NEW ADVANCEMENTS in

ORTHOPAEDIC SPORTS MEDICINE

NEW ADVANCEMENTS in

ORTHOPAEDIC SPORTS MEDICINE

Prof. Berkes, I. Prof. Berkes, I.

PRIORITIES in SPORTS MEDICINE

• Antidoping

• Prevention

• Safe and effective surgeries

– Minimal invasivity– Autografts– Solid fixation– Early and accelerated rehabilitation

DISTRIBUTION of SPORTS INJURIES

Spine-trunk 17 %

Lower extremity 61 %

Upper extremity 22 %

ANTERIOR CRUCIATE LIGAMENT (ACL)

ANTERIOR CRUCIATE LIGAMENT (ACL)

ACL RECONSTRUCTIONACL RECONSTRUCTIONACL RECONSTRUCTIONACL RECONSTRUCTION

• USA 75.000 -100.000 / year

• Hungary 7.000 / year

• 85 % of orthopedic surgeons perform less than 10 ACLR / year

• USA 75.000 -100.000 / year

• Hungary 7.000 / year

• 85 % of orthopedic surgeons perform less than 10 ACLR / year

ACL RECONSTRUCTIONACL RECONSTRUCTIONACL RECONSTRUCTIONACL RECONSTRUCTION

• 75 - 90 % success rates

• 10 % pain and instability

• Revision surgery• Faulty surgical technique

• Improper tibial and femoral bone tunnel placement

• Osteoarthritis 35 %

• 75 - 90 % success rates

• 10 % pain and instability

• Revision surgery• Faulty surgical technique

• Improper tibial and femoral bone tunnel placement

• Osteoarthritis 35 %

PPREVENTIONREVENTIONPPREVENTIONREVENTION

Consensus

• Good & balanced muscular strength• Eccentric and concentric resistance training

• Muscle flexibility• Stretching

• Good proprioceptive function• Proprioceptive training

• Good aerobic & anaerobic stamina• Controlled endurance training

Consensus

• Good & balanced muscular strength• Eccentric and concentric resistance training

• Muscle flexibility• Stretching

• Good proprioceptive function• Proprioceptive training

• Good aerobic & anaerobic stamina• Controlled endurance training

PPREVENTIONREVENTIONPPREVENTIONREVENTIONChallenges

• Introduction is often difficult• Resistance from club and coaches

• Most methods: well-defined effective doses,BUT does the schedule allow to apply them?

• They prevent non-contact injuries effectively,BUT what about contact injuries?

Acute knee ligament injuries will keep on happen…

Challenges

• Introduction is often difficult• Resistance from club and coaches

• Most methods: well-defined effective doses,BUT does the schedule allow to apply them?

• They prevent non-contact injuries effectively,BUT what about contact injuries?

Acute knee ligament injuries will keep on happen…

DDIAGNOSISIAGNOSISDDIAGNOSISIAGNOSIS

Consensus

• Good history taking

• Injury mechanism

• Physical examination

Consensus

• Good history taking

• Injury mechanism

• Physical examination

HEMARTHROSIS HEMARTHROSIS

• Calls for differentiated approach

• „Diagnostic arthroscopy”- Has any therapeutic benefit?

• „Morphologic diagnosis by arthroscopy”

– Carries several potential risks!

• Calls for differentiated approach

• „Diagnostic arthroscopy”- Has any therapeutic benefit?

• „Morphologic diagnosis by arthroscopy”

– Carries several potential risks!

• Activity and occupational level

• Associated lesions (i.e. repairable menisci)

• Age

• Combined ligamentous injuries

• Instability producing functional disability

• Ability of a patient to comply with a rehab program

• Activity and occupational level

• Associated lesions (i.e. repairable menisci)

• Age

• Combined ligamentous injuries

• Instability producing functional disability

• Ability of a patient to comply with a rehab program

INDICATIONSINDICATIONS

• > 20 different techniques> 20 different techniques

• > 5 different grafts> 5 different grafts

• DDifferent rehabifferent rehabilitationilitation protocols protocols

• DDifferent outcome assessmentsifferent outcome assessments

• > 20 different techniques> 20 different techniques

• > 5 different grafts> 5 different grafts

• DDifferent rehabifferent rehabilitationilitation protocols protocols

• DDifferent outcome assessmentsifferent outcome assessments

ACL RECONSTRUCTIONACL RECONSTRUCTION

• Preoperative rehabilitation

• Surgeons’s skills and experience

• Graft material

• Graft placement

• Initial graft tension

• Preoperative rehabilitation

• Surgeons’s skills and experience

• Graft material

• Graft placement

• Initial graft tension

AFFECTING FACTORSAFFECTING FACTORS

• Graft fixation

• Concomitant injuries

• Rehabilitation

• Graft healing

• Insertion site healing

• Graft fixation

• Concomitant injuries

• Rehabilitation

• Graft healing

• Insertion site healing

AFFECTING FACTORSAFFECTING FACTORS

• Increase in ROM• Muscle build-up• +• Patient’s involvement and confidentiality• Learning new motor controls• Learning new skills

Preop rehabilitation is benefitial !

