ACL Lesions in high level football players

JOÃO ESPREGUEIRA-MENDES, MD, PhDA. Monteiro, H. Pereira, P. Varanda, N. Sevivas, João Pedro Araújo, Isabel Lopes,

R. Pereira, F. Brandão, M. Oliveira, RA Sousa, R.L. Reis and Niek van Dijk

Chairman and Professor Orthopaedic Department - Minho University

President of the European Society of Knee Surgery, Arthroscopy and Sports TraumaSenior Researcher of 3B`s

PORTO – PORTUGAL

MINHO UNIVERSITY PORTO UNIVERSITY ISAKOS

ISAKOS approved teaching center

ESSKA approvedteaching center

ESPREGUEIRA-MENDES - Sports ClinicDragão Stadium – FC Porto

“FIFA MEDICAL CENTRE OF EXCELLENCE”

LITERATURE

Meta-analyses evaluating success rates of ACL recon:69%-95%

(Freedman AJSM 2003)

1/3.000 - new tears each year USA

150.000/year (S. Woo, JOS, 2006)

ACL BIOMECHANICS� ACL is the primary restraint to tibial

anterior translation that is normallyaccompanied by a couple tibial rotation

� AM bundle is more important forresisting AP translation.

� PL bundle is tight near extension andplays a role in tibial internal rotation

� ACL is the primary restraint to tibialanterior translation that is normallyaccompanied by a couple tibial rotation

� AM bundle is more important forresisting AP translation.

� PL bundle is tight near extension andplays a role in tibial internal rotation

KSSTA, April 2012

• Cross all rehab protocols and assess time frames and criteria of each associatedinjury

• Respect timeframe of each repair/reconstruction technique/tissue healing. Flexionmay be limited to 90 degrees - 3/4 weeks - in repairs of the posterior horn

• Criteria based progress – accept a delay on ROM, weightbearing, strenghteningexercises, proprioception, neuromuscular reeducation if needed

• Take advantage of time window for meniscal repair in the setting of concomitantinjuries (ACLR)

NO CONSENSUS IN LITERATURE ABOUT TECHNIQUE & RETURN TO SPORT

MENISCUS & ACLR

3D kinematic analysis to evaluate the functional levels ofthe knee, it has been found that in the ACL-deficientknee there is anterior tibial translation and excessivetibial rotation during everyday activities.

ACLR is successful in restoring these functions when low-demanding activities such as walking are performed.

During high-demanding activities, ACLR seems to fail torestore excessive tibial rotation, which may be the causeof further degeneration in the medial compartment evenafter ACLR.

• Absence of pain, swelling• Restoration of ROM and muscle strength• Restoration of proprioception• Return to work• Return to sport activity

• Return to sports at the same level• Prevention of degenerative OA• Restoration of normal knee kinematics

GOALS OF ACLR“YOU CAN MAKE A DIFFERENCE!”

“The soccer players do not appear to spend muchtime on preventive work

You need to bring the coaching staff & players to your side early (with the youngsters)

The using the available science will reduce theinjuries and post-injury problems”

PREVENTION

Lars Engebretsen, Editorial, KSSTA, May 2009

Engebretsen et al , AJSM, 2008Hurd et al, AJSM, 2008Soligard, et al, BMJ, 2008

Methods36 patients 29 ♂ and 7♀, with recent rupture of ACL were compared with other 36 subjects 29 ♂and 7 ♀, without any knee pathology.

We measured in the femur: the diameter of the shaft, height and anteroposterior diameter of theexternal condyle, the flattened lower limit of the epiphysis and the distance of the latter to the

anterior and posterior cortical diaphysis (yz and xw).In the tibia, we measured the AP diameter of the tibial plateau and tibial slope.

Results♂ with non traumatic rupture of the ACL (compared with healthy population) we found:

A bigger height and AP length of the external condyle (yz and xw).A smaller AP diameter of the tibial plateau.

The results suggest that the parameters above can be risk factors in the ACL rupture.

RISK FACTORSDoes bone morphology play a role in laxity & rotation?

M. Fernandes, A. Monteiro, N. Sevivas H. Pereira and Espregueira-Mendes (in press)

“Bone morphology ofthe external femoral &tibial condyles are thetrochlea of the ACL”

Conclusion:

•There are significant differences in bone morphology

• Significant differences in bone morphology betweenACL-injured and non-injured subjects

•Notch width measures on MRI and arthroscopically have nocorrelation

•Condyle size is a risk factor for ACL injury – may influenceknee Kinematics

DIAGNOSIS

� HEMARTROSIS : 82% ACL� Clinical evaluation� X-Ray� MRI� Arthrometer/PKTD� Arthroscopy

CLINICAL EVALUATION

“..THE DIAGNOSIS OF AN ACL RUPTURE IS DONE BY HAND..”

