Name: ACL Repair with Augmentation
Uploaded: 2017-06-14T00:00:00Z
Channel: Arthrex
Description: Professor Adrian Wilson, MBBS, BSc, FRCS, (Windsor, United Kingdom) presents cases using ligament reinforcement of grafts with FiberTape ® suture and other repair options for ACL and PCL procedures.

<p>Professor Adrian Wilson, MBBS, BSc, FRCS, (Windsor, United Kingdom) presents cases using ligament reinforcement of grafts with FiberTape<sup>® </sup>suture and other repair options for ACL and PCL procedures.</p>

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VPT1-00801-EN | B | ACL Repair with Augmentation

Professor Adrian Wilson

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ACL Repair with Augmentation

So what are the options. And we've heard a lot. I'm going to be going over points that have already been raised in terms of what we can do for ACL and ACL surgery, and we've seen this being presented already, this fantastic piece of work that Gordon's son Ben and the team in Munich have done, this brilliant piece of research looking at the new ways of making the internal brace work better. And we've heard about that already. So in terms of reinforcing or using an internal brace, my indications are to use it for all repairs, all small autographs, all allografts, all revision surgery, all PCL reconstructions, where I think it's going to be absolutely the gold standard very shortly. And all extra articular reconstructions. And we've now done over 300 reinforced ligament cases over the last five years. And we have a mean follow up of 37 months with the range as shown above. If we split down just into the ACLs and we look at how many I've done where I've not been tinkering with the anterolateral ligament doing any posterolateral corner work. We've isolated 59 patients, and we're getting very nice data with good CT results with minimal side to side difference. And when we look at the objective scoring with the stegna, the very favorable results in this series, and very importantly, whenever a patient does have any reason to have an MRI scan more commonly, but occasionally CT scans, we're not seeing any issues at all relating to any kind of bony reaction to the FiberTape. So this is one of my recent cases where we're using a FiberTape to reinforce the ligament. And you can see in the top right hand corner the new button that's been developed, which is conical in shape. So we then use this compression system which I've developed with Reinhold and the team to downsize so we can take our eight millimeter graph down to seven and a half or sometimes seven millimeters to preserve bone. And you can see the tails of the FiberTape being loaded into the new conical button. And then we load as we do with a standard ABS button. We load into the sides our abs TightRope and then we cinch down as we would normally do, and we do final tensioning after we've tensioned the internal brace. So the internal brace is. Then the FiberTape is then fixed with a 4.75 swivel lock. We make a pilot hole which is 4.5mm and then fix it, making sure that we don't over tension. And Gordon's discussed that. So I do think that this will become very shortly the gold standard for PCL reconstructions. When we do our standard reconstructions we leave the table with a favorable result. But at 3 to 6 months, quite frequently our patients will have significant laxity that we find disappointing. But when we do this technique, actually you'll be very, very happy with your results. It really will transform your practice. And when you do have a reason to look inside the knee, you will always see this. The FiberTape will always adopt the same laxity as your as your ligament. It will never be tight, It always goes to the native tension of the ligament. So this is a look at 18 months. And every time you look in, whether it's three months, six months, 18 months, three years, this is what you see. This was a bit of a heart sink patient All-inside a PCL that I carried out in an 11 year old, a very, very juvenile 11 year old boy who was referred to me at age ten due to injury, knee dislocation. I stuck him in a brace for 18 months and just hoped it would all sort of settle down, and he eventually healed up enough on the lateral side for me to just take on the PCL. So one thing that's very interesting about about pediatric graphs is they don't widen, they just lengthen. So in this case we have a license to take parental donate donated tissue. So I took the semi in the gracilis and I used that as the graft for this child. And it gave me a nice nine millimeter graph. So as I say they'll lengthen but they'll never widen. So if you put a 5.5mm graft into a ten year old child, it will be 5.5mm when they're when they're 25 years of age. So on this I had to come up with some new ways of doing it. So I decided to drill below the fists on the tibia using the FlipCutter system, which worked extremely well. And then I did free drilling inside to out just below the fighters on the femur. And this child has done extremely well, I'm delighted to say. So when we look at that entire series of reinforced or patients that have been treated with the internal brace, I see a very low complication rate in my patients and very good results. So what about repair? Well, I'm going to whizz through these slides because we've heard some we've heard some fantastic talks already. And this is clearly the way to go when you have a type one injury. So you have a femoral detachment. You have good stump quality. I think it must be done in children. I think if you treat pediatric patients, this is a fantastic procedure for children. And it's something that's really transformed my practice. So we know from the work done in Australia, there's a very, very high rate in this group of under 20 year olds, perhaps as high as high as 30%. So you're drilling tunnels, which are then potentially going to be revisited. And what we want to do is give the children the best outcome for that first procedure and also not burn bridges for the for the future. So we presented our work on two cases, a five year old and a six year old, which I which I published in the last year. We've got Greg's paper from HHS with his 36 cases in arthroscopy. And Gordon has also published. So we're beginning to see some work coming through and some published articles for our colleagues to grab hold of and give them the faith to actually do this