Meniscal and Anterior Cruciate ligament injuries

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Imperial college. St Mary’s hospital. Charing Cross Hospital. Meniscal and Anterior Cruciate ligament injuries. Chinmay Gupté PhD (Dip IC), FRCS (Tr&Orth), MA (Oxon), BMBCh Consultant Orthopaedic Surgeon/Senior Lecturer E Ali, Trauma Fellow A Dodds, SpR - PowerPoint PPT Presentation

Text of Meniscal and Anterior Cruciate ligament injuries

Osteoarthritis-the human perspective

Meniscal and Anterior Cruciate ligament injuries

Chinmay GuptPhD (Dip IC), FRCS (Tr&Orth), MA (Oxon), BMBChConsultant Orthopaedic Surgeon/Senior LecturerE Ali, Trauma FellowA Dodds, SpRImperial College Hospitals and Imperial College London

Imperial collegeCharing Cross HospitalSt Marys hospital1Competing interestsnoneWhats our agenda?Improve our practiceEnhance our knowledgeAddress controversiesCutting edge technologies/treatmentsSummaryAnatomy BiomechanicsMeniscal tears: repair or resect?Meniscal deficiencyACL: whats new?(PCL)Emerging technologiesMenisciMenisciIntraarticular knee structuresSemi-lunar (axial)Wedge-shaped (coronal/saggital)Fibro-cartilaginous (type I Collagen)

MedialLateralAnterior

LateralMedialAnterior

Menisci anatomy6

pMFLaMFLPCLLMAnteriorMeniscal ligamentsInsertionalAnterior Intermensical (AIL)Mensicofemoral (MFLs)Deep Medial Collateral (dMCL)

TibiaFemurMedialdMCLAIL

LateralInsertionalLigamentsMFLsMeniscal attachments7Histology1-3Tissue bulk: circumferentialfibre bundles (Type I)Surface:Meshwork of thin fibrils/radial tie fibres

(Taken from: Petersen & Tillmann, 1998, Anat Embryol)Histology and biomechanicsTensile properties of intra-articular tissues (in MPa)TendonLigamentMeniscus(circumferential)Labrum(circumferential)Cartilage500-70030011030-602-201Petersen & Tillmann 1998, Anat Embryol2Bullough et al. 1970, JBJS-Br3Beaupre et al.1986, CORR4Tissakht & Ahmed 1995, J Biomech8Meniscus functionsReduce contact stressesLoad spreadersShock absorbersStabilityLubricationProprioceptionNutrition99Axial load transferred through the joint is converted into meniscal hoop stresses

TibiaFemurThe meniscusconforms to thefemoral condylesincreases its circumferencetranslates outwardsspreads the load overa large contact areahence reduces the stresses on the underlying cartilageInsertional ligaments are key70-99% of the joint load is carried by the menisci1Load transmission1Seedhom & Hargreaves, 1979, Eng Med10Anchor menisci on tibial plateauControl meniscal motion Prevent excessive meniscal extrusionLoss of one completely de-functions the meniscusTensile modulus in human1

MedialLateralAnterior~ 165 MPa~ 90 MPa~ 75 MPa~ 90 MPaInsertional ligaments1Haut-Donahue & Hauch, July 2008, ESBMFLsAILdMCLOccurrence92% 1(at least one MFL)75% 5-7100%FunctionSecondary restraints to posterior drawer2??Significant anatomical variabilitySecondary restraint to valgus at 60-90 flexion8Relation to meniscal functionMFL-deficiency results in 10% increase in contact stresses3Controls meniscal motion in conjunction with the insertional ligaments (?)Restrains excessive mobility of the medial meniscus?? Contact stresses ??Tensile propertiesModulus ~ 250 MPa4i.e. similar to the major knee ligaments??1Gupte et al,2003, Arthroscopy2Gupte et al,2003, JBJS-Br3Amadi et al,2008, KSSTA4Gupte et al,2002, J.Biomech.5Kohn & Moreno, 1995, Arthroscopy6Nelson & LaPrade, 2000, AJSM7Berlet & Fowler, 1998, AJSM8Robinson et al,2006, AJSMMeniscal ligaments stabilise kneeMeniscectomy results in1-3 Cartilage to cartilage contactLess conformityDecreased contact areaIncreased contact stresses(up to 200%)1Increased shear stresses

IntactMeniscectomised1Baratz et al, 1986, AJSM2Seedhom & Hargreaves, 1979, Eng Med3McDermott et al, 2008 KSSTA(Taken from: McDermott et al, 2008 KSSTA)Total meniscetomy13Meniscetomy Stresses

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Removal of meniscus: reduce surface area of contact>>>increased contact stressesDoes repair restore meniscal stress function???No long term studies14Meniscectomy consequences15

Lateral meniscectomy results in OA; also probably medialLate degenerative changes after meniscectomy. Factors affecting the knee after operation.PR Allen, RA Denham, and AV Swan.JBJS1984Chatain 2001 KSSTABrophy RH, Gill CS, Lyman S, et al. Effect of anterior cruciate ligament reconstruction and meniscectomy on length of career in National Football League athletes: A case control study. Am J Sports Med 2009;37:2102-2107.15Circumferentialparallel to the load-bearing fibressmall effect on meniscal functionRadial Vertical cut across the load-bearing fibreslarge effect on meniscal functionFlapBucket handleHorizontal cleavageComplex

Radial

RadialAxialTearCircumferential

Meniscal Tears16ConservativeRepairPartial meniscectomyTotal meniscectomyAllograft transplantationImplants (?)Tissue engineering (?)

