Disclosure Allograft ACL Reconstruction in the Adolescent Steve J. Barad, MD and Stephen M. Howell, MD Private Practice Orthopedic Surgery, Sacramento, CA Professor of Mechanical Engineering, UC Davis Consultant and receives royalties from Biomet Sports Medicine and Zimmer Editorial board of American Journal of Sports Medicine and Arthropaedia UCSF Pioneered Research on Allograft ACL Reconstruction 1982: Effect of minus 80 degrees C on Viability of the Rhesus Monkey Patellar Tendon 1983: Effects of Cyclosporin A on Bone Allografts in the Rat Model Presented Leroy C. Abbott Society Scientific Program S. Barad, J.Rodrigo and E.Cabaud ACL Reconstruction with Allograft is Controversial Some studies show 4-8 times higher risk of failure with allograft than autograft Pallis AJSM 2012; Kaeding J Spts Health 2011,Kambien AJSM 2013, Barrett Artrhroscopy 2010 Allograft in adolescents is of greater concern AANA 2013 NEVER use an allograft for ACL reconstruction in the young athlete 1
Is Irradiation and Chemical Processing of Allograft Driving the Controversy? When allografts treated with irradiation and chemical cleansing were excluded, the results with allografts were the same as autograft no outcome difference Krych Arthro 2008, Lawhorn Arthro 2012, Marisculo AJSM 2013, Li AJSM 2013, Zang AJSM 2012 ACL ALLOGRAFT ADVANTAGES: save time in OR easier surgery easier recovery avoids harvest morbidity avoids weakness with flexion w Hamstring avoids patellar pain w Patellar-Tendon-Bone ACL Allograft Disadvantages cost immune response delay graft incorporation bacterial/viral transmission you are not using a dead person s ligament in my child Hypothesis The use of fresh-frozen, non-irradiated and non-chemically processed allograft results in high self-reported satisfaction, function, and return to sport (KOOS and Lysholm), a stable knee (KT-1000, pivot shift) and low failure rate after ACL reconstruction in adolescents 2
METHODS AND MATERIALS Patient Selection All patients 14-19 years of age treated with allograft ACL reconstruction from 2008-2013 were identified from searching our office and hospital database 21 patients met the inclusion criteria 4 were lost to follow-up 17 patients, 10 female 7 male F/u 9 month- 6 years ( mean 4 years) 12 Soccer 3 Football 1 Volleyball 1 Mountain Climbing 1 Baseball 1 Basketball Patient Selection Evaluation 17 patients reported patient satisfaction, function and ability to return to sport by filling out the KOOS and Lysholm questionnaires 12 pts had a physical examination including pivot shift and KT-1000 (manual maximum test) and single-leg hop test 3
Surgical Technique Surgical Technique Fresh frozen, non- irradiated Posterior TibialisTendon Transtibial technique using a guide that helped prevent impingement in extension and flexion Cortical Locking device used for femoral fixation, screw and washer with bone graft used for tibial fixation Technique Picture of XRAY 4
RESULTS Results PE: 10 pts normal exam with negative lachman and pivot shift test 1 pt had negative lachman with 1 plus pivot 1 pt had positive lachman with 2 plus pivot HOP test ave diff : 2.5 inches KT -1000 Satisfaction and Return to Sport Manual Max Exam 6-0 mm 2 -.5 mm 3-1-2mm AVE. 1.omm 1-7mm (f) KOOS range: 82-100 14 excellent 3 good average 95 80-90 good Lysholm range: 86-100 90-100 excellent 14 excellent 3 good average 95 5
Results Conclusions Self satisfaction: 14 excellent/3 good Objective : 1 failure / 17 pts 16/17 pts able to return to sport Failure Rate <6% Our experience with use of Allograft tendon in the young, athletic population was favorable. We did not see the level of failure reported in many of the articles reviewed Unfortunately our sample size was small. Not all of the 17 pts were available for Physical Examination. Even with good satisfaction scores, their may have been laxity in this group detected by manual and KT evaluation one day we will use allograft tendons to reconstruct the anterior cruciate ligament Thank You Special thanks to Laura Osorio M.A. ED CABAUD The Cabaud Memorial Award 6