new advancements in orthopaedic sports medicine prof. berkes, i
TRANSCRIPT
NEW ADVANCEMENTS in
ORTHOPAEDIC SPORTS MEDICINE
NEW ADVANCEMENTS in
ORTHOPAEDIC SPORTS MEDICINE
Prof. Berkes, I. Prof. Berkes, I.
PRIORITIES in SPORTS MEDICINE
• Antidoping
• Prevention
• Safe and effective surgeries
– Minimal invasivity– Autografts– Solid fixation– Early and accelerated rehabilitation
DISTRIBUTION of SPORTS INJURIES
Spine-trunk 17 %
Lower extremity 61 %
Upper extremity 22 %
ANTERIOR CRUCIATE LIGAMENT (ACL)
ANTERIOR CRUCIATE LIGAMENT (ACL)
ACL RECONSTRUCTIONACL RECONSTRUCTIONACL RECONSTRUCTIONACL RECONSTRUCTION
• USA 75.000 -100.000 / year
• Hungary 7.000 / year
• 85 % of orthopedic surgeons perform less than 10 ACLR / year
• USA 75.000 -100.000 / year
• Hungary 7.000 / year
• 85 % of orthopedic surgeons perform less than 10 ACLR / year
ACL RECONSTRUCTIONACL RECONSTRUCTIONACL RECONSTRUCTIONACL RECONSTRUCTION
• 75 - 90 % success rates
• 10 % pain and instability
• Revision surgery• Faulty surgical technique
• Improper tibial and femoral bone tunnel placement
• Osteoarthritis 35 %
• 75 - 90 % success rates
• 10 % pain and instability
• Revision surgery• Faulty surgical technique
• Improper tibial and femoral bone tunnel placement
• Osteoarthritis 35 %
PPREVENTIONREVENTIONPPREVENTIONREVENTION
Consensus
• Good & balanced muscular strength• Eccentric and concentric resistance training
• Muscle flexibility• Stretching
• Good proprioceptive function• Proprioceptive training
• Good aerobic & anaerobic stamina• Controlled endurance training
Consensus
• Good & balanced muscular strength• Eccentric and concentric resistance training
• Muscle flexibility• Stretching
• Good proprioceptive function• Proprioceptive training
• Good aerobic & anaerobic stamina• Controlled endurance training
PPREVENTIONREVENTIONPPREVENTIONREVENTIONChallenges
• Introduction is often difficult• Resistance from club and coaches
• Most methods: well-defined effective doses,BUT does the schedule allow to apply them?
• They prevent non-contact injuries effectively,BUT what about contact injuries?
Acute knee ligament injuries will keep on happen…
Challenges
• Introduction is often difficult• Resistance from club and coaches
• Most methods: well-defined effective doses,BUT does the schedule allow to apply them?
• They prevent non-contact injuries effectively,BUT what about contact injuries?
Acute knee ligament injuries will keep on happen…
DDIAGNOSISIAGNOSISDDIAGNOSISIAGNOSIS
Consensus
• Good history taking
• Injury mechanism
• Physical examination
Consensus
• Good history taking
• Injury mechanism
• Physical examination
HEMARTHROSIS HEMARTHROSIS
• Calls for differentiated approach
• „Diagnostic arthroscopy”- Has any therapeutic benefit?
• „Morphologic diagnosis by arthroscopy”
– Carries several potential risks!
• Calls for differentiated approach
• „Diagnostic arthroscopy”- Has any therapeutic benefit?
• „Morphologic diagnosis by arthroscopy”
– Carries several potential risks!
• Activity and occupational level
• Associated lesions (i.e. repairable menisci)
• Age
• Combined ligamentous injuries
• Instability producing functional disability
• Ability of a patient to comply with a rehab program
• Activity and occupational level
• Associated lesions (i.e. repairable menisci)
• Age
• Combined ligamentous injuries
• Instability producing functional disability
• Ability of a patient to comply with a rehab program
INDICATIONSINDICATIONS
• > 20 different techniques> 20 different techniques
• > 5 different grafts> 5 different grafts
• DDifferent rehabifferent rehabilitationilitation protocols protocols
• DDifferent outcome assessmentsifferent outcome assessments
• > 20 different techniques> 20 different techniques
• > 5 different grafts> 5 different grafts
• DDifferent rehabifferent rehabilitationilitation protocols protocols
• DDifferent outcome assessmentsifferent outcome assessments
ACL RECONSTRUCTIONACL RECONSTRUCTION
• Preoperative rehabilitation
• Surgeons’s skills and experience
• Graft material
• Graft placement
• Initial graft tension
• Preoperative rehabilitation
• Surgeons’s skills and experience
• Graft material
• Graft placement
• Initial graft tension
AFFECTING FACTORSAFFECTING FACTORS
• Graft fixation
• Concomitant injuries
• Rehabilitation
• Graft healing
• Insertion site healing
• Graft fixation
• Concomitant injuries
• Rehabilitation
• Graft healing
• Insertion site healing
AFFECTING FACTORSAFFECTING FACTORS
• Increase in ROM• Muscle build-up• +• Patient’s involvement and confidentiality• Learning new motor controls• Learning new skills
Preop rehabilitation is benefitial !
