It was a great privilege to talk at the ISAKOS meeting in June 2015, where I was asked to discuss my new developments in ACL and PCL reconstruction - to talk on the all-inside technique, to touch a little on the anterolateral ligament, and also present my early results of ACL repair in both adults and children.
I believe that primary repair in both adults and children is going to be a game-changer and the results that we are achieving - certainly in the 2- and 5-year groups that we are following up (whose data we have collected through our efforts with the research team and the contributions from the patients) - are really superb.
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In the children that I’ve done the results have been superb - I’ve had no failures, return to sport within 4 or 5 months with full activity, no risk to growth plates because all done either below or above the growth plate through tiny tunnels, and that presentation is a very good message and really describes and explains that in some detail.
ISAKOS Meeting June 2015
ACL/PCL GraftLink Reconstruction Prof. Adrian Wilson
Thank you Mark, thank you Bertrand, it’s a real privilege to be here at the real ISAKOS. I’m very excited, and what they wanted today was some new stuff, so I was going to talk today a lot about ACL repair in the child.
So, I’d like to acknowledge my Fellows and my trainees that help put the projects together and this is where we come from – Basingstoke, which is a very small little town in between London and Southampton.
So, I am sure many of you now are using the all-inside technique so I was going to concentrate more today on results, talk a little bit about how we can enhance our grafts, reinforce them, and then finish with some repair stuff.
So, we know the principles of all-inside surgery are to be soft-tissue-preserving, to just use a semi-T, and that leaves the gracilis for stability, strength and proprioception but also these other important reconstructions that we can carry out: ALL, posterolateral corner, minimally invasive and occasionally MPFL. So we tend to use the semi-T - an autograft - and we quadruple this and if we need to of course we can combine a gracilis to make an eight-strand graft. When we use allografts, these are very expensive in the UK, they have become much more available but they are £3000 each so to just use one allograft for an ACL reconstruction is a huge cost saving.
And now of course, we have some very nice MIS devices and techniques which Arthrex has helped pioneer through a surgeon in Atlanta and this is a very nice device for taking the quadriceps which also represents a very good graft.
So what about all-inside and how do we do it? Well we only need one semi-T, we cut that at 27cm in my unit, we make the femoral tunnel to 20, we tension on the tibia and it’s really very reproducible and we’ve got some very good results.
So, if we look at those results, we’re just about to take another look at this, but up until August of last year 324 cases, a number of revisions which have come from other units, mean age 33 - a slightly older population - and that’s our follow-up.Now in our hospital we receive a lot of tertiary referrals for knee dislocation work and we do lots of multiligament procedures and you can see from the heterogeneity of the patients that many of them, as is often the case in the UK, have to have meniscal surgery and chondral surgery.
We are very happy with the scores: So, our activity scores, our Koos, our Lysholm, our Tegners are all where I would like them.
Of course we have failures, and at the moment the failure rate is approximately 4% - it’s 3.1 here but when we re-evaluated it last week it was approaching 4%, which I’m very happy with and we’ve had very few other complications.
And of course now - although this is just getting going in the UK, in the US and in other countries - SOS, the Arthrex surgical database system for surgeons - is really beginning to show that in BTB vs GraftLink the GraftLink seems to be outperforming the gold standard on these well-recognised scores.
And in fact a very nice study done by Philippe Hardy, which was published last year, compared randomised GraftLink vs 4-strand and they found actually superior results and interestingly the pain was less in their patients which is something that we possibly see.
What about all-inside PCL reconstruction? For me now this is an absolute no-brainer - this makes a difficult operation much, much more straightforward.
Really the ideal graft is 80-85, you can do it with autograft but really you do need an allograft I think to make this work, and to make it easy, we tend to use a peroneus longus.
And Bruce Levy - who is in the audience - has got a very nice guide that’s just about to be available that makes this even safer and more straightforward in terms of getting to the back of the knee - you hit the target, you feel it, you get that reproducible sense that you are safe and you avoid this horrible complication.
