Evolving Technique Update The Dislocated Knee: My Algorithm for - - PowerPoint PPT Presentation

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Evolving Technique Update The Dislocated Knee: My Algorithm for - - PowerPoint PPT Presentation

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Evolving Technique Update The Dislocated Knee: My Algorithm for Success What Has Worked For Me Gregory C. Fanelli, M.D. 115 Woodbine Lane Danville, PA 17822-5212 570-271-6700 gregorycfanelli@gmail.com GC Fanelli Disclosure

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GC Fanelli

Evolving Technique Update The Dislocated Knee:

My Algorithm for Success

What Has Worked For Me

Gregory C. Fanelli, M.D.

115 Woodbine Lane Danville, PA 17822-5212 570-271-6700 gregorycfanelli@gmail.com

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GC Fanelli

Disclosure

  • Royalties:

– Springer

  • PCL Textbooks
  • Multiple Ligament Injured Knee Textbooks

– Innomed

  • Stock options: None
  • Consultant:

– Biomet Sports Medicine

  • PCL ACL Instrumentation System
  • Speaker

– Conmed

  • Speaker
  • Research support: None
  • Educational support: None
  • Other support: None

2013

2nd Edition

2015

2nd Edition

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GC Fanelli

  • 1. Multisystem Injury Complex
  • Ligaments:

– ACL – PCL – PLC – LCL – MCL – PMC

  • Vessels:

– Popliteal artery – Popliteal vein

  • Skin
  • Nerves:

– Tibial – Peroneal

  • Bones

– Tibia – Femur – Patella – Pelvis – Spine

  • Head Injury

– H.O. – Spasticity

  • Other Organ System

Trauma

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GC Fanelli

  • 1. Multisystem Injury Complex
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GC Fanelli

  • 1. Not all knee dislocations are equal

Surgical Timing Acute KD

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GC Fanelli

  • 1. Surgical Timing Acute KD

Modifiers-Considerations

  • My preferred approach

– Single stage procedure – Within 2 to 4 weeks of the initial injury

  • Vascular injuries
  • Irreducible dislocations
  • Open injury
  • Skin condition
  • Extensor mechanism disruption
  • Reduction stability

– Collateral ligament injury severity

  • Fractures and articular surface injuries
  • Other orthopaedic injuries
  • Multiple system injuries

– Head trauma – Visceral trauma

  • Take home message:

– Ideal surgical timing is not always possible – External fixation

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GC Fanelli

  • 1. External Fixation
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GC Fanelli Lateral Posterolateral Capsular Shift and/or Reattachment Always Peroneal Nerve Decompression Always Screw and Washer Allows Adjustability

Most of the Time +/- Interference Screw Hyperextension (+ Heel Lift Off) Tibia Fibula Joint Injury Revision PLR

  • 2. Control the Posteromedial and Posterolateral Corners
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SLIDE 9

GC Fanelli

  • 2. Control the Posteromedial and Posterolateral Corners
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GC Fanelli

Posteromedial Capsular Shift and/or Reattachment Always Screw and Washer

  • r

Adductor Magnus Loop

  • 9. Surgical Technique
  • 2. Control the Posteromedial and Posterolateral Corners
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GC Fanelli

High Grade Acute Medial Side Tear

  • 2. Control the Posteromedial and Posterolateral Corners
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GC Fanelli

  • 3. Allograft and Autograft Both Successful in PCLR/MLR
  • Fanelli GC, Giannotti B, Edson CJ. Arthroscopically assisted combined ACL/PCL reconstruction.

Arthroscopy, 1996; 12(1):5-14.

  • Fanelli GC, Giannotti B, Edson CJ. Arthroscopically assisted PCL/posterior lateral complex reconstruction.

Arthroscopy,, 1996; 12(5):521-530.

  • Fanelli GC, Edson CJ. Arthroscopically assisted combined ACL/PCL reconstruction. 2-10 year follow-up.

Arthroscopy,, 2002; 18(7):703-714.

  • Fanelli GC, Edson CJ. Combined posterior cruciate ligament –posterolateral reconstruction with Achilles

tendon allograft and biceps femoris tendon tenodesis: 2-10 year follow-up. Arthroscopy,, 2004; 20 (4): 339- 345.

