Jonathan T. Bravman, MD

Transcription

1 Jonathan T. Bravman, MD Assistant Professor Director of Sports Medicine Research Division of Sports Medicine and Shoulder Surgery Department of Orthopedics University of Colorado Team Physician for CU Buffaloes and DU Pioneers

2 Smith&Nephew Consultant Stryker, Depuy/Mitek, Biomet, Smith&Nephew Fellowship support Stryker, Synthes Research support

3 Primary repair Healing response Synthetic Grafts Extra-articular reconstruction Iliotibial Band

4 Primary Repair Historical, anecdotal technique New technologies with graft augmentation Primarily in animal models MMurray, BFleming et al. AJSM 2013 Demonstrated improved healing in Yucatan mini-pig model Seitz, Pichi, et al. Intl Orthop 2013 Improved biomechanical properties in sheep model

5 Synthetic Grafts Carbon fiber grafts Gore-tex grafts Bioinductive grafts- LK graft LARS graft All associated with high failure rates Some with catastrophic and systemic sequelae

6 Extra-articular reconstruction Pediatric Population

7 Intra-articular reconstruction Bone-patellar tendon-bone (BPTB) Ipsilateral or contralateral Doubled or quadrupled hamstring tendon (HT) Semitendinosis, gracilis Allografts Multiple choices available

8 Intra-articular Reconstruction Quadriceps tendon Ipsilateral vs contralateral

9 Other Grafts Directed donor Goddard, Bowman, et al. AJSM children, avg 13 yrs ACL recon using HT from a parent, mean graft size 7.2mm Min 2 yr f/u subjective IKDC 97, 93% returned to preinjury activity, 97% of parents would donate again

10 Bone patellar tendon bone autograft Central 1/3 patellar tendon with bone plug at each end

11 Bone patellar tendon bone autograft Pros Gold Standard High strength and stiffness Bone to bone healing Interference screw (aperture) fixation

12 Bone patellar tendon bone autograft Cons Kneeling pain Risk for patellar fracture Patella baja (scarring) Concerns about damage to the extensor mechanism

13 Bone patellar tendon bone autograft Contralateral autograft Less damage to ipsilateral knee May result in symmetric knee disability

14 Hamstring autograft Semitendinosis/Gracilis quadrupled Has become more widely used secondary to to BPTB morbidity

15 Hamstring autograft Pros Biomechanically superior graft (may be related to increased collagen) Decreased donor site morbidity?anterior knee vs kneeling pain

16 Hamstring autograft Cons Tendon to bone healing Size limitations Inferior fixation techniques (?improving) Decreased flexion strength Increased laxity

17 Multiple options for graft choice include Anterior/posterior tibialis tendon Peroneal tendon BPTB Hamstring tendon Quadriceps tendon Achilles tendon

18 Graft choice may depend on Graft availability Cost Fixation technique Surgeon preference

19 Pros No donor site morbidity Decreased OR time Variability in graft sizes/greater choice available

20 Cons Risk of disease transmission/infection Cost Graft preparation/sterilization techniques?slower incorporation/age of donor Lack of long-term outcome data Increased risk of graft failure Especially in younger patients

21 Autografts Multiple studies comparing BPTB to Quadrupled hamstring grafts Weaknesses Different techniques, fixation, assessment of results, follow-up periods

22 Comparing apples to apples (fixation techniques, outcomes assessment) Ejerhed et al. incr kneeling pain Shaieb et al. incr PF pain, decr ROM Beard et al. no difference Pinczewski et al. incr kneeling pain (nr) Corry et al. incr kneeling pain, incr laxity in HT in females (nr)

23 Comparing outcomes regardless of technique (BPTB to HT) Jansson et al. no sig difference Eriksson et al. no sig difference O Neill et al. sig diff in flexion (HT) & ext (BPTB), no sig functional difference Aune et al. incr kneeling pain, decr single-hop, incr flex strength, decr pt satisfaction Tashiro et al. incr flexion strength Feller et al. improved activity scores Mohammadi et al. no sig difference in hamstring torque, but improved functional testing triple-hop, crossover hop and jump landing in HT

