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EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
The Graft Source in ACL Surgery
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Timothy E. Foster, MD, MBA, MS
ASSOCIATE EDITOR, AJSM
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Look for us in 2020 !
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
What would you do ?Case #1Sophomore
Sprinter
All-American Division 1
Twisted knee in off season.
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
What would you do?Case #2College Football Player
Quarterback
League MVP
22 Years Old
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
What Would You Do?Case #342 Year Old male
Recreational Athlete
Skier
Sports Every Weekend
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Case #4 College Ice Hockey Player.
Autograft Hamstrings done in Canada failed.
National Championship Game last season.
1 Season Remaining
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
What Would You Do (If it were you?)Case #5
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Sources of ACL Grafts•Autograft
-BTB
-Hamstrings
-Quad Tendon
- Primary Repair
•Allograft
-Achilles Tendon
-Tibialis Anterior
-Tibialis Posterior
-Peroneus Longus
-BTB
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
How Does the Surgeon Select a Graft?
Surgeon’s Technical Preference - #1
Patient Preference - #2
Graft Matching - #3
Scientific Data #4
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Surgeon’s Selection of a Graft: Objective/Subjective Parameters
Age of Patient
Sex of the Patient
Patient Specific Anatomy
Level of Participation
Perception of Athletic Ability
Specific Sport
Specific Position
Rehabilitation Concerns
Happy Meal BTBAllograft with a shake
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
The Perfect Graft
Strong (as strong as the native ACL)
Durable (millions of cyclic loads)
Retear Rate Lower Than the Native ACL
Volumetrically Identical to the Native ACL
No Donor Site Morbidity
No Patient Morbidity
Easy To Harvest
Easy to Rehab
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Some Debates Seem to Last Forever…
So Let’s Settle at Least 1 Debate….
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Debate #1 Hamstring Versus BTB ?
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Allograft Versus Autograft: The West Point Experience
122 ACL Reconstructions in 120 Patients
20 Failures
BTB Failure 11%
Hamstring Failure 13%
Allograft Failure 44%
Pallis, Svoboda, Cameron, Owens; AJSM,2012
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Autograft Hamstring Versus BTB: The Army Experience
No Significance Difference in Re-rupture Rate
No Significant Difference Activity Level
No Significant Difference in Knee Laxity
No Significant Difference in Pain with Kneeling
No Difference in IKDC
Taylor, DeBerardino,Nelson e tal; AJSM,2009, Level 1
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
The 20 year Prospective Evaluation of isolated ACL Reconstruction with Autograft BTB and Hamstrings
Patella Tendon and Hamstring Rupture Rates Were Similar
- Predicted by Male Patient
- < 18 Years of Age ( Increased Posterior Slope and Hamstring Graft is Critical)
- Non-Anatomic Tunnels
IKDC Scores 86% for Patella Tendon and 89% for Hamstrings
53% of Patella Tendon Patients Participated in Strenuous Exercise Compared to 57% for Hamstring Patients
Kneeling Pain 63% in BTB Group and 20% in Hamstring Group
Radiographic DJD in 61% of BTB Patients and 41% of Hamstring Patients
Thompson, Salmon, Waller: AJSM, 2016, Level 2
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Survival of the ACL Graft and the Contralateral ACL at 15 Years
Bourke, Salmon, Waller; AJSM, 2012, Level 4
Is the use of a BTB Autograft a Harbinger for a Contralateral ACL Tear?
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Debate #2Does Age Matter?
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Fifteen-Year Survival of ACL Grafts in Patients Aged 18 and Younger
Morgan, Salmon, Waller: AJSM, 2016 Level 4
15 Year Graft Survival 83%
1 in 3 Patients Had an ACL Graft “Incident”
15 Year Graft Survival For The Contralateral Knee 81%
Decreased Survival of the Contralateral Knee Was Predicted
- Male Patients
- Return to Competitive Athletics in Team Sports
Significantly Higher Failure and Risk to the Contralateral Knee
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
ACL Reconstruction in Patients >40 Years Old
Brown, Adams, Harris, Safran; AJSM,2013, Systematic Review
The Graft Source Did Not Effect The Result
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Debate #4 Allograft Versus Autograft ?
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Activity Level and Graft Type As a Risk Factor For ACL Graft FailureReturning to High Level Sports Competition After ACL Surgery and/or The Use of Allograft Tissue Leads to a Higher Failure Rate
Borchers, Pedroza, Kaeding; AJSM, 2009
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Autograft Compared to Allografts
Very Large Confidence Intervals for Allograft with More Failures
Smaller Allograft Numbers – Dr. Schepsis’ and Edgar’s Study Skewed the Data
Allograft Failures Tended to Occur in Younger, Athletic Patients
No Difference in Laxity Between BTB and Hamstring Autograft
After 30 it Didn’t seem to Matter.