• Increase in ROM• Muscle build-up• +• Patient’s involvement and confidentiality• Learning new motor controls• Learning new skills
Preop rehabilitation is benefitial !
PREOP REHABILITATIONPREOP REHABILITATION
Biological graft materials:• Autograft: BPTB, Hamstrings, Quad-
tendon• Allograft: Achilles, BPTB, ACL
Biological graft materials:• Autograft: BPTB, Hamstrings, Quad-
tendon• Allograft: Achilles, BPTB, ACL
GRAFT SELECTIONGRAFT SELECTION
Synthetic graft materials have not Synthetic graft materials have not been successful.Engineered biological ACL scaffolds:still experimental.
Single collagen fibersSingle collagen fibers
attaching to boneattaching to bone – –
„„Sharpey’s fibers”Sharpey’s fibers”
Single collagen fibersSingle collagen fibers
attaching to boneattaching to bone – –
„„Sharpey’s fibers”Sharpey’s fibers”
TENDON-to-BONE HEALINGTENDON-to-BONE HEALING
BONE-to-BONE HEALINGBONE-to-BONE HEALING• Schiavone et al., 1993. Knee Surg. Sports Traumatol. Arthros.
• Rabbit study• Incorporations 4 months• Normal insertion 6-9 months
• Hidas et al., 2005.Hidas et al., 2005.
• Schiavone et al., 1993. Knee Surg. Sports Traumatol. Arthros.
• Rabbit study• Incorporations 4 months• Normal insertion 6-9 months
• Hidas et al., 2005.Hidas et al., 2005.
ARE RESULTS GRAFT- DEPENDENT?ARE RESULTS GRAFT- DEPENDENT?
Aglietti et al. Am J Sports Med 1994;22(2):211
„…no significant overwhelming differences between
BPTB and hamstring implantation…“
Denti et al. Knee Surg Sports Traumatol Arthrosc. 2006 Jan 10:1-4
„…no statistical differences in the clinical and instrumental evaluations of stability after 1 and 2 years (Lachman and Jerk test, KT1000) between BPTB and hamstring…“
Aglietti et al. Am J Sports Med 1994;22(2):211
„…no significant overwhelming differences between
BPTB and hamstring implantation…“
Denti et al. Knee Surg Sports Traumatol Arthrosc. 2006 Jan 10:1-4
„…no statistical differences in the clinical and instrumental evaluations of stability after 1 and 2 years (Lachman and Jerk test, KT1000) between BPTB and hamstring…“
HOWEVERHOWEVER
„…delayed TENDON-BONE healing (soft grafts) with potential risk of graft stretch out in bony cannal is presumeble…“
„…delayed TENDON-BONE healing (soft grafts) with potential risk of graft stretch out in bony cannal is presumeble…“
Meister K, Huegel M, Indelicato PA, et al. Current concepts in the recognition and treatment of knee injuries. APTA SPTS HSC-00: Lacrosse, WI; 2000. Meister K, Huegel M, Indelicato PA, et al. Current concepts in the recognition and treatment of knee injuries. APTA SPTS HSC-00: Lacrosse, WI; 2000.
Slightly different approach to RHB according to graft selection
Slightly different approach to RHB according to graft selection
• Hamstrings (ST and / or GR)• Most primary indications, less active, older patients, PF problems,
less demanding activities, some revisions
• BPTB • Professional athletes, some revisions
• Allograft• Some revisions, PF and hamstrings problem
• Hamstrings (ST and / or GR)• Most primary indications, less active, older patients, PF problems,
less demanding activities, some revisions
• BPTB • Professional athletes, some revisions
• Allograft• Some revisions, PF and hamstrings problem
OUR GRAFT SELECTIONOUR GRAFT SELECTION
• 60 % HS60 % HS
• 35 % BPTB35 % BPTB
• 5 % Allografts5 % Allografts
• 60 % HS60 % HS
• 35 % BPTB35 % BPTB
• 5 % Allografts5 % Allografts
USE of DIFFERENT GRAFTSUSE of DIFFERENT GRAFTS
GRAFT PLACEMENTGRAFT PLACEMENT
GRAFT FIXATIONGRAFT FIXATION
GRAFT FIXATIONGRAFT FIXATION
GRAFT TUNNEL MOTIONGRAFT TUNNEL MOTION
TUNNEL WIDENINGTUNNEL WIDENING
Universal problem
• in Hamstrings and BPTB
• in auto- and allografts
Universal problem
• in Hamstrings and BPTB
• in auto- and allografts
Etiology?Etiology?
