http://www.kneeguru.co.uk/KNEEsurgeon/ en-us Nucleus CMS v3.22 © Weblog http://backend.userland.com/rss http://www.kneeguru.co.uk/KNEEsurgeon//nucleus/nucleus2.gif http://www.kneeguru.co.uk/KNEEsurgeon/ http://www.kneeguru.co.uk/KNEEsurgeon/index.php?itemid=204 Anatomical ACL.

Two prominent surgeons, Freddie Fu and Charlie Brown, have been working on the idea of anatomical ACL reconstruction. They would stand up at meetings and say “I’ve done 5,000 ACL reconstructions and looking back at what I was doing I now think that I put 5,000 ACLs in the wrong place because we now know that we have been putting it in the wrong place. Although we can get an excellent clinical result, almost everyone that has an ACL reconstruction will eventually go on to develop osteoarthritis.”

Up to now surgeons were convinced that it is the other damage that you get as a result of the injury – a significant bone bruise, damage to the cartilage and the menisci that occur at the time of the injury or, if you don’t get the knee fixed and it continues to give way you get secondary damage – which causes the knee to go on to develop osteoarthritis. We all still accept that if you damage your knee and you have an ACL rupture and you also damage the joint surface and/or the menisci, then that’s going to cause you problems in the future, but now it has become apparent that a very significant factor to actually developing osteoarthritis is the reconstruction itself. This is because if you put the ACL in a functional but non-anatomical position it captures the knee and it changes the way the knee moves. So as a result of that you can have an elite athlete playing elite sport, but if this ‘piece of string’ that you put into their knee is not where it is supposed to be – you have not put it in the correct anatomical location – you change the way the knee moves very subtly and the knee reacts to that. Over ten to fifteen years if you don’t take an X-ray – even if an individual hasn’t got any symptoms - you see the beginnings of osteoarthritis.

So this group of prominent surgeons, including several leading Japanese surgeons, looked more carefully at the anatomy and doing a different kind of ACL reconstruction and came up with this concept of ‘double-bundle’ ACL reconstruction, as opposed to a single bundle ACL reconstruction. That is a very anatomical way of doing the surgery as it is re-creating the anatomy by replacing the two ruptured bundles of the original ligament with two new bundles. The problem with that is that it is technically very difficult and drilling two tunnels in the tibia and two tunnels in the femur is not only technically difficult but revising those patients if there is a problem can be a real challenge, and there are so many problems with it that it has been pretty much abandoned and is no longer considered to be a mainstream way of doing ACL surgery.

Last April (2009) a UK surgeon, Tim Spalding, launched his ideas at BASK with an excellent presentation last April (2009) in Oxford where he demonstrated an improved method of locating the real anatomical position for a single bundle procedure – what they are calling the direct measurement technique for ACL surgery. He has now followed that up with a clinical study with high-resolution CT scanning and that article has just been submitted for publication. The new ‘buzz’ way of describing an anatomical ACL reconstruction is called ‘footprint’ ACL surgery or ‘anatomical’ ACL surgery. Tim Spalding and his group have now done a very in-depth study looking at this work over the last year and they have found a very high degree of accuracy between the direct measuring technique that they developed correlated with CT scans to show that they have had a great success in putting the ACL exactly where it should be.

I have been working on a new technique that facilitates the placing of the new ligament in this real anatomical position – doing all the work from the medial side, which is much easier than the old techniques. So you actually look from the medial side and do all the work from the lateral side with some special instruments that go around the corner into the notch and allow you to prepare the femur, mark the femur and then accept this drill bit.

I would like to show you this method which I have illustrated via live surgery in Garmisch, in Southern Germany in 2011 (location of 2011 World Ski Championships) when I was presenting my approach to the German arthroscopic association, and you will find the video below.

This is the view from the patient’s room!




Here are two photos - one showing the surgical staff preparing the patient for surgery while the other shows the recording team seeing to the video and sound equipment.





The next two photos show the surgical team in action looking up at the monitor with the arthroscope on the medial side - you can see how busy it all is with the video crew and the surgical team all in the room together!





Finally, I will show you a video of the new procedure. The video highlights some new concepts –

• Surgeons are no longer going to have to look from the lateral side. With anatomical ACLR in its current form the whole procedure has to be done medially ie viewing and working through 2 small holes or "portals". This is technically difficult as the arthroscope and tools for working are in very close proximity to one another. This causes "crowding". The good thing is that this anatomical technique allows excellent visualisation by viewing from the medial as opposed to the lateral or outer side of the knee. A good analogy here is that the current technique is like putting your face against the wall and trying to identify a window or something at a distance, whereas with anatomical technique it is like walking comfortably into the middle of the room and looking face on at the wall.