So again, when we looked at our results, we don’t do a huge number of PCLs. We’ve just published this and we’ve just presented this at ISAKOS actually: 19 patients, this is our follow-up, the grafts have tended to be peroneus longus and again we are very happy with our results and we’re showing very few failures. I’m going to talk a little bit more later on in this talk about how we can make our PCLs work better.So we are very happy with this for what we consider to be quite a difficult operation.
So what about enhancing our grafts? How can we make our grafts more biological? How can we make them a better shape?
Most of you will be familiar now with the whole concept of using ACP in your practice, to allow your grafts to potentially heal up better and there’s no doubt this is a good thing to do - bactericidal, it lubricates, and it has this enhanced biological response.
And I also thought what about doing something with a soft tissue graft similar to what we’ve been doing over the years with our BTBs and trying to compress the grafts and take out any dead space? So we worked on a number of different prototypes and then we came up with these compression sleeves – this was the primitive version that we were using and practicing last year, and Arthrex have now worked…and I’ll show you the finished product.
This works very, very well in terms of making our grafts compress to a more uniform size. So we downsize when we are actually using these – we are able to take smaller amounts of bone away, less bone stock, better fixation, and we provide a more uniform size. We only need to use one FlipCutter for all-inside, we only have one socket size for both ends of the graft.
And this is particularly true for allografts - so an 11 allograft will compress down to a 9½ quite frequently if you take out the dead space!
And of course we need to examine this biomechanically - so Andrew Amis is doing a study at the moment with Breck Lord and we are showing not surprisingly that actually there is no difference in terms of the biomechanical properties; certainly no adverse features.
And this is the technique. We have these compression tubes which Arthrex have now launched, and they allow you to downsize so you take……in this case it was a paediatric case, so we’re suturing the graft and just going to run this along, and there’s our reinforced 7mm graft with FibreTape, and then we pull that through and measure it, and usually we would take that as the size that we would go for. So you see, we pull it into the compression tube, here it is going into a size 7, most people would accept that and perhaps even up-size, because you saw we struggled a bit to put it in, perhaps? It certainly didn’t just fly into that 7mm tunnel, so we leave it in there for a short period of time and as we pull it out if we want we can inject, there are little holes for ACP and that’s a feature that I think is very nice, and then as it comes out of the end it’s bulletised and it’s conicalised (if that’s a real word) and it will go into the tunnels much better. So now you see we’re pulling it into a 6.5!. Now this is a bit of a struggle and I’m sure many of you would abandon and say “no, this is too tight”, and finally we get it in. So what happens then is that we’ve had it in the 6.5 and then we test it. Meanwhile we are operating, this is just on the back table, so this has been in for 2 minutes and suddenly it’s moving very smoothly, and if we leave it for a little bit longer – here we are at 4 minutes – it’s beginning to move very, very easily, and then finally at 6 minutes it’s just moving very easily.
So what about reinforcing the graft? So FibreTape - I’m sure many of you are familiar with this and it’s got a great track record in the shoulder, in the ankle, and so on, and many of us now will be familiar with the concept of the internal brace.
More than 900,000 FibreTapes have been sold and very few adverse reactions have been reported.
In terms of how we reinforce our grafts, I think this is something that is a really very useful thing to do for PCLs. Here we see my technique for preparing the GraftLink; we simply load on a FibreTape, and then we pull the FibreTape inside, and then simply suture it up. Suture that up as we would normally, and it’s a simple as that.
So then when we are faced with this case: This is actually a case of Peter Myers’ when I was doing my Fellowship; a very sloppy knee. We would operate on that and we would finish with a nice tight knee but 6 months down the line many of us would find residual laxity as the graft stretches out and it really is truly remarkable what happens if you splint a knee with FibreTape during that healing period.So the graft is fixed and then independently, once you’ve fixed the graft and you have completed your PCL reconstruction, you then fix the FibreTape below with a SwivelLock.
And this is how we do it, we drill first with a 2.4 wire, we go with a 4.5 drill, we load on the FibreTape and we simply insert that into the socket.
