ACL Graft Choice. Disclosures. ACL Graft Options 8/10/2016. Michael B. Ellman, MD Panorama Orthopedics Sports Medicine

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1 ACL Graft Choice Michael B. Ellman, MD Panorama Orthopedics Sports Medicine Disclosures Educational Consultant Stryker Endoscopy and Sports Medicine ACL Graft Options Optimal ACL graft Structural and biomechanical characteristics of native ACL Allows for secure fixation Permits rapid biologic incorporation Limited donor site morbidity 1

2 Graft Choices Mall et al, 2012 In residency, I thought there was only one great option ACL Graft Options 2

3 My Practice: ACL GRAFT USAGE ACL Graft Usage BTB ALLO 1% STAGE 1 REVISION 1% BTB AUTO 15% TA/TP ALLO 22% HAMSTRING AUTO 61% 61% Hamstring Auto 15% BTB Auto 22% Allograft Graft Options First Decision: Allograft vs Autograft? 3

4 Allografts Advantages No donor site morbidity Decreased pain Shorter OR times Better cosmesis Disadvantages Cost Delayed tissue incorporation Safety? Clinical Outcomes? Cost Allografts are the most expensive option Nagda, CORR 10, Barrera Arthrosc 11: Allograft ACLRs more costly, despite surgical time savings But, are they cost effective??? NO available studies showing clinical superiority of allo vs. auto OTHER than donor site morbidity benefits Safety Risk of Allograft Use Disease Transmission? Sterilization Process? Allograft Processing? Irradiated? Supercritical CO2? 4

5 Safety Infection risk NO DIFFERENCE Williams et al. AJSM 1997 Indelli et al. CORR 2002 Barker et al. AJSM 2010 Disease transmission Since 1985: 1 HIV infected donor 1 Hep C infected donor HIV risk = 1:8,000,000 Sterilization: Effects of Irradiation Irradiation significantly compromises the biomechanical properties of allograft tissue Krych etal., Arthroscopy 2008; Sun et al., KSSTA 2008;. Rappe et al., AJSM 2007; Mehta et al., Orthop 2010: ***Sig biomechanical difference between irradiated (>2.5mRad) and non irradiated allografts ***NO SIG DIFF BETWEEN NON IRRADIATED ALLOGRAFTS AND AUTOGRAFTS Yanke AJSM 2013: Low dose XRT (1.2mRad) no effect on biomechanical properties of BTB allograft, with exception of 20% decrease in graft stiffness Conclusions: Avoid irradiation >2.2mRad; Non irradiated may be best option Sterilization Non irradiated allografts with Supercritical CO 2 sterilization Alternative to standard irradiation + wash/cleanse technique Baldini KSSTA 2014: Supercritical CO 2 sterilization decreases graft stiffness 27 36%;? Clinical impact Further studies warranted on optimal tissue processing technique Know your tissue bank! 5

6 Clinical Outcomes: Allografts and Age Mounting evidence that allograft failure rates are SIGNIFICANTLY higher in young, active patients Age and Activity level RFs for failure with allograft STUDY Barrett Arthroscopy 10, 11 Pallis AJSM 12 FINDING < 40 yo: x higher failure rate < 25 yo: allo failure 29%/ auto failure 11% 7.7 x higher failure rate in military cadets Steadman Arthroscopy x higher revision rate in pts. 18yo MOON cohort AJSM 11,13 Fu AJSM 12 Allograft and younger age correlated with failure/reoperation rate Younger Feel Better. age correlated Do More. with allograft failure CONCLUSION: Younger age and Allografts predict higher reoperation and revision rates ***Factors associated with revision ACLR: younger age, allograft, teaching hospital *** Risk factors for revision ACLR: allografts, hamstring autografts, younger age, males ***Allo failure rate: 29%, Auto failure rate 11% ***NCAA Div 1 athletes revision rate: 62% (ALLO) VS. 0% (AUTO), Higher revision rates in pts < 25 yo 6

7 Autograft vs Non irradiated Allograft: 6% vs 9% failure rate Autograft vs Irradiated Allograft (2.5mRad): 6% vs 34% failure rate Higher failure rates in young, active patients with allograft use Indications for Allograft (MBE) Select revisions Multi ligamentous injuries Unique co morbidities that are contraindications to autograft tissue BTB: PFJ DJD, kneelers Hamstring: chronic hamstring issues, collagen disorders, require use of medial stabilizers Older patients: >35 40 In everyone else, Autograft Autograft Options 7