• Increase in ROM• Muscle build-up• +• Patient’s involvement and confidentiality• Learning new motor controls• Learning new skills

Preop rehabilitation is benefitial !

PREOP REHABILITATIONPREOP REHABILITATION

Biological graft materials:• Autograft: BPTB, Hamstrings, Quad-

tendon• Allograft: Achilles, BPTB, ACL

Biological graft materials:• Autograft: BPTB, Hamstrings, Quad-

tendon• Allograft: Achilles, BPTB, ACL

GRAFT SELECTIONGRAFT SELECTION

Synthetic graft materials have not Synthetic graft materials have not been successful.Engineered biological ACL scaffolds:still experimental.

Single collagen fibersSingle collagen fibers

attaching to boneattaching to bone – –

„„Sharpey’s fibers”Sharpey’s fibers”

Single collagen fibersSingle collagen fibers

attaching to boneattaching to bone – –

„„Sharpey’s fibers”Sharpey’s fibers”

TENDON-to-BONE HEALINGTENDON-to-BONE HEALING

BONE-to-BONE HEALINGBONE-to-BONE HEALING• Schiavone et al., 1993. Knee Surg. Sports Traumatol. Arthros.

• Rabbit study• Incorporations 4 months• Normal insertion 6-9 months

• Hidas et al., 2005.Hidas et al., 2005.

• Schiavone et al., 1993. Knee Surg. Sports Traumatol. Arthros.

• Rabbit study• Incorporations 4 months• Normal insertion 6-9 months

• Hidas et al., 2005.Hidas et al., 2005.

ARE RESULTS GRAFT- DEPENDENT?ARE RESULTS GRAFT- DEPENDENT?

Aglietti et al. Am J Sports Med 1994;22(2):211

„…no significant overwhelming differences between

BPTB and hamstring implantation…“

Denti et al. Knee Surg Sports Traumatol Arthrosc. 2006 Jan 10:1-4

„…no statistical differences in the clinical and instrumental evaluations of stability after 1 and 2 years (Lachman and Jerk test, KT1000) between BPTB and hamstring…“

Aglietti et al. Am J Sports Med 1994;22(2):211

„…no significant overwhelming differences between

BPTB and hamstring implantation…“

Denti et al. Knee Surg Sports Traumatol Arthrosc. 2006 Jan 10:1-4

„…no statistical differences in the clinical and instrumental evaluations of stability after 1 and 2 years (Lachman and Jerk test, KT1000) between BPTB and hamstring…“

HOWEVERHOWEVER

„…delayed TENDON-BONE healing (soft grafts) with potential risk of graft stretch out in bony cannal is presumeble…“

„…delayed TENDON-BONE healing (soft grafts) with potential risk of graft stretch out in bony cannal is presumeble…“

Meister K, Huegel M, Indelicato PA, et al. Current concepts in the recognition and treatment of knee injuries. APTA SPTS HSC-00: Lacrosse, WI; 2000. Meister K, Huegel M, Indelicato PA, et al. Current concepts in the recognition and treatment of knee injuries. APTA SPTS HSC-00: Lacrosse, WI; 2000.

Slightly different approach to RHB according to graft selection

Slightly different approach to RHB according to graft selection

• Hamstrings (ST and / or GR)• Most primary indications, less active, older patients, PF problems,

less demanding activities, some revisions

• BPTB • Professional athletes, some revisions

• Allograft• Some revisions, PF and hamstrings problem

• Hamstrings (ST and / or GR)• Most primary indications, less active, older patients, PF problems,

less demanding activities, some revisions

• BPTB • Professional athletes, some revisions

• Allograft• Some revisions, PF and hamstrings problem

OUR GRAFT SELECTIONOUR GRAFT SELECTION

• 60 % HS60 % HS

• 35 % BPTB35 % BPTB

• 5 % Allografts5 % Allografts

• 60 % HS60 % HS

• 35 % BPTB35 % BPTB

• 5 % Allografts5 % Allografts

USE of DIFFERENT GRAFTSUSE of DIFFERENT GRAFTS

GRAFT PLACEMENTGRAFT PLACEMENT

GRAFT FIXATIONGRAFT FIXATION

GRAFT FIXATIONGRAFT FIXATION

GRAFT TUNNEL MOTIONGRAFT TUNNEL MOTION

TUNNEL WIDENINGTUNNEL WIDENING

Universal problem

• in Hamstrings and BPTB

• in auto- and allografts

Universal problem

• in Hamstrings and BPTB

• in auto- and allografts

Etiology?Etiology?