MRIEvaluate associated lesionsMeniscusCartilageBone bruiseOther Ligaments

Measure instability &evalute partial ruptures

Is a diagnosis of partial or even total ACL rupture enough to indicate surgery in 2013 (PL in high level football players?)

How to be sure about the functioning of the remaining bundle?

Can we correctly measure AP translation & rotation?

Can we control rotation without knowing the value of normal pattern?

Do we know how much AP translation, rotation or both combined causes instability (“cut point”)?

“A simple clinically applicable tool, similar to KT 1000 arthrometer, thatcould be used to quantify laxity and rotation needs to be developed”

J. Irrgang, J. Bost & F. Fu Letter of AJSM 2009

“ Both instrumented laxity and MRI need to be used in combinationwith proper clinical evaluation to possibly acquire a greater diagnosisvalue.” D. Dejour et al, Arthroscopy, March, 2013

PORTO KNEE TESTING DEVICE PORTO-KTD

ACL evaluation with IR & ER

PCL PL & PM Instability

PORTO-KTD

NO PRESSUREAP TRANSLATION & I ROTATIONAP TRANSLATION

ROTATION OF KNEE -MRI EVALUATION

28 cases with symptomatic andarthroscopy confirmed total

ACL RUPTURE

MRI EVALUATION with PKTD(injured + healthy knee)

KSSTA,Vol. 20, Nº 4

April 2012

PORTO – KTD

� Identify the patients that will need/not needreconstruction

� Correct indications for partial ruptures

� Verification of the functioning of the remaining bundle

� Useful in comparing SB with DB

� Prevention? (increased internal rotation?)

� Can be useful for objective evaluation of AP &Rotation laxity of an ACL deficient knee

GRAFT CHOICE

• B-P-B (gold standard)

• Triple or quadrupled hamstrings

• Quadriceps tendon

• Fresh frozen allograft (multiple ligament recon)

Graft

position

Our Preferred Technique in 2013

SINGLE BUNDLE

BPB

FEMUR� RESTORE ANATOMY (NO 10h or …)� AM PORTAL TO VIEW THE PLACE OF F/TUNNEL� AM ACESSORY PORTAL TO DRILL F/TUNNEL� NO TRANSTIBIAL� F/TUNNEL IN FULL FLEXION

“12h”

AM

AAM

TIBIAL PLACEMENT

Restore anatomy (remaining ACL/footprint)

Measure footprint to size the graft

No 10 mm or 14 mm… in front of PCL…

ACL Partial Rupture“Double bundle concept – F. Fu”

AM torn and PL intact

WHEN?

As soon As:�Attempt of 0 - 90º mobility�No pain and no swelling

IN ACUTE -EXCEPTIONAL !!

� Blocked knee� We repair MCL grade III in football� ACL+MCL+IM (PCL…)

LITERATURE

Postoperative range of motion followingACL recon with autograft hamstrings – aprospective, randomized study

- Bottoni at al AJSM, Vol. 38, 2008

Excellent clinical results can be achieved in acute with arehab protocol emphasizing extension and early rangeof motion

� Restore the anatomy� Restoration of normal knee kinematics & function

� Indication?� Difficulty in revision? � Long-term outcomes?

DOUBLE-BUNDLE ?

AM

PL

Improvement of theknowledge of

anatomy & betterplacement of a SB

IMPORTANT INSTABILITY

Severe antero-lateral instability LPS +++ and varus test +

PRESENT:Double Bundle (1TT&2FT)

PAST:Lemaire

“RED-RED-ZONE” AND “RED-WHITE-ZONE”.

Arnoczky und Warren (1982)

Am J Sports Med

MENISCAL SUTURE

Suture in Red-Redand

simple ruptures in RR and RW

Do not suture stable and

peripheral ruptures < 1cm

1. Scarce tissue characterization concerning cells

2. Limited information about native repair mechanisms and injuryresponse

3. Limitations of comercial scaffolds:early failure;reduced size with time;neo-tissue different from fibrocartilage.

4. No clinical study testing advanced TERM strategy combining scaffoldsenhanced by cells, GFs, nanotechnology…

NO SUFFICIENT DATA IN LITERATURE REGARDING SPORTS

TERM in Athletes?

