. Operative Techniques in Orthopaedics. Anatomic ACL Reconstruction. Part I. 2005

4 Biomechanics ACL Gabriel MT, Woo SL et al. Distribution of in situ forces in the anterior cruciate ligament in response to rotatory loads. J Orthop Res. 2004

5 Biomechanics? Yasuda K et al. Anatomic reconstruction of the anteromedial and posterolateral bundles of the anterior cruciate ligament using hamstring tendon grafts. Arthroscopy 2004.

6 Double Bundle R 2006 to 2008: 400 ACL DB Graft Rupture Cyclops Syndrome 20% Pivot Shift ++ Sonnery-Cottet B et al. Clinical and operative characteristics of cyclops syndrome after double-bundle anterior cruciate ligament reconstruction. Arthroscopy Meredick RB et al. Outcome of single-bundle versus double-bundle reconstruction of the anterior cruciate ligament: a meta-analysis. Am J Sports Med. 2008

7 New Ligament..?

8 Anatomy Jack Hughston, 1976 Anterolateral structures = middle one third of the lateral capsular ligament Werner Muller, 1982 Lateral Femorotibial Ligamentous attachment = deep posterior portion of the iliotibial tract + Middle capsular ligament Hughston JC, Andrews JR et al. Classification of the knee ligament instabilities. Part II. The lateral compartment. J Bone Joint Surg Am W. Muller, The Knee, Springer-Verlag, 1982

9 New Ligament..? Monaco E et al. Orthopedics 2010 ALL Thaunat, Sonnery-Cottet et al. KSSTA 2013 Vincent, Neyret et al. KSSTA 2012

10 Anterolateral Ligament Claes S, Bellemans et al. Anatomy of the anterolateral ligament of the knee. J Anat. Oct 2013 Gobbi RG, Camanho GL et al. Anatomy and Histology of the Knee Anterolateral Ligament. Orthop J Sports Med. Dec 2013 Dodds AL, Amis AA et al. The anterolateral ligament: Anatomy, length changes and association with the Segond fracture. Bone Joint J. March 2014 Claes S et al. Gobbi et al. Dodds et al.

11 Anterolateral Ligament Sonnery-Cottet B et al. Arthroscopic Identification of the Anterolateral Ligament of the knee Arthros Tech 2014

12 Biomechanics of ALL Monaco E et al. Navigated knee kinematics after tear of the ACL and its secondary restraints: preliminary results. Orthopedics 2010 The lesion of the AnteroLateral FemoroTibial Ligament increases tibial rotation and could be correlated to the pivot shift phenomenon. Claes et al. ISAKOS 2013, AAOS 2013 Selective cutting of ACL bundles/all Ruptured ALL is prerequisite for grade 3 Pivot shift in ACL deficient knee

13 Biomechanics of ALL Length Change Patterns in the Lateral Extra-articular Structures of the Knee and Related Reconstructions. Kittl C, Amis AA et al. Am J Sports Med. 2015

14 Biomechanics of ALL + 16% de length 0 to 90 KUROSAWA AJSM 1991 CLAES J Anatomy 2013 Helito AJSM 2014

15 Biomechanics of ALL Courtesy Dr Imbert Dr Lutz

16 Biomechanics of ALL

17 Biomechanics of ALL

18 Biomechanics of ALL

19 Surgical Technique

20 Surgical Technique Courtesy Dr Claes A Courtesy Dr Chassaing

21 Surgical Technique

22 Anterolateral Ligament

23 Anterolateral Ligament

24 ACL + ALL reconstruction From January 2011 to January primary ACL reconstructions At minimum 2 years 92 ACL + ALL reconstruct - IKDC objective & subjective - Tegner, Lysholm - Instrumented laxity: Rolimeter - Complications

25 ACL + ALL reconstruction 396 ACL Recontructions 304 (77%) Isolated ACL R 92 (23%) ACL+ ALL R 83 for final evaluation 1 lost to follow-up, 1 ACL graft rupture, 7 Controlateral ACL rupture

26 ACL + ALL reconstruction Indications Pivoting Sport High Level Pivot Shift ++ Chronic ACL Lateral notch X-rays Segond facture

27 ACL + ALL reconstruction Subjective IKDC 30% 25% P<0, % 15% PREOP 10% 5% 0%

28 ACL + ALL reconstruction P<0,0001 7,4 7,3 7,3 P<0, ,4 PREOP 7,2 PREOP POSTOP 7,1 7,1 POSTOP 0 7 LYSHOLM TEGNER

29 ACL + ALL reconstruction Objective IKDC 100% 80% 60% 40% 92% 63% 37% p<0,001 PREOP POSTOP 20% 0% 8% 0% 0% 0% 0% A B C D

30 ACL + ALL reconstruction Pivot shift 100% 80% 92% P<0,001 60% 40% 20% 0% 49% 28% 23% 8% 0% 0% 0% A B C D PREOP POSTOP

31 ACL + ALL reconstruction 35% 30% 25% 32% 27% Instrumented AP laxity side-to-side (mm) 32% PREOP 23% POSTOP 20% 18% 18% 17% P<0,001 15% 10% 5% 0% 12% 3% 2% 3% 1%

32 ACL + ALL reconstruction No specifics complications : 6 failures of meniscal suture 1 cyclop syndrome Full ROM +++

33 ACL + ALL reconstruction Number of patients included 92 Men/Women 68/24 Age at surgery 24 ( + 9) BMI 24 ( + 2.7) Mean follow-up (month) 32,4 ( + 3.9) Lost for Follow-up 1 Graft rupture during the study period 1 Contralateral ACL rupture 7 Number of patient for final evaluation 83

34 Imaging of ALL IR FE T1 Koichi Muramatsu MD, Watanabe Hiroki MD, Yudo Hachiya MD ALL is visualized more clearly on 3D-T2 image 3D-T2 Hachiya Orthopaedic Hospital, Nagoya, Japan

35 Conclusions ACL R alone is not sufficient to control the rotational instability in all cases Double-bundle ACL reconstruction emerged in an attempt to minimize persistent rotational laxity, but to date evidence for clinical efficiency is mixed Increased interest for secondary restraints of the knee in particular ALL Debate anatomy/ isometry «ALL needs more work to confirm»

36 Thank you and Welcome to Lyon

37 Anterolateral Structures Proximal insertion Supracondylar insertion Retrograde insertion ITB dissected / flapped down G Courtesy Fib Andy Williams, Christophe Kittl, Andrew Amis