3/13/2018. Common Options. ACL Graft Selection in When my Cojones Are On the Line - What I Do in ACL Reconstruction

Transcription

1 ACL Graft Selection in 2018 James P Bradley, MD Clinical Professor UPMC Head Team Physician Pittsburgh Steelers Consultant Miami Marlins Michael S Nickoli, MD University of Pittsburgh Sports Fellow When my Cojones Are On the Line - What I Do in ACL Reconstruction Allograft BTB Hamstring Achilles Common Options Autograft BTB Hamstring Quadriceps 1

2 Clinical Experience 30 yrs 27 yrs as NFL team physician Average ACL recons/yr 70% BTB autograft 15% HS Auto (graft link) 10% Achilles Allo (NR) < 5% quads auto My BTB auto overall (all comers) failure rate < 4% 55 ACLs in NFL all BTB +/- MCL repair +/- internal brace My Preference BTB Autograft (IF screw fixation) In the right place Why BTB autograft? 1. East to harvest 2. Multiple fixation options 3. Reliable & predictable graft size & RTP 4. Autologous bone to bone healing for each tunnel 5. No risk of disease transmission 6. Ultimate tensile strength & stiffness > native ACL 7. Proven outcomes in the literature: Knee stability Low re-rupture RTS predictable Fewer revisions Gold standard in the NFL 2

3 NFL primary ACL graft choice 2013 D Cooper Ipsilateral BTB Autograft: 27 (82%) 86% 2010 jpb Ipsilateral 4 strand HS: 4 (12%) Achilles Allograft: 2 (6%) Level IV Survey of 267 NFL & NCAA Division I orthopaedic team physicians 51% response rate Years experience = 16.75yrs Graft preference: Autograft = 99.3% BTB = 86% Double-bundle = 1 surgeon RTP 55.8% at 6 mos Arthroscopy, 2014 Level IV Survey of 94 orthopaedic team physicians in NHL, MLS, & FIS (World Cup ski/snowboard) Graft preference: Autograft = 89.4% BTB = 70.2%, HS = 14.9%, quad = 4.3% Single bundle = 100% Am J Orthop,

4 AUTOGRAFT VS. ALLOGRAFT Not even close especially in young athletes Cohort study of US Military Academy registry ( ) Primary ACLR prior to service included 122 ACL reviewed (120 cadets) Mean: 1.49 year f/u from entry to academy 50% BTB auto, 36.9% HS auto, 13.1% allo 1.64% cumulative failure rate AJSM 2013 Level II Allograft has higher failure rate: vs. BTB, HS AUTO Cadets who enter the USMA with an allograft ACL are 7.7x more likely to re-rupture than BTB auto group AJSM 2013 Level II Meta-Analysis: 76 studies Primary ACL reconstructions included: BTB auto vs BTB allo 5182 ACLs reviewed ( ) Graft re-rupture rate, return to pre-injury level IKDC, Lysholm, Tegner activity level, Cincinnati Knee Rating System Pivot shift, single-legged hop test, KT-1000 BTB auto did better: vs BTB Allo Higher IKDC, Lysholm, Tegner, single-legged hop, KT Allo BTB had 3x re-rupture rate vs auto BTB 4

5 Level II Revisions 83 surgeons (52 sites), 1205 pts Collected demographics, surgical technique, pt reported outcomes 2 year F/U Revision statistics: Average 3.4 years since primary Autograft was better: In revision ACLs Higher IKDC, KOOS sports & recreation, Marx activity level scores Fewer re-ruptures (2.78x less likely than allograft) BTB VS HS AUTO PRCT 68 pts: 34 BTB & 34 HS auto ACL recons BTB showed improved 2 years: Anterior knee laxity: 1.5mm vs 2.5mm (p<.05) Less rotational laxity Higher return to sport (p<.01) HS had NOT reached baseline HS torque Proven Outcomes BTB vs HS Higher RTS Improved Knee Stability Improved Muscular Strength 5

