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ImagingworkupfortheFailedACL

JamesRobinsonConsultantOrthopaedicKneeSurgeon

• AmeticulousapproachshouldbeutilizedforpatientsafterfailedACLsurgery

• RevisionACLsurgeryisassociatedwithasignificantlyinferioroutcomesvs1surgery

• Toavoidanother failure– avoidcompromise…

• NeedtoworkoutwhythefirstACLRFailed

RevisionACLPre-opplanning

• What Hardwear needs to be dealt with

• Tunnels?Ø Where are they

Ø Are they enlarged ?

• Is there Mal-alignment ?

• Status of Ø Cartilage

Ø Menisci

Ø Ligaments.

Whatdoyouneedtoknow….?

• 1or2stageRevision….?

• NeedforOsteotomy?

• Needforadditionalligamentsurgery– MCL,PCL,PLC?

• NeedforExtra-articularplasty?

• NeedforMeniscalsurgery– Menisectomy,Repair,RootRepair,MAT

• Cartilage,Notchplasty,etc

QuestionsIaskmyself…...

MyStandardWork-up

• APandLateralview– weightbearinginextension

• Skylinepatellaview

• Rosenbergviews

• StandingAPalignmentbothlowerextremities(longfilm)

• CTscan

• MRIscan

PlainX-rayAPandLateral

• Bestforoverallassesment of

– SignificantArthritis

– Whattypeofreconstruction

– Hardwear youneedtodealwith

– ideaoftibial slopeandanteriortibial subluxation

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Hardware?

NoSubstitutefortheoldOperationNote!

Graft inclination angle

= 12°

Measuringpositionofthetunnel

<16degrees=Higherfailue rate(LeoPincewski)

ValueoftheLateral

Measuringthepositionofthetunnel

0%100%

42%

AmisandJacob’sLine

42%=ACLcentre

30%=AMcentre

50%=PLcentre

RosenbergViews

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• Results in high tensile loads on the ACL graft which can result in graft failure

LowerLimbMalalignment Weightbearinglonglegalignmentview

ProperlyTaken• Patellaforward• Bothlegs

Alignment- Don’tForgettheLateral! LateralLongLegAlignment

• LargeSlope• Primary

– considerLateralExtra-articular

• Revision– considerslopechangeosteotomy

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Untreated laxity may result in abnormal tensile loads on the ACL which can lead to graft failure

ACL

StressX-rays

• Objectiveassessmentofinstability

• Validatesinstabilitypattern

StressX-rays– DeterminingandDocumentingInstability

(LaPradeetal,AJSM2010)

Side-to-sidelaxity

0° 20°

sMCLonly

>1.7mm >3.2 mm

Complete

MCL>6.5 mm >9.8 mm

CTScan16mm

2D- Determiningtunnelenlargement 2D- Determiningtunnelenlargement

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3DCT=goldstandardforevaluationofbonetunnelenlargement&bonetunnelplacement

X-ray=Good?….Bad?….Ugly?

AmJKneeSurg 1997 Arthroscopy2006

Study AMBDepth

PLB Depth Ave Depth AMB

HeightPLB

HeightAve

Height

Bernard-Hertel (1997), N = 10 24.8 28.5

Yamamoto (2004), N = 10 25 29 27 16 42 29

Colombet (2006), N = 7 26.4 32.3 29.4 25.3 47.6 36.5

Zantop (2008), N = 20 18.5 29.3 23.9 22.3 53.6 38.0

Tsukada (2008), N = 36 25.9 34.8 30.4 17.8 42.1 30.0

Lorenz (2009), N = 12 21 27 24 22 45 34

Forsythe (2010), N = 8 21.7 35.1 28.4 33.2 55.3 44.3

Pietrini (2010), N = 12 21.6 28.9 25.3 14.6 42.3 28.5

Weighted averages 23.1 31.5 27% 20.3 46.0 34%

CenteroftheFemoralTunnel

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FemoralTunnelPossibilities

• TYPE 1=Correct:(easy)– overdrillexistingtunnels

• TYPE 3=Entirelyincorrect:(easy)– drillnewtunnels

• TYPE 2=Almostcorrect:(difficult)– potentialfortunneloverlap

Type1 Type1

TType1 Type3

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Type3 Type3

Type3 Type2

Type2 3DCTscan- TIbia

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KSSTA2015

AP ML

Study n AMB PLB Centre AMB PLB Centre

Tsukada etal. 36 37.6 50.1 43.9 46.5 51.2 48.9

Lorenzetal. 12 37 48 42.5 48 50 49

Sadoghi etal. 30 41 49

Leeetal. 15 36.7 42.2 39.5 47.3 53.8 50.6

Parkinsonetal. 76 39 48

WeightedMean

37.3 47.8 41.1 47.0 50.8 50.4

AP=39.5%

ML=52.1%

2DCTmayunderestimatetheProblem

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MRI• ?VerticalGraftIntact

– DeficientACLbutgraftpresent

• ?Chondral Surfaces• ?MeniscalTear• ?RootTear

MRI LateralMeniscusRootTear

MRI• SignificantChondralLesion

• PeripheralLigamentInjuryorReconstruction

• ?NeedforHTO

CaseExample• 27yr Man

• 2PreviousACLreconstructions- last5yearsago

• Subsequentmedialmeniscusinjury– menisectomy

• Furtherinjurywithpainandswelling:MRIconfirmsGraftrupture

• Nowpainmediallybutmaincomplaintofinstability

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Algorithm

LigamentStability

Alignment

Meniscus

Cartilage

• Osteotomy

• ACLrevision

– Contra-lateralhamstrings

• MeniscusAllograft

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1yearPost-op

0

10

20

30

40

50

60

70

80

90

100

Pain Symptoms ADL SportandRecreation

QoL

Pre-op 1yrPostop

CaseExample– TheEasyrevision….?

BTBGraftHarvest

TibialTunnel

Coalescence

Bail outandBonegraft

WasthisPredictable?

• PatientHeight=5ft1’!

CaseExample– TheEasyrevision….?

55%43%

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• Helpful to identify hardware and the location of the original bone tunnels

Intra-operative Flouroscopy

• New tunnel position controlled using intraoperative c-arm images

Intra-operative Flouroscopy

MyStandardWork-up

• APandLateralview– weightbearinginextension

• Skylinepatellaview

• Rosenbergviews

• StandingAPalignmentbothlowerextremities(longfilm)

• CTscan

• MRIscan

• ConsiderIntra-opflouroscopy