Name: Alternatives in Multiligament Treatment
Uploaded: 2021-11-12T00:00:00Z
Channel: Arthrex
Description: Gregory S. DiFelice, MD (New York, NY), presents alternatives in multiligament treatment.

Knee

<p>Gregory S. DiFelice, MD (New York, NY), presents alternatives in multiligament treatment.</p>

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VID1-002879-en-US | A | Alternatives in Multiligament Treatment

Gregory S. DiFelice

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Alternatives in Multiligament Treatment

I've been coming to Arthrex probably since I think 2003. And I practiced when I originally came out. I practiced in a, in an urban level one trauma center, and I saw much the same cases that were just presented to you. And the evolution of my thought came along. And it's interesting how you listen to all the different perspectives, because it's really the evolution of thought is the same as we all start questioning the previous generation's conclusions. And this is the place where I worked, I'm convinced that a lot of the old experience say, for example, with the MCL, the previous generation was was burned in repairing the MCL for one reason alone is because they put the patient in a cast for two months after they did the surgery. And everybody knows if you put a if you cast someone for a long period of time, it's kind of like imagining do a total knee and then put them in a cast at 20 degrees for two months and then tell me how they're going to do. It's so it's really moving the patients. It's all these little things. And I really have to thank Reinhold and Arthrex for continually innovating and coming up with a new ways of doing it that minimize things and, and allow us to really kind of evolve our surgical thought. So I started off with and I learned a lot of things about multi legs. And one was that you need to get to them quickly, or else things that are neglected like this will turn into that. And this is kind of this was one of the pictures from way back when, when I was doing multi legs in the early 2000. And there's hardware everywhere. There's a lot of different ways to do it, but really kind of the thought was to reconstruct everything early. We talk a lot about failure, but we don't talk a lot about the morbidity of the procedure. And anyone who does a lot of multi legs knows that you're going to get stiffness, you're going to get recurrent PCL sag. You're going to have to go back and re-operate to do lysis of adhesions. And these are the things that make people avoid these multi legs. And so I went from this. And then my my techniques evolved as, as the RetroCutter came through and things and I could minimize the surgical insult. And this is A1I think one of the first all-inside multi legs that was presented. And then it started to evolve to try and minimize the surgery even more. And when I would see this type of dislocation with, with ACLs and Pcls that were literally popped right off the bone, I started trying to repair them like I talked about in the in the ACL repair talk. And so the benefits of repair in the multi leg are in what I use is a ligament preservation approach. I explained to my patients essentially, look, I'm going to go in and try and repair what I can. If I can't repair it, I'm going to try and repair as much as I can and add a graph to it to keep the biology. And if I can't, then I'm going to use reconstruction as a last resort. So it's a stepwise approach. I call it ligament preservation. I think early intervention in these things is tremendously important, and the literature bears that out. A repair or this preservation approach decreases the morbidity, decreases the stiffness. And the InternalBrace technology has really led to, you know, a lot of windows opening in this in this old haunted house of the multi ligament knee. It maintains the natural biology, proprioception and anatomy. And it doesn't burn bridges if you have a repair. I call it damage control orthopedics. If you have one of these horrifically injured knees, sometimes you can sneak in there, tack a few things back into place. You can always come back to fight another day and some. A lot of times you'll find out that everything heals up anyways. You don't even have to come back. So my question is always, should we be looking for home runs in the treatment of these horrific injuries, or should we be just trying to get base hits? Should we just trying to make things better? And in a stepwise fashion, do we all have to do it? Do we have to do it all right at the first go around? So this is one of my first papers. I actually started with my repair evolution and journey. I actually started repairing the PCL. And I'll give the credit to Doctor Warren at HSS, who used who taught me when I was a resident that sometimes the PCL pops right off the bone, and