CARTILAGEWB < 1,5cm2 and all NWB – III/IV

MICROFRACTURES in > 90% cases

CARTILAGE> 1,5 cm2 in WB area “GUT” MOSAICPLASTY

A new ostheochondral graft from the upper tibio-fibular joint - GUT

Espregueira-Mendes, A. Monteiro, P. Amado

ICRS, 2004, Medimond

Anatomy of the proximal tibio peroneal joint

Espregueira-Mendes, M. Vieira da Silva

KSSTA, March 2006

Osteochondral transplantation using autografts from the upper tibio-fibular joint for the treatment of knee cartilage lesions – 10y FU

Espregueira-Mendes, H. Pereira, M. Oliveira, Rui L. Reis

KSSTA, June 2012

BPB + VALGUS OSTEOTOMY

NEVER in High Level Football Players!

� PRP (42 cases)

� Stimulate revascularization?

� > Ligamentization?

� > Bone healing?

� Less pain and haematoma

GROWTH FACTORS(… high level soccer players?)

?

POST-OP

� Full extension (orthosis 5 days)� CPM at 24 hrs.� Ice (Criocuff) pre & post-op� Weight bearing 24 hrs. � 90º 5th day

POST-OP PAINMULTIMODAL ANALGESIA

� Synergistic effects from different analgesics� Reduction in the drugs’ doses� Lower incidence of side effects� Less pain / Better mobility

PRPICE (CrioCuff pre-op and post –op)Local ropivacaineCOX 2 inib (peripheral/central effect)

CRITERIA FOR SAFE RETURN TO SPORT AFTER ACLR

Return

to

Sports

Rehabilitation

Muscle strength and performance: Isokinetic test & one leg hop test < 10-

20% deficit

No pain or effusion

Full ROM

SurgeryFunctional Knee stability :

Clinical examination and objective measurments ex: motion analysis

Static knee stability:

Clinical examination and objective measures

Kt 1000 & PORTO KTD

Associated Injuries

I.E. menisci, cartilage, other ligaments, etc

Other Factors

Psychological factors

I,e. motivation, scholarship,

fear of re-injury, etc.

Social

I,e. family, pregnancy, finished college, etc.

1989 - 2005

82 (6%)Professional Football Players

1364 PRIMARY ACLR1364 PRIMARY ACLR

RETURN TO SPORTS

82Professional Football Players

97%Sports

83% (90%)

ProFootball(7% related other joints/motif)

75%Same level

TAKE HOME MESSAGE� High Level Sports Players special prob.& concerns

(coach, directors etc)

� Important correct pre-op evaluation

� Associated instabilities

� Correct surgical technique

� Need to improve rotational stability

� Basic science studies support anatomic

double-bundle ACL reconstruction (indication)

� Growth factors are promising (more studies needed)

� Rehabilitation and Good Team

� Prevention is the best treatment!

THANK YOU!

FEMUR

� AT 10H30 or 2H30

� POSTERIOR WALL WITH 2mm.

� MEDIAL APPROACH

Reconstruction of PL Bundle Only

BONE/BONE

BONE/TENDON FIXATION

BPB, HAMSTRINGS or QT GRAFTS Resofix(PLLA R&L)

AM intact with PL rupture

ACL Partial Rupture

“RED-RED- ZONE” AND “RED-WHITE-ZONE”.

Arnoczky und Warren (1982)

Am J Sports Med

MENISCAL SUTURE

Suture in Red-Red and simple ruptures in RR and RWDo not suture stable and periferic ruptures < 1cm

CARTILAGE< 1cm2 or NWB

MICROFRACTURES

CARTILAGE> 1cm2 in WB MOSAICPLASTY with “GUT”

GROWTH FACTORS

Autologous platelet gel and fibrin sealant enhance the efficacy of total kneearthroplasty: improved range of motion, decreased length of stay and a reducedincidence of arthrofibrosis

Peter Everts et al Journal Knee Surgery, Sports Traumatology, Arthroscopy Volume 15 Number 7 July 2007

Platelet gel and fibrin sealant reduce allogenic blood transfusions in total kneearthroplasty.