• We have developed a new way of carrying out anatomical or Footprint ACLR which we have called the TransLateral technique. This has been made possible by the development of a series of new instruments that allow all viewing to be done medially (which is good!) and all work or preparation is done from the lateral side. This means that the surgeon can work effectively from both sides of the knee without crowding. This has made what is technically a very difficult operation much more straightforward and reproducible. This will be extremely good for both orthopaedic surgeons and their patients.

The full video of the procedure with commentary can be found here - http://www.youtube.com/watch?v=vKVcibPApPU]]> General http://www.kneeguru.co.uk/KNEEsurgeon/index.php?itemid=204 Sun, 13 Feb 2011 20:40:22 +0100 http://www.kneeguru.co.uk/KNEEsurgeon/index.php?itemid=199
The same applies to the hip as well – if there is a proximal femoral problem sometimes we do a rotation osteotomy at the hip to sort the femur out so that you get the right rotation. But it’s quite an uncommon problem. This miserable mal-alignment is someone who is typically female, 20+, they have valgus alignment of the legs and they have more valgus than the average person so it’s not a deformity they have but an increased valgus alignment of their legs, their patellae often face each other – kissing patellae – and their tibial tubercles are too far displaced laterally. Usually they are slightly overweight, they are valgus, they have increased Q angles with laterally placed tibial tubercles – the whole lot is trying to take the patella off to the side the whole time, so when you examine them they have got tilted patella, increased Q angle, valgus, weak inner vastus and the whole thing is making the patella slide laterally the whole time. They have this feeling of instability. Sometimes they go on to dislocate, but usually they only have pain.

That is a completely different problem to patellofemoral instability – the pain issue – and if you look at individuals who have presented their series of say Elmslie-Trillat realignment procedures they do very well for instability but they don’t do well for pain. Miserable malalignment is different from having a rotational deformity. So what we need to do is almost educate people that it is a series of different elements that make people have pain when they are unlucky and they have valgus aligned tibiofemoral knee joints, laterally placed tibial tubercles, tilted patella off the side and perhaps some soft cartilage on the undersurface of the patella, and all the time the patella is trying to slide laterally and that causes pain. Complex rotational deformity is usually either developmental which is very rare or post traumatic. ]]> General http://www.kneeguru.co.uk/KNEEsurgeon/index.php?itemid=199 Fri, 18 Jun 2010 10:07:21 +0200 http://www.kneeguru.co.uk/KNEEsurgeon/index.php?itemid=198
Over the last 5-7 years there have been two guys in particular – Freddie Fu and Charlie Brown – they have been doing a lot of work on “Where’s the right place to put the ACL?” We all thought we were doing the right thing ten years ago, then we all thought we were doing the right thing five years ago but actually when you look at the results of the old-fashioned ACLs they got great results, they got their sportsmen back playing sport but they all go on and tend to get arthritis – if you look at them at 10-15 years down the line.

And everyone is now questioning things – either the insult or the injury is so great that you get arthritis or when we do our ACL reconstruction we are not putting it in the right place. And they have looked – Freddie Fu in particular – really hard at the anatomy again in the lab, in the cadavers, on CT, on MRI and so on, and what they have discovered is that we have been way out on our tunnel positioning on both the tibia and the femur. So there was this vogue to do double bundle procedures – two tunnels on the tibia and two tunnels on the femur – to recreate a more anatomical ACL but that procedure has not really taken off as no one can show at the moment a clinical advantage to the patients either in the clinic or there is no way of testing to say if it is any better than a single bundle. And I think most of us feel at the moment that probably double bundle is not the way to go. There is this famous phrase ‘double bundle double trouble – just keep it simple’. But what has spun out of all their research is particularly on the femur people were miles out on where they were putting it, and there has been this big debate over the last ten years of the best way of drilling the femur, and the traditional way is to do the tibial tunnel first, come up into the femur and then drill the femur. You were very fixed. Once you had drilled that tibial tunnel you had to go that way to drill the femur.

So the Australians came up with this idea of trans-portal drilling. So you drill your femoral tunnel and your tibial tunnel independently. So you drill the femoral tunnel first and you drill it through the medial portal with the knee really bent up (well that is the way I like to do it). We all thought we had been doing it brilliantly – we had been viewing from the lateral side and drilling from the medial side. But what is really interesting is that if you look from the medial side and you drill from the medial side you realise that we all tend to put the femoral tunnel a bit too high and a bit too towards the midline and we are not around the clock face enough. We need to bring it lower in the femur as you look at it and you need to bring it actually surprisingly less posterior than we have been putting it but below where we had been putting it. Tim Spalding did a brilliant presentation at BASK looking at all the evidence – everyone’s CTs and everyone’s MRI scans and what everyone is saying and he has worked out that actually if you measured the distance on the medial side – you are looking and you put in a ruler and you take a halfway point from the back of the femur and the articular surface at the front in the notch below the so-called registrar’s ridge (intercondylar ridge) – if you take midpoint that is the centre of the ACL and it is a long long way away from where people have been traditionally drilling it.