Clinical significance?Clinical significance?
Single bundle ACL reconstruction (BPTB and Hamstrings)
+ AP stability restored
– Rotational stability not restored
– Pivot shift not restored
Single bundle ACL reconstruction (BPTB and Hamstrings)
+ AP stability restored
– Rotational stability not restored
– Pivot shift not restored
BIOMECHANICAL RESEARCHBIOMECHANICAL RESEARCH
ACL RECONSTRUCTIONACL RECONSTRUCTION
• Single bundle ACL reconstruction - procedure of choice for instability in the past decade
• Clinical and biomechanical studies: SB ACL reconstruction restored the sagittal stability but not the rotational stability
• Anatomical reconstruction of the two functional bundles of the ACL is necessary?
• Single bundle ACL reconstruction - procedure of choice for instability in the past decade
• Clinical and biomechanical studies: SB ACL reconstruction restored the sagittal stability but not the rotational stability
• Anatomical reconstruction of the two functional bundles of the ACL is necessary?
From anterior and central tibia
to posterior and medial aspect of LFC
Primary restraint to anterior tibial translation
Controls pivot shift phenomenon
ACL
Anteromedial bundle
Posterolateralbundle
2 major bundles: Anteromedial Posterolateral
Different tension patterns and elongation behaviors of different fiber bundles with knee flexion
KINEMATICS
Nomenclature of the bundles related to their tibial insertion
AM
PL
AM
PL
Femoral insertion AM: anterior and proximal
PL: posterior and distal
No ACL remnants in chronic lesionsNeed to know arthroscopic anatomy
ACL Reconstruction
12
6
39
30°
Femoral InsertionArthroscopic Nomenclature
Tibial Tunnel Position
Less important for ACL graft kinematics
Muneta, Am J Sports Med, 1993Hefzy, Am J Sports Med, 1994
Avoid impingement !Howell & Taylor, JBJS, 1993
0 20 50 80 110
20
40
60
Knee flexion (°)
Gra
ft t
ensi
on (
New
ton)
Zavras & Amis, KSSTA, 2001
isometric
shallow
Strongly affects graft tension and knee kinematicsPosition close to AM bundle insertion more isometric
Femoral Tunnel Position
12
639
Double bundle (anatomic) reconstruction
OUR RATIONALE
1) To adopt a reproducible surgical technique
2) Based on cadaveric validations
Comparative Study
Single bundle 1 tibial, 2 femoral 2 tibial, 2 femoral
CONCLUSIONS
ACL insertions show a high variability both in location and dimension
Often in ACL injuries no femoral footprint remnants can be visualized at arthroscopy
Need for precise landmarks and reproducibility
CONCLUSIONS
Single bundle ACL reconstruction is effective in limiting anterior translation but does not control pivot-shift
Double bundle sounds promising, but clinical results are necessary to confirm lab results
ARTHROSCOPIC MENISCUS SURGERY
ARTHROSCOPIC MENISCUS SURGERY
• To preserve as much healty To preserve as much healty meniscus tissue as possiblemeniscus tissue as possible
MENISCAL HEALINGMENISCAL HEALING
• The peripheral blood supply can produce a The peripheral blood supply can produce a reparative response reparative response
• Fibrovascular scar tissue by 10 weeksFibrovascular scar tissue by 10 weeks
HEALING ENCHANCEMENT
HEALING ENCHANCEMENT
• Fibrin glueFibrin glue• Fibrin clot insertionFibrin clot insertion• Vascular access channelsVascular access channels• Synovial abrasionSynovial abrasion• Modulators of healingModulators of healing
CLASSIFICATION CLASSIFICATION
TREATMENT OPTIONSTREATMENT OPTIONS
• Leave aloneLeave alone• Benign neglectBenign neglect• PuncturePuncture• ResectResect• RepairRepair
IDEAL TEAR FOR REPAIRIDEAL TEAR FOR REPAIR
• TraumaticTraumatic
• Vertical longitudinal Vertical longitudinal
• Peripheral 3 mm Peripheral 3 mm
• 1 - 4 cm1 - 4 cm
• No damage to the meniscal bodyNo damage to the meniscal body
CONTRAINDICATIONSCONTRAINDICATIONS
• Complex geometryComplex geometry
• Flap tearsFlap tears
• Complete radial tearsComplete radial tears
– Recovery time?Recovery time?