he would put some stitches in it and just pull it back. Well, as the rotator cuff technology and the anchors and the stitches came out and they started getting better and better, I would go into these knees and I started to stitch the PCL back first. And this is the first paper I ever published talking about PCL repairs. So if I had a repair like this with a proximal tear off the bone on the sagittal and the coronal, this is what it looks like. It's there. Always kind of sagged back because as the tibia sags posteriorly, it drags that proximally torn PCL with it. And then you have to reduce the piece, the tibia to see if the PCL is going to reach. And here you can see me with my grasper pulling the PCL up. A lot of times people will go in and grab it, pull and say it's not going to make it. It's because you're not reducing the tibial sag, and it gives you this kind of erroneous thought that the PCL won't reach. Put some stitches in it. And this is real. This is old stuff. Some of you have been around for a while. You might recognize this is the the RetroCutter drill. That was the only Cannulated drill way back when. And so we put that in and and tie that PCL up nicely. Well this is six year post-op MRI. You can see it's healed up nicely. Well eventually that evolved to PCL with internal brace. And that's a little trickier. And as you do more of these you have to get to the back of the knee like was shown with that Posteromedial portal is incredibly helpful. And this one is very similar. Here I am reducing it. This is the opposite leg. So it's everything's reversed. We're reducing it to see if it will reach. And we've got the stitches in it. We're pulling it up. And again we've got at this point I'm using suture anchors. And you can see that top anchor. I've got the TigerTape in there. And now I'm going to, I've drilled a hole up through my tibia and I've got a passing suture. And I'm going to pull that TigerTape down along the back of the PCL and through the tibia, just just like I would pull the ACL repair along the front of the ACL. Now this is looking at it from a front internally braced ACL and PCL primary repairs. And this is looking at it from the back. You're looking from a Posteromedial portal. And you can see that TigerTape and the body of the PCL and the TigerTape is running along the posterior aspect of the PCL there and then down through the tibia to reinforce it. Sometimes you have a PCL avulsion fractures. You can treat these just like McKeever fractures for the ACL. It's a little trickier. You have to take down the posterior veil of tissue behind the PCL. But you can get in on these, pull them down and tie them over a button. Sometimes I'll even I'll put a button on the inside too. I'll put my FiberTape over the fracture fragment if it's comminuted, and I'll pull that down through the tibia and then put it over another button down distally. That's my current technique talking about MCL, which we just had a nice talk about. I think you really have to divide MCL between superficial and deep MCL injuries and then the whole medial side of the knee. And I'm going to show you a nice case here where the entire medial side of the knee was gone. And each of the individual components of the medial side of the knee were easily dissected. Out here you can see we have a proximal tear. But this patient was much this this is actually just a standard MCL. And you can see right here where the. We're off at the femur. These are pretty straightforward. You can see this is a medial approach. You can see that MCL sticking up at you. We're going to put some stitches in it and use the SwiveLock there to anchor it down. And then run our internal brace distally. I can you can do a percutaneous approach here because it's not a tremendously involved MCL and anchor it down distally. You can also do this for the LCL. And here's an LCL that's popped right off the fibula. We're going to make a lateral exposure. We're going to do a drill, our oblique tunnel entering Anterolaterally and out posterior immediately. And I like to run that that FiberTape through that tunnel, bring it up and anchor it at the epicondyle to reinforce things. I've also got another technique sometimes that the the top of the fibular head is a little comminuted. You don't have great bone. You can't get good fixation. So stick this one in your pocket. You can take you can do an No oblique drill through the fibula and exit down on the neck of the fibula there. And you can you can drop a button in there and get a far cortical bite. And that's a great technique to to allow you to pull down soft tissue to a little compromise. Proximal fibular bone. I forgot to include the picture with the buttons in there, but the button would be sitting on there just like you'd do. You'd use anywhere, and that's the fine. Finally, the