1. G.C. COARI A. TRIPODO THE DOUBLE BUNDLE ACL RECONSTRUCTION FROM AM PORTAL “ SAN CAMILLO” PRIVATE HOSPITAL FORTE DEI MARMI (LUCCA) - ITALY
2. ARTHROSCOPIC & PROSTHESYS SURGERY UNIT “ SAN CAMILLO” PRIVATE HOSPITAL FORTE DEI MARMI (LU) - TUSCANY - ITALY WWW.SANCAMILLOFORTE.IT ORTOPEDIA@SANCAMILLO.NET 2 CHIEFS: G.C. COARI - A. MONTANO ORTHOPEDIC STAFF: A. TRIPODO - P. RIGHI F. MIELE - F. TROIANI S. CAPPATO - A. DAGNINO A. PERA - A. BIAGI
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4. HOW COULD THE 10-30% WORSE RESULTS BE IMPROVED ? THE ANATOMICAL DB ACL RECONSTRUCTION IS “ AN ENCHANTING HYPOTESIS ” SEARCHING TO RECREATE THE COMPLEX ACL ANATOMY AND FUNCTION
7. AM PL PL AM Yasuda, Arthroscopy 2004 OTT 7 ANATOMY THE FEMORAL ORIGIN HAS AN OVAL SHAPE WITH THE AM CLOSE TO THE OVER THE TOP POSITION AND THE PL 10mm MORE DISTAL, CLOSE TO THE ANTERIOR (8mm) AND INFERIOR (5mm) CARTILAGE BORDER
8. ANATOMY AM PL AM PL 8 THE TIBIAL ORIGIN IS AN OVAL SHAPE WITH THE AM CLOSE TO THE ANTERIOR HORN OF THE LATERAL MENISCUS, WHILE THE PL IS BETWEEN THE TWO TIBIAL SPINES, ABOUT 8mm POSTERIOR AND LATERAL FROM THE AM BUNDLE
9. 9 AM PL AM PL AM PL AM PL AM PL AM PL AM PL AM PL AM PL AM PL AM PL AM PL AM PL AM PL AM PL AM PL AM PL AM PL AM PL AM PL AM PL Giron, Arthroscopy, 2007 21 NORMALIZED: HIGH VARIETY IN SHAPE AND SIZE
10. WE MAKE ACL SURGERY IN 90° PL BUNDLE AM BUNDLE EXTENSION FLEXION FEMORAL INSERTION ALIGNMENT CHANGES WITH KNEE FLEXION 10
13. PATIENT SETUP 90 o flexion 120 o flexion 70 o flexion A RANGE OF MOTION BETWEEN FULL EXTENSION AND 120° DEGREES OF FLEXION INTRA-OPERATIVELY IS ESSENTIAL
19. PL FEMORAL TUNNEL 8 mm 5 mm LFC articular cartilage border 19 8 MM FROM THE ANTERIOR AND 5 MM FROM THE INFERIOR L.F.C. CARTILAGE THE KNEE IS FLEXED TO 120° TO AVOID THE PERONEAL NERVE AND TO ENSURE ADEQUATE TUNNEL LENGTH
20. THE PL FEMORAL TUNNEL IS DRILLED FROM THE ACCESSORY ANTEROMEDIAL PORTAL WITH A 4,5 MM ACORN DRILL. WE MEASURE THE LENGTH AND THEN CHOOSE A FIXATION (EB FAMILY) 20
22. PL TIBIAL TUNNEL AM PL THE PL TIBIAL INSERTION SITE IS LOCATED WITHIN THE TRIANGLE FORMED BY THE AM, THE PCL, AND THE POSTERIOR ROOT OF THE LATERAL MENISCUS
24. AM TIBIAL TUNNEL AM PL THE ENTRY OF THE AM GUIDE WIRE IS DRILLED MORE ANTERIOR AND PROXIMAL TO THE PL WIRE, AND THERE SHOULD BE A BONE BRIDGE OF AT LEAST 1 CM BETWEEN THE TWO TUNNELS
39. TENSIONING AND TIBIAL FIXATION LENGHT/STRAIN PATTERNS OF NORMAL AMB AND PLB P.L. BUNDLE TIGHT NEAR EXTENSION AND RELAXED DURING FLEXION A.M. BUNDLE TIGHT NEAR EXTENSION, MOST RELAXED AT 30°- 60° AND TIGHT AGAIN OVER 90° ONLY NEAR EXTENSION WE GET EQUAL STRAIN OF THE TWO BUNDLES Yasuda ISAKOS 2005
41. IT’S THE RIGHT WAY TO IMPROVE OUR OUTOCOMES ? 41 WE NEED PROSPECTIVE RANDOMIZED CLINICAL STUDY BETWEEN SB AND DB TECNIQUE WITH 10 YS FOLLOW-UP MINIMUN
42. DOUBLE BUNDLE VS SINGLE BUNDLE PROSPECTIVE CONTROLLED RANDOMIZED CLINICAL STUDY 42 AIM OF THE STUDY: TO COMPARE THE CLINICAL OUTCOMES OF PATIENTS TREATED EITHER WITH AN ANATOMICAL SB (AM PORTAL), WITH TRANSTIBIAL SB (HOWELL) AND WITH A DB (AM PORTAL) TECHNIQUE
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45. UP TO NOW ONLY 40% OF PATIENTS HAVE REACHED A 6 MONTHS FOLLOW-UP 45 WE STILL HAVE TO WAIT TO GET COMPLETE OUTCOMES
Up to now we’ve been performing ACL reconstruction using SB surgery. .....showed us a high rate of success ranging from 70 to 95 %.... in the remaning percentage a persist........has been observed In long term f-up patients had degenr.......... and only the 47% of.......
WITH DB MORE.....WE’VE BEEN REGISTERING BETTER OUTCOMES STILL WAITING FOR CONFIRMATION IN THE LONG RUN
CHANGES ACCORDING TO EX....WHERE THE DB ARE VERTICAL AND FLEX.....WHERE THEY ARE ORIZZ....
the table is in its full length/we use the whole table BUT EVEN if you use the hanging table
THE ANTEROLATERAL AND ANTEROMEDIAL PORTALS ARE ESTABLISHED ADIACENT TO THE LATERAL AND MEDIAL PATELLAR TENDON BORDERS AT THE LEVEL OF THE INFERIOR POLE OF THE PATELLA.
IF WE COMPARE THE VIEWS WITH AL AND AM SCOPE WE CAN SEE THAT IN THE LATTER ONE WE GET A BETTER VIEW OF THE CFL
WE NOW MARK THE ENTRY AND EXIT POINTS OF THE ORIGINAL ACL ON FEMUR AND TIBIA