Everts PAM, Devilee RJJ, Brown-Mahoney C et al - Acta Anaesthesiol Scand 50:593–599 (2006)

Platelet-rich plasma stimulates osteoblastic differentiation in

the presence of BMPs

Akihiro Tomoyasu et al

Biochemical and Biophysical Research Communications

Volume 361, Issue 1, 14 September 2007 pages 62-67

Comparision of Surgically Repaired Achilles TendonTears Using Platelet-Rich Fibrin Matrices

Faster reabilitation

Less wound problems

Less tendon volume on the scar tissue

M Sanchez et al. 35: 245-251 , Am J Sports Med 2007 Feb

Enhanced histologic repair in a central wound in tha ACL with a collagen-platlet – rich plasma scaffold

Martha Murray et alt, JO Research, August 2007

“The use of a collagen- PRP-scaffold can ameliorate the healing of na ACL rupture in dogs”

Use of growth factors in ACL surgery : preliminary study

Ventura et alt, JO Traumatology, 2005

10 patients with hamstrings graft and GPS

10 patients with hamstrings graft without GPS

NO Dif in Tegner score and KT 1000

“In the PRP with GPS group the density of the ACL graft was better in CT scan and the integration in the tunnels was faster”

LITERATUREThirty-five years of f-u of ACL deficient knees in high level athletes

(Olympic) - W. Nebelung, H. Wuschech, Arthroscopy, Vol. 21, Issue 6, 2005

• 1963-1965 ACL ruptures without recon. and return to high level sports (19)

• 20y after: Meniscectomy in 18 (94%), Condral lesion IV in 13 (68%)

TKA in 10 (52%) - until 2000

Prospective trial of a treatment of algorithm for the

management of the ACL injured knee

Eithian DC, et al. AJSM 2005

• Degenerative radiographic changes in 90% of patients 7 years after

ACL reconstruction

• 47% of patients returned to previous activity level after ACL

reconstruction

Graft passage

ACL ReconstructionGraft fixation

G

GRAFT FIXATION

1 YEAR

� Narrow footprint

� Skeletal immaturity

� Early OA

� LFC osseous contusion

� IC notch stenosis

� Combined ligament injury

DOUBLE-BUNDLE CONTRA

INDICATIONS

G

Xray and TELOS

The Injury Mechanism of the ACL is Complex (Rotation / Flexion / Hyperextension / Varus / Valgus), and is

Reflected by the Different Rupture Patterns of the ACL

+++ Valgus/Flexion/External Rotation in our series

INJURY PATTERN

1301 - BPB

23 - Hamstrings

17 - BPB/Lemaire

12 - Quadriceps tendon

11 - Allografts

1989 - 2005

1364 PRIMARY ACLR1364 PRIMARY ACLR

CLASSICAL GRAFT POSITION(Our preferred technique 1989 – 2005)

SINGLE BUNDLE

PL

236 (17,3%) F / 1128 (82,7%) M

Mean age : 24,5 years (11 - 53)

Sports activities: Sports in 956 ( 70,3 %)

Football > 75%

1989 - 2005

1364 PRIMARY ACLR1364 PRIMARY ACLR

FEMUR� “AT 10H (9h30) or 2H (2h30)” ….?

� POSTERIOR WALL WITH 2mm…?

� TUNNEL in FULL FLEXION!

Reconstruction of AM Bundle Only

“Double bundle concept”

Is “nearly normal” good enough for ACL treatment in 2013 (high level football players?)

Can we correctly measure AP translation & rotation?

Can we control rotation without knowing the value of normal pattern?

Do we know how much AP translation and rotation causes instability (“cut point”)?

“A simple clinically applicable tool, similar to KT 1000 arthrometer, that could be used to quantifylaxity and rotation needs to be developed”

J. Irrgang, J. Bost & F. Fu Letter of AJSM 2009

Branch TP et al,

KSSTA (2009)

Robert H. et al,

Rev. COT (2009)

Tsai AG, F. Fu et al, .

BMC Muscu Disord. (2008)

T. Branch, H. Mayr, et alArthroscopy, 2010

Kubo S. et al.

Clin Orthop Relat Res.

A. Hemmerich, B. Van der Merwe, et al, C. J. Biomechanics, 2009

NOTCHPLASTY

Rare!

Only in chronic cases

Most of the times impingement is an incorrect placement

of the graft!

Mean 33,4 ± 9.4 y

25 MALES & 3 FEMALESSEX

AGE

SIDE

2008 - 2010

MRI 1,5 T GE Healthcare Signa, USA T1,T2, STIR, FatSat, 3D SPGR

13 LEFT & 15 RIGHT

25,3 (SD = 3,1)BMI

KT1000/2000

NO ROTATION MEASUREMENTNO MEASUREMENTS BETWEEN FEMUR & TIBIA

“GLOBAL” AP MEASUREMENT