Name: ACL Preservation
Uploaded: 2016-04-01T00:00:00Z
Channel: Arthrex

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VPT1-00632-EN | A | ACL Preservation

Gregory S. DiFelice

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ACL Preservation

If you look up the word contrarian in Webster's, you come up with the following definition. Opposing or rejecting a popular opinion and going against current practice. As you'll learn from this talk, ACL preservation is a contrarian approach to the treatment of ACL injuries, but one that is straightforward. It makes intuitive sense, and one that I know that you will warm up to if you keep an open mind. I want you to know that I didn't just wake up one morning and cavalierly say to myself, let's go against everything I've ever been taught and everything that I know, and try to repair the ACL. It was really my experience treating the tidal wave of multi ligament injured knees that I saw in my early career. That opened my eyes to this concept. It was the frustration with these lengthy and morbid surgeries that led me to first experiment with arthroscopic ACL primary repair with good success, and that eventually led to developing many techniques for arthroscopic ACL primary repair and augmentation. A quick step back. The clinical literature on ACL repair is largely historic and is based on antiquated open ACL repair techniques. It really has limited modern day applicability for the reasons shown here. The exception, of course, is Mark Sherman's paper that showed that even though open repair wasn't predictable enough to be recommended, the proximal tears tended to do well. But that didn't matter. His paper might well have been the obituary of ACL repair because the concept went extinct. That was in two until two extremely bright chaps on the other side of the pond independently began developing modern day methods to repair the ACL. Our techniques differ slightly, but the message is still the same. With a modern day approach, we can successfully repair the ACL. Recently, several colleagues and I published a systematic review on ACL repair to determine exactly what is out there in the literature over the past decade. The CliffsNotes version is that the only clinical papers were long term follow up of the historical studies that showed roughly 50% failures, or, as I read it, 50% success. There were also quite a few excellent animal studies from Martha murray's group that we don't have time to delve into. So what is what exactly is ACL preservation? It is intuitive when you stop and think about it. Certainly my patients get it. Acl preservation describes an approach to the surgical treatment of ACL injuries that places focus on maximizing the biologic and biomechanical contribution of the injured ligament remnant to the stability and function of the knee. It preserves the biology, blood and nerve supply of the ligament while decreasing the morbidity of the procedure and burning few surgical bridges. The current decision tree for the ACL injured patient is rather black and white. Generally, if you are and want to remain athletic, then you get some form of reconstruction, including the inherent risks and lengthy, difficult recovery. If you're not athletic, then you treat it conservatively and see how you do. In essence, that is it. That's the only decision that is made. Aside from the technical details of graft and fixation options, which we can never agree on. Unfortunately, this one size fits all approach has significant limitations that are really impossible to deny. The techniques are ablative resecting most, if not all, of the native blood supply and nerve endings. The surgery is painful. Recovery is slow, and the complications are real. Outcomes are variable depending on how success is measured. As we've heard, despite 30 years of arguing about the best way to do it, and significant bridges are burned when burned when they fail, as you can see from the photos on the bottom. Finally, I don't know how you feel when you encounter relatively normal appearing proximal detachments like this one, but to me, resecting it to put in a graft has always seemed wrong. It is my opinion that our simplistic binary approach is not good enough, and that we can do better, given the quantum leaps that have been made across the board, some of which are listed here. Heck, that's what this entire forum and Arthrex for that matter is all about. So although my ACL decision tree starts off with a similar yes no fork, it is at this point where the concept of ACL preservation differs. I use MRI to get an idea of what type of tear I'm dealing with, and then discuss with my patients the three options I will choose between in surgery. Essentially, the options are small, medium, and medium and large, that is repair. Versus augmentation. Versus reconstruction. I customized the surgical approach that I will use for each patient, depending on the particular ligamentous injury pattern they have. For proximal avulsion type teres as seen here, I currently perform primary repair with internal brace reinforcement. However, I use suture anchors, which is a little bit different than Gordon's approach. For the proximal third teres, I currently perform primary repair with central augmentation and for mid substance teres or those tears with little salvageable tissue. I currently perform a variety of standard reconstruction techniques. My practice breakdown is currently 50% repair and augmentation and 50% reconstruction. Let's take a look at primary repair that I currently use for about 20% of my patients. I originally presented my technique in early results at the 2014 Faculty Forum, but had been working on it since all the way back in 2008. The talk and the technique video are on the Arthrex website if you care to look at them. Here's how I do it. This is an abbreviated version of the technique. When the terror type and tissue quality are confirmed to be adequate for repair, as is seen here, a passport cannula is placed into the medial portal to allow easy in and out of the joint. I then use a Scorpion suture passer to pass locking type stitches of number two FiberWire into the anteromedial bundle, and this is then repeated with the number two TigerWire for the posterolateral bundle, which I'm not going to show here. Next, through an accessory Inferomedial portal. The bundles are retensioned to their origins using vented biocomposite SwiveLock, as can be seen here. And the final construct, as