MENISCUS REPAIRMENISCUS REPAIR
MENISCUS-REPAIRMENISCUS-REPAIR
DART DART (ARTHREX)(ARTHREX)DART DART (ARTHREX)(ARTHREX)
FASTENER FASTENER (MITEK)(MITEK)FASTENER FASTENER (MITEK)(MITEK)
CLEARFIX SCREW CLEARFIX SCREW ( MITEK )( MITEK )CLEARFIX SCREW CLEARFIX SCREW ( MITEK )( MITEK )
STAPLE STAPLE (ARTHROTEK)(ARTHROTEK)STAPLE STAPLE (ARTHROTEK)(ARTHROTEK)
T – FIX T – FIX (SMITH + (SMITH + NEPHEW )NEPHEW )T – FIX T – FIX (SMITH + (SMITH + NEPHEW )NEPHEW )
REFIXATION IMPLANTSREFIXATION IMPLANTS
REHABILITATION REHABILITATION
• Depends on repair!Depends on repair!
– Weight - bearingWeight - bearing– Range of motionRange of motion– BracingBracing– Squatting >120 degreeSquatting >120 degree– Return to sportsReturn to sports
REHABILITATIONREHABILITATION
• 6 WKS - WEIGHT-BEARING RESTRICTION6 WKS - WEIGHT-BEARING RESTRICTION
• 3 MO - LOW IMPACT SPORTS3 MO - LOW IMPACT SPORTS
• 6 MO - RETURN TO PREVIOUS LEVEL OF6 MO - RETURN TO PREVIOUS LEVEL OF
ACTIVITYACTIVITY
» DeHAVENDeHAVEN
REHABILITATIONREHABILITATION
• 0 - 2 wks – wbat0 - 2 wks – wbat
• 2 - 4 wks – closed kinetic chain resistance 2 - 4 wks – closed kinetic chain resistance
• 4 - 8 wks – sports specific functional 4 - 8 wks – sports specific functional progressionprogression
» SHELBOURNESHELBOURNE
HANGODY’s MOSAICPLASTY
STEADMAN’s MICROFRACTURE
REHABILITATIONREHABILITATION
Depends on graft fixationDepends on graft fixation
slowslow
rehabilitationrehabilitation
fastfast
Must be accelerated and not aggressive!Must be accelerated and not aggressive!
TODAY
• Immediate mobilization
• Gradual increase in ROM – Graft dependent
• Progressive weight-bearing
• Proprioception restoration
• Immediate mobilization
• Gradual increase in ROM – Graft dependent
• Progressive weight-bearing
• Proprioception restoration
GRAFT DIFFERENCE
• Hamstrings– Hamstrings strenghtening from 5 ws– Running 12 ws, jumping 12-14 ws– Full sports 6 ms
• BPTB – Full hamstrings strenghtening from beginnig– Running 14-16 ws– Full sports 6-9 ms
• Allograft– Program focused more on prevention of arthrofibrosis
• Hamstrings– Hamstrings strenghtening from 5 ws– Running 12 ws, jumping 12-14 ws– Full sports 6 ms
• BPTB – Full hamstrings strenghtening from beginnig– Running 14-16 ws– Full sports 6-9 ms
• Allograft– Program focused more on prevention of arthrofibrosis
INSERTION SITE HEALINGINSERTION SITE HEALING
TTendonendon-to-to--BBone healingone healingTTendonendon-to-to--BBone healingone healing
Near future?Near
future?
Growth-FactorsGrowth-Factors
ANATOMYANATOMY
BIOMECHANICSBIOMECHANICS
MUSCLE BIOPSYSTEM CELLS
MUSCLE BIOPSYSTEM CELLS
GROWTH-FACTORGROWTH-FACTOR
SCAFFOLDSCAFFOLD
ROBOTICSROBOTICS
Year 2020Year 2020
CT-scanCT-scan Fetal cord cellsFetal cord cells
ligament scaffoldenhanced with autologous cells
ligament scaffoldenhanced with autologous cells
Gene transferGene transfer
TAKE-HOME MESSAGE
„Attention to detail
is the key to success!”