Clinical significance?Clinical significance?

Single bundle ACL reconstruction (BPTB and Hamstrings)

+ AP stability restored

– Rotational stability not restored

– Pivot shift not restored

Single bundle ACL reconstruction (BPTB and Hamstrings)

+ AP stability restored

– Rotational stability not restored

– Pivot shift not restored

BIOMECHANICAL RESEARCHBIOMECHANICAL RESEARCH

ACL RECONSTRUCTIONACL RECONSTRUCTION

• Single bundle ACL reconstruction - procedure of choice for instability in the past decade

• Clinical and biomechanical studies: SB ACL reconstruction restored the sagittal stability but not the rotational stability

• Anatomical reconstruction of the two functional bundles of the ACL is necessary?

• Single bundle ACL reconstruction - procedure of choice for instability in the past decade

• Clinical and biomechanical studies: SB ACL reconstruction restored the sagittal stability but not the rotational stability

• Anatomical reconstruction of the two functional bundles of the ACL is necessary?

From anterior and central tibia

to posterior and medial aspect of LFC

Primary restraint to anterior tibial translation

Controls pivot shift phenomenon

ACL

Anteromedial bundle

Posterolateralbundle

2 major bundles: Anteromedial Posterolateral

Different tension patterns and elongation behaviors of different fiber bundles with knee flexion

KINEMATICS

Nomenclature of the bundles related to their tibial insertion

AM

PL

AM

PL

Femoral insertion AM: anterior and proximal

PL: posterior and distal

No ACL remnants in chronic lesionsNeed to know arthroscopic anatomy

ACL Reconstruction

12

6

39

30°

Femoral InsertionArthroscopic Nomenclature

Tibial Tunnel Position

Less important for ACL graft kinematics

Muneta, Am J Sports Med, 1993Hefzy, Am J Sports Med, 1994

Avoid impingement !Howell & Taylor, JBJS, 1993

0 20 50 80 110

20

40

60

Knee flexion (°)

Gra

ft t

ensi

on (

New

ton)

Zavras & Amis, KSSTA, 2001

isometric

shallow

Strongly affects graft tension and knee kinematicsPosition close to AM bundle insertion more isometric

Femoral Tunnel Position

12

639

Double bundle (anatomic) reconstruction

OUR RATIONALE

1) To adopt a reproducible surgical technique

2) Based on cadaveric validations

Comparative Study

Single bundle 1 tibial, 2 femoral 2 tibial, 2 femoral

CONCLUSIONS

ACL insertions show a high variability both in location and dimension

Often in ACL injuries no femoral footprint remnants can be visualized at arthroscopy

Need for precise landmarks and reproducibility

CONCLUSIONS

Single bundle ACL reconstruction is effective in limiting anterior translation but does not control pivot-shift

Double bundle sounds promising, but clinical results are necessary to confirm lab results

ARTHROSCOPIC MENISCUS SURGERY

ARTHROSCOPIC MENISCUS SURGERY

• To preserve as much healty To preserve as much healty meniscus tissue as possiblemeniscus tissue as possible

MENISCAL HEALINGMENISCAL HEALING

• The peripheral blood supply can produce a The peripheral blood supply can produce a reparative response reparative response

• Fibrovascular scar tissue by 10 weeksFibrovascular scar tissue by 10 weeks

HEALING ENCHANCEMENT

HEALING ENCHANCEMENT

• Fibrin glueFibrin glue• Fibrin clot insertionFibrin clot insertion• Vascular access channelsVascular access channels• Synovial abrasionSynovial abrasion• Modulators of healingModulators of healing

CLASSIFICATION CLASSIFICATION

TREATMENT OPTIONSTREATMENT OPTIONS

• Leave aloneLeave alone• Benign neglectBenign neglect• PuncturePuncture• ResectResect• RepairRepair

IDEAL TEAR FOR REPAIRIDEAL TEAR FOR REPAIR

• TraumaticTraumatic

• Vertical longitudinal Vertical longitudinal

• Peripheral 3 mm Peripheral 3 mm

• 1 - 4 cm1 - 4 cm

• No damage to the meniscal bodyNo damage to the meniscal body

CONTRAINDICATIONSCONTRAINDICATIONS

• Complex geometryComplex geometry

• Flap tearsFlap tears

• Complete radial tearsComplete radial tears

– Recovery time?Recovery time?