See The Appendix for This Talk
Foster, DeHaan, et al, AJSM 2012, Level 1 systematic review
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Graft Failures
Graft Source
Num
ber
of E
vents
Per
100 P
atients
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Risk Factors For ACL Failure: The Moon Group
Ipsilateral ACL Graft Tear 4.4%
Contralateral Graft Tear 3.5%
Allograft with 5.2x Greater Chance of Re-rupture
Chance of Ipsilateral re-rupture decline by nearly 1% per year of aging
Chance of Contralateral Tear Decreased by ½% per year…
Kaeding, Spindler et al; AJSM,2015, Level 3
Probability of Risk and Occurrence
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Debate #5 Size of The Graft Matters
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
MRI Signal Intensity and Graft Volume Predict the Clinical and Functional Outcome
Biercevicz, Akelman, Fadale, et al. AJSM, 2015 Level 3 Cohort Study
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Augmentation of Hamstring Autograft with Allograft Tissue
Higher Failure Rate with Smaller Graft Diameter
Hybrid Grafts Mitigated That Risk
Hybrid Grafts Were Cost Effective Compared to a Potential Revision.
Jacobs, Burnham, Makhni; AJSM,2017
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Augmentation of Hamstring Autograft with Allograft TissueHigher Failure Rate with Smaller Graft Diameter (<7 mm)
Hybrid Grafts May Have Increased The Risk
Average Age 15.7 Years
Pennock, Ho et al; AJSM,2016
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Debate #6Graft Choices for Patients With Segond Fractures?
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Are Patients with a Segond Fracture Predisposed to Graft Failure?
Gaunder, Bastrom, Pennock: AJSM 2017 Level 3 Cross Sectional Study
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Debate #7Does ACL Surgery Cause DJD?
=20 Years
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Does Anterior Cruciate Ligament Reconstruction With BTB Lead to DJD ?
Higher Rate of DJD in Operative Knee
- Meniscal Injury
- Partial Menisectomy
- Chondral Injury
Murray, Lindh, Cross et al; AJSM,2011
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Debate #8High Rates of Osteoarthritis Develop After ACL Surgery
5 Years = 11.3%
10 Years = 20.6%
20 Years = 51.6%
Increased Chronicity from Injury to Surgery a Factor
Increased Age a Factor
Cinque, Dornan, LaPrade, et al, AJSM, 2017, Winner Systematic Review Award
ACL Tears Cause DJD – There is NO Doubt – More Research to Determine the Risk Factors
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Debate #9The Use of Alternative Graft Sources? 5-6 Stranded Hamstring Graft
Tutkus et al, Knee Surg, Trauma, Sports and arthroscopy, 2018
100% Chance of Getting a >8 mm Graft…often 9mm-11mm
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Quad Tendon Graft
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Quadriceps Tendon Autograft Compared to Hamstrings Autograft
3.6 Year Follow-up
Level 3 Cross-Sectional Study
Hamstring and Quad Tendon Had Similar Morbidity Profile
Quad Tendon Grafts with Improved Lachman Tests
Similar Functional Results
AJSM, 2017, Cavaignac, et al
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
What would you do ?Case #1Sophomore
Sprinter
All-American Division 1
Twisted knee in off season.
Allograft Tibialis Anterior – 5 Year Follow-up
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
What would you do?Case #2College Football Player
Quarterback
League MVP
22 Years Old
BTB Autograft – Played Senior Year - Re-rupture at 18 Months in Basketball Game - Revised with 6 Standed Semi-T
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
What Would You Do?Case 3#42 Year Old male
Recreational Athlete
Triple Diamond, Back Woods Skier
Sports Every Weekend
Allograft Tibialis Anterior – Revised with Autologous BTB
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Case #4 College Ice Hockey Player.
Autograft Hamstrings failed.
National Championship Game last season.
1 Season Remaining
Revised with Quad Tendon
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
What Would You Do (If it were you?)Case #5
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Appendix
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Study Design •Systematic Review
•Only Prospective Studies Included (Level I and II Studies Only)
•Studies Included Allograft Patients or Autograft Patients or Both.
•Objective Data and Validated Scores Had to Be Reported.
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Methods
A Review of All English Language Prospective Studies.
Ovid Medline and PubMed.
Cross Reference of Bibliographies from Each Publication.
