NEW ADVANCEMENTS in ORTHOPAEDIC SPORTS MEDICINE Prof. Berkes, I.
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Transcript of NEW ADVANCEMENTS in ORTHOPAEDIC SPORTS MEDICINE Prof. Berkes, I.
![Page 1: NEW ADVANCEMENTS in ORTHOPAEDIC SPORTS MEDICINE Prof. Berkes, I.](https://reader035.fdocuments.net/reader035/viewer/2022062519/5697c0231a28abf838cd4142/html5/thumbnails/1.jpg)
NEW ADVANCEMENTS in
ORTHOPAEDIC SPORTS MEDICINE
NEW ADVANCEMENTS in
ORTHOPAEDIC SPORTS MEDICINE
Prof. Berkes, I. Prof. Berkes, I.
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PRIORITIES in SPORTS MEDICINE
• Antidoping
• Prevention
• Safe and effective surgeries
– Minimal invasivity– Autografts– Solid fixation– Early and accelerated rehabilitation
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DISTRIBUTION of SPORTS INJURIES
Spine-trunk 17 %
Lower extremity 61 %
Upper extremity 22 %
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ANTERIOR CRUCIATE LIGAMENT (ACL)
ANTERIOR CRUCIATE LIGAMENT (ACL)
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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
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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 %
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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
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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…
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DDIAGNOSISIAGNOSISDDIAGNOSISIAGNOSIS
Consensus
• Good history taking
• Injury mechanism
• Physical examination
Consensus
• Good history taking
• Injury mechanism
• Physical examination
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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!
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• 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
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• > 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
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• 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
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• Graft fixation
• Concomitant injuries
• Rehabilitation
• Graft healing
• Insertion site healing
• Graft fixation
• Concomitant injuries
• Rehabilitation
• Graft healing
• Insertion site healing
AFFECTING FACTORSAFFECTING FACTORS
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• 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
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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.
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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
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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.
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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…“
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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
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• 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
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• 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
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GRAFT PLACEMENTGRAFT PLACEMENT
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GRAFT FIXATIONGRAFT FIXATION
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GRAFT FIXATIONGRAFT FIXATION
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GRAFT TUNNEL MOTIONGRAFT TUNNEL MOTION
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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?
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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
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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?
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From anterior and central tibia
to posterior and medial aspect of LFC
Primary restraint to anterior tibial translation
Controls pivot shift phenomenon
ACL
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Anteromedial bundle
Posterolateralbundle
2 major bundles: Anteromedial Posterolateral
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Different tension patterns and elongation behaviors of different fiber bundles with knee flexion
KINEMATICS
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Nomenclature of the bundles related to their tibial insertion
AM
PL
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AM
PL
Femoral insertion AM: anterior and proximal
PL: posterior and distal
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No ACL remnants in chronic lesionsNeed to know arthroscopic anatomy
ACL Reconstruction
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12
6
39
30°
Femoral InsertionArthroscopic Nomenclature
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Tibial Tunnel Position
Less important for ACL graft kinematics
Muneta, Am J Sports Med, 1993Hefzy, Am J Sports Med, 1994
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Avoid impingement !Howell & Taylor, JBJS, 1993
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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
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12
639
Double bundle (anatomic) reconstruction
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OUR RATIONALE
1) To adopt a reproducible surgical technique
2) Based on cadaveric validations
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Comparative Study
Single bundle 1 tibial, 2 femoral 2 tibial, 2 femoral
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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
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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
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ARTHROSCOPIC MENISCUS SURGERY
ARTHROSCOPIC MENISCUS SURGERY
• To preserve as much healty To preserve as much healty meniscus tissue as possiblemeniscus tissue as possible
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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
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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
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CLASSIFICATION CLASSIFICATION
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TREATMENT OPTIONSTREATMENT OPTIONS
• Leave aloneLeave alone• Benign neglectBenign neglect• PuncturePuncture• ResectResect• RepairRepair
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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
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CONTRAINDICATIONSCONTRAINDICATIONS
• Complex geometryComplex geometry
• Flap tearsFlap tears
• Complete radial tearsComplete radial tears
– Recovery time?Recovery time?
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MENISCUS REPAIRMENISCUS REPAIR
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MENISCUS-REPAIRMENISCUS-REPAIR
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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
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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
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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
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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
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HANGODY’s MOSAICPLASTY
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STEADMAN’s MICROFRACTURE
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REHABILITATIONREHABILITATION
Depends on graft fixationDepends on graft fixation
slowslow
rehabilitationrehabilitation
fastfast
Must be accelerated and not aggressive!Must be accelerated and not aggressive!
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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
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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
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INSERTION SITE HEALINGINSERTION SITE HEALING
TTendonendon-to-to--BBone healingone healingTTendonendon-to-to--BBone healingone healing
Near future?Near
future?
Growth-FactorsGrowth-Factors
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ANATOMYANATOMY
BIOMECHANICSBIOMECHANICS
MUSCLE BIOPSYSTEM CELLS
MUSCLE BIOPSYSTEM CELLS
GROWTH-FACTORGROWTH-FACTOR
SCAFFOLDSCAFFOLD
ROBOTICSROBOTICS
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Year 2020Year 2020
CT-scanCT-scan Fetal cord cellsFetal cord cells
ligament scaffoldenhanced with autologous cells
ligament scaffoldenhanced with autologous cells
Gene transferGene transfer
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TAKE-HOME MESSAGE
„Attention to detail
is the key to success!”