Early results of anatomical ACL Reconstruction using The all-inside, Trans-lateral technique S Srinivasan, Y Hamed, R Shah, Dipen K Menon Kettering General Hospital NHS Foundation Trust (Affiliated teaching hospital: University of Leicester) COKS2017: Noosa, Queensland, Australia Sunday, 15/10/2017

Disclosures & ACKNOWLEDGEMENTS No conflict of interests Individual contributions Mr S Srinivasan Registrar Data collection & Analysis Mr Y Hamed Specialist trainee Data collection Mr R Shah Mr Dipen K Menon FRCS (Eng) Tr & Orth Member: BASK Consultant T&O Planned and guided study Performed all operations Acknowledgements: Anaesthetist: Dr A Sultan, FRCA, Consultant Anaesthetist Theatre Nurse: Mrs Sandra Roberts (Staff Nurse) COKS2017: Noosa, Queensland, Australia Sunday, 15/10/2017

TRANS-LATERAL ANATOMICal ACL RECONSTRUCTION Technique pioneered in the UK by Wilson et al (Basingstoke). Modifications to anatomical technique and instrument design Detailed technical description in Logan et al KSSTA 2012 & Wilson et al Arthros Tech 2013 Sockets prepared from inside-out, in the anatomical footprint of ACL. Single bundle ACLR using quadrupled ST COKS2017: Noosa, Queensland, Australia Sunday, 15/10/2017

Anatomical considerations Femoral and tibial ACL attachments Arthroscopic view of ACL femoral attachment COKS2017: Noosa, Queensland, Australia Sunday, 15/10/2017

Socket/ tunnel placement within the anatomical ACL footprint results in knee kinematics closer to the intact knee COKS2017: Noosa, Queensland, Australia Sunday, 15/10/2017

TRANS-LATERAL ANATOMICAL ACL RECONSTRUCTION: TECHNIQUE Supine, Knee flexed to 90 degrees (Side support & Foot-rest). Tourniquet EUA, Arthroscopy & Supplementary procedures (e.g.: Menisceal repair, Chondroplasty) Portals: Central Medial (viewing portal) & Central Lateral (working portal): lower and more central than standard portals Notch debridement: RF device (calibrated device available) COKS2017: Noosa, Queensland, Australia Sunday, 15/10/2017

patient positioning Side support and foot rest Knee in 90 degree flexion Adductor canal: Saphenous Nerve block COKS2017: Noosa, Queensland, Australia Sunday, 15/10/2017

portals Central medial Central lateral COKS2017: Noosa, Queensland, Australia Sunday, 15/10/2017

Graft preparation Graft harvest (Semitendinosus only): Length: 270mm Graft quadrupled. Secured with 2 Cortical adjustable suspensory fixation devices: usual length of prepared graft: 67-70mm Graft diameter measured Graft Pre-tensioned. Compressed: in graft sizer Prepared graft on graft work-station: Tensioned COKS2017: Noosa, Queensland, Australia Sunday, 15/10/2017

sockets Socket preparation using a flip-cutter (mid- bundle position, drilled from inside-out) Femoral socket depth: 20mm Tibial socket depth: 30-35mm COKS2017: Noosa, Queensland, Australia Sunday, 15/10/2017

Femoral & tibial sockets Femoral socket with fibre stick within Tibial socket with flip-cutter within COKS2017: Noosa, Queensland, Australia Sunday, 15/10/2017

TRANS-LATERAL ANATOMICAL ACL RECOnSTRUCTION: TECHNIQUE Graft remnant debrided to allow smooth passage of prepared graft Avoid soft-tissue bridge or intertwining in the lead sutures Pre-tensioned graft is fixed, by flipping the buttons of the device. Winched into each prepared socket by reciprocal toggling of the sutures of the 2 Cortical adjustable suspensory fixation devices (Femoral side first) COKS2017: Noosa, Queensland, Australia Sunday, 15/10/2017

