Evolvi ving T Techni hniqu ques es i in t the P e Partial A - - PowerPoint PPT Presentation

Evolvi ving T Techni hniqu ques es i in t the P e Partial A ACLR- Repair v

• vs. Reconstr

tructi ction - Bac ack t k to

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Future

Thomas M. DeBerardino, MD Professor of Orthopaedic Surgery, Baylor College of Medicine Co-Director, Baylor-San Antonio, Texas Sports Medicine Fellowship The San Antonio Orthopaedic Group Medical Director, BRIO

OSET

Disclosure

• The following relationships with commercial interests related to this

presentation existed during the past 12 months:

• Research support: MTF and Arthrex
• Consultant: Arthrex, MTF
• Dr. DeBerardino does not intend to discuss the use of any off-label

use/unapproved use of drugs or devices

Literature Review

• Partial tears of the ACL represent 10–27% of total
• Reasons for protecting non-torn bundles are biomechanical, vascular

and proprioceptive

• Continued presence of the bundle also serves as protection during

the healing process.

• Controversy regarding the definition of these injuries, which is based
• n anatomy, clinical examination, translation measurements, imaging

examinations and arthroscopy

Temponi EF, de Carvalho Júnior LH, Sonnery-Cottet B, Chambat P. Partial tearing of the anterior cruciate ligament: diagnosis and treatment. Revista Brasileira de Ortopedia. 2015;50(1):9-15

Literature Review

• Treatment depends on the existing laxity and instability
• Conservative treatment is a consideration for cases without

instability, with a focus on motor rehabilitation

Temponi EF, de Carvalho Júnior LH, Sonnery-Cottet B, Chambat P. Partial tearing of the anterior cruciate ligament: diagnosis and treatment. Revista Brasileira de Ortopedia. 2015;50(1):9-15

Surgical Management

• Surgical treatment is a challenge, since it requires correct positioning
• f the bone tunnels and conservation of the remnants of the torn

bundle

• The pivot shift test under anesthesia,the magnetic resonance

findings,the previous level and type of sports activity and the arthroscopic appearance and mechanical properties of the remnants will aid the orthopedist in the decision-making process

• Conservative treatment
• Surgical treatment with strengthening of the native ACL (selective

reconstruction)

• Classical (anatomical) reconstruction

Temponi EF, de Carvalho Júnior LH, Sonnery-Cottet B, Chambat P. Partial tearing of the anterior cruciate ligament: diagnosis and treatment. Revista Brasileira de Ortopedia. 2015;50(1):9-15

Sonnery-Cottet B et al.2009

• Prospective study
• Evaluated 174 with ACL injury
• 78.7 % had complete tears
• 21.3 % had isolated Bundle tears
• 22 pts with PLB tears
• 15 pts with AMB tears
• A significant difference in preoperative differential knee laxity

between the group with complete ACL rupture and the group with partial ACL rupture

Sonnery-Cottet B et al. Arthroscopic Identification of Isolated Tear of the Posterolateral Bundle of the Anterior Cruciate Ligament Arthroscopy: The Journal of Arthroscopic & Related Surgery,2009: Volume 25, Issue 7, Pages 728-732

Sonnery-Cottet B et al.2009

• 36 pts with isolated AMB tears.
• Reconstructed AMB while leaving PLB intact
• Grafts (ST 16pts, QS 20 pts)
• 11 pts with meniscal tears
• Avg age 32
• At Avg 24 months post op
• IKDC Objective evaluation
• Grade A (normal): 73%
• Grade B (near normal): 24%
• Grade C (abnormal): 3%

Sonnery-Cottet B et al. Arthroscopic Identification of Isolated Tear of the Posterolateral Bundle of the Anterior Cruciate Ligament Arthroscopy: The Journal of Arthroscopic & Related Surgery,2009: Volume 25, Issue 7, Pages 728-732

Complete Vs. Partial Tear

• Complete tearing ofthe ACL can be diagnosed through clinical examination,

while partial tearing often cannot

• In such cases, complementary examinations are needed for confirmation
• Definitive diagnosis of a partial ACL tear is reached by combining clinical

findings, imaging examinations and, when necessary, arthroscopic findings.

• Essential to assess the competence and functionality of the remaining

fibers with regard to knee stabilization

• Has to be ascertained whether the event in question was a partial tear or

whether there was a complete tear that is now healing

Temponi EF, de Carvalho Júnior LH, Sonnery-Cottet B, Chambat P. Partial tearing of the anterior cruciate ligament: diagnosis and treatment. Revista Brasileira de Ortopedia. 2015;50(1):9-15

Definition

• Colombet described three bands for the ACL that have anatomical and

functional importance: anteromedial (AM), posterolateral (PL) and intermediate

• Others have described 2 bands with known & accepted functionality
• Each band contributes separately toward stabilizing the knee and could be

injured separately in partial tears

• According to Hong et al., partial tears would be those in which less than

50% of the ligament is torn

• According to Noyes et al., the definition of partial tears would be related to

the percentage of the ACL fibers that are torn, given that tearing of 50–75%

• f the diameter would be highly correlated with clinical failure

Colombet P, Dejour D, Panisset JC, Siebold R. Current concept of partial anterior cruciate ligament ruptures. Orthop Traumatol Surg Res. 2010;96(8 Suppl):S109–18

Diagnosis

• Diagnosing partial ACL tears remains a challenge
• It needs to be based on a combination of clinical examination and

imaging examinations (radiography and magnetic resonance), with the definitive diagnosis reached through arthroscopic assessment, when indicated

