Transcript THE ADDITIONAL LATERAL TENODESIS OF THE KNEE

THE ADDITIONAL LATERAL TENODESIS OF THE KNEE :
EARLY RESULTS IN SOCCER PLAYERS
Karachalios G.G. , Tamviskos A. , Krinas G. ,
Pavlides E. , Milionis G.
Arthroscopic Surgery and Sports Injury dpt
Metropolitan Hospital , Piraeus , Hellas
Laertion Rehabilitation Center , Piraeus , Hellas
R . T . P. after ACL reconstruction
1986 : only 30% active 3 years post.op. –
none 7 years post.op.
Roos
2011 : 94% return to normal training 10
months - 89% to elite level competition 12
ms post.op.
Walden
Usual range 60 – 85%
amateurs professionals
Which factors
can explain
these differences ?
RTP
FUNCTIONAL STABILITY
ROTATIONAL STABILITY
pivot shift
?
OSTEOARTHRITIS
Recent studies correlate residual rotatory instability
with decreased patient satisfaction , increase functional
instability , chondromalacia and the development of
osteoarthritis . . .
Ayeni Tanaka
positive pivot sign after ACL reconstruction is prognostic
of o/a in the future . . .
Jonsson
restoring rotational kinematics during dynamic pivoting
activities after ACL reconstruction is predictive of
functional outcome . . .
Zampeli , Pappas , Giotis , Hantes , Georgoulis 2012
But . . .
ACL reconstruction , with graft either hamstrings
or BTB , and with the recent techniques , can not
restore the rotation of the tibia to the previous
physiological levels during activities with
increased rotational loading of the knee ,
although the abnormal anteroposterior tanslation
of the tibia has been restablished
Prof An. Georgoulis
Improved
techniques
?
“ posterolateralization ” ?
a more horizontal placement of the femoral
tunnel ,close to 10 o΄clock , which is
anatomically closer to the insertion of the p/l
bundle , can improve rotational stability , without
full restoration
Lucchetti
Double – bundle technique ?
the anatomical double-bundle
reconstruction can decrease the translation and
rotation of the tibia during pivot-shift
Zaffagnini
there are no studies showing any major clinical
advantages in terms of using the double-bundle
surgical technique
Meredick , Sammuelson
technically demanding
dependent on individual anatomical factors
revision ?
Lateral tenodesis ?
. . . The addition of a lateral extra-articular
reconstruction to a standard single bundle ACL
reconstruction with hamstrings tendons graft , is more
effective in reducing the IR of the tibia at 30o of knee
flexion , as compared with a standard single bundle
ACL reconstruction and with an anatomic double
bundle reconstruction . . .
Monaco 2007
Results
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Isolated extra-articular tenodesis : only 50% of
patients reported good to excellent results
is no longer recommended
ACL reconstruction and extra-articular tenodesis :
80-90% good to excellent results
Dodds ( review )
THE AIM OF THIS STUDY IS . . .
. . . To present our experience with this combined
procedure regarding . . .
The procedure itself
The time of return to play
The special issues ( if any ) during rehabilitation
The stability of the knee and
An early follow-up
MATERIAL
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37 male soccer players
Recent ( < 30 days ) ACL rupture
2014 : at least 12months follow-up ( 12 – 21 )
16 – 34 years old
Level :
3 first division
16 second/third division
18 amateurs
CONCOMITANT INJURIES
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20 meniscal injury
14 lateral
6 medial
8 chondral injuries
7 ICRS < II
1 ICRS III
INCLUSION CRITERIA / INDICATIONS
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High demanding players
Age < 20
Findings of anterolateral instability ( 34 pts )
pivot shift
lateral compartment bone edema ( MRI )
SURGICAL TECHNIQUE :
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4- strand autologus ST/G tendon graft
Retain and pull-out the torn ligament’s remnants
Notchplasty
“ monoloop ” lateral tenodesis
knee in 20-30o fl ( initially 90o ) and ex.rot. of the
tibia
8 meniscal repair , 7 trimming and 5 partial
meniscectomies .
No any special treatment for the chondral
injuries
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Mark of anatomical
structures
4-5 cm incision centered
on the lateral femoral
epicondyle
Retaining of the thread
suture of the intrarticular
graft
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A strip of 10 -12 mm width
and of 5 cm. length .
We don΄t go all the way to
Gerdy΄s tubercle .
Just posterior to the
epicondyle , as to do not
overtight the patella .
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Find the lateral colateral
ligament
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Create a tunnel
underneath the ligament
Suturing of the
end of the strip .
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Krackow f-9 point
Proximal and posterior to
the insertion of the LCL ,
where the lateral
intramuscular septum
ends up .
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Looking for the
intraarticular graft button
to don΄t violate its
fixation .
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Prepare the
K f9 with an osteotome
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The strand is pulled
underneath the LCL .
Fixation of the strip
with a tendon staple.
 Knee in 30o and
external rotation .
 Check .