So what happens to this FibreTape that you leave in the knee? So here’s a gentlemen who we did recently, we did him at a year, this is his ACL and he had a reinforced graft and you can just see it in the background there where the probe is, just beginning to see the FibreTape which is synovialised; the interesting thing in all the cases we’ve been back in it always adopts the same laxity as the graft, it’s never particularly tight, it’s a nice quiet knee with no synovial reaction, the X-rays are fine, there’s no evidence of any lysis, that’s true of the MRIs as well.
Here’s a case: this poor chap, I’ve been back into his knee for a third time now and actually again it shows a very similar result at 3 years. And again we see it’s synovialised, we see it healed effectively to the side of the ACL, no abrasion, and actually again it’s adopted the same laxity as the ACL graft.
So then what I wanted to talk about now was how we use FibreTape in the paediatric case. How can we repair? We’re going to hear more about the adult but what about the paediatric ACL? So this was a heart-sink moment for me; a 5 year old with a complete rupture of their ACL, a little girl.
So, she presents with pain, swelling and a knee that didn’t work particularly well.
And when I examined her, sure enough, the Lachmann and the pivot were grossly positive in this child and of course when we went in the knee we saw an empty notch.
Now normally we would have very few options, but in this case what we decided to do was to use Gordon Mackay’s technique of ACL repair and internal brace, and here we are loading a FibreLink suture, we passed that round the stump of the ACL as you can see here, and that then gives you control of the stump.That then allows you to go to the drilling. In this case we were below the physis on the femur obviously using fluoroscopic control, and here you can see the guide wire and then the drill which looks enormous, I mean this is only a 3mm drill but it looks enormous in this little knee.
And then on the tibia I actually when through the physis in this case, again with a 3mm drill.
And here you can see the graft, you can see the ACL and you can see the internal brace alongside.
A relatively happy patient at 4 weeks, she had very little discomfort after this minimally invasive procedure.And here she is just before we did the second look; she’s got a normal gait, she can run, she’s very happy but I wanted to take all of the hardware out and obviously I was quite interested in seeing what was going on inside the knee.
So, pre-op EUA we have a stable knee: Negative anterior drawer, Lachman and pivot and then when we then look and see what happened to this FibreTape, how difficult is it to remove? I’ve cut the button on the femur and I’ve got hold of the tape distally and I’m just about to pull that out. It slipped the first time but you’ll see now as I’m just about to pull on it, the tape comes out very easily – well relatively easily – and the arthroscopic findings were a quiet knee and interestingly well, to no surprise, the ACL had healed.I’ll just run this on…here’s the ACL and I was very happy with the appearance of that ACL, and when I did the final EUA it was stable, once I’d removed the hardware.
So obviously we need to publish this so we presented this work at the British Knee Society. This little girl is being followed up. So this was her at 4 months after removal of hardware and she’s got a full range of motion and she’s completely back to normal; normal activity. Happy little girl.
And then we’ve obviously had to follow her up with long leg x-rays to make sure there’s no growth disturbance and we intend to publish this, all we need is the 1 year results. But it is…I know this is anecdotal, but the father sent me this text, I’ve obviously been keeping a very close eye on this patient and this came in to me a couple of weeks ago, they were sitting on a beach in North Cornwall watching his daughter running in and out of the waves with a normal knee. That’s a very difficult problem to deal with, I’ve not burnt any bridges, it’s healed up.
So what about a 6 year old? So here we have a 6 year old boy, skiing injury, isolated ACL and we did a similar thing, when we do the EUA, very similar finding, his pivot shift was positive as was his Lachmann, but we changed the technique very slightly.
So, in the previous technique I drilled a 3½mm tunnel, or 3mm tunnel, to allow me to pass the button, here I actually just drilled 2.4 and the button doesn’t get passed through the knee – I’ll explain in a second – so, you can see I’m well below the physis and you can see actually that if I just go back to that I am actually just above the physis this time on the tibia and I’m coming in, fluoroscopic control, with my guide wire on the femur, and again on the tibia. So, only a 2.4mm tunnel, so even if this causes a problem that is the only amount of bone that’s been drilled so far in this child. Now what I am doing is I am about to pull in the internal brace, now rather than pulling it up from the tibia and the button passing through the knee we have made a very small incision on the side of the knee laterally and we are pulling the internal brace down.
