Chronic Clicking and Locking: Anterior Horn Tear CAPT Matthew T. - PowerPoint PPT Presentation

Chronic Clicking and Locking: Anterior Horn Tear CAPT Matthew T. Provencher, MD, MC USNR Shoulder, Knee and Sports Surgery The Steadman Clinic & Steadman Philippon Research Institute Chairman, Vail Health IRB Professor of Surgery, USUHS

Disclosures • Royalties - Arthrex • Stock - None • Consultant - Arthrex; JRF • Research Support - AOSSM Grant (2005); AANA Research Grant (2008; 2006); OREF Grants (2002; 2004); BUMED (2009; 2012; 2014) • Editorial Boards - Elsevier (Arthroscopy - Asst. Editor in Chief; JSES), JBJS, JAAOS, SLACK (Orthopaedics, JKS), Sage (AJSM) • Board Memberships - AOSSM (Board of Directors, Research); SOMOS (Past Pres.); AAOS (Program; Annual Meeting); BOS/BOC (Research); ISAKOS (UE); AANA (Program/Education); ASES (Program; Membership; Technology)

Case • 17-Year-Old with Chronic Clicking and Locking

Lateral Meniscal Root Anatomy 2014 • Anterior lateral distance from center of ACL - 5.0 mm posteromedial • Anterior lateral distance from apex of lateral tibial eminence - 14.4 mm posterolateral • AL root attachment - mean area of 140.7 mm 2 - Inserted deeply beneath the ACL in all specimens. Overlap of the ACL on the AL root averaged 88.9 mm 2 , 63.2%

Lateral Meniscal Root Anatomy 2014 • Anterior medial distances from apex of tibial tuberosity - 27.0 mm lateral - 27.0 mm distal • anterior medial distance from apex of medial tibial eminence - 27.5 mm posterior • AM root attachment - mean area of 110.4 mm 2 - central attachment 56.3 mm 2

ACL Tibial Tunnel Reaming 2014 • Anterior lateral (AL) meniscal root overlaps with ACL footprint • Tibial tunnel reaming of ACL tunnel decreases AL root attachment area and ultimate failure strength ✴ Laterally placed ACL tibial tunnels should be avoided

2016 • Safranin O-stained coronal sections to access type I vs. II collagen signal distribution and density Type II collagen density of the LMAI was higher than that of the ACL tibial insertion and ACL-LM transition zone

2017 • Mean % of ACL ALMR: - coronal plane, 41.0% - sagittal, 53.9% • % of insertion overlap significantly higher in sagittal plane ACL ALMR

Often Iatrogenic - How does it present clinically? 2016 ruptured ACL remnant LMAI

Often Iatrogenic - How does it present clinically? 2016 ACL remnant edge bridging ACL tissue remnant footprint

Often Iatrogenic - How does it present clinically? 2016 Distance between grafts and medial intercondylar ridge Bundle guide pins Lateral shift of the tendon grafts

Often Iatrogenic - How does it present clinically? 2016 Post-op

Often Iatrogenic - How does it present clinically? 2016 Post-op tendon graft tendon graft proximal shift of the LMAI

Often Iatrogenic - How does it present clinically? 2016 Post-op tendon graft tendon graft proximal shift of the LMAI proximal shift of the LMAI

Anterior Horn LM Repair Technique

Prepare - Cannula Insert - Sutures

Anterior Horn LM Repair Technique

Double Row Repair of Root

Showing ACL Location to Avoid

Thank You!