ACL update Brian McKeon MD BSSC Chief Medical Officer Boston Celtics Assistant Clinical Prof TUSM

Transcription

1 ACL update 2013 Brian McKeon MD BSSC Chief Medical Officer Boston Celtics Assistant Clinical Prof TUSM

2 Levels of evidence in ACLR research Samuelsson et al ASJM, ,154 studies 1,510 included with clinical outcome Case series 32.7% Expert opinion 29.1% RCTs 9.2% Prospective comparative 7.6% Case Control, Systematic review, Meta-analysis Level 1 6.2%

3 General Injury stats school yr, 7.6 mill HS sports (nat fed of HS assoc) 30-40,000 young athletes same time (nat council on youth sports) 2 mill inj HS/yr (Powell, J ath train, 1999) CDC mill inj in ER

4 ACL stats Females 2 to 8x increase (soccer and bball) (hewett, AJSM 2006) (Zazulak, AJSM 2007) 67% noncontact 38,000 ACL tears in women 650 million dollars HS and college CHOPPS 2012: 400% increase in ACL tears from

5 ACL Prevention Females land and cut diff than males (landry AJSM 2007) Trained females 3.6x lower than untrained, untrained female 5x higher incidence than untrained males (hewett,asjm 1999) 74% decr in ACL injury with neuromuscular training compared to control group (Mandelbaum, AJSM 2005) Jumping, landing strategies and weak hips

6 incidence 200,000 tears (AAOS, july 2007) Failure rate 10-25% Technical problems Femoral vs tibial tunnel position revisions

7 ACL prevent arthrosis? Acute ACL recon with mensicus preservation lowest incidence of OA Return to high level activity with unstable knee?- 95% meniscus/ac damage over 20 yrs (Nebelung, Arthroscopy, 2005) Lohmander (Arth Rheum,2004) and Von Porat (Ann Rheum Ds, 2004) no prevention

8 Trauma to menisci with torn ACL

9 ACL prevent arthrosis Oiestad, AJSM 2009; Review Murray, AJSM 2012

10 Single vs double bundle Markoff, JBJS Cadaver biomech study Single bundle similar graft forces, laxities, and tibial rottaions more closer to normal!! High Forces in posterolat graft! Song, AJSM 2013 Sim clinical outcome 4 yr follow up, 130 patients Siebold, Arthro 2008 Prosp

11 Double bundle Van Eck, Arthroscopy, ; 206 ACLs (168 double/38 single) 9 month min f/u 8.6 month RTP 13 %DB failed and 11% SB failed

12 Computer assisted? 100 pts prospective(mueffels, JBJS 2012) Brainlab, Germany 3D CT tunnel eval (prior 3 randomized trials used radiographs) 26.7 min incr op time Equipment costs Radiation NO difference in accuracy or precision

13 Transtibial vs AM portal tech in single bundle ACL Wang et al, 2013 Outcomes of knee kinematics during walking AM assoc with loss of extension in the late stance phase AM better restored AP translation during swing phase

14 Allograft Smith ajsm, No sig slippage/no incr 1 yr Shybut, Hosp Jt Ds Bull, 2013 Recommend against tib ant allo Only 19 patients. 2 failures, 37% fair/poor result

15 Hams-Autograft Leiter, 2013 Knee Sports Trauma, Long term f/u ACL with ham autograft Restrospective case series, 75 % near normal IKDC at 15 yrs Med men surgery strong predictor OA 9% failure (5% contralat ACL)

16 BTB- autograft Ahn. Arthr 2012, Long Term ACL using BTB: analysis of factors affecting dveplmnt of OA 117 pts with 10.3 yr f/u; IKDC mean 90.6 Walking hard ground pain 38.4% Skin numbness 37.6% OA 30.7 medial compt. Sag femoral tunnel positon Med men tear

17 Auto vs allo Meta-analysis auto vs allo. Tibor et al, Sport Health studies after 1990 Age less than 41 Allo more lax only conclusion Auto vs nonirradiated Allo ACL- systematic review. Mariscalco, et al studies ( 6 BPTB allo vs auto; 3 hams allo vs auto; 1 tib ant allo vs hams auto) No diff in any outcome measure!! Age range 24.5 to 32 yrs!

18 Bone Bruise Hanypsiak, AJSM 2008 Twelve yr follow up ACLR: long term outcomes of prospectively studied osseous and articular inj All Bone brusies healed at f/u IKDC same for BB and non BB pts AC abnormality on MRI did not influence IKDC Theologis Arhtrosco 2009,. Eval of Bone Bruises and Assoc Cart in ACL injured and reconstructed knees using Quantitative MRI. 1 yr cohort study 9 patients 50% BB resolved at 1 year Cartilage macromulecular evaluation demonstrates damage to the matrix even with BB resolution Dunn AJSM 2010, Which preop factors, Incl Bone Bruise, are assoc with pain/sxs at index ACLR? MOON group BB assoc with younger age and not jumping at time of injury Not assoc with pain

19 Revision ACL Pascual-Garrido, 2013 Knee surg sports Trauma Arthro Rev acl with allograft <40 yrs 85% g/e result 2 to 4 yrs Retrospective level IV Wasserstein, 2013 AJSM Risk factors for recurrent ACLR Popln study Canada, 5 yr f/u, cohort study level 3 12,967 ACLR, 15 to 60 yrs Contralat ACLR 4.6% ACL revision 2.6%

20 Return to play Brody, AJSM RTP and future ACL injury risk after ACLR in soccer:moon 72% of 100 RT soccer mean age 24.2 yrs 7yrs 36% playing Athletes who had ACL non-dominant limb had higher future rate of contralateral ACL 16% vs 3.5% who had dominant ACLR Females more likley to have future ACLR 20% vs 5.5% males

21 RTP Arderm, Br J sports Med RTP after ACLR; sytematic review 48 studies, , 5770 pts 82% returned to some kind of sport 63% preinjury 44% competitive sport at f/u Impairment based function laxity, strength, IKDC 85% g/e!!

22 Stem cells/prp

23 McKeon years and older allograft 14 to 25yo Hamstring auto with allo augmentation Hams alone if solid 9 mm graft, rare in my experience Revision Typically allograft Will do auto hams/allo if allo used as primary

24 technique Informed Consent EUA High tourniquet Hams harvest 1 st Prep, generous notchplasty, native torn preservation Transtibial Button femur, PEEK tibia

25 Informed Consent All inclusive Always consent for allograft Graft augmentation Is a 7.5 mm graft adequate? Supplement for failure of adequate graft harvest

26 Evaluate Notch EUA

27 EUA Residents Ridge

28 Notchplasty

29 High tourniquet

30 Hamstring Harvest Follow path of anatomy

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32 Summary Know the anatomy Graft your comfortable with and that works for you Know how to do all (central quad tendon?) Setting patient (family ect..) expectations immediately RTP success not a guarantee- even with good MRI and functional scores 18 month active recovery