ACL Reconstruction: What is the Role of Sex and Sport in Graft Choice?

Transcription

1 ACL Reconstruction: What is the Role of Sex and Sport in Graft Choice? Jo A. Hannafin, M.D., Ph.D. Professor of Orthopaedic Surgery, Weill Cornell Medical College Attending Orthopaedic Surgeon and Senior Scientist Hospital for Special Surgery Team Physician WNBA NY Liberty Head Team Physician US Rowing Epidemiology of Injury in High School Athletes A Multisport Epidemiologic Comparison of Anterior Cruciate Ligament Injuries in High School Athletics (Joseph et al, J Athletic Training, 2013) ACL injury studied in 100 high schools Injury rate per 100,000 athletic exposures: Competition (17.6) > practice (2.4) ACL accounted for 20.5% of all knee injuries Girls (7.2) and boys (6.2) had similar ACL rate In sex comparable sports: girls 8.9x higher rate Boys injured the ACL in football > soccer > basketball Girls injuries were most common in soccer > basketball > softball Highest rates in Girls soccer (12.2/100,000 AE) Boys football (11.1/100,000 AE) Girls basketball (10.3/100,000 AE) High incidence of ACL injury in football and the number of boys playing the sport reinforces the need for study of ACL injury and prevention in both sexes Epidemiology of Injury Young Adult Collegiate basketball and soccer Arendt and Dick, AJSM, 1995 NCAA Injury Surveillance System ( ) Females had increased rate of ACL injury Soccer: 0.31 versus 0.13 Basketball: 0.26 versus 0.07 Collegiate basketball and soccer (Agel et al, AJSM, 2005) NCAA Injury Surveillance System ( ) Soccer Athletes sustain more ACL injuries More non-contact injury Females: increased rates on non-contact ACL Males: injury rates have decreased Basketball: No sex difference in contact versus non-contact ACL Rates of injury remained constant in basketball Injury rates continue to be higher in females 1

2 Sex Differences: Knee Risk factors associated with revision and contralateral ACL reconstruction Kaiser Registry (Maletis, AJSM, 2015) 17,436 ACL reconstructions Male sex is associated with increased risk of revision Female sex is associated with increased risk of contralateral ACL Swedish National Register (Andernord, AJSM, 2015) 9,061 primary ACL reconstructions Female sex and contralateral HS harvest 3x increased risk of contralateral ACL injury Sex Difference: Knee Incidence of ACL Reconstruction in Adults (Collins et al, AJSM 2013) Cohort study, 2307 patients ( ) 3 year incidence of reconstruction = 22.6% Females were less likely to undergo reconstruction with increasing age ACL Reconstruction: Do Outcomes Differ by Sex? (Ryan et al, JBJS, 2014) Systematic review of 13 studies 146 studies eliminated because outcomes were not reported by sex Meta-analysis revealed No sex difference in graft failure risk (n= 8) No difference in contralateral ACL risk (n= 3) No sex difference in post-operative knee laxity on clinical exam (n=6) Collins et al., AJSM, 2013 Goals Stable post-operative knee Smooth post-operative course Minimize perioperative morbidity Customize graft choice based on: Patient age Patient sex Skeletal maturity Goals for return to sport and type of sport Goals for return to work Size of available grafts: MRI now permits pre-operative assessment of patellar tendon and hamstring grafts 2

3 Role of Imaging in Determination of Graft Choice Anterior cruciate ligament reconstruction with autologous hamstring: Can preoperative magnetic resonance imaging accurately predict graft diameter? Grawe et al OJSM, mm x 3.5 mm central 1/3 graft size = 28 sq mm 26.1 x 4.7 mm Central 1/3 graft size = 42 sq mm 4.8 mm x 2.7 mm 4.2 mm x 3.1 mm 4 fold = 52 mm2 6 fold = 78 mm 2 7 JH1 Graft Options Autograft BTB or Quad tendon Autograft ST/GR Allograft PRO Strong graft Predictable size Uniform tensioning Bone-bone fixation Strong graft Decreased risk of patellar tendon pain Less donor site morbidity Customize graft size No donor site morbidity Multiple graft options CON Anterior knee pain Larger incision Tendon and fat pad scar Residual quad weakness Variability in tendon size Requires uniform tensioning Residual HS weakness Bone-soft tissue fixation Disease transmission Increased risk of graft failure in younger patients Slower graft incorporation BTB or Quad Tendon Graft High school or collegiate athlete Soccer, basketball, football, lacrosse, field hockey No history of patellofemoral or extensor mechanism complaints Normal PF cartilage on MRI No significant patellar tendinosis on MRI Ligamentous laxity Quad tendon is used for revisions if inadequate HS, not a primary graft choice 3

4 Slide 8 JH1 Jo Hannafin, 4/22/2014

5 Hamstring Graft High school, collegiate, or post-collegiate athletes Skeletally immature Appropriate size of HS History of anterior knee pain Abnormal PF cartilage or patellar tendon on MRI Occupational concerns Patients over age 40 who do not want allograft Not indicated in athletes with ligamentous laxity My indications have expanded with changes in fixation techniques and ability to reproducibly measure hamstring size Allograft Multiple choices BTB allograft is my graft of choice Patients > 40 yrs Revision surgery if autograft is not an option Multi-ligament knee injury Concerns Bone loss in tunnels surrounding soft tissue allograft significantly impacts revision Delayed graft incorporation Take Home Points Be comfortable using multiple graft types Measure potential grafts on MRI, these data are predictable and reproducible Use fixation techniques to optimize uniform tension across graft bundles if using hamstring Customize graft based on Sports demands History of extensor mechanism issues Size of available autogenous grafts Sports specific demands 12 4

6 Thank you 5