you can see, is both anatomic and stiff. After my first 15 patients, I modified my technique to include an internal brace reinforcement stitch of doubled FiberTape based on several bench studies that showed superiority. This video is showing that the Anteromedial bundle anchor is placed, and you can see here a nitinol passing wire that was placed up through the ligament, pulling down the fiber tapes through the substance of the ligament, and they are then tensioned in extension and attached to the tibia distally using a another SwiveLock. To date, I've performed ACL repair on 50 patients, with follow up ranging from two weeks to seven and a half years. All have been MRI and scope confirmed. Type one proximal teres. The first 15 were simply to anchors, and the majority of the rest used the internal brace modification. So far we are at about 90% successful outcomes with the only one early failure. At three months and the and the rest later. Injuries at over one year post op during sporting activities. Two of these underwent simple primary BTB revisions. The gentleman on the on your left is three and a half months status post ACL primary repair, and he returned and played a full rugby season at four months. He's now three and a half years out and continues to do well. He says that he never thinks about his knee or the outcomes of my first 11 patients using this technique were recently published in the November issue of arthroscopy. So we have some clinical results to discuss. The study we designed was simple retrospective review of my first 11 patients with 100% follow up. The cohort was mostly male, average age 37 with sporting injuries, and an average three and a half year follow up. Subjective and objective outcome scores were high, Tegna scores were maintained, and CT 1000 data showed less than less than three millimeters side to side difference on all but one patient. The single failure in the group. The take home message regarding ACL primary repair is this with proper patient selection and my modern day technique focusing on proximal avulsion type tears, it works. Morbidity to the patient is minimal and more in line with an arthroscopy. Recovery is much faster and less painful than with reconstruction. And if it fails, revision is like a primary reconstruction. Now, for those patients with tears that don't quite reach the wall, augmentation is a great option and one that I currently use for 30% of my patients. The concept and my technique was introduced in my talk on ACL preservation at last year's faculty forum, and the technique video is also accessible on the website. Bertrand Coté has a similar technique that he calls the samba technique. Augmentation is not a new concept, and I must admit that there are there are multiple authors, largely from Europe and Asia, that have published on this. My technique is slightly different in that I use my ACL repair approach to tension the remnant while augmenting centrally within the remnant. This avoids the Cyclops lesion. Here you can see me dissecting the proximal tear off of the ACL of the PCL. A repair stitch is placed into the Am bundle, and then a small cannulated reamer is passed up into the footprint with care taken not to tear up the ligamentous insertion like with the samba technique mentioned. The repair stitches are threaded through the TightRope and the whole construct is advanced up through the femoral socket. The graft is then advanced through the ACL remnant, and the remnant is then tensioned up around the augment. As you can see here, if you watch closely. Giving a composite graft, the construct, as you can see here, is stiff and anatomic with excellent blood supply. If you watch closely you'll see the capillary refill at the tibial insertion. The benefits of repair with augmentation are multiple. By preserving the native tissue, less tissue is needed. I often use just a doubled semi tee with 6 to 8 millimeter tunnels. If I use the compression tubes that Adrian invented, maybe I can make a four millimeter tunnel. Thus the morbidity is less. I tension the remnant to avoid both the Cyclops lesions and restore the mechano environment to a more normal state, like isolated repair. A revision is like primary reconstruction, and thus ACL preservation is a little like getting a fourth strike while you're up at bat. Finally, if there's little salvageable tissue left to work with, I will resort to one of the many forms of reconstruction that have been discussed. This currently makes up 50% of my ACL practice, although I do admit that this number has been dwindling each year as I gain more experience with ACL Reservation. So, as probably one of very few surgeons with this modern day experience with ACL preservation, I've drawn some conclusions and formulated some opinions. It's high time that we reevaluate our approach to ACL surgery. Decisions made decades ago based on archaic techniques and understanding stunted the evolution of surgical thought to consider only reconstructive options. The cutting edge, lower morbidity procedures that I and others have described really changed the risk benefit curve of ACL surgery, and have opened the way for a more balanced surgical approach to evolve. Currently, for fully 50% of my patients, I avoid a big reconstruction with all of its downsides while giving the same and arguably better outcomes. Acl preservation is less painful, and recovery is often dramatically faster than with reconstruction. I just saw a patient who was one month out from out from surgery, and he told me as he walked in without his brace with no limp, that since one week post-op he had full range of motion, no swelling and was walking normally. He decided to discontinue the brace on his own because his knee felt normal. And oh, by the way, he didn't take a single Percocet post-op. That's quite a bit different than the experience from the ACL reconstructions. Maintaining the native anatomy and biology of the ACL remnant often results in a more normal feeling knee with the conservative ACL preservation approach. The inevitable Re injuries can be simply revised by doing a primary reconstruction, as no surgical bridges have been burned. And thus not only is this an excellent choice for adults, but it should be strongly considered as the first option for children. It's not always easy being contrarian. Sometimes you don't know how your new approach is going to end up.

ACL Preservation

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