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IC 107-2023: Optimizing ACL Reconstruction in 2023 ...
IC 107 - Optimizing ACL Reconstruction in 2023: A ...
IC 107 - Optimizing ACL Reconstruction in 2023: A Case-Based Approach (4/5)
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Video Transcription
So why do we want to augment the ACL? So we all know that there's a ton of ACL reconstruction that's done in the US and internationally. Reported retear rates vary, but anywhere from 3% to 20%, which could be upwards of 20,000 retears per year, which is a lot, which is a big problem. So obviously, even though we've been doing ACL reconstruction for a long, long time, retears are still an issue, and it's still something that creates problems for us and creates problems for our patients. So we're always trying to do something to decrease the retear rate. So how do we do that? Well, so both Mary and Cassandra both talked about appropriate graft choice, particularly in young patients probably not using allograft. Appropriate rehab, we're all aware of that. Appropriate return to play timing, that's a whole different talk for another ICL. But what are some of the things that we as surgeons can do at time zero? Well, improve knee stability, whether that be lateral augmentation or improve construct strength, potentially with internal augmentation. And so that's what we're gonna talk about and get into here. So here's some of our go-to options and some of the things that I'm gonna discuss in more detail. So ALL, anterolateral ligament reconstruction, lateral extra-articular tenodesis, and then internal suture augmentation. And we'll get into some of the biomechanics and some of the research and some of the clinical outcomes of each of these things and then some cases for some technique as well. Jump right into ALL and anterolateral ligament. So this is one of the initial studies that looked at anterolateral ligament reconstruction and both modified LaMer or a lateral extra-articular tenodesis. Looking at cadaver knees and they show that there was increased laxity in an ACL reconstruction alone knee with increased anterior translation and internal rotation, but the addition of some sort of lateral augmentation procedure, whether it be an ALL or an LET, restored the knee to intact values similar to the intact knee. This is one looking at the iliotibial band in particular and shows that the IT band is a secondary stabilizer to anterolateral rotatory instability and that both a LaMer, a LET, and an ALL helped to restore some of those native kinematics. And so again, you kind of get in the theme that some sort of an anterolateral reconstruction or anterolateral complex reconstruction potentially restores the native kinematics of the knee better than an isolated ACL reconstruction alone. How about some clinical outcomes? This is clinical outcome study looking at ALL reconstruction again or a lateral extra-articular tenodesis. This was a nice kind of summary of 20 different studies, 11 of which were randomized controlled trials looking at an ACL reconstruction alone versus an ACL plus some sort of anterolateral procedure and the ACL plus anterolateral procedure had improved pivot shift grades, decreased graft failure rates regardless of whether it was an ALL or LET technique or regardless of the time from injury. So the one thing that they showed in this study is that the patients having the LET had slightly increased risk of stiffness and adverse events but still had decreased retear rates. So you're getting kind of a theme already going. How about let's just boil it down to the basics? So this is one of the initial studies looking at the anterolateral, anterolateral ligament of the knee. This has been called a lot of different things over the last five to 10 years now, but this is kind of some of the anatomy studies that initially got people back on the anterolateral complex, so to speak. And so this area of the knee structure runs kind of obliquely over the anterolateral tib-fib joint, roughly about 50 millimeters long, six millimeters wide and then it's about 22 millimeters in between GERDI's tubercle and the center of the fibular head as you see depicted there and about one centimeter below the joint line. So this is what we're kind of trying to recreate when we talk about reconstructing the anterolateral complex or the anterolateral side of the knee. And the important point is that this area of the knee is under tension with internal tibial rotation with the knee at 30 degrees. And so again, that's the forces we're trying to resist and trying to help when doing an augmentation to the ACL reconstruction. So this is a pretty nice study kind of looking at a few different articles. It's kind of a little bit of a hodgepodge. So there's a little bit of heterogeneity with the study, unfortunately, but at least you kind of get the sense of a pooled number of studies. So it's a systematic review and meta-analysis of randomized controlled trials, but then also has some biomechanical studies and technique articles included. So again, the biomechanics show that anterior translation, internal rotation and pivot shift were restored superiorly with an ACL plus ALL versus an ACL alone. And then most of the clinical studies show decreased retear rates when an ALL was added to an ACL reconstruction versus a primary ACL reconstruction alone. Most of the patient reported outcome measures were very similar otherwise and not statistically significantly different. So let's just talk a little bit about a kind of an example case and technique. And so this is the ALL reconstruction