6 298 competitive athletes 4 yr f/u after ACL BTB vs HS auto Re-injury rates: BTB 6.1% vs HS 12.7% Soccer had highest re-injury rate = 20.8% RTS <7 months postop = 15.3% re-injury (13.9% BTB vs 16.6% HS) RTS >7 months postop = 5.2% re-injury (2.6% BTB vs 7.6% HS) Proven Outcomes: BTB better vs. HS Lower Re-Rupture Rate in a Young, Active Population Higher RTS Cohort study of Scandinavian ACL registry ( ) Primary ACL reconstructions included 45,998 ACL reviewed Mean: 3 year f/u 14.6% BTB auto, 84.1% HS auto, 1.3% allo/repair 2.60% revision rate Level II BTB auto is better: vs. HS Fewer revisions compared to HS auto (hazard ratio=0.63) Lower risk of revision across all subgroups: age, gender, concomitant cartilage injury. A Systematic Summary of Systematic Reviews on the Topic of the ACL Michael J. Anderson, MD, * William M. Browning, III, DO, MS, * Christopher E. Urband, MD, * Melissa A. Kluczynski, MS, * & Leslie J. Bisson, * Pts with patella tendon grafts were more likely to RT preinjury level of competition.t BPTB Autograft Versus HT Autograft Numerous studies compared BPTB auto vs HT auto & have found that BPTB is associated with greater improvement in stability compared with HT auto; however, there is no difference in clinical knee scores & rate of failure. 6

7 Bone Patellar Tendon Bone Vs Hamstring Tendon Autografts for Primary ACL Reconstruction A Systematic Review of Overlapping Meta-analyses Hayden B. Schuette,* BS, Matthew J. Kraeutler, MD, Darby A. Houck,* BA, and Eric C. McCarty,* MD Investigation performed at the CU Sports Medicine and Performance Center, University of Colorado School of Medicine, Department of Orthopedics, Boulder, Colorado, USA 2017 The current best evidence suggests BPTB auto provides superior static knee stability there are fewer postop complications with HS autografts. The effects of hamstring harvesting on outcomes in anterior cruciate ligamentreconstructed patients: a comparative study between hamstring-harvested and - unharvested patients. Kim JG 1, Yang SJ, Lee YS, Shim JC, Ra HJ, Choi JY. HS weakness These results indicate significant knee flexion weakness compared with the unaffected knee after ACL reconstruction Registry Studies Study Dates Patient Demographics Results Gifstad Scandinavia Rahr-Wagner Denmark Andernord Sweden Maletis Kaiser , % BTB vs 84.1% HS 3yr follow-up 13, % BTB vs 85.6% HS 3yr follow-up 13,102 10% BTB vs 90% HS 2yr follow-up 17, % BTB, 32% HS, 42.7% allograft 2.4yr follow-up Lower revision rate in BTB (2.8%) vs HS (4.2%; p<0.001) Lower hazard ratio for revision in PTB (0.63) Lower revision rate in BTB vs HS 0.16% vs 0.65% (1yr) and 3.03% vs 4.45% (5yr) No difference in revision rate between groups 1.20% BTB vs 1.65% HS (p=0.214) Lower risk of revision in BTB (0.74) vs HS (1.07) vs allograft (1.26) per 100 yrs observation 7

8 SINGLE VS DOUBLE BUNDLE QUAD TENDON AUTO Has potential! Quad Tendon Auto No loss of flexion strength vs HS Less kneeling pain, graft site pain, sensitivity (RCT) Lund et al, Arthroscopy 2014 Similar clinical outcome Xerogeanes, Arthroscopy 2015 Increased cross section area vs BTB Shani et al, Arthroscopy

9 Quad Tendon Disadvantages Rectus femoris retraction with too proximal harvest Bleeding Fluid extravasation during arthroscopy Risk of fracture with bone block Initial rehab more difficult Systematic Review of 14 studies with 1,154 pts with quad ACL No differences Stability (Lachman, KT, pivot) Functional outcomes (IDKC, Lysholm) ROM Similar complication rate, less donor site pain Conclusions BTB autograft Wins Impressive track record in all levels athletes Autograft heals quicker Bone to bone healing predictable Predictable timetable for rehab Improved knee stability in multiple studies Excellent RTS Ant knee pain, kneeling pain, risk of patellar fx, all decreased with Osferion plugs Decreased revisions 9

10 PAY ATTENTION TO WHAT THE ORTHOPAEDIC SURGEON DOES FOR THE ATHLETE ON HIS/HER TEAM AS THEY KNOW THE RESULTS, GOOD OR BAD, IT WILL BE WITH THEM ON A DAILY BASIS ( and in the newspaper jpb) - John Bergfeld 1975 Thank You City of Champions 10