Old principles versus new perspectives in anterior cruciate ligament surgery

Transcription

1 Old principles versus new perspectives in anterior cruciate ligament surgery Prof. László Hangody M.D., Ph.D., D.Sc. Semmelweis University, Department of Traumatology Uzsoki Hospital, Department of Orthopaedics & Traumatology Budapest, Hungary

2 USA

3 Hungary

4 ACTIVE STABILIZING COMPONENTS: pes anserinus-group (semitendinosus, gracilis, sartorius muscles) m. semimembranosus m. biceps femoris m. soleus, m. popliteus m. quadriceps femoris Posterior tibial translation Anterior tibial translation

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6 Surgical approach of knee instabilities according to the type of instability macroinstability - microinstabilityicroinstabilit Curl, W., W. - Krome, J. - Gordon, E., S. et al.: Cartilage injuries: A review of 31,516 knee arthroscopies. The Journal of Arthroscopic and Related Surgery 13: , 1997

7 Therapeutical viewpoints ACL - Time between injury and therapy - Location of the injury - Grade of instability - Age - Activity level - Concomitant injuries - Patient s s compliance - Objective and subjective conditions conservative treatment delayed reconstruction Theoretical options primary ry reconstruction

8 Development of ACL reconstruction surgery: 70 extraarticular techniques 80 arthroscopic ACL reconstructions; synthetic c ligaments 90 BTB graft, as gold standard 00 preference of semitendinosus graft option 05 anatomic c double-bundle bundle reconstruction Uzsoki KórhK rház, Ortopéd-traumat traumatológiai Osztály, Budapest

9 Primary ACL reconstruction success rate: 75-93% (C. H. Brown - F. W. Carson) Uzsoki Hospital, Budapest HUNGARY

10 ACL reconstruction: three T st Tissues Tunnels Techniques Uzsoki Hospital, Budapest HUNGARY

11 Graft selection: autograft allograft synthetic ligament Uzsoki Hospital, Budapest HUNGARY

12 Autogenous graft options: patellar tendon quadriceps tendon hamstring tendons Uzsoki Hospital, Budapest HUNGARY

13 Graft selection: patellar tendon Uzsoki Hospital, Budapest HUNGARY

14 Graft selection: hamstring tendons good tensile properties smaller diameter than PT Uzsoki Hospital, Budapest HUNGARY

15 Advantages of hamstring grafts: Less donor site morbidity Less arthrofibrosis complications Better rotational stability Less scar problems Stronger than BTB Survival of tendocytes Johnson L., L L.: The outcome of a free autogenous semitendinosus tendon autograft in human anterior cruciate reconstructive surgery. A histological study. Arthroscopy opy 9; 2: , 142, 1993

16 Tunnel positioning: isometric points 10/14 is better than 11/13 tibial tunnel is determining: - don t t damage the pes anserinus tendons - AM portal in case of difficult femoral positioning lateral directioning of femoral tunnel Uzsoki Hospital, Budapest HUNGARY

17 Fixation considerations: cortical layer is more reliable, than cancellous bone optimal fixation is near to the end of the graft avoid bungee effect titanium is advantageous in follow up MRI biodegradable materials may cause cystic formation no hardware press-fit techniques Uzsoki Hospital, Budapest HUNGARY

18 Uzsoki KórhK rház, Ortopéd-traumat traumatológiai Osztály, Budapest

19 Possible disadvantages in case of successful ACL reconstruction : not sufficient rotational stability persisting pivot p shift in spite of good stability different stability values in different flexion angle Uzsoki Hospital, Budapest HUNGARY

20 New trends anatomic approach: Double-bundle, bundle, four-tunnel ACL reconstruction: Uzsoki KórhK rház, Ortopéd-traumat traumatológiai Osztály, Budapest

21 Anteromedial bundle: tension in flexion Posterolateral bundle: tension in extension Duthon et al., ESSKA 2004 Anatomy: Uzsoki KórhK rház, Ortopéd-traumat traumatológiai Osztály, Budapest

22 reconstruction probably the most successful concomitant procedure

23 Thank you for your attention!