We’ve then taken those repair sutures that have been up through the knee and we are now going to tie those onto the button so when the button goes down and gets tensioned the repair can be tied on to the button. So this can all be done through this little tiny wound that you make on the side of the knee, so minimally invasive.
So there you can see the repair sutures, the button is going down onto the bone, and then once I’m happy that I’ve fixed the button with a swivel lock on the tibia I can then tie off my repair sutures. So there the repair suture is being tied and I think this minimal trauma…this child is just coming up for removal of hardware he’s doing extremely well, he has regained a full range of motion, has a stable knee, and at 12 weeks I am going to take all the hardware out.
This is a slightly different injury but still fairly terrible. So, it’s a McKeever with a massive bone fragment that’s lifted off – more a plateau fracture – in a 7 year old. I did exactly the same thing in terms of the internal brace and I just pulled that bone fragment down.I went back in at 9 weeks and had a look; she had a little bit of arthrofibrosis which I took down, and this is the appearance of her ACL and again I took out the hardware. So again, what about the knee? How much synovitis was there? How irritated was the knee by having this FibreTape material? As we’ve seen in all of the adult cases it causes no reaction and besides the stiffening that was caused by the fracture, the internal brace seemed to work very well and didn’t cause any adverse problems.
So again, we’re following up this girl very closely; here she is at 14 weeks. Nice stable knee and I’m sorry that the long leg isn’t here but there is no growth disturbance at a year and she is back to full activity.
So, final case - this is bringing everything together. This is all-inside PCL, this is a repair of the remaining single bundle of the ACL which was slightly lax, it was the AM Bundle, and we did a PL augmentation using a single semi-T from the patient looped up.
So here we are inside the knee, AL bundle slightly lax, but still a fair amount of good tissue there that’s connected to the PCL so I didn’t want to get rid of that. So I pass in my Mini Scorpion, get control of that remaining tissue just as you’ve seen previously, and here the FibreLink is being sutured down and then that gets pulled out of the way. Once I’ve got control of that I’ll pull that back out of the passport cannula and pull such that I create enough space to come in on the femu. So we’re going to make a 6½mm socket with a FlipCutter because we are putting a semi-T into this knee, so we were just checking first with the 2.4 guidewire, here the FlipCutter’s coming in, I’m pulling the remnant out of the way, and then I’m going to drill and make my socket.
So now the semi-T and the repair are both going to go up that common tunnel, obviously we need to pass shuttling sutures to do that. This shuttling suture is taken out, I cut it in two - one is used to pull the repair up and the other one goes down the tibia and shuttles the internal brace up…the semi-T up.
And here we are drilling – we’re all familiar with this – so first checking with the guidewire and then going again with the…and here we’re just shuttling some sutures, so that’s the repair going up, and now the Semi-T is coming up, there’s the button….
We’ve learnt a lot from actually coming and visiting Bertrand, we do direct visualisation of the button now which is something that he showed me, and this semi-T was attached on the pes just as he leaves his attached, so we’ve got a biological fixation…then we come in… (We are obviously not quite in synch here)...we do these tunnels first actually. Here we are coming in and doing our PCL tunnel and the all-inside technique for this really does make this, as I said, a very, very straightforward operation. So, making a tunnel on the femur, or a socket, and here the very important CaliBlator which you need to use for every single case, which allows you to measure and mark exactly where you need to be (I also designed it) and here we are pulling in the PCL.
So, the PCL is going down, and this is another one of the massive advantages of doing a PCL all-inside, is graft passage is so easy, you’re feeding the ACL into the knee, it’s going around that so-called 'killer turn' the wrong way – it’s only sutures – it passes so easily, it doesn’t get caught up, and once you’ve tried this - very few people who’ve come and they’ve come to Munich or the labs, or come to watch me in the UK - very few people go back to another technique. Plus of course this is reinforced - and there’s the final view. And it’s very easy to pass that.
So, ACL in the UK: Well we need some more evidence for this so we’re actually part of a multi-centre study, we are just looking for funding for this, just ensuring that we can get this through the MRC, the application has gone in, five centres in the UK and we’re going to hopefully have a prospective look at ACL repair from five UK centres. Thank you very much.