operation. So what about doing an ACL reconstruction when it goes wrong? So this is a 15 year old girl. She's skeletally mature. She had a poorly done ACL reconstruction in 2014. A subtotal medial meniscectomy an arthroscopic partial meniscectomy. So she'd failed at six months. She was grossly unstable, severe medial knee pain, and she actually had signs of a of a failing medial compartment. So if you can see on the MRI scan. No medial meniscus. She's lost the nose of the lateral meniscus. And when we do the alignment films, if you look on the normal side, she's completely neutral. But if you look on the failings of the on the ACL repaired side, reconstructed side, she's actually already going into various. So she's going to need an osteotomy. This is a this is a disaster. This girl should have had an ACL repair. So the first case that I presented before it's this girl is now coming up for three and a half years following surgery. She's a five year old who injured her knee. Trampolining, grossly unstable at the UA. And when I looked in the knee, she had evidence of a partial thickness tear to the lateral meniscus, but it was partial thickness, an empty notch. So I went ahead using Gordon's technique, using a single FiberLink to cinch the ACL. And then I went below the forces on the femur, and I went through the forces on the tibia and just drilled 2.4mm holes. So tiny little tunnels that are much more appropriate for a child of this size and age. There we see the InternalBrace lying alongside the repair, and I always take these children back and release this this InternalBrace and remove the button because it often causes some irritation. So you can see the hardware that has been removed in the top right and a healed ACL at three months. So on the objective assessment stable in terms of the Lachman anterior drawer negative pivot negative less than two millimeters side to side difference. She's got back to surfing. As I say, she's now three and a half years down the line and doing extremely well being followed up closely. What about a six year old boy, a heart sink patient? Because the mothers are really quite an interesting person to deal with because she's so worried about her son. But anyway, the surgery went well. He reported a normal knee, normal function, wants to get back to football at a year. His mother wasn't happy, which kept his nose slightly low. But at 18 months or just beyond 12 months, he went on to win Sports Day at his school and is now playing full contact sport again. This is an interesting case. This is a 12 year old boy, a medial knee pain for three months and when he came in, if you look at this ACL there's good tissue there. You wouldn't want to throw this in the bin. So what about doing the repair. Well, we see in the technique and it really is as easy as repairing a meniscus. So it takes just a few seconds. This is real time to cinch the ACL. Then we make our our tunnel in the femur and we pull up our sutures. And you can see how when I pull on the suture, I can retension the ACL so it's loose, and then we can apply tension, put it to the sidewall, create some biology there, and we can get some nice healing. So when we drill up this wants to heal. There's blood inside the ACL coming through that bony tunnel that's going to help us. And you can see me feeding up the internal brace up through the center of the ACL as near as possible. And this this is slightly eccentric. I'll just whiz through this. And this is the end result. So this child went back to football at four months. It wasn't something they wanted to do, but it was something he felt confident to do with a Tegna score of eight. So these. This is slightly out of out of date now. The first eight patients in this series are all beyond a year. Many are approaching two years now with very favorable results. And I'm glad to say that in the 14 cases that I've done in the pediatric series, I've had no failures. No one has required a revision to date, and I've had no complications. So I think it really will become the gold standard. And we've all got videos of patients that are sending in their results. This is a snowboarder. This is four months following his ACL reconstruction. And you see it time and time again. Because as surgeons, we're really very surprised to see our patients performing at this sort of level at such an early stage. So what about putting it all together? I treat a lot of multi ligament injured patients. And here's an interesting case. So we see some nice tissue. There's an Am bundle there that I wanted to keep. So I felt that I could actually repair that. So I repaired the Am bundle in the ways that you've just seen using a using the FiberLink suture and just cinching that, then moved on to drilling for the posterolateral bundle. And here I'm coming in with a 6.5mm FlipCutter or six millimeter FlipCutter to make my my posterolateral bundle. Then I can pull that up in a traditional way. Complete tunnel on the tibia. Here you can see me tensioning that anteromedial bundle, and then coming up through the remnant of the ACL for my for my posterolateral bundle. And this is the finished result. So that's some of the surgery over then coming in. And if you could play that video please PCL socket being drilled with FlipCutter, you could just press play on that video. Thank you very much. And these guides Bruce Levy has developed a really lovely guide for the tibial component of this procedure. And of course, this is reinforced as I've just explained. Very easy to do. So these multi ligament cases are now taking half the time that it used to take, particularly as it's so easy to pass the graft using the All-inside technique. And the graphs are passed. And we have a really nicely reconstructed knee. I went on to do the posterolateral corner as well. And this is the way to do this surgery I believe. So in summary repair works and I think we now have 5 or 6 year data showing that we're moving into the midterm results very nicely. I think with the low complication rate and the fact that we're seeing so few failures. It will become the gold standard in any of these type one injuries. And also in children. It preserves biology. It's selective bundle reconstruction is possible, and we're having minimal complications and excellent results with this concept.

ACL Repair with Augmentation

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