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POSTOPERATIVELY :
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5 days Knee brace in full extension
No Meniscal injury or
Meniscectomy
Full ROM
Knee brace 4 weeks
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Meniscal repair
5 – 21 days knee
brace 0-60o
light touch
21 – 42 days knee
brace 0 - 90o
Phase 1 0 – 4 w.
purpose :
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Graft fixation protection
Control & reduction of inflammation
Full extension
Flexion 90%
Patellar mobilization
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Partial wb
Control of muscle contraction
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Gradual retraining of proprioception ( both legs )
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NO CPM
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Phase 2 4-8 w .
purpose :
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Phase 1 +
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Flexion 120o
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Weaning of crutches and brace
Gradual muscle strengthening
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Static bike
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Phase 3 8- 12 w .
purpose :
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Phase 3 +
Flexion > 120o
Swimming pool
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Walking and slow skipping on traboline
Run retraining
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Single leg step up
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Phase 4 12-16 w .
purpose :
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Phase 3 +
Improving the confidence of the knee
Avoid stresses and excesses in cutting and
pivoting
Start running
Phase 5 16 w . +
purpose :
Gradual return to sports activities
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Criteria for progress in 5 phase :
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Painfree ROM
No irritation at the PF joint
Enough muscle strength and proprioception
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RTP criteria :
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Advanced specialized exercises ( focused on the
soccer )
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LSI strength > 90% on knee extensor as well as
knee flexor strength
LSI hop performance 90% on two maximum as well
as one endurable
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Roland Thomee et al 2011
EARLY RESULTS :
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35 pts returned to unrestricted training < 7 ms
20 pts lack of flexion < 10o
5 pts minimal lack of extension without anterior
knee pain
One reoperation due to symptomatic extension
deficit
Transient restriction of patellar motion
3 pts disappointed with the scar
12 – 21 months :
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2 pts Lachman test 2- 5 mm
6 pts anterior drawer test 2- 5 mm
None pivot sign positive
None subjective instability
12 – 21 months :
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No rerupture
No meniscal repair failure
No secondary chondral injury
21 footballers same team
11 same division
5 lower division
Last assessment :
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One pt with pivoting episode without rerupture
on MRI ( pivot + )
One medial meniscus tear
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Two dropped level ( winter 2015 – 2016 )
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In summary our EARLY results showed :
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Improved stability ( mainly in the last degrees of extension )
and protection of the knee
Without elongation of the recovery time
Slight delay in achieving full ROM
Without any special demands
Particularly for athletes with high
demanding pivot and cutting activities (
such as footballers ) , the addition of
lateral tenodesis provides a more stable
knee and offers an unrestricted return to
Thank you
and
have a nice day
phase 3 purpose 4-6
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Phase 2 +
Flexion 90-120o
Weaning of crutches and brace
Static bike
Phase 5 8-12
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Phase 4 +
Gradual run retraining
Slow skipping on the trampoline
Single leg step up
… tibial rotation is not restored after ACL
reconstruction with a hamstring allograft . . .
Georgoulis et al . 2007
Tanaka 2012
Anatomical structure
Paul Segond 1879
“ Segond ” fracture
...
Terry and LaPrade 1996 capsulo-osseous layers
LaPrade 2000 midthird lateral capsular lig.
Campos 2001 lateral capsular lig.
Vieira 2007 anterolateral ligament
Vincent 2012
anterolateral ligament ( ΑLL ) 100% of the knees
Claes 2013
97% of the knees
Biomechanical
and
anatomical
reconstruction
Εξωαρθρική τενόδεση
Mac Intosh (1) 1972
Lemair 1967 & 1975
Losee΄s
Ellison΄s
+ improves the anterior-lateral rotation of
the tibia and lowers the risk of anterior
subluxation of the lateral tibial condyle
during rotational movements ( pivot )
- Does not decrease the anterior translation
of the tibia
Πρώτες συνδυασμένες
Mac Intosh ( 2) & (3)
Marcacci
Combined techniques ( intra- and extra- )
Additional rotatory stability
Improved control of the IR of the tibia
« protection » of the intraarticular graft
Engebretsen
Criteria
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clinically
High positive pivot sign
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imaging
MRI bone bruising of the anterior-lateral
femoral and posterior – lateral tibial
condyle .
X-Ray fracture Segond
indications
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marked anterolateral rotational instability with
pronounced pivot sign or > 5 mm difference on Lachman
test
High demanding athletes in sports with cutting , pivoting
or contact
Revision surgery after ACLgraft rerupture
High risk patients for rerupture ( age < 20 y. )
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In cases of using cadaveric allograft , particularly in
revision surgery
in combination with osteotomies and coexistant
instability
Patients with generalized joint laxity
Women with valgus knee
Τechnique
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Strip of ITT with restoration of the distal insertion at Gerdy΄s
tubercle
10-12 mm width and 12-18cm of length
Fixation : posterior and proximal of the insertion of the LCL –
at the end of the lateral intramuscular septum
( Krakow f9 point )
Monoloop ( shorter graft ) , doubleloop , tripleloop .
fixaton in 30ο or 90ο flexion and the tibia in neutral
position or external rotation
The ITT strip is twisted 180o
Results
ACL Single-bundle and extra-articular tenodesis
VS
Double-bundle Reconstruction
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Slightly superior with combined procedure
Monaco
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Similar , but better pivot and dynamic behavior with D-B.
Zaffagnini
Results
revision cases
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Addition of a lateral extra-articular tenodesis increases
knee stability
Trojani ( multicenter )
Conclusion
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The addition of a lateral tenodesis to a standard ACL S-B
reconstruction improves rotational stability in high
demands patients , in patients with marked pivot shift
and in cases of revision ACL reconstruction .
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Playing level
Post.op. rehabilitation
Time difference
surgical technique
? Probably improvement of
but . . . There are no studies showing a long – term
difference in functional outcome between different
surgical techniques such as the use of hamstring – or
patellar tendon as grafts
Ekstrand
DEGENERATIVE CHANGES – O/A
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ACL reconstruction VS conservative treatment
Risk factors :
age
sex
BMI
post injury time
meniscectomy
chondral lesions
Type of graft
technique
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double – bundle technique ?
improved control rotational stability through
independent reconstruction and tensioning of the
posterior – lateral bundle
technically demanding
dependent on individual anatomical factors