Revision ACL Reconstruction: My Clinical Results and Complications—What I have Learned 20+ Years Later Mark D. Miller, MD S. Ward Casscells Professor UVA Team Physician, JMU University of Virginia Orthopaedic Surgery Disclosures • Elsevier/LWW – Book Royalties • JBJS – Deputy Editor • MRC – Founder/Director COLORADO 2015 University of Virginia Orthopaedic Surgery Practice Profile [Shout out to Chris Harner, MD] • Location: University of Virginia, Charlottesville, VA, USA • Years in Practice: 22 • ACL Reconstructions/Year: ~100 – Primary: 70 – With MLI: 10 – Revisions: 20 • Graft Preferences – AUTOGRAFT!!! – BPTB > Hamstring – Use the one available • Even from the opposite leg! University of Virginia Orthopaedic Surgery ACL Graft Failure “On the other hand, it’s not the end of the world.” University of Virginia Orthopaedic Surgery ACL Graft Failure Pitt Classification University of Virginia Orthopaedic Surgery Revision ACL 20+ Years Later Overview • Results • Complications • Lessons Learned: 1. History and Physical Examination 2. Imaging 3. Details of Prior Surgery 4. Planning 5. Technical Pearls University of Virginia Orthopaedic Surgery Revision ACL 20+ Years Later Results MARS Outcome Study Am J Sports Med 2014 42:2301 • IKDC/KOOS/WOMAC Scores: All Mid 70’s • Graft Rerupture 3.3% – Allograft 2.8 x Failure Rate • Marx Activity Score 11=>7 (Less Active) UVA One Stage Revision Study (Arthroscopy In Press) • IKDC/KOOS: Low 70’s • Graft Laxity: 5% (No Frank Reruptures) • Tegner Activity Score: 5 (Less Active) University of Virginia Orthopaedic Surgery Revision ACL 20+ Years Later Complications • • • • Missed concurrent injuries Graft migration Non-anatomic placement Graft Harvest & Preparation • Rehab issues • Loss of Motion • Other University of Virginia Orthopaedic Surgery Missed Concurrent Injuries Posterolateral Corner Injury * University of Virginia Orthopaedic Surgery Graft Migration Be prepared Don’t create oval tunnels Liberal Fluoro Use Back it Up! University of Virginia Orthopaedic Surgery Non-Anatomic Placement: A vertical graft shouldn’t be replaced with a vertical graft University of Virginia Orthopaedic Surgery Intra-op Fluoro • If you get stuck… take a picture! University of Virginia Orthopaedic Surgery Tunnel Placement Radiographic Measurements Merchant, Noyes Am J Sports Med 2010; 38:1987-96 • 107/122 ACL Revisions referred were “nonanatomic” • Recommended 8mm offset guide for revisions Sommer KSSTA 2000; 8:207-213 Bernard AJKS 1997; 10:14-22 • Femoral tunnel should be in 4th Quadrant Amis, Jacob KSSTA 2001; 9:104-109 • Tibial tunnel should be 43% of A-P distance • The problem with use of radiographic measurements alone is that the “anatomic” insertion sites vary between individuals (Fu) • This femoral tunnel was drilled with an 8-mm offset guide, and it is NOT in the 4th Quadrant (it is 72% of the A-P distance along B’s line)! University of Virginia Orthopaedic Surgery Back it UP! Revision with BPTB: Femoral Side Large Interference Screw Aperture Fixation (Endobutton) Tibial Side Large Interference Screw Aperture Fixation (Screw and Post/Button) University of Virginia Orthopaedic Surgery Graft Harvest Issues ACL Complications--Fractures • Most Fractures occur 8-12 weeks post-op • Reducing incidence: – – – – – Smaller Saw Blade* Cutting Undersurface Drill holes at corners Less Rectangular graft Bone graft defects Viola et al, Arthroscopy 1999 University of Virginia Miller, et al, Athroscopy 1999 Orthopaedic Surgery ACL Complications Hamstring Harvest • Graft Amputation • Saphenous Nerve Injury – Saphenous Nerve passes superficial to gracilis tendon (between gracilis and Sartorius) at the posteromedial joint line • ? Loss of Terminal flexion strength University of Virginia Orthopaedic Surgery ACL Complications • BPTB incision – medial of midline from inferior pole of patella to tibial tubercle – Dangers: Infrapatellar branch of Saphenous N University of Virginia Orthopaedic Surgery Remember—hold onto the graft!! University of Virginia Orthopaedic Surgery Environmental