MENISCUS REPAIRMENISCUS REPAIR

MENISCUS-REPAIRMENISCUS-REPAIR

DART DART (ARTHREX)(ARTHREX)DART DART (ARTHREX)(ARTHREX)

FASTENER FASTENER (MITEK)(MITEK)FASTENER FASTENER (MITEK)(MITEK)

CLEARFIX SCREW CLEARFIX SCREW ( MITEK )( MITEK )CLEARFIX SCREW CLEARFIX SCREW ( MITEK )( MITEK )

STAPLE STAPLE (ARTHROTEK)(ARTHROTEK)STAPLE STAPLE (ARTHROTEK)(ARTHROTEK)

T – FIX T – FIX (SMITH + (SMITH + NEPHEW )NEPHEW )T – FIX T – FIX (SMITH + (SMITH + NEPHEW )NEPHEW )

REFIXATION IMPLANTSREFIXATION IMPLANTS

REHABILITATION REHABILITATION

• Depends on repair!Depends on repair!

– Weight - bearingWeight - bearing– Range of motionRange of motion– BracingBracing– Squatting >120 degreeSquatting >120 degree– Return to sportsReturn to sports

REHABILITATIONREHABILITATION

• 6 WKS - WEIGHT-BEARING RESTRICTION6 WKS - WEIGHT-BEARING RESTRICTION

• 3 MO - LOW IMPACT SPORTS3 MO - LOW IMPACT SPORTS

• 6 MO - RETURN TO PREVIOUS LEVEL OF6 MO - RETURN TO PREVIOUS LEVEL OF

ACTIVITYACTIVITY

» DeHAVENDeHAVEN

REHABILITATIONREHABILITATION

• 0 - 2 wks – wbat0 - 2 wks – wbat

• 2 - 4 wks – closed kinetic chain resistance 2 - 4 wks – closed kinetic chain resistance

• 4 - 8 wks – sports specific functional 4 - 8 wks – sports specific functional progressionprogression

» SHELBOURNESHELBOURNE

HANGODY’s MOSAICPLASTY

STEADMAN’s MICROFRACTURE

REHABILITATIONREHABILITATION

Depends on graft fixationDepends on graft fixation

slowslow

rehabilitationrehabilitation

fastfast

Must be accelerated and not aggressive!Must be accelerated and not aggressive!

TODAY

• Immediate mobilization

• Gradual increase in ROM – Graft dependent

• Progressive weight-bearing

• Proprioception restoration

• Immediate mobilization

• Gradual increase in ROM – Graft dependent

• Progressive weight-bearing

• Proprioception restoration

GRAFT DIFFERENCE

• Hamstrings– Hamstrings strenghtening from 5 ws– Running 12 ws, jumping 12-14 ws– Full sports 6 ms

• BPTB – Full hamstrings strenghtening from beginnig– Running 14-16 ws– Full sports 6-9 ms

• Allograft– Program focused more on prevention of arthrofibrosis

• Hamstrings– Hamstrings strenghtening from 5 ws– Running 12 ws, jumping 12-14 ws– Full sports 6 ms

• BPTB – Full hamstrings strenghtening from beginnig– Running 14-16 ws– Full sports 6-9 ms

• Allograft– Program focused more on prevention of arthrofibrosis

INSERTION SITE HEALINGINSERTION SITE HEALING

TTendonendon-to-to--BBone healingone healingTTendonendon-to-to--BBone healingone healing

Near future?Near

future?

Growth-FactorsGrowth-Factors

ANATOMYANATOMY

BIOMECHANICSBIOMECHANICS

MUSCLE BIOPSYSTEM CELLS

MUSCLE BIOPSYSTEM CELLS

GROWTH-FACTORGROWTH-FACTOR

SCAFFOLDSCAFFOLD

ROBOTICSROBOTICS

Year 2020Year 2020

CT-scanCT-scan Fetal cord cellsFetal cord cells

ligament scaffoldenhanced with autologous cells

ligament scaffoldenhanced with autologous cells

Gene transferGene transfer

TAKE-HOME MESSAGE

„Attention to detail

is the key to success!”