FiberTape being brought up independently and tacked up at the epicondyle to reinforce the construct. You put it all together. Acl, PCL, MCL. And this is that case I was talking about. Have a have a look at this one. It's great anatomy on the medial side of the knee. Let's see if we can get it to play here. He's got grade three valgus wide open. The entire medial side of his knee is ripped open. And as is typical with these things, you can see this is an ACL, ACL, MCL, laxity. Okay. So you can look at the anatomy here in a single 4 or 5 full fed Corkscrew to bring up the whole posteromedial capsule. And now things look a lot more orderly. We still have this portion of our superficial MCL. We can also see over here we got the Mpfl that's going to come over the top here, and we've got a little bit of the meniscofemoral that we're going to tack underneath there, and it's all going to come together real nicely, as you can see, and close the whole medial side of the knee. Now we can go in and scope the knee and our fluid will actually stay in the knee. So sometimes you just got to get in there. This is these are the repaired cruciate ACL and PCL. This is five days post-op. Nice res. Just a little bit of lag to be expected with such a big surgery. Now go ahead and bend it for me as best you can. And you haven't been to any therapy yet, have you? No. Not yet. So we've already got 90 degrees range of motion. And we've got good active quad because we didn't beat him up too much with the surgery. See here. We've already got 90 degrees range of motion, and we haven't really done any therapy yet. Okay, he was off pain meds in three days. We can see here that we just have a slight jog to posterior draw, which is fine because most most posterior cruciate ligament reconstructions end up with a slight jog. And then anteriorly we've got no movement where we brace the ACL. We can see here nicely that the Lockman exam is completely negative. And if you come over to here, we're going to look at the valgus exam and show that it's not moving at all. The valgus that patients five days post-op from a triple ligament surgery and is not on any pain medicine whatsoever. At some point we have to think about the injury that we're causing to the patient and how much pain meds and how much stiffness. And we have to find the right spot to where, where repair can fit into our algorithm. We can't just go in and reconstruct everybody. It is not necessary. We can use a preservation first approach, and we just have to refine our techniques and and we'll see the benefits of these procedures. So in my practice in my study group, we looked at the multiple ligament injured knee. And we looked back in a retrospective study from 2009 to 18. And we tried to figure out how many times we were able to repair the ligaments. So we had 48 patients, average age 32, 54% male. And we looked at the demographics, the injury patterns, treatment and short term outcomes. What we found was that 46% of the injuries were CD one, including one cruciate and one cruciate, and one of the collaterals, and then 54% of them were CD three, 40% were medial and 14% were laterals. And what we found was pretty interesting. 53% of the ACLs that were torn had proximal tears. So that's a little more common than in the isolated ACL tears for pcls of about 47% proximal but also 11% distal MCL is 55 were proximal, 39% distal and Lcl's 53% were distal. Most of them were distal. When we could get them, we found that we were able to repair 55% of all the ACLs that we encountered, 73% of the ACLs, 88% of the Mcls, and 87% of the Lcls. When we looked at multivariate analysis, we found that age over 35 was predictive of whether we could repair those ligaments. And again, so it's that older age group that tends to pull the ligaments off the bone. Personally, I believe it's a vascular issue, just like the rotator cuff tears right at the bone because of watershed areas. I think the same thing happens to the ACL. And then BMI, the lower BMIs tended to be a little more little more frequent. Incidents and repairability. So of the ACLs, 98% were torn. And when we looked at all the multi legs, they always had an ACL involved, 55% were repaired and only two out of 23 of those failed. Both of them were distal pcls 56% torn, 73% repaired, three out of 18 loosened up on US and MCL, 69% torn, 88% repaired. None of them loosened up, and LCL 31% torn, 87% repaired, and 18% loosened up. Of the 43 patient, 90% were eligible for repair of at least one ligament. Again, I'd like to thank my research team for helping to publish and analyze all of this data, and I do believe that a ligament preservation approach is appropriate in these severe injuries. Thanks for your attention.

Alternatives in Multiligament Treatment

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