Hazards University of Virginia Orthopaedic Surgery If you must fall… Protect the graft! University of Virginia Orthopaedic Surgery Revision ACL Complications • Rehabilitation Rehab Issues – 1989: Immobilzation for 6 weeks in ankle-to-groin cast in 30o flexion – 1990’s: “Accelerated”/ “Aggressive” rehab – 21st Century: Moderation? Avoid resisted non-weight-bearing (open chain) knee extension between 0o and 30o during first six weeks of Rehab because of increased stress on the graft! Max @ full extension. University of Virginia Orthopaedic Surgery ACL Complications: • Pre-op Loss of Motion (LOM) – ROM, Effusion, Quad tone, Gait – MCL/MPFL Injury • Intra-op – Tunnels & Tension • Post-op – Hemarthrosis (Ice) – Early LOM (Extension!) • LOA/MUA after 6-12 weeks if PT and serial splinting fails – RSD (CRPS) University of Virginia Orthopaedic Surgery Fighting LOM Extension Drop Out Cast Extension Board LOA/MUA Orthopaedic Surgery University of Virginia ACL Complications Other Problems ACL Reconstruction Complications: • Infection – Aggressive Approach • Hemarthrosis – Aspirate • Tunnel Osteolysis – Observe • Cyclops Lesion – Fibroproliferative tissue blocks extension – “Click” at terminal extension University of Virginia Orthopaedic Surgery ACL Revision Lessons Learned 1. History and Physical Examination 2. Imaging 3. Details of Prior Surgery 4. Planning 5. Technical Pearls University of Virginia Orthopaedic Surgery ACL Revision: 5 Lessons 1. History & Physical Examination • History Instability vs Pain “Do you trust your knee?” • Physical Examination Lachman Pivot Shift Posterior Drawer Varus/Valgus ER Asymmetry University of Virginia Orthopaedic Surgery ACL Revision: 5 Lessons 2. Imaging Plain Radiographs Standing Flexion PA Hyperextension Lateral Sunrise Hip-Ankle Alignment Stress Radiographs? MRI CT University of Virginia Orthopaedic Surgery ACL Revision: 5 Lessons 3. Prior Surgery Details • • • • Op Report/Images Graft(s) Used Tunnel Locations Concurrent Surgery University of Virginia Orthopaedic Surgery ACL Revision: 5 Lessons 4. Planning • ROM • Quadriceps Strength • Equipment – Revision Instruments – Dilators – Bone Graft • Tunnels • Osteolysis – One vs Two Stage? • Hardware • Fluoro Available University of Virginia Orthopaedic Surgery ACL Revision: 5 Lessons 5. Technical Pearls • • • • • • Use Autograft Retain Hardware if Possible Plug Tunnels (Dowel) Plan Divergent Tunnels Use Secure Fixation Two Stage if Necessary University of Virginia Orthopaedic Surgery ACL Revision: Technical Pearls Graft Choices • Autograft University of Virginia Orthopaedic Surgery ACL Revision: Technical Pearls Retain Hardware¹ • Avoids Defects/Oval Tunnels • Stainless Steel (Drill Bit) is Stronger than Titanium (Interference Screw)! ¹Miller MD. Revision Cruciate Ligament Surgery with Retention of Femoral Hardware. Arthroscopy 1998; 14(1): 111-114. University of Virginia Orthopaedic Surgery ACL Revision: Technical Pearls Bone Dowels • Used to fill previous Tunnels or Defects from Hardware removal¹ • Sizes: 10-18 mm Ø, Up to 30 mm in Length • 100% incorporation with no Osteolysis or Cysts² ¹Battaglia T, Miller MD; Arthroscopy 2005; 21:767.e1-767.e5. ²Werner BC, Gillmore CJ…Miller MD. Revision ACL Single Stage Femoral Tunnel Allograft Dowel Bone Grafting. Arthroscopy, In Press. University of Virginia Orthopaedic Surgery with Femoral ACL Revision: Technical Pearls Divergent Tunnels • Accessory Medial Portal • Two-Incision • Over the Top? University of Virginia Orthopaedic Surgery ACL Revision: Technical Pearls Plan Secure Fixation • Do not count on an intact femoral cortex • Plan on Poor bone quality • Double Fix¹ ¹Hamann J and Miller MD. Single Stage ACL Revision Reconstruction in Marx RG (Ed) Revision ACL Reconstruction; NY: Springer 2014; pp 119-126. University of Virginia Orthopaedic Surgery Two Stage University of Virginia Orthopaedic Surgery ACL Revision Do it right the Second Time! University of Virginia Orthopaedic Surgery Thank You! University of Virginia Orthopaedic Surgery
© Copyright 2024 ExpyDoc