8 BTB Autograft Advantages Rigid initial fixation Bone Bone healing Gold Standard for young athletes Disadvantages Anterior knee pain / numbness Technical considerations GT mismatch Patella fx / patellar tendon rupture Quadrupled Hamstring Autograft Advantages Strongest graft (4000N) Improved cosmesis Decreased anterior knee pain Disadvantages Soft tissue healing Decreased peak flexion strength Possible increased laxity over time Quadriceps Autograft Advantages Largest x sectional area (62mm 2 ) Bone Bone fixation x1? Less donor site morbidity vs BTB Disadvantages Patella fracture = 2 9% Anterior knee pain = 7 22% Quad tendon rupture? Loss of extension strength 8

9 Graft Options No single right answer Surgeon and Patient Choice Conclusions Limit use of allograft in young, active patients If using allograft, know your tissue bank Autograft recommended in patients <35 No difference in outcomes between BTB and Hamstring Educate your patients to make the best choice for them! Thank you 9

10 Autograft Options 10

11 Then on to fellowship Still only one option Clinical Outcomes: Common Themes Non irradiated allografts may outperform irradiated grafts Low dose irradiation appears to be safe and effective Patient age and activity level correlated with increased risk of allograft failure use autograft! 11

12 MOON Data 2011 WHY??? Too early RTS? Increased activity level in younger pts? For MBE ***No sig difference between allograft BTB vs. allograft tibialis posterior trend toward higher failure rate with BTB allo Rothman Institute group 12

13 MOON Data Spindler, K. P., Huston, L. J., Wright, R. W., Kaeding, C. C., Marx, R. G., Amendola, A., et al. (2011). The prognosis and predictors of sports function and activity at minimum 6 years after anterior cruciate ligament reconstruction: a population cohort study. The American Journal of Sports Medicine, 39(2), Hettrich, C. M., Dunn, W. R., Reinke, E. K., MOON Group, & Spindler, K. P. (2013). The rate of subsequent surgery and predictors after anterior cruciate ligament reconstruction: two and 6 year follow up results from a multicenter cohort. The American Journal of Sports Medicine, 41(7), CONCLUSION: Younger age and Allografts predict higher reoperation and revision rates MOON Data BTB Autograft 13

14 Questions? Safety? Clinical outcomes? Cost? Have things changed between 2009 and 2015??? For JTJ Stanford group : 2683 patients MOON DATA 14

15 Location Conclusions Allografts are safe but expensive Exercise caution when considering allografts for younger patients Non irradiated allografts outperform irradiated grafts The trends continue 2013 AND BEYOND 15

16 New MOON Data ***ACL retear odds 5.2x greater for allograft vs. autograft, risk s with age and s with increased activity level The outlier ***No difference between non irradiated allograft vs. autograft in pts. < 25 yo Meta analyses Study Kraeutler (CU) AJSM 13 Mariscalco (OSU) AJSM 14 Mascarenhas (Rush) Athros 15 Cvetanovich (Rush) Arthros 14 Lamblin (NM) Arthros 13 Auto Allo No Difference Nonirradiated grafts only 16

17 2015 Conclusions: Mounting evidence against use of allografts in younger active patients Even low dose irradiation effects are still concerning Conclusions Unavailable data Any study that shows that allos outperform auto At best, outcomes are equivalent The Value Proposition At what age do allografts become costeffective??? 17

18 Final Q Given available data, why would we choose to use an allograft as our first choice for primary isolated ACLR without relevant co morbidities in active young patients (< 40 years old)??? CAG opinion at this point: I wouldn t ***Factors associated with revision ACLR: younger age, allograft, teaching hospital 18

19 *** Risk factors for revision ACLR: allografts, hamstring autografts, younger age, males ***Allo failure rate: 29%, Auto failure rate 11% ***NCAA Div 1 athletes revision rate: 62% (ALLO) VS. 0% (AUTO), Higher revision rates in pts. < 25 yo 19

20 ***Younger age and used of allografts were risk factors for revision surgery. 20

21 ***In active pts < 40 yrs old, BTB allograft failure rates were x higher than BTB autografts ***In pts < 25 yo allograft failure rate (29%) vs. autograft BTB failure rate (11%) Q: What graft do you prefer for your pro athletes? All over the board Trend to use hamstring. I like btb for the jumpers but they seriously mostly ask for allo Anonymous knee surgeon