(Taken from: Arnoczky & Warren, 1983, AJSM)Meniscal Tears: treatment optionsComplex tear repairs have poor outcomesRepair vs reconstruction results not clear cut (Shelbourne)Complications of repair:Chondral scuffing (Anderson)Hardware loose/Dart indentationFailed repairs lead to more meniscal lossPersistent painNerve damage

Meniscal Tears: lets repair them allBut:Shelbourne, K.D. and D.R. Carr, Am J Sports Med, 2003. 31(5): p. 718-23. Meniscal repair compared with meniscectomy for bucket-handle medial meniscal tears in anterior cruciate ligament-reconstructed knees.Anderson Arthroscopy 2000; Austin AJSM 1993

Meniscal Repair Versus Partial Meniscectomy: A Systematic Review Comparing Reoperation Rates and Clinical Outcomes. Paxton et alArthroscopy 2011ResectionRepairReoperation rate3.9%20.7%Lysholm (functional) scoresLower (n=1)HigherRadiographic degenerationMoreLessLower reoperation rate with repair after ACLR

Whereas the combined reoperation rate after a partial meniscectomy is quite low, at 4%, the relatively high reoperation rate of almost 23% after meniscal repair may be acceptable if there is a potential long-term benefit to the joint. The lower reoperation rate of 14% after meniscus repair at the time of ACLR is even more likely to be acceptable assuming long-term benefit can be shown.

Repair TechniqueInside out is Gold standard:Large bucket handle especially posterior portionDouble barrelled guideStryker retraction tool20 suture eg ethibondAnterior to gastrocWatch saphenous nerve medially and peroneal laterally

TechniqueAll inside (Ultra fastfix):Better newer prosthesesPortals slightly higher1.4mm on stopAvoid scuffingVertical sutures: radial tie fibresCurved needles2up/1down

White/white zone tear: younger/longitudinal/lateral/ACLRRasping/trephining:stable/>> medial meniscal tearsACL reconstruction reduces MM tear (Meunier Acta O Scand 1999)Mensical repair more successful with ACLR

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28ACL controversies29Tunnel positionsDoes ACLR obliterate Pivot shift?Single vs double bundledExtra articular reconstruction

29Natural history of the unstable ACL deficient The ACL Injury Cascade

ACL disruption

SubluxationGiving way

Meniscal injurySports disability

Joint arthrosisACL bundles31

AM bundle: tight in flexion (anterior drawer)PL bundle tight in extension (Lachmanns)PL bundle: further away for axis of rotation (resists pivot)

31ACL Tunnel position: femur32

Harner JBJS A 2000

32ACL Tunnel positionsFemoral tunnel has become more oblique with time (more anatomic)Has this led to increased rerupture rate?3333Tibial Tunnel positions34

34Non anatomic Tunnel positions35

AnatomicNon anatomic35Tunnel positionEnsure adequate notch clearance: vertical PCLDrill through medial portal (?view accessory medial portal)10:00 (R) or 2:00 (L) positionMark with chondral pick 70degrees?use offset guide/guide wire4.5mm solid drillEnsure knee fully flexedTibia: 2/3rds along line from anterior horn LM insertion to medial tibial spine

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36Single vs double bundled37Adachi et al JBJS 2004 RCT Single vs double no differenceMeredick metaanalysis AJSM 2008 no differenceYasuda Arthroscopy 2006 better but n=4Siebold Arthroscopy 2008: RCT DB better resultsHussein ..&Fu AJSM 2011 RCT 5 yr results DB better pivot but no functional difference Double bundledMore anatomicGreater control of pivot (93% vs 67% Hussein et al)Better tunnel position

Single bundled:DB technically challengingNo better functional results with DBMore oblique SB just as goodDifferential failure of DB bundles

37Pivot38Main functional problem in ACL rupture is the pivot phenomenonSB reconstruction does not obliterate pivot in 33% (Hussein 2011)Double bundled: Greater control of pivot (93%, Hussein)But more technically difficult/no functional benefitIs there any other way to deal with the pivot?Extraarticular augmentation of ACL reconstruction

Galway HR, Beaupre A, MacIntosh DL. Pivot shift: a clinical sign of symptomatic anterior cruciate insufficiency. J Bone Joint Surg. Br 1972;54:763-4.Zantop et al Arch Orth Trauma Surg 2010

38Previous extra-articular reconstructionUsed as an isolated technique and combined with intra-articular techniques.First description by Hey- Groves- 1920Several different methods popular:LemaireMacIntoshEllisonLoseeMarcacci

MacIntosh reconstruction

Used strip of ITB- the lateral substitution reconstructionMarcacci Repair

Hamstring graft as intra-articular reconstruction with extra-articular augmentationExtra articular reconstruction: poor historical results42Failure of isolated extraarticular reconstruction and recurrent instability (Dandy 1995)Degenerative change in the lateral compartment (Roth 1987; Strum 1989)

ButStretch of tenodesis in isolated extraarticular or augmented with nonanatomic intraarticular placementDegenerative change from 4 weeks in plaster post opNewer rehab techniques and braces

Neyret et al: Extraarticular tenodesis in skiiers BJSM 199442Can we do any better?Understand anterolateral capsular anatomy (Segond fracture)Assess new procedures biomechanically in vitroA more anatomic approach may prevent some of the problems from the past:-Reduce failure ratesDecrease risk of lateral overtighteningMinimally