revision anterior cruciate ligament reconstruction ... · 34 conclusion revision reconstruction of...
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C.K. Yiannakopoulos, PJ Fules,C.K. Yiannakopoulos, PJ Fules,
R. Goddard, MAS MowbrayR. Goddard, MAS Mowbray
Department of Orthopaedics, Mayday University Hospital, Department of Orthopaedics, Mayday University Hospital, London, UKLondon, UK
REVIS ION ANTERIOR CRUCIATE REVIS ION ANTERIOR CRUCIATE LIGAMENT RECONS TRUCTION LIGAMENT RECONS TRUCTION
FOLLOWING S YNTHETIC LIGAMENT FOLLOWING S YNTHETIC LIGAMENT FAILURE US ING HAMS TRING TENDONSFAILURE US ING HAMS TRING TENDONS
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Background Background
Increasing number of primary ACL reconstructions leads to increase of revision
replacements
The incidence of graft failure following primary ACL replacements is 0.7 – 8 %
Restoration of the normal knee kinematics is a challenge after failed ACL
ligament replacement
Results of revision ACL reconstruction are not as favorable as primary ACL
replacements
With every surgical procedure the anatomical and technical conditions become
worse
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General Problems at Revision ACL General Problems at Revision ACL ReplacementReplacement
Poor placement of the graft leading to impingement
Anteriorly placed femoral tunnel
Inappropriate graft length with loss of motion
Tunnel enlargement needing bone grafting
Intraosseous metal fixation devices removal +/- bone grafting
Staged procedures
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IntroductionIntroduction
At Mayday University Hospital London 1992 to 2000 29 procedures
Isolated ACL Revisions were carried out following failed previous ABC prosthetic ligament reconstruction
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Database Database Total No of ACL Revisions 29
Replacement with Prosthetic ABC ligament 5 Autograft 24
Quadriceps Tendon Graft 2
Patellar Bone Tendon Bone Graft 1 Four Strand Hamstring Graft 21
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Orthopaedic PrinciplesOrthopaedic Principlesof Mayday ACL Revision Replacement of Mayday ACL Revision Replacement
TechniqueTechnique
Double Incision Arthroscopically Guided Operation
Permanent Strong 4 Strand STG BH Polyester Soffix Complex
“Straight through” Low Stress Placement
Impingement Free Tibial Tunnel with Mayday Jig
Grooved “Over the Top” Femoral Siting
Tibial Tunnel Edge Chamfering
Firm Monocortical Bollard Fixation
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Materials & MethodsMaterials & Methods
Algorithm for ACL Revision replacement
Return of Subjective Instability – Giving Way
KT 2000 Assessment & Physical Examination
Arthroscopy – Tightening / Removal
Physiotherapy
Autologous ACL Revision Replacement
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Failed ABC Ligament
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Revision ACL S TG ReplacementRevision ACL S TG Replacement
Removal of Removal of failed failed ABCABC
LigamentLigament
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ACL S TG Replacement ACL S TG Replacement Hamstring HarvestingHamstring Harvesting
Surgical Approach STG Preparation / Stripping
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ACL S TG Replacement ACL S TG Replacement
Hamstring Harvesting
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ACL S TG Replacement ACL S TG Replacement
Harvested STG Tendons with Mayday BH Soffix
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Mayday BH Polyester S offix Mayday BH Polyester S offix
Mayday BH Soffix on Frame
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S TG / S offix Complex S TG / S offix Complex Tendon Braiding & Fixation with Ethibond Tendon Braiding & Fixation with Ethibond
S uturesS utures
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4 S trand S TG Mayday BH S offix Complex
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Tibial Tunnel Placement with Mayday Jig
Mayday Jig Jig Placement into the Intercondylar Notch
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Mayday Jig in use X ray
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Check the Guide WireCheck the Guide Wire
Position of Guide wire Arthroscopic view
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Re-Drilling of the Tibial Tunnel
Cross sectional MR from Re-Drilled Tibial Tunnel
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Tunnel Edge Radiusing & Chamfering
Back Radius Cutter Position on AP & Lateral X-ray
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Preconditioning Preconditioning of the Graft-S offix Complex of the Graft-S offix Complex
With 2-300 N Maximum Manual Pulling Force
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Pulling the Graft into the Tibial Pulling the Graft into the Tibial TunnelTunnel
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Distal & Proximal Fixation at 15° Knee Distal & Proximal Fixation at 15° Knee Flexion With 50 N Manual Pulling ForceFlexion With 50 N Manual Pulling Force
Proximal Femoral Proximal Femoral Bollard FixationBollard Fixation
Distal Tibial Bollard Distal Tibial Bollard FixationFixation
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Graft in S traight Through final “Over the Top” Graft in S traight Through final “Over the Top” Position Position
Coronal & Lateral MR Scan from 4 Strand STG ACL GraftCoronal & Lateral MR Scan from 4 Strand STG ACL Graft
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Early RehabilitationEarly Rehabilitation
Brace Wearing in Full Extension for 2 weeks
Early Full Weight Bearing
Closed Chain Exercises for 3 month
Jogging over 4 month
Return to full activity, cutting & contact sports over 1 year
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Results
Male : 25
Female : 4
Average Age at Follow-up (Years) : 36
Range (Years) : 25-51
Mean Total Follow up Time: 34 Months (4-80)
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S ubjective AssessmentS ubjective Assessment
Modified Lysholm Scoring System
Tegner Activity Scoring System
IKDC Patient’s Subjective scoring
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Objective AssessmentObjective Assessment
Lachmann’s Test
Pivot Shift Test
Instrumented Measurement (KT 2000 Arthrometer Side to Side Difference, SSD)
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ResultsTegner Activity S coringTegner Activity S coring
Pre-inj Pre-op Present
Tegner Score
7,6
2,57
5
0
2
4
6
8
10
Different catagories of Tegner scoring
Teg
ner
Sco
re
Pre-injPre-opPresent
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ResultsResults
IKDC S coreIKDC S core
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KT 2000 ArthrometerKT 2000 Arthrometer
Total mean KT-2000 Measurement
SSD 1.70 mm +/- 1.64 SD
17
3 31
02468
10121416182022
A B C D
0-2 mm
2-3 mm
3-5mm
=>5mm
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Pivot S hiftP ivot S hift
Negative 21 Glide +/- 7 Frank 1
Total 29
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ConclusionConclusion Revision reconstruction of the anterior cruciate ligament can provide improvement in function and stability in the short to medium term
The outcome following revision surgery is not as satisfactory as that the following primary procedure.
We feel that highly accurate low stress, straight through placement of the tibial tunnel and over- the-top routing of the reconstruction avoiding the complications associated with re-drilling the femoral tunnel is the best routing for this type of surgery.
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ConclusionConclusion
Our technique has the advantage of being relatively easy to
perform in what is otherwise difficult surgery.
Use of a double looped hamstring tendon graft device can restore
stability to the knee following failure of the primary reconstruction
and even good results can be obtained in the short term in the
multiply re-operated knee.
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Thank you for your Thank you for your attentionattention