24 Meta-analyses (comparing apples to horseshoes) Freedman et al. 1,976 pts BPTB Lower graft failure rate Less laxity Higher pt satisfaction Higher incidence of knee pain Yunes et al. 411 pts BPTB Less laxity Higher rate of return to pre-activity levels

25 Systematic Review Goldblatt et al. Inclusion criteria Identical rehab protocols Minimum 2yr F/U Subjective or objective data BPTB Normal Lachman, pivot shift, KT-1000 Greater flexion strength HT Decr PF crepitus Less extension loss Less kneeling pain

26 Systematic Review Goldblatt et al. No significant difference Instability/giving way Functional outcome scores (Lysholm, Tegner, IKDC) Graft rupture Return to pre-injury activity Need for further surgery Complications

27 Systematic Review Spindler et al. Inclusion Criteria Prospective RCT Minimum 2 yr F/U Slight increase in laxity for HT in 3/7 studies Increased kneeling pain for BPTB 4/4 studies

28 Systematic Review Spindler et al. No significant difference Graft failure (related to fixation type not graft type) Anterior knee pain Return to activity

29 Systematic Review Herrington et al. Inclusion criteria Randomized/quasi-randomized trials Outcome measures Activity recovery Pain Instability IKDC Complications/further surgery No significant difference in any category

30 Allografts Weaknesses Comparing different techniques for different types of allografts Relatively short-term data available Significantly more data available

31 Allografts Results Shelton et al. BPTB auto vs allo, no sig diff Harner et al. similar results but improved extension in allograft Victor et al. increased rupture rate & laxity in allografts Poehling et al. no difference Barrett et al. allograft offered faster return to activities, but increased laxity

32 Allografts Results Stringham et al. increased rupture rate Kleipool et al. no difference Peterson et al. no difference Chang et al. no difference

33 Allografts Meta-analysis of 5182 pt Kraeutler, Bravman, McCarty AJSM 2013 BPTB auto vs BPTB allo Allografts demonstrated a 3-fold increased risk of rerupture Subjective IKDC, Tegner, Lysholm scores, single-leg hop test, KT favored autografts Return to preinjury level, overall IKDC, anterior knee pain, pivot shift favored allograft

34 Allografts Systematic Review Mariscalco, Kaeding, et al. AJSM Aug 2013 Compared autografts to nonirradiated allografts 9 studies 6 BPTB auto vs BPTB allo, 2 studies HT auto vs HT allo, 1 HT auto vs TA allo No sig differences in graft failure rate, knee laxity, or patient reported outcome measures Patient ages range from 24-40

35 Allografts Systematic Review Lamblin, Lubowitz et al. Arthroscopy papers included, non-irradiated, non-chemically treated allografts No significant difference in IKDC, Lysholm, pivot shift, KT-1000, failure rates

36 Allografts in Young Athletes Pallis, Svoboda, et al. AJSM 2012 West Point Study 122 ACL recon prior to matriculation Revision as the primary outcome measure 7/61 BPTB auto (11%) 6/45 HT auto (13%) 7/16 (44%) allografts 7x increased failure rate with allograft

37 Allografts in Young Athletes TR Carter; AANA annual mtg 5/ pts -> avg age 17yrs All non-irradiated grafts 64mo f/u 1 failure (13 months) 76% return to sport at previous level IKDC 90.2 / Lysholm 91

38 Allograft Conclusions Numerous studies have demonstrated increased failure rates of irradiated grafts Anterior cruciate ligament reconstruction with BPTB autograft, irradiated versus nonirradiated allograft: a prospective randomized clinical study. Sun K, Tian S, Zhang J, Xia C, Zhang C, Yu T. Knee Surg Sports Traumatol Arthrosc May;17(5): doi: /s Emerging studies demonstrating increased failure rates among young and active patients

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40 Significant controversy exists Surgeon selection What procedure are they comfortable with Patient selection What is the patient comfortable with Age and activity of the patient!

41 What Do I Do? Surgeon selection BPTB, HT autografts, ant/post tib or peroneal allograft, occasional BPTB allograft (non-irradiated!) Patient selection Explain the pros and cons of each and involve the patient in the decision-making process

42 Revision ACL Reconstruction Same considerations Patient Age Activity Level Previous Graft Choice Consider 2-stage procedure

43 Jonathan T. Bravman, MD CU Sports Medicine