  • Fanelli GC, Tomaschewski D. Allograft use in the treatment of the multiple ligament injured knee. Sports

Medicine and Arthroscopy Review, 2007; 15 (3):139-148. (Allograft efficacy)

  • Fanelli GC, Edson CJ. Surgical treatment of combined PCL, ACL, medial, and lateral side injuries (global

laxity): surgical technique and 2 to 18 year results. Journal of Knee Surgery, 2012; 25 (4):307-316.

  • Fanelli GC, Sousa P, Edson CJ. Long term follow-up of surgically treated knee dislocations: stability

restored, but arthritis is common. Clinical Orthopaedics and Related Research, 2014; 472 (9):2712-2717.

  • Fanelli GC, Fanelli DG, Edson CJ, Fanelli MG. Combined anterior cruciate ligament and posterolateral

reconstruction of the knee using allograft tissue in chronic knee injuries. Journal of Knee Surgery, 2014; 27(5):353-358.

  • Autograft-allograft, acute-chronic

– No statistically significant difference

  • KT 1000, stress x-ray, HSS, Lysholm, Tegner
  • Long term results MLIK

– Static stability retained

  • Physical examination, KT 1000, stress x-ray
  • 18 to 22 years post op

Graft Selection

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GC Fanelli

  • SB reconstructions
  • PCL PL

20

  • PCL PM

1

  • PCL PL PM

2

  • ACL PCL PL

12

  • ACL PCL PM

2

  • ACL PCL PL PM

8

  • Total

45

  • DB reconstructions
  • PCL PL

11

  • PCL PM
  • PCL PL PM

9

  • ACL PCL PL

11

  • ACL PCL PM

5

  • ACL PCL PL PM

8

  • ACL PCL

1

  • Total

45

Single vs. Double Bundle PCL Reconstruction

Fanelli GC, Beck JD, Edson CJ. Single compared to double bundle PCL reconstruction using allograft

  • tissue. Journal of Knee Surgery, 2012; 25 (1):59-64

SB BC/KD 22 DB BC/KD 25 No isolated PCL tears

  • 4. PCLR SB v DB
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GC Fanelli

Overall Group Single Bundle 34/45 75.6% Double Bundle 30/45 66.7% p = 0.358 PCL Collateral Ligament Group Single Bundle 20/23 86.9% Double Bundle 15/18 83.3% P = 0.756 Bi-cruciate Group Single Bundle 17/22 73.3% Double Bundle 21/25 84.0% P = 0.572

Single vs. Double Bundle PCL Reconstruction Return to Pre-Injury Level of Function

Fanelli GC, Beck JD, Edson CJ. Single compared to double bundle PCL reconstruction using allograft tissue. Journal of Knee Surgery, 2012; 25 (1):59-64

No SS difference

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GC Fanelli

Know graft location preoperatively

  • 4. PCLR Vascular Considerations

PCL ACL Lateral Medial PA tear Vascular Repair Vein Graft ORIF Tibial Plateau Fracture

Gortex Arterial Graft

  • Keser, Arthroscopy, 2006; 22 (6):656-659

– PA lateral to central axis 94.3% – PA on central axis 5.7%

  • Kim, Ann Surg, 1989, 210 (6):776-781

– Normal PA branching 92.2% – PA variants 7.8% – High origin of anterior tibial artery 72% of the 7.8%

  • Butt, J Arthroplasty, 2010, 25 (8):1311-1318

– Anterior tibial artery anterior to popliteus muscle 2.1%

  • Mavili, Diagnostic and Interventional Radiology, 2011; 17:80-83

– Normal PA branching 88.1%

  • 12% of popliteal arteries may have abnormal branching

Butt, J Arthroplasty, 2010, 25 (8):1311-1318 Kim, Ann Surg, 1989, 210 (6):776-781

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GC Fanelli

  • 4. Mechanical Graft Tensioning
  • Fanelli GC, Edson CJ. Arthroscopically assisted combined ACL/PCL reconstruction. 2-10 year follow-up.

ARTHROSCOPY, 2002; 18(7):703-714.

  • Fanelli GC, Edson CJ. Combined posterior cruciate ligament –posterolateral reconstruction with Achilles

tendon allograft and biceps femoris tendon tenodesis: 2-10 year follow-up. ARTHROSCOPY, 2004; 20 (4): 339-345.

