21
8/10/2016 1 Feel Better. Do More. 3032331223 panoramaortho.com Feel Better. Do More. 3032331223 PanoramaOrtho.com ACL Graft Choice Michael B. Ellman, MD Panorama Orthopedics Sports Medicine Feel Better. Do More. 3032331223 panoramaortho.com Feel Better. Do More. 3032331223 PanoramaOrtho.com Disclosures Educational Consultant – Stryker Endoscopy and Sports Medicine Feel Better. Do More. 3032331223 panoramaortho.com Feel Better. Do More. 3032331223 PanoramaOrtho.com 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

ACL Graft Choice...ACL Graft Options • Optimal ACL graft – Structural and biomechanical characteristics of native ACL – Allows for secure fixation – Permits rapid biologic

  • Upload
    others

  • View
    11

  • Download
    0

Embed Size (px)

Citation preview

Page 1: ACL Graft Choice...ACL Graft Options • Optimal ACL graft – Structural and biomechanical characteristics of native ACL – Allows for secure fixation – Permits rapid biologic

8/10/2016

1

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

ACL Graft Choice

Michael B. Ellman, MDPanorama Orthopedics

Sports Medicine

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

Disclosures

• Educational Consultant – Stryker Endoscopy and Sports Medicine

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

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

Page 2: ACL Graft Choice...ACL Graft Options • Optimal ACL graft – Structural and biomechanical characteristics of native ACL – Allows for secure fixation – Permits rapid biologic

8/10/2016

2

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

Graft Choices

Mall et al, 2012

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

ACL Graft Options

• In residency, I thought there was only one great option…

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

Page 3: ACL Graft Choice...ACL Graft Options • Optimal ACL graft – Structural and biomechanical characteristics of native ACL – Allows for secure fixation – Permits rapid biologic

8/10/2016

3

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

My Practice: ACL GRAFT USAGE

HAMSTRING AUTO61%

TA/TP ALLO22%

BTB AUTO15%

BTB ALLO1%

STAGE 1 REVISION

1%

ACL Graft Usage 2014‐15

61% Hamstring Auto15% BTB Auto22% Allograft

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

Graft Options

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

First Decision: Allograft vs Autograft?

Page 4: ACL Graft Choice...ACL Graft Options • Optimal ACL graft – Structural and biomechanical characteristics of native ACL – Allows for secure fixation – Permits rapid biologic

8/10/2016

4

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

Allografts• Advantages

– No donor site morbidity

– Decreased pain

– Shorter OR times

– Better cosmesis

• Disadvantages– Cost

– Delayed tissue incorporation

– Safety?

– Clinical Outcomes?

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

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

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

Safety

• Risk of Allograft Use

– Disease Transmission?

– Sterilization Process? 

• Allograft Processing?

• Irradiated?

• Supercritical CO2?

Page 5: ACL Graft Choice...ACL Graft Options • Optimal ACL graft – Structural and biomechanical characteristics of native ACL – Allows for secure fixation – Permits rapid biologic

8/10/2016

5

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

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

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

Sterilization: Effects of Irradiation

• Irradiation significantly compromises the biomechanical properties of allograft tissue 

• Krych etal., Arthroscopy 2008; Sun et al., KSSTA2008;. 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

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

Sterilization

– Non‐irradiated allografts with Supercritical CO2

sterilization

• Alternative to standard irradiation + wash/cleanse technique

• Baldini KSSTA 2014: Supercritical CO2 sterilization decreases graft stiffness 27‐36%; ? Clinical impact

• Further studies warranted on optimal tissue processing technique 

– Know your tissue bank!

Page 6: ACL Graft Choice...ACL Graft Options • Optimal ACL graft – Structural and biomechanical characteristics of native ACL – Allows for secure fixation – Permits rapid biologic

8/10/2016

6

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

Clinical Outcomes: Allografts and Age

STUDY FINDING

Barrett Arthroscopy ’10, ‘11 < 40 yo:  2.6 – 4.2 x higher failure rate < 25 yo:  allo failure 29%/ auto failure 11%

Pallis AJSM ‘12 7.7 x higher failure rate in military cadets

Steadman Arthroscopy ‘12 15 x higher revision rate in pts.    ≤    18yo

MOON cohort AJSM ’11,13 Allograft and younger age correlated with failure/reoperation rate

Fu AJSM ‘12 Younger age correlated with allograft failure

Mounting evidence that allograft failure rates are SIGNIFICANTLY higher in young, active patients• Age and Activity level RFs for failure with allograft

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

CONCLUSION:  Younger age and Allografts predict higher reoperation and revision rates

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

***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

Page 7: ACL Graft Choice...ACL Graft Options • Optimal ACL graft – Structural and biomechanical characteristics of native ACL – Allows for secure fixation – Permits rapid biologic

8/10/2016

7

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

• 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

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

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…

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

Autograft Options 

Page 8: ACL Graft Choice...ACL Graft Options • Optimal ACL graft – Structural and biomechanical characteristics of native ACL – Allows for secure fixation – Permits rapid biologic

8/10/2016

8

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

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

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

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

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

Quadriceps Autograft

• Advantages– Largest x‐sectional area (62mm2)

– 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

Page 9: ACL Graft Choice...ACL Graft Options • Optimal ACL graft – Structural and biomechanical characteristics of native ACL – Allows for secure fixation – Permits rapid biologic

8/10/2016

9

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

Graft Options

• No single right answer• Surgeon and Patient Choice

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

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!

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

Thank you

Page 10: ACL Graft Choice...ACL Graft Options • Optimal ACL graft – Structural and biomechanical characteristics of native ACL – