2015 os - fanelli pcl powerpoint
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PCL PowerpointTRANSCRIPT
GC Fanelli
The Knee Dislocation 20 Years Later: What I Have Learned,
I Get It Stable, But Do I Solve The Arthritis Problem
Practical Manage of the Multiple Ligament Injured (Dislocated) Knee
Gregory C. Fanelli, M.D.
115 Woodbine Lane
Danville, PA 17822-5212
570-271-6700
GC Fanelli
Disclosure • Royalties:
– Springer
• PCL Textbooks
• Multiple Ligament Injured Knee Textbooks
• Stock options: None
• Consultant:
– Biomet Sports Medicine
• PCL ACL Instrumentation System
• Speaker
– Conmed
• Speaker
• Research support: None
• Educational support: None
• Other support: None
GC Fanelli
1. Vascular Assessment Acute MLIK
• Incidence 1.6 to 50% (Whalen, Green, Welling)
• Bicruciate tears = TF Dislocation (Wascher)
• Beware post traumatic DVT
• Hyperextension – Anterior
– Popliteal artery stretch • Arterial rupture
• Dashboard knee – Posterior
• Arterial contusion (intimal damage)
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• What to do:
• Physical exam + ankle brachial index
• Abnormal pulses or ABI < 0.9
– Arteriography, MRA, CTA
• Mills, J Trauma, 2004
• Non flow limiting intimal tear
– Observe
– No tourniquet during surgery
– Vascular surgery available • ABI = doppler systolic arterial pressure in injured limb (ankle) /
doppler systolic arterial pressure in uninjured limb (brachial)
1. Vascular Assessment Acute MLIK
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Popliteal Artery Variations • 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
GC Fanelli Kim, Ann Surg, 1989, 210 (6):776-781
Butt, J Arthroplasty, 2010, 25 (8):1311-1318
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PCL ACL Lateral Medial PA tear
Vascular Repair Vein Graft
ORIF Tibial Plateau Fracture
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2. Peroneal Nerve Injury
• Incidence as high as 50% KDs
• Contributes to poor outcomes
• Nerve repair:
– Small gap, minimal tension, end to end repair
• Nerve grafting:
– Graft length main predictor of outcome
– Successful functional recovery (Kim, Neurosurgery, 2004)
• < 6 cm, 75%
• 6 to 12 cm, 38%
• 13 to 24 cm, 16%
• Our preferred treatment :
– Peroneal nerve neurolysis
– Serial EMGs after 1 month
– Posterior tibial tendon transfer
• Predictable functional recovery (Cush, SMAR, 2011)
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• Exam under anesthesia assisted with
flouroscopy
• Anterior posterior translation
• Hyperextension
• Varus and valgus laxity
• Determine stable hinge
• Beware axial rotation
• Diagnostic arthroscopy
3. Correct Diagnosis
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• Indications (Stuart, Op Tech Sports Med, 2001)
– Open dislocations
– Vascular repair
– Inability to maintain reduction
• External fixator vs. brace (Khanna, Levy, AANA, 2008) • Preoperative spanning external fixation
• Post op, no SSD, IKDC, Lysholm, manipulation
• ROM external fixator: 102` flexion
• ROM brace: 129` flexion
• P = 0.02
• External fixation group more complex cases
• Post operative external fixation (Compass Knee Hinge )
• Stannard, JBJS, 2014 – Recurrent instability
» Brace 27%
» CKH 4%
» P < 0.05
• Take home message
– Control the knee in a brace, use the brace
– Cannot control the knee in a brace, use external fixation
4. External Fixation
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Ultra Low Energy Injury
• 34 year old female
• 5’4”, 460 pounds
• Slipped on a wet floor in
her kitchen
• Twisting injury to the right
knee
• Acute tibial femoral
posterior dislocation
• Arteriogram negative
• Nerve function intact
• ACL PCL Lateral Side
tears
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4. External Fixation
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• Vascular status
• Medial and lateral side injury severity
• Degree of instability
– Reduction stability
• Delayed or staged reconstruction 2-3 weeks-less
postoperative motion loss
– Fanelli, Arthroscopy, 1996, 2002, 2005, JKS 2005, JBJS 92
A 2010
– Wascher, Arthroscopy, 1999
– Mook, Miller, JBJS 91 A, 2009
• My preferred approach
– Single stage procedure
– Within 2 to 4 weeks of the initial injury
5. Surgical Timing Acute MLIK
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5. Surgical Timing Acute KD Modifiers-Considerations • 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
• Take home message:
– Ideal surgical timing is not always
possible
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6. Repair or Reconstruct, Graft Source
• PCL ACL reconstruction (allograft, autograft)
– No SSD between allograft and autograft (Fanelli, Arthroscopy, 1996, 2002)
– Bony/soft tissue avulsions (Beware interstitial ligament damage)
• Posterolateral corner
– Stannard, AJSM, 2005 • Repair only, 37% failure
• Repair + reconstruction, 9% failure
– Levy, AJSM, 2010 • Repair only, 45% failure
• Posteromedial corner
– Levy, AANA, 2008
• Repair only, 29% failure
– Stannsrd, AOSSM, 2009
• Repair only, 20% failure
• Autograft reconstruction, 3.7% failure
• Allograft reconstruction, 4.8% failure
• Take home message
– Posterolateral and posteromedial primary repair with augmentation / reconstruction provides better success than primary repair alone
– Allograft and autograft are both successful
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7. Arthroscopic or Open PCL ACL Reconstruction?