Graft Graft with knee in 90 degree Graft: femoral attachment flexion COKS2017: Noosa, Queensland, Australia Sunday, 15/10/2017

Graft fixation Tensioning of graft with knee in almost full extension in reverse-Lachman position Repeated cycling and re-tensioning possible COKS2017: Noosa, Queensland, Australia Sunday, 15/10/2017

fully tensioned graft COKS2017: Noosa, Queensland, Australia Sunday, 15/10/2017

EARLY results 43 consecutive patients had Trans-lateral, All-inside, Anatomical, Single bundle ACL reconstruction (2013-2015). Prospective data collection Males: 39 Females: 4 1 non-surgical mortality: prior to 1 year FU Minimum 1 year Follow-up Mean Age: 27.05yrs (Range: 16-49yrs) Tegner-Lysholm score Mean (Range) Pre-operative 68.5 (29-95) Post-operative 90 (38-100) COKS2017: Noosa, Queensland, Australia Sunday, 15/10/2017

LYSHOLM SCORE COKS2017: Noosa, Queensland, Australia Sunday, 15/10/2017

RADIOLOGICAL RESULTS AP and Lateral x-rays Femoral socket: Bernhard & Hertel grid, Am J Knee Surg,1997 All femoral sockets in our study measured to be in the accurate position described by Columbet et al, Arthroscopy, 2006 Tibial socket: Amis-Jakob line, Knee Surg Sports Traumatol Arthros, 1998: Recommended position of the centre of socket on the line: (41-44%) Tibial socket position ranged from 32-47% in our study (Mean: 41.8%) COKS2017: Noosa, Queensland, Australia Sunday, 15/10/2017

RADIOLOGICAL ASSESSMENT 40.2% ACL centre 27% along Blumensaat’s line & 34% of the height of the intercondylar notch Bernhard-Hertel grid Amis-Jakob line COKS2017: Noosa, Queensland, Australia Sunday, 15/10/2017

immediate post-operative X-rays COKS2017: Noosa, Queensland, Australia Sunday, 15/10/2017

X-RAYS: 1 YEAR POST-SURGERY COKS2017: Noosa, Queensland, Australia Sunday, 15/10/2017

Socket position on MRI SCANS COKS2017: Noosa, Queensland, Australia Sunday, 15/10/2017

complications No cases of posterior wall blow-out No graft ruptures No infections 1 intra-operative complication: button deployed in error in the pilot hole on the femoral side and needed supplementary fixation with a staple. Good clinical outcome at 1 year No hardware failure COKS2017: Noosa, Queensland, Australia Sunday, 15/10/2017

Advantages of Trans-Lateral, Anatomical acl reconstruction Sockets: Bone conserving compared to tunnels Post-operative pain scores are better, 2 RCTs (Lubowitz et al, Arthroscopy 2013, Benea et al, Knee 2014) Femoral socket drilled from inside-out (Accurate, Flexible, Excellent view from medial portal). Medial portal drilling: technically more demanding (Lubowitz, Arthroscopy 2009) COKS2017: Noosa, Queensland, Australia Sunday, 15/10/2017

Advantages of Trans-Lateral, Anatomical acl reconstruction Socket positions reproducible Single hamstring tendon harvest: preserves hamstring strength (Yosmaoglu et al, KSSTA 2011) (Gracilis available as graft or secondary stabiliser) Quadrupled ST thicker than conventional ST- Gracilis combination Adjustable loop fixation equivalent to fixed loop constructs clinically COKS2017: Noosa, Queensland, Australia Sunday, 15/10/2017

CONCLUSION The early results of this technique are encouraging In this series we were able to reproduce the results of the Basingstoke group (Yasen et al, 2017) COKS2017: Noosa, Queensland, Australia Sunday, 15/10/2017

Thank-you COKS2017: Noosa, Queensland, Australia Sunday, 15/10/2017