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Inclusion CriteriaEnglish Language
Prospective
Arthroscopic Reconstruction
2 Year Follow Up
70% Follow Up per Study
Minimal Age of 14 Years
Evaluation of at Least 1 Outcome Measure (i.e. KT 1000)
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Exclusion Criteria
•Retrospective Studies
•Less Than 2 Year Follow Up
•Extra-articular Procedures
•Graft Augmentation
•Graft Sources Other Than BTB or Hamstrings
•Open or Mini-Open Surgery
Less Than 70% Follow Up
High-Dose Irradiation of Allografts
Ethylene Glycol
Revision Surgery
Multi-Ligament Surgery
Age Less than 14
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Results: Combined Autograft and Allograft Data
•Over 400 Articles Identified.
•31 Fulfilled Inclusion Criteria
- 27 Autograft Studies
- 4 Allograft and Autograft
- 0 Isolated Allograft Studies
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Objective DataLysholm
IKDC
KT-1000
Pivot Shift
Failures
Complications
The New NFL Refs Were Trained in
the Lachman and Anterior Drawer …
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
KT1000Instrumented Knee Laxity Test
Objective Evaluation of Anterior Tibial Translation (not rotation)
Compared to Contra-lateral Knee
< 3 mm* = Acceptable
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
KT 1000 Results21/31 Articles
122 Knees in Allograft Group
1768 in Autograft Group
Average 1.4 mm for Allograft Group
Average 1.8 mm for Autograft Group
Statistically Significant
P < .02
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
KT-1000 Scores
Graft Source
Perc
enta
ge o
f Pa
tien
ts w
ith
Sid
e to
sid
e la
xity
<3
mm
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Pivot ShiftPhysical Exam Test For Rotation Stability.
Results are Correlated with IKDC Scale
Negative Exam 0 =“A”
Pivot Glide 1 = “B”
Clunk 2 = “C”
Gross Laxity 3 = “D”
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Pivot Shift Results19/31 Studies Recorded Pivot Shift.
66 Allograft Patients
1271 Autograft Patients
Patients with Pivot Shift > +1
Allograft = 5% +-2.7%
Autogrfat = 2.7% +-0.5%
NOT Statistically Significant.
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Pivot Shift
Graft Source
Rate
of A
bnorm
al P
ivot
Shift
at F
ollo
w U
p
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Lysholm ScorePatient Based, Validated Score.
Domains Include
Limping
Locking
Pain
Stair Climbing
Use of Supports
Instability
Swelling
Squatting
100 Point Scale
95-100 Excellent
84-94 Good
65-83 Fair
< 65 Poor
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Results of Lysholm Score17/31 Studies
137 Knees in Allograft Group
1087 Knees in Autograft Group
Autograft = 92.4 +-0.3
Allograft = 92.8 +-0.6
NO Difference
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Lysholm ScoreM
ean L
ysholm
Score
(100 P
oin
t S
cale
)
Graft Source
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
IKDC ScoresMost Complete Knee Documentation
Scored A, B, C, D
A Normal
B Near Normal
C Slightly Abnormal
D Abnormal
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
IKDC RESULTS18/31 Studies
82 Knees in Allograft
1482 in Autograft
Pooled Allograft A and B = 82.9%
Pooled Autograft A and B = 87.2%
No Statistical Difference
IKDC “A” Allograft Score = 43.9%
IKDC “A” Autograft Score 28.2%
Statistically Significant
Autograft Hamstrings had a Statistically Higher “A” and “B” Score Compared to Allograft.
Auto BTB had the worse “A Scores”
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
IKDC Scores
RATED as ‘A” (Normal) Rated as “A” or “B” (Near Normal)
IKD
C S
core
(1
00 P
oin
t S
cale
)
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
FailuresDefined As:
-Graft Rupture
-Need For Revision Surgery
- Abnormal Pivot >1+
-KT 1000 > 5 mm
-NO Statistical Difference
-A Trend Toward Higher Allograft Failures.
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
ComplicationsInfection
Removal of Hardware
Loss of Motion
Reported per 100 patients.
No Statistical Difference
Rana Type 1 Lesion
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Complications
Graft Source
Num
ber
of
Events
Pe
r 100 P
atients
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Conclusion
The Success or Failure is Probably Related to Graft Source.
Bone Tunnel Position Is a key Component.
Factors in Control of the Surgeon Are The Most Important Key to Success.
EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
The EndFuture Studies Need to Examine Allograft Tissue Strength (it’s not all the same).
Trust Me on The Tunnel Placement.
Thanks!