Single v Two Stage
Single Stage Open
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7. Arthroscopic or Open PCL ACL Reconstruction?
Single Stage Open
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7. Arthroscopic or Open PCL ACL Reconstruction?
Single Stage Open
GC Fanelli 7. Arthroscopic or Open PCL ACL Reconstruction?
Single v Two Stage
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Stage 1
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Stage 2
• Take home message:
– Everyone of these cases is different
– The central pivot disruption is relatively constant
– The medial side, lateral side, extensor mechanism injury
severity determines the surgical approach
• Arthroscopic
• Open
• Single stage
• Two stage
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Patient Positioning \ Set Up PCL/ACL Reconstruction
8. Surgical Technique
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PCL Reconstruction Transtibial Technique
Posteromedial Safety Incision Protect the neurovascular structures!
8. Surgical Technique
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PCL Reconstruction
8. Surgical Technique
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ACL Reconstruction 8. Surgical Technique
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Tensioning and Fixation
• Graft tensioning – Graft tensioning boot
– MLIK set 0` (PCL and ACL)
– Full Arc Dynamic Tensioning
• Final fixation flexion angle – PCL DB and SB 70`- 90`
– ACL 20 - 30`
• Full ROM
• Lateral and medial sides (30`)
• Primary fixation – Resorbable interference screw
– Aperture opening
• Back-up fixation – Button
– Spiked ligament washer
8. Surgical Technique
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Lateral Posterolateral Capsular Shift and/or Reattachment Always
Peroneal Nerve Decompression and Neurolysis Always
Most of the Time
=/- Interference Screw Hyperextension (+ Heel Lift Off)
Tibia Fibula Joint Injury
Revision PLR
8. Surgical Technique
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8. Surgical Technique
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Medial Posteromedial Reconstruction
Posteromedial Capsular Shift
and/or
Reattachment
Always
Screw and Washer
or
Adductor Magnus Loop
8. Surgical Technique
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High Grade Acute Medial Side Tear
8. Surgical Technique
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• Full extension long leg brace
• Crutch ambulation – NWB 3 to 5 weeks
• Progressive ROM – POW # 3 or POW # 5
• Progressive weight bearing – POW # 3 or 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)
9. Post Operative Rehabilitation Program
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10. Outcomes: What To Expect Long Term
• Fanelli, Edson, Giannotti. AA combined ACL PCL reconstruction.
Arthroscopy, 1996
• Fanelli, Edson. AA assisted combined ACL PCL reconstruction. 2-10
year results. Arthroscopy, 2002
– No graft tensioning boot
• Fanelli, Edson, et al. Treatment of combined ACL PCL MCL PLC
injuries of the knee. J Knee Surgery, 2005
– Tensioning boot utilized
• Fanelli, Beck, Edson. Single compared to double bundle PCL
reconstruction using allograft tissue. J Knee Surgery, 2012
• Fanelli, Edson. Combined PCL ACL lateral and medial side (global
laxity) reconstruction. Technique and 2 to 18 year results. J Knee
Surgery , 2012
• Fanelli GC, Sousa P, Edson CJ. Long term follow-up of surgically
treated knee dislocations: stability restored, but arthritis is common.
CORR, 2014
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• Autograft-allograft, acute-chronic
– No statistically significant difference • KT 1000, stress x-ray, HSS, Lysholm, Tegner
• Mechanical graft tensioning boot (Biomet)
– Without boot 46% normal posterior drawer
– With boot 87-92% normal posterior drawer
– PLI and PMI corrected in both series
• SB vs DB PCL Reconstruction
– No statistically significant difference
• Static stability (stress x-ray [2.56mm and 2.36 mm], KT 1000)
• Return to pre-injury level of function (73 to 84%)
• Long term results MLIK
– 60% return to pre-injury level of function (Tegner) • 93% same or one Tegner grade lower level of activity
– 23 to 30% rate of degenerative joint disease
– Static stability retained • Physical examination, KT 1000, stress x-ray
• 18 to 22 years post op
10. Outcomes: What To Expect Long Term
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• Rom: R 0-112°, L 0-105°
• KT 1000 (mm excursion)
– PCL screen L=0, R=1, SSD=1
– Corrected Posterior L=1, R=2, SSD=1
– Corrected Anterior L=2, R=1, SSD=1
– 30° ADM 30# L=10, R=11, SSD=1
• HSS L 92/100, R 87/100
• Lysholm L90/100, R 95/100
• Tegner 4, preinjury 4-5
10. Outcomes: What To Expect Long Term
Seven Years s/p Bilateral Knee Dislocations
GC Fanelli 22 Years Post Op PCL ACL PL PM Reconstruction
10. Outcomes: What To Expect Long Term
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Gregory C. Fanelli, M.D.
115 Woodbine Lane TYJ
Danville, PA 17822-5212
570-271-6700
2013 2015