A selection of discussions at a clinical meeting of knee experts held in Worcester, UK, in May 2015.

discussions after the lectures

This annual course in the UK is a favourite of mine. It is in a wonderful venue at the conference centre of Worcester Rugby Club in the UK, and combines intimacy with a great international faculty.

 

Duncan Learmonth, BSc FRCS - Why do ligament reconstructions fail?

  • Poor patient selection - some patients will 'hammer' their graft or not co-operate with rehab. They may be young, and if they want to return to high risk sports they need to know the risks and maybe attend a FIFA programme
  • Additional pathology, such as posterolateral corner laxity, medial collateral laxity, meniscal root injury, articular cartilage damage. Repair of a meniscal tear will hamper things because rehab needs to go slower with meniscal repair
  • Surgeon factors - tunnel position in the notch needs to be optimal
  • Graft type & thickness - autograft is best. Graft needs to be 8mm or more (but don't overstuff the notch)
  • Graft tensioning & fixation - tensioning is important (25-30 Newtons). Most modern fixation devices are acceptable, but the endobutton needs to be flush on the bone
  • ?Failure to preserve the ACL remnant - preserving the remnant may help in healing and proprioception

 

Charles Brown MD - Anatomic ACL reconstruction

  • The debate continues about where in the femoral footprint the graft should be placed
  • The point is that the footprint is larger than the drill hole, so it has to be decided where on the footprint one should make the tunnel
  • Surgeon technique is important as the correct use of portals and knee position optimise access to the footprint
  • Use of posts to hold the knee during surgery allow exact positioning without assistance
  • If the remnant is being preserved, it is useful to use fluoroscopy to position the tunnels as the remnant obscures the view (but too much remnant may lead to a cyclops lesion)

 

Konrad Slynarksi MD PhD - Current thinking of ACL reconstruction

  • Surgeons need to better understand the anatomy, especially with regard to the pivot shift and instability
  • It is important to assess in particular the anterolateral ligament (the rotational stabiliser of the knee)
  • It has become evident that the ACL remnant is important because of its nerve supply, and surgeons are using a new augmentation device of FibreTape wrapped in a porcine scaffold to help preserve the remnant
  • Technically the inside-out drilling through an accessory antero-medial portal allows correct identification of the footprint of the ACL, and preserves more bone for any future revision

 

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