ACL Reconstruction. The Final Answer: Allograft v. Autograft What do you secretively do???

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1 ACL Reconstruction Orthopaedic Summit 2017 The Final Answer: Allograft v. Autograft What do you secretively do??? John C. Richmond, MD New England Baptist Hospital Tufts University School of Medicine

2 Speaker s Disclosure Our fellowships and registry receive support from: Arthrex, DePuy-Synthes, DonJoy, Smith & Nephew, Conmed Linvatec, Zimmer, Stryker Consultant: DePuy Synthes Mitek Sports Medicine Smith & Nephew Histogenics Flexion Therapeutics Visgo Therapeutics Amplex

3 Audience Survey What is your graft of choice for a young (<35 yo), active athlete with an ACL tear? Allograft or Autograft Hands up for Allograft

4 ACL Allograft v. Autograft? Is it time to come out of the closet? Bruce 1976 Caitlyn 2015

5 Successful ACL Reconstruction Requires the following 1. High strength graft 2. Anatomic positioning 3. Rigid fixation

6 Historical Perspective Early 1980 s: Autografts Post-op Prolonged Immobilization RESULTS Stiffness Anterior knee pain Articular surface damage Delayed return to athletics

7 In the 1980 s ACL Reconstruction = Autograft Could we find Alternative Graft Sources? Synthetics (Gortex, Dacron, etc.) in the 1980 s were all removed from the market Xenografts from the 1980 s were a disaster Would allografts be a reasonable solution?

8 Allograft ACL Reconstructi0n Expanded use in the 1990 s and into the 1 st half of the past decade There were some bumps along the road Ethylene oxide sterilization lead to bone resorption and cyst formation A death from a contaminated allograft (Clostridium sp.) brought safety (and the FDA) to the forefront Irradiation, at variable dosages, and chemical washes were instituted at a number of tissue banks

9 Even Low Dose Irradiation Affects Stiffness Bach et al. Am J Sports Med : 835 Small number of samples, was underpowered for some measures Cyclic creep + strain also likely increased This will lead to increased laxity

10 Now that we have some background Let s see what some smart people have to say on this subject

11 What Does Dr. Indelicato Say? Nonirradiated Versus Irradiated Achilles Allograft: In Vivo Failure Comparison. AJSM, (Level 3 case series) January of 2002 tissue bank added Mrad 33% Failure at 6-24 mo. F/U in irradiated group the senior authors decided to discontinue the use of irradiated allografts

12 What Does Our Moderator Say? Johnson, et al. Failure of Primary Anterior Cruciate Ligament Surgery Using Anterior Tibialis Allograft, Arthroscopy, (Level 4 case series) 35% revision in <25 yr. old vs. 13% in >25 yr. old with non-irradiated grafts Given the failure and reoperation rate that we observed, caution is warranted in using anterior tibialis allograft in younger patients He should have said: You are crazy to use allografts in younger patients

13 Can we get Higher Level Evidence? Lubowitz, et al. Anterior Cruciate Ligament Reconstruction With Autografts Compared With Non-irradiated, Non-chemically Treated Allografts. Arthroscopy, (Level 3 Systematic Review) This systematic review failed to show any significant differences in various functional and objective outcome measures after ACL reconstruction with autografts or nonchemically treated non-irradiated allografts.

14 Can we get Higher Level Evidence? Lubowitz, et al. Anterior Cruciate Ligament Reconstruction With Autografts Compared With Non-irradiated, Non-chemically Treated Allografts. Arthroscopy, Level 3 Systematic Analysis Threw in a new hooker Non-chemically treated 9 of the 11 studies were done either before the FDA became involved or outside of the USA

15 Dr. Indelicato Couldn t Swear off Allografts Aseptically processed and chemically sterilized BTB allografts for anterior cruciate ligament reconstruction: a prospective randomized study KSSTA, 2013

16 Today, Can You Get a Non-irradiated, Nonchemically Treated Allograft in the US? Information from their Web Sites Allosource MTF RTI Lifenet TBI DCI Sterigraft Vivex Antibx, alcohol, peroxide Detergent, peroxide, alcohol Mechanical and chemical wash (BioCleanse) Wash, low dose-cold irradiation Proprietary wash, low dose-cold irradiation Wash, unknown dose irradiation Cleansing, low dose irradiation Aseptic processing no additional info

17 Can we get the Highest Level Evidence? Spindler et al. 6 Year MOON Study. AJSM, 2011 Prospective Level 2 Cohort Study with 85% follow-up on nearly 400 patients Allografts were statistically significantly worse than autografts In conclusion, our MOON results revealed that choosing an autograft would significantly, and in a clinically meaningful way, improve sports function and knee-related quality of life.

18 Failure Rates Shared with MOON Group in 2005

19 Could Failure Rates Change Behavior? Kaeding et al. Change in Anterior Cruciate Ligament Graft Choice and Outcomes Over Time. Arthroscopy, 2017 MOON surgeons response

20 Could Failure Rates Change Behavior? Kaeding et al. Change in Anterior Cruciate Ligament Graft Choice and Outcomes Over Time. Arthroscopy, 2017 MOON surgeons response

21 ACL Allograft v. Autograft? Some Docs are Already out of the closet Peter Indelicato Thomas Carter

22 Richmond is Still a Closet Allograft User: Current Surgical Treatment Algorithm High demand : eg. competitive athlete Autologous B-PT-B 20% of current patients Moderate demand : eg. recreational athlete Autologous Q-ST&G, +/- allograft augment 30% Lower demand (>40 y.o.) or other modifying circumstance (age, autologous tendon issues, revision, or patient request) Allograft (tibialis or B-PT-B) 50%

23 Audience Survey Has anyone changed your graft of choice for a young (<35 yo), active athlete with an ACL tear? Allograft or Autograft Hands up if this has altered your choice

24 Thank You