  • Fanelli GC, Edson CJ, Orcutt DR, Harris JD, Zijerdi D. Treatment of combined ACL-PCL-MCL-PLC injuries
  • f the knee. JOURNAL OF KNEE SURGERY, 2005, 18 (3):240-248.
  • Normal posterior drawer
  • (KD) without boot 46%
  • (KD) with boot 86.6%
  • (PCL PL) without boot 70%
  • (PCL PL) with boot 91.7%
  • PLI and PMI corrected in all series
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GC Fanelli Surgical Technique When There Are Open Growth Plates

  • PCLR SB TTT ATAL FF without bone plug

– Femoral tunnel crossed the physis – Cortical suspensory fixation stacked polyethylene buttons – Tibial tunnel below physis

  • Bioabsorbable interference screw (cortical margin)
  • Cortical suspensory fixation screw and spiked washer

– No fixation device crossed the growth plates

  • ACLR TTFT
  • ATAL
  • Trans physeal tunnels
  • PLR

– FHBF8 STAL + primary repair + capsular shift – Common biceps tendon loop and suture fixation

  • No fibular head drill holes or hardware distal lateral femur
  • PMR

– Primary repair or posteromedial capsular shift + STAL – Tibial side screw and washer, femoral side AM loop and suture

  • No fixation device crosses physis
  • Procedure determined by stage of physeal development

PCL Based Multiple Ligament Knee Injuries in Patients 18 Years of Age and Younger

Fanelli GC, Fanelli DG. Knee dislocations in patients 18 years of age and younger. Surgical technique and outcomes. Journal of Knee Surgery, 2016; 29(4): 269-277.

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GC Fanelli

  • Full extension long leg brace
  • Crutch ambulation

– NWB 3 to 5 weeks

  • Progressive ROM

– POW # 3 to POW # 5

  • Progressive weight bearing

– POW # 3 to POW # 5

  • Progressive ROM, strength, proprioceptive skills training
  • Sports / heavy work in 12 months

– Strength, ROM, proprioceptive skills

  • Functional brace (may protect collateral ligament complex)
  • Must observe carefully and individualize

– Get a “feel for the personality of the knee” – ROM under anesthesia

Edson, Fanelli, Beck. Postoperative rehabilitation of the MLIK Sports Medicine Arthroscopy Review, 2011, 19 (2) Edson, Fanelli, Multiple Ligament Injured Knee, Fanelli (Ed), Second Edition, Springer, 2013

  • 5. Post Operative Rehabilitation Program
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GC Fanelli

Fanelli, Edson. Combined PCL ACL lateral and medial side (global laxity) reconstruction. Technique and 2 to 18 year results. J Knee Surgery, 2012; 25 (4)

  • 40 combined PCL ACL lateral medial reconstructions (worst of the worst)
  • 28/40 available 2 to 18 year follow up (70% follow up rate)
  • Knee ligament rating scales Mean (Range)

– HSS 79.3/100 (56 to 95) – Lysholm 83.8/100 (58 to 100) – Tegner 4.0/10 (2 to 9)

  • KT 1000 SSD mm Mean (Range)

– PCL 90 degree screen 2.02 (0 to 7) – Corrected posterior 2.48 (0 to 9) – Corrected anterior 0.28 (-3 to 7) – 30 degree posterior to anterior 1.0 (-6 to 6)

  • Telos stress radiography SSD to test PCL Mean (Range)

– 90 degrees flexion posterior displacement force 2.35 (-2 to 8)

  • Range of motion flexion loss SSD degrees Mean (Range) 14.0 (0 to 38)

– No flexion contractures

  • Symmetrical: varus (93.3%), valgus (92.6%)
  • Dial test: symmetrical (85.2%), tighter (11.1%), greater-lax (3.7%)
  • Posttraumatic degenerative joint disease: Yes (29.6%) No (70.4%)
  • Return to pre injury level of function: Yes (59.3%) No (40.7%)

– 91% return to preinjury or one grade lower level of Tegner function

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GC Fanelli 2013

2nd Edition

2015

2nd Edition

Thank you to my patients

Gregory C. Fanelli, M.D.

115 Woodbine Lane Danville, PA 17822-5212 570-271-6700 gregorycfanelli@gmail.com