So everyone is now desperately trying to develop a nice technique for doing an anatomical ACL reconstruction in a way that can be replicated by your average surgeon. At the moment the only way of doing it is to look from the medial side and do all the work from the medial side and that is quite difficult you know. It’s quite a small little area that you are working in and it is possible but it is fiddly. So what I am going to do is that I am off to Munich – and the main reason is that Arthrex has these nice jigs for drilling – you basically pass a guide wire into the knee and then you externally turn the end of the wire, it has a little crank on it, and it cranks open a little drill and it allows you then to back the drill into the femur – they are called flip cutters and are absolutely fantastic. I am hoping to develop a new technique so that you actually look from the medial side and do all the work from the lateral side with some special instruments that go around the corner into the notch and allow you to prepare the femur, mark the femur and then accept this drill bit.

That idea of anatomical ACL reconstruction is just so completely different from what people have been doing up to now – it is going to revolutionise the way that ACL reconstruction gets done. What has been really difficult up until now is actually quantifying where the centre of the true anatomical ACL footprint is on the femur and what Spalding has done is that he has come up with a really simple way of doing it – get a ruler, measure the front, measure the back – it is usually about 20mm – take the halfway point just below the intercondylar notch and there it is, and you’re in the middle. And it’s probably 4 mm lower and 4 mm anterior to what we all used to think it was. So it was way off, way off. The problem is that there is no way of proving that it is any better until we have plenty of data, but the evidence so far is telling us is that what we are doing at the moment is not remotely anatomical.]]> General http://www.kneeguru.co.uk/KNEEsurgeon/index.php?itemid=198 Tue, 15 Jun 2010 16:06:40 +0200 http://www.kneeguru.co.uk/KNEEsurgeon/index.php?itemid=188 an ISAKOS website, unfortunately with only the French language. You can find all these videos on my website.]]> General http://www.kneeguru.co.uk/KNEEsurgeon/index.php?itemid=188 Thu, 15 Jan 2009 21:36:20 +0100 http://www.kneeguru.co.uk/KNEEsurgeon/index.php?itemid=175 General http://www.kneeguru.co.uk/KNEEsurgeon/index.php?itemid=175 Sun, 3 Feb 2008 14:56:16 +0100 http://www.kneeguru.co.uk/KNEEsurgeon/index.php?itemid=160 1cm in the periphery of the meniscus which is of traumatic (nondegenerative) etiology. The knee should be stable or a concomitant ligament reconstruction should be performed.

The reality is that quite often meniscal tears do not clearly fall into the above criteria and may be responsible for relatively lower meniscal repair rates in some centres. Age of the patient and chronicity of tear are not contraindications for meniscal repair. Incomplete stable tears do not require repair. The intra-operative dilemma usually is whether the tear is peripheral enough. The commonest tears are in the posterior third of the medial or lateral meniscus and it is important to develop arthroscopy skills to visualise the ‘rim width’ in this area of the meniscus. The vascular zone has been shown to be present in the peripheral 4mm or up to 25-30% of meniscal periphery. Adequate preparation of the tear edges using rasps/shavers, meniscal trephination and synovial abrasion can help increase success rates and extend indications for meniscal repair into white-white zones. The success of newer generation suture based all inside techniques along with the above augmentation techniques should help the surgeon increase repair rates and improve results.]]> General http://www.kneeguru.co.uk/KNEEsurgeon/index.php?itemid=160 Mon, 24 Sep 2007 11:32:13 +0200 http://www.kneeguru.co.uk/KNEEsurgeon/index.php?itemid=137 To know of symptoms, you have then proceeded
To look and feel and move the painful knee
To postulate the main pathology.]]> General http://www.kneeguru.co.uk/KNEEsurgeon/index.php?itemid=137 Sun, 15 Apr 2007 10:50:13 +0200 http://www.kneeguru.co.uk/KNEEsurgeon/index.php?itemid=136
Now before you start the tender task
Of examination, you must ask
"Where is this pain? If you can be precise
"To show me its location would be nice"]]> General http://www.kneeguru.co.uk/KNEEsurgeon/index.php?itemid=136 Sun, 15 Apr 2007 10:46:33 +0200 http://www.kneeguru.co.uk/KNEEsurgeon/index.php?itemid=135 Informed quite well in all the details how
Pain within the knee is generated
And how it can be treated and ablated.]]> General http://www.kneeguru.co.uk/KNEEsurgeon/index.php?itemid=135 Sun, 15 Apr 2007 10:40:15 +0200 http://www.kneeguru.co.uk/KNEEsurgeon/index.php?itemid=134 One skin cut down the middle is all there needs to be.
For this goes down the watershed where venous blood divides
Medially and laterally to drain to both the sides.]]> General http://www.kneeguru.co.uk/KNEEsurgeon/index.php?itemid=134 Sun, 15 Apr 2007 10:37:41 +0200