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EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION

The Graft Source in ACL Surgery


Timothy E. Foster, MD, MBA, MS

ASSOCIATE EDITOR, AJSM


Look for us in 2020 !


What would you do ?Case #1Sophomore

Sprinter

All-American Division 1

Twisted knee in off season.


What would you do?Case #2College Football Player

Quarterback

League MVP

22 Years Old


What Would You Do?Case #342 Year Old male

Recreational Athlete

Skier

Sports Every Weekend


Case #4 College Ice Hockey Player.

Autograft Hamstrings done in Canada failed.

National Championship Game last season.

1 Season Remaining


What Would You Do (If it were you?)Case #5


Sources of ACL Grafts•Autograft

-BTB

-Hamstrings

-Quad Tendon

- Primary Repair

•Allograft

-Achilles Tendon

-Tibialis Anterior

-Tibialis Posterior

-Peroneus Longus

-BTB


How Does the Surgeon Select a Graft?

Surgeon’s Technical Preference - #1

Patient Preference - #2

Graft Matching - #3

Scientific Data #4


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


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


Some Debates Seem to Last Forever…

So Let’s Settle at Least 1 Debate….


Debate #1 Hamstring Versus BTB ?


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


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


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


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?


Debate #2Does Age Matter?


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


ACL Reconstruction in Patients >40 Years Old

Brown, Adams, Harris, Safran; AJSM,2013, Systematic Review

The Graft Source Did Not Effect The Result


Debate #4 Allograft Versus Autograft ?


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


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


Graft Failures

Graft Source

Num

ber

of E

vents

Per

100 P

atients


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


Debate #5 Size of The Graft Matters


MRI Signal Intensity and Graft Volume Predict the Clinical and Functional Outcome

Biercevicz, Akelman, Fadale, et al. AJSM, 2015 Level 3 Cohort Study


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


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


Debate #6Graft Choices for Patients With Segond Fractures?


Are Patients with a Segond Fracture Predisposed to Graft Failure?

Gaunder, Bastrom, Pennock: AJSM 2017 Level 3 Cross Sectional Study


Debate #7Does ACL Surgery Cause DJD?

=20 Years


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


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


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


Quad Tendon Graft


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


What would you do ?Case #1Sophomore

Sprinter

All-American Division 1

Twisted knee in off season.

Allograft Tibialis Anterior – 5 Year Follow-up


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


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


Case #4 College Ice Hockey Player.

Autograft Hamstrings failed.

National Championship Game last season.

1 Season Remaining

Revised with Quad Tendon


What Would You Do (If it were you?)Case #5


Appendix


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.


Methods

A Review of All English Language Prospective Studies.

Ovid Medline and PubMed.

Cross Reference of Bibliographies from Each Publication.


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)


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


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


Objective DataLysholm

IKDC

KT-1000

Pivot Shift

Failures

Complications

The New NFL Refs Were Trained in

the Lachman and Anterior Drawer …


KT1000Instrumented Knee Laxity Test

Objective Evaluation of Anterior Tibial Translation (not rotation)

Compared to Contra-lateral Knee

< 3 mm* = Acceptable


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


KT-1000 Scores

Graft Source

Perc

enta

ge o

f Pa

tien

ts w

ith

Sid

e to

sid

e la

xity

<3

mm


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”


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.


Pivot Shift

Graft Source

Rate

of A

bnorm

al P

ivot

Shift

at F

ollo

w U

p


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


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


Lysholm ScoreM

ean L

ysholm

Score

(100 P

oin

t S

cale

)

Graft Source


IKDC ScoresMost Complete Knee Documentation

Scored A, B, C, D

A Normal

B Near Normal

C Slightly Abnormal

D Abnormal


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”


IKDC Scores

RATED as ‘A” (Normal) Rated as “A” or “B” (Near Normal)

IKD

C S

core

(1

00 P

oin

t S

cale

)


FailuresDefined As:

-Graft Rupture

-Need For Revision Surgery

- Abnormal Pivot >1+

-KT 1000 > 5 mm

-NO Statistical Difference

-A Trend Toward Higher Allograft Failures.


ComplicationsInfection

Removal of Hardware

Loss of Motion

Reported per 100 patients.

No Statistical Difference

Rana Type 1 Lesion


Complications

Graft Source

Num

ber

of

Events

Pe

r 100 P

atients


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.


The EndFuture Studies Need to Examine Allograft Tissue Strength (it’s not all the same).

Trust Me on The Tunnel Placement.

Thanks!

the graft source in acl surgery - amazon web...

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