Temponi EF, de Carvalho Júnior LH, Sonnery-Cottet B, Chambat P. Partial tearing of the anterior cruciate ligament: diagnosis and treatment. Revista Brasileira de Ortopedia. 2015;50(1):9-15

Source: Dr. Bertrand Sonnery-Cottet, Santy Orthopedics Center, Lyon, France Temponi EF, de Carvalho Júnior LH, Sonnery-Cottet B, Chambat P. Partial tearing of the anterior cruciate ligament: diagnosis and treatment. Revista Brasileira de Ortopedia. 2015;50(1):9-15

My Clinical Experience

• Positive Lachman with normal anterior drawer and pivot glide (not

shift) correlates with isolated PL bundle tear

• Positive drawer with negative Lachman and negative glide correlates

with isolated AM bundle tear

• Consider complete tear when classic LFC/ LTP MRI signal present-

pathognomonic for complete ACL tear

• Patients complain of subtle instability passed off by other providers
• Poor MRI read usually states fibers intact- when in fact NOT true.
• Trust history and exam (Do not forget the prone Lachman- Dr. Feagin)

Temponi EF, de Carvalho Júnior LH, Sonnery-Cottet B, Chambat P. Partial tearing of the anterior cruciate ligament: diagnosis and treatment. Revista Brasileira de Ortopedia. 2015;50(1):9-15

Treatment

• Treatment needs to be individualized and appropriate for each patient
• Identifying patients with low and high risk of progression of the clinical

deficiency of the ACL is fundamental for providing therapeutic guidance

• High-risk patients are the ones with proven clinical instability and lifestyles

that present a high risk of new torsion

• In these cases, the best option may be to perform surgical reconstruction
• The treatment strategy always needs to take into consideration the

symptoms, clinical examination, percentage of fibers remaining, associated injuries, length of time since the injury and daily physical work demands

Temponi EF, de Carvalho Júnior LH, Sonnery-Cottet B, Chambat P. Partial tearing of the anterior cruciate ligament: diagnosis and treatment. Revista Brasileira de Ortopedia. 2015;50(1):9-15

My Algorithm

• Clinical suspicion based upon history and exam
• Correlate MRI findings (lack of pathognomonic complte ACL signs)
• Discuss selective bundle reconstruction with patient
• Stress need to make final call during surgery!!
• EUA: Pivot glide, Lachman, drawer
• Diagnositc scope: use probe a small shaver or cautery device- be an

archaeologist (iatrogenic injury may push toward reconstruction)

• Final decision to perform selective bundle reconstruction, complete

ACLR or repair.

Conservative Treatment

• Immobilization while the patient remains symptomatic and then,

after the acute phase, stimulation of complete movement and progressive weight-bearing

• Principles of rehabilitation for patients with partial tears are the same

as those used for patients with complete tears

• Exercises for muscle stretching and strengthening and cardiovascular,

proprioceptive and adaptive training

• Pujol et al. demonstrated that partial ACL tears may have the capacity

to heal, contrary to what had been thought

Pujol N, Colombet P, Cucurulo T, Graveleau N, Hulet C, Panisset JC, et al. Natural history of partial anterior cruciate ligament tears: a systematic literature review. Orthop Traumatol Surg Res. 2012;98(8 Suppl):S160–4

Surgical Treatment Indications

• Selective ACL reconstruction in cases of partial tears may be justified by

different factors…

• Clinical: many partial tears progress to complete tears with increasing differential

anterior translation and the consequent possibility of meniscal and chondral

• Biological: the central fibers of the ACL provide adequate vascular and nervous

supplies to the new ligaments

• Mechanoreceptors present in the remaining ligament are responsible for

preserving and restoring the stability and joint balance

• Histological evaluations on ACL remnants have demonstrated that they

have the capacity to accelerate cell proliferation, revascularization and integration of the graft

Temponi EF, de Carvalho Júnior LH, Sonnery-Cottet B, Chambat P. Partial tearing of the anterior cruciate ligament: diagnosis and treatment. Revista Brasileira de Ortopedia. 2015;50(1):9-15

Arthroscopic Evaluation

• Evaluation is visual with confirmation of the presence of continuous

fibers connecting footprints

• Consider Figure of 4 position to best assess PL bundle integrity
• Tension is assessed by means of palpation and via clinical tests under

arthroscopic viewing

5-13-10 Case

• 36 y/o ex-college Basketball playing female
• c/o subtle giving way and instability
• Told repeatedly that her ACL was fine
• Exam:
• Negative ADT
• 2B Lachman
• + Pivot Glide

MRI findings

• AM intact
• PL not visualized
• Supported clinical exam

Patient LZ, Left Knee

Patient LZ, Left Knee

Patient LZ, Left Knee

Final Native AM and Allograft PL Bundle

Video Clips

SOS Data- 133 ACL Augmentations

WOMAC Function Score

Conclusions

• Few published papers have compared classical ACL reconstructions

and selective reconstruction procedures, with functional and non- functional remnant ligaments

• More studies required to evaluate the environment created by the

remnants and their effect on graft healing

• Results from selective reconstruction are encouraging, although there

is still a lack of evidence that would prove its real benefit

Papalia R, Franceschi F, Zampogna B, Tecame A, Maffulli N, Denaro V. Surgical management of partial tears of the anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc. 2014;22(1):154–65

Questions?

Thank You!