technique or the standard kind of basic technique that most people do. Sorry, hopefully these will play. There we go. So typically you can utilize a gracilis auto or allograft on the lateral side of the knee. Initial incision typically is placed over the femur where you see the X there and then a guide can be placed there just posterior to the lateral epicondyle. Then you can drill line to line and place your graft and anchor as I'm gonna show and demonstrate here. So here we are drilling just posterior and lateral to the lateral epicondyle. Drill line to line for what you could place your graft and anchor. And again, this can be utilized with any type of anchor, standard kind of interference screw if necessary. And then you can tunnel down again. So I've marked out the fibular head and GERDI's tubercle. There's the joint line marked out. So again, about a centimeter distal to the joint line centrally between GERDI's tubercle and the fibular head. Again, another guide pin placed. Ream line to line. And then we'll tunnel the graft beneath the soft tissue utilizing just a standard suture passer that anything like that. And again, you can utilize gracilis autograft or allograft. Skip ahead there since that seemed to catch for some reason. And the nice thing about doing this is you can check isometry. You can leave your tibial pin in place and you can wrap the graft around the pin and check isometry. And then you can utilize any type of interference screw or forked screw again to affix the graft into the tibial side. Typically we'll fix the graft and with the knee in neutral position in about 30 degrees of flexion. Again, those biomechanical studies show that the lateral complex of the knee resists tibial internal rotation at about 30 degrees of flexion. So we fix it in neutral rotation at 30 degrees of flexion. So that's the ALL technique. How about lateral extra-articular chinadesis as the cohort or the other option for a lateral augmentation to the knee? So this is the classic study that everyone quotes when it comes to lateral extra-articular chinadesis. This is the stability trial. This is a multi-center prospective randomized trial. Really well done study. It looks at a single bundle hamstring ACL reconstruction with or without a modified lamare lateral extra-articular chinadesis. And they look at it in young patients. So patients less than 25 years old and they also had to have two or more of the following, a grade two pivot shift or greater, high risk, playing at a high risk or pivoting, cutting sport or overall generalized ligament laxity. So this is the patient population we're concerned about, right? This is our young athletes that these are the people that re-tear. These are the people that we're trying to get better at not having that happen. And so this is the study. This is the population that we want to look at. So a good amount of patients, 618 patients. And they show that ACL reconstruction with hamstring single bundle autograft alone versus ACL reconstruction with an LET, a lateral extra-articular chinadesis added. The graft re-rupture rates were 11% versus 4%. So they dropped it about 7% by adding an LET which is statistically significant. The number needed to treat with an LET to prevent one graft rupture was about 14.3 over a two year span. So anybody that has a pretty busy ACL practice, that's not that many patients to be able to decrease that re-rupture rate. And at three months, they also showed that ACL alone had less pain. So again, that's kind of consistent with some other studies but the overall pain and overall patient reported outcomes equalized at one in two years. So this was kind of the landmark trial. And then there's now the stability two trial that's occurring, which is actually looking at BTB plus or minus LET and also quad tendon plus or minus LET. So stay tuned on that for stability two if you're a BTB or a quad tendon user or person as opposed to a single bundle hamstring. So this is the technique. This is one of the techniques. There's a lot of different ways to affix this. This is the technique that we published in arthroscopy techniques. So again, similar, you can make an incision directly over the lateral epicondyle. You can see I've made the X down towards Gertie's tubercle. In this particular case, I'm using a double edge knife blade that has two blades on either side. That's one centimeter apart. So I can harvest an exact one centimeter strip of the IT band there and the central to posterior one third of the IT band. And then you can whip stitch the, you can release it approximately, usually release it about eight centimeters approximately from Gertie's tubercle. And then you can whip stitch that proximal part. And then you pass the proximal part beneath the FCL as you can see us doing there. So then it's secure beneath the FCL. And then you can affix it proximal and posterior to the lateral epicondyle using whatever you want, but classically it's been described with a staple, sometimes suture anchors. I prefer now using a knotless suture anchor, which works really, really well. Cause I just bring it right underneath the knotless suture anchor and pull it down and get good fixation there. And so I'll show you that. And again, similar, similar position of the knee, again, flexed, slightly flexed and with the knee in neutral and neutral rotation. So there you go. You can see kind of the final image with the Coker showing the LAT coming underneath the fibular collateral ligament. So this is kind of a case example of what this looks like. So this is similar to the case that Cassandra showed earlier with a soccer