T.Buchhorn G.Ebner H.J.Eichhorn P.Angele J.Ludwig M. Strobel A.

Schtz

H.Fett C.Tibescu

10 Years Experience with the Double Bundle Reconstruction

Dr.med. Jrgen Eichhorn
technical support H.Hoffmann

mentors

Werner Mller

(the knee, 1982)

Thomas Rosenberg

(whirlpool
discussion, 1995)

mentors

double bundle

3 tunnels

basics

Savio Woo, Andrew Amis and navigation proves better kinematics via double bundle

statistics
Double bundle reconstructions in Straubing

1996 106 1997 187 1998 218 1999 246 2000 267 2001 291

2002 342 2003 381 2004 455 2005 472 2006 469

statistics
Double bundle reconstructions in Straubing

n=3434

principles

92 % STT only
we try to leave the gracilis in function proven better internal rotation proprioceptive function

development steps

single bundle

2 tunnels

double bundle
double bundle

3 tunnels
4 tunnels

1 tibia 2 femur

double bundle
double bundle

4 tunnels
4 tunnels

replacing the AM or PL bundle in partial ruptures

with additional aperture fixation

double bundle navigated

4 tunnels

principles

inappropriate graft length

Triple-technique

- thick tendon

- weack tendon + gracilis

single bundle

2 tunnels

Quad Semi-T

! open physes
long, transepiphysial graft required
(no need for periosteum)

(triple-technique)

development steps

single bundle

2 tunnels

double bundle
double bundle

3 tunnels
4 tunnels

1 tibia 2 femur

double bundle
double bundle
with additional apertur fixation

4 tunnels
4 tunnels

replacing the AM or PL bundle in partial ruptures

double bundle navigated

4 tunnels

double bundle

3 tunnels

Quad Semi-T triple channel

development steps

single bundle

2 tunnels

double bundle
double bundle

3 tunnels
4 tunnels

1 tibia 2 femur

double bundle
double bundle

4 tunnels
4 tunnels

replacing the AM or PL bundle in partial ruptures

with additional aperture fixation

double bundle navigated

4 tunnels

double bundle

4 tunnels

advantages 4 Channels compared with 3 - Channels

more contact between bone and tendon better individual tensioning of each bundle higher reduction of the internal and external tibial rotation

double bundle

3 tunnels

Inappropriate graft length

additional harvesting of gracilis implanting: 4 - Channel technique

semitendinosus = triple or quadruple gracilis = triple

double bundle

3 tunnels

Graft can be adapted to the patients needs

instruments
Aesculap

position
instruments
for double bundle reconstruction since

1998

instruments

instruments

double bundle

4 tunnels

double bundle

4 tunnels

double bundle

4 tunnels

double bundle

4 tunnels

double bundle

4 tunnels

double bundle

4 tunnels

double bundle

4 tunnels

double bundle

4 tunnels

double bundle

4 tunnels

double bundle

4 tunnels

instruments

instruments

the principle of the disk-twister

instruments

double bundle

4 tunnels

45

double bundle

4 tunnels

10

double bundle

4 tunnels

Bungee and windshield wiper effect protection

pressfit placement
tunnel drilling in 0.5mm steps

preconditioning of the graft

double bundle with stress sharing final tensioning with the twister

double bundle

4 tunnels

Advantages 4 Channel technique

anatomic reconstruction
-reconstruction of the anteromedial and posterolateral bundle -reconstruction of the femoral and tibial foot prints

better femoral fixation better stabilisation in higher degrees of flexion and in the frontal plane contact between bone and STT doubled

development steps

single bundle

2 tunnels

double bundle
double bundle

3 tunnels
4 tunnels

1 tibia 2 femur

double bundle
double bundle

4 tunnels
4 tunnels

replacing the AM or PL bundle in partial ruptures

with additional aperture fixation

double bundle navigated

4 tunnels

infrastructure

Semitendinosus graft procedure

archieves excellent results...

... but

...staff and skill demanding !!!

TCP

PL
TCP AM

TCP

TCP

TCP

TCP
tibial
femoral

TCP

infrastructure

Extra security for intermediate skills

development steps

single bundle

2 tunnels

double bundle
double bundle

3 tunnels
4 tunnels

1 tibia 2 femur

double bundle
double bundle

4 tunnels
4 tunnels

replacing the AM or PL bundle in partial ruptures

with additional aperture fixation

double bundle navigated

4 tunnels

anatomic situation
PCL AM AM PL?

AM

AM

treatment strategy

AM
K-WIRE AM

AM PASSING SUTURE AM

PL

clinics

AM-bundle PL-bundle intact intact

KT 1000 < 3mm KT 1000 > 4mm pos. pivot shift neg. pivot shift

development steps

single bundle

2 tunnels

double bundle
double bundle

3 tunnels
4 tunnels

1 tibia 2 femur

double bundle
double bundle

4 tunnels
4 tunnels

replacing the AM or PL bundle in partial ruptures

with additional aperture fixation

double bundle navigated

4 tunnels

double bundle navigated

double bundle navigated

double bundle navigated

double bundle navigated

navigation avoids extensive notch debridement aiming without direct vision

navigated stability-test

benefit documentation of double bundle (AM, PL) reconstruction

navigated stability-test

internal rotation 20
reduction via single bundle 6 (+/- 2,4) app 30%

reduction via double bundle 14 (+/- 3,1) app 70%

navigated stability-test
IR

navigated stability-test

external rotation 14
reduction via single bundle 3 (+/- 1,2) app 20%

reduction via double bundle 8 (+/- 1,4) app 57%

navigated stability-test
ER

Navigated double bundle

actual status
Navigated anteromedial bundle

Posterolateral bundle in relationship to the anteromedial

Navigated double bundle

Future perspective
Individual navigation process for each tunnel

results

8-Year Quad Semi-t Results

Double-bundle vs. Single-bundle

8 years quad semi-t results 4 groups

Single channel:

isolated ACL

48
63

2 ACL + associated lesions

8 years quad semi-t results 4 groups

Double channel:

isolated ACL

71
82

4 ACL associated lesions

time 03. 96 - 11. 96 1 surgeon

8 years quad semi-t results associated lesions II MCL

II PLRI
III - IV cartilage lesion loss of meniscus

8 years quad semi-t results group

1 year

(1 channel- ACL + assoc. lesion.)

0 -2

10 -1

15 17 0 1

14 2

2 3

3 4

1 5

1 >5

89%

8 years quad semi-t results group

8 years

(1 channel- ACL + assoc. lesion.)

0 -2

8 -1

14 16 0 1

14 2

3 3

4 4

2 5

2 >5

83%

8 years quad semi-t results group

1 year

(2 channel + assoc. lesions)

2 -2

19 18 27 -1 0 1

9 2

2 3

1 4

2 5

1 >5

91%

8 years quad semi-t results group

8 years

(2 channel + assoc. lesions)

2 -2

18 19 -1 0

27 10 1 2

2 3

2 4

2 5 >5

90%

The race for quality has no finish line !!!

Thank You for Your Attention !