player. So this was a, this is an 18 year old female soccer player who had a failed single bundle ACL reconstruction. She had hyperextension. She had a large pivot shift. So again, hypermobility. So this is that young patient. This is the patient that unfortunately we've all seen in our offices, this young female cutting pivoting sport with hyperlaxity and hyperextension. So we revised her with a quad tendon autograft. She also had a medial meniscus ramp lesion, a large ramp lesion that we repaired and then did a lateral extraticular genidesis. And so you see what those incisions look like for a revision surgery with the addition of a lateral augmentation procedure. Okay. So how about comparing LAT versus ALL? A lot of people always say, well, which one do you use and why? Or which one is better? Or what does the literature say about each of them? So long and short of it is, the literature says they're pretty equivocal from an outcome standpoint. And so this was a study kind of comparing the two from the Santee Group, which is a big database. So they looked at revision ACL patients with two year followup and they did a one to one ratio of hamstring width plus an ALL versus BTB plus an LAT. And the theme is not really many significant differences in anything. So no differences in graft rupture, reoperations, complications, return to play, patient reported outcomes. The only difference they noted was for them, the hamstring and ALL had a slightly shorter surgical time, a 41 versus about an hour. So pretty much essentially equivocal in terms of all of those types of outcomes. So in other words, it's basically kind of dealer's choice for those two. Obviously, this has been a big thing. I mean, anytime that someone forms a consensus group solely about one thing, you know, it's hotly contested topics. So they form the anterolateral complex consensus group and had a whole meeting about it. They came up with tons of recommendations. But the basic one that I think is the big takeaway is that there's not a ton of evidence to support one thing or another, although there's more and more coming out frequently, but appropriate indications for some sort of a lateral augmentation procedure, whether you prefer an ALL or an LAT are probably setting the setting of a revision ACL, high-grade pivot shift, generalized ligamentous laxity or recurvatum, and then young patients returning to cutting or pivoting sports. So again, you get the theme now, I think. What are some other options? If you say, okay, what about how can we strengthen the ACL? How can we strengthen the biomechanical construct of our graft itself? So this is a concept that's relatively coming about more and more in internal suture augmentation with an independent suture tape. And so this is one of the initial studies looking at the biomechanics of internal suture augmentation. And so they looked at both what they considered small, such as an eight millimeter graft versus standard, which was a nine millimeter graft. And they looked at those grafts both with and with internal suture tape, with them as well, and tested them at loads of 250 and 400 newtons. And they noted that the reinforcement with the internal suture significantly decreased dynamic elongation. And with the small diameter graft, that it decreased it by even more, at 38% and 50% at the different loads. And then even with the standard diameter graft of nine millimeters, it still decreased it though by not quite significantly as much, at 15% and 26% at those different loads. So they concluded that an independent reinforcement leads to reduced elongation and higher ultimate load to failure, especially in smaller grafts. So this is one of the clinical studies that then kind of came out. But this one looks, or excuse me, this is the biomechanical study on BTB. So this is, for those of you that are BTB users, this looked at eight standard ACL BTBs versus BTB plus suture tape. They did cyclic loading for a number of cycles. They showed no real overall difference in graft displacement, but they did show a higher stiffness in the augmented group, and a higher load to failure in the augmented group. So no difference in basic displacement, but a higher load to failure in the augmented group. And so their conclusion was that the suture tape augmentation increases graft construct strength and stiffness. So how about this? This is one of the first outcome studies. So this looked at 40 augmented versus 40 non-augmented hamstring ACL reconstruction patients. The retear rate in the augmented versus the non-augmented was five versus 17.5%. So a big reduction in retear rate. We can talk about their retear rate of 17.5 in the non-augmented as well, but nonetheless, they showed a significant decrease in retear rate by augmenting their routine or their standard hamstring ACL reconstructions. And otherwise, they had no differences in their patient-reported outcome measures. So this is one, this is kind of a review of a number of different studies. Again, a little bit of heterogeneity here and a hodgepodge of things. But look, the basics of the internal suture tape is that from a biomechanical standpoint, the tape-augmented grafts perform better. So better load to failure, reduced elongation. And the idea is that the tape augments and shares the load of the graft at different levels and different loads. And then some of the clinical reviews showed, again, similar patient-reported outcomes with no differences in complications. But in this particular study, their overall graft failure wasn't powered to be assessed. So what's this rationale? Again, you're getting kind of the theme. What's the rationale for internal suture augmentation? It's not like it used to be for anybody in the room that's utilized some of the old school stuff or remembers like the Gore-Tex days and some of that kind of crazy stuff when people were trying to put in an artificial ligament in the knee. It's not that, and so it's much smaller. And it's truly used to augment the graft as opposed to create this kind of artificial ligament or that sort of thing. And so there's a lot less stress shielding. That's the question that everyone always asks is what about stress shielding with your graft? And so there's minimal stress shielding of the graft. It's actually independent of the graft itself. And the idea for that is that at higher loads, it's a load-sharing device. And so it's this concept of a seatbelt where it's there to help kind of hold things and load share, which gives you improved graft support. There does need to be more clinical data on it as most of the studies, as you saw, are biomechanical or basic in nature, but certainly there's a lot more clinical data coming soon. So this is kind of like how it's, this is kind of what it's looked like and how it's done. There's a couple of different ways that you can do internal suture augmentation. So you can do ligament augmentation on the top right where you loop the suture around the graft, or you can do what's called ligament reinforcement where you loop the suture around your device and then it's truly independent of the graft itself. So in B on the right, you can see it's looped around a cortical suspensory button. And so you can do it multiple different ways. Typically, either whether you do augmentation or reinforcement, you pass it and secure it on the femoral side. However, you normally secure your femoral graft depending on what type of graft you're using and what type of fixation you're using. And then on the tibial side, the suture tape is typically, again, secured independently, which again, can depend on what type of preference you have, whether it be a suture anchor or cortical button or just tying it off on that side as well. So what are the overall, bringing it all together, what are the indications for ACL augmentation? So particularly a lateral augmentation, whether that be an ALL or an LET. So high-risk patients, those are the patients with hyperlaxity, high-grade pivot shift, or if they're playing in a cutting or pivoting activity or sport. Revisions in young patients. For the ALL in particular, for me, if they've had a previous lateral-sided surgery or any type of IT band disruption or something related to that, then that's an indication to go straight to an ALL because obviously the IT band could have issues trying to do an LET. And I think the question becomes, should we be doing these in more of our primary patients or possibly even most of our primary ACLs, especially in young patients? Certainly the stability trial would suggest that we should do this probably more often than we used to, especially in these high-risk patients that we just discussed and probably in the primary setting. What about internal suture augmentation? So for me, I add it to all allograft ACL reconstructions, which again is a pretty low percentage of practice now. It's usually older, more sedentary patients, but I add it for the biomechanical strength to reinforce the allograft tissue for all allograft ACL reconstructions. I add it to most revisions as well. I add it to small diameter soft tissue grafts, which I'm a big quad proponent, as many of the panel here are now, so I don't have that problem so much anymore as I used to when I had hamstrings in small females. I don't think I've had a less than eight millimeter graft in a really, really long time. But I would add it to a small diameter soft tissue graft if that's what you still utilize or that's what you happen to come up with. Primary ACLs in high-risk patients with a soft tissue graft, the data is kind of trending towards that, but again, we need more clinical data and more studies. And again, the question of whether or not this should be used in the primary setting or not, I don't think is completely borne out in the literature, but certainly again, with soft tissue grafts, it's certainly a consideration as we know that it reinforces and strengthens the graft. Thank you.
Video Summary
In this video, the speaker discusses the need to decrease the retear rate in anterior cruciate ligament (ACL) reconstruction surgeries. They mention that retear rates vary from 3% to 20%, potentially resulting in up to 20,000 retears per year. The speaker explores different techniques for augmenting the ACL to improve knee stability and reduce the retear rate. This includes utilizing appropriate graft choice, proper rehabilitation, and implementing lateral augmentation or internal suture augmentation at the time of surgery. The speaker discusses specific techniques such as anterolateral ligament reconstruction, lateral extra-articular tenodesis, and internal suture augmentation. They also mention research studies and clinical outcomes supporting the use of these techniques in reducing retear rates. The speaker emphasizes the need for further clinical data and studies to better understand the efficacy of these augmentation techniques. Overall, the video highlights the importance of augmenting the ACL to address the retear problem and improve outcomes for ACL reconstruction patients.
Asset Caption
Clayton Nuelle, MD
Keywords
ACL reconstruction surgeries
retear rate
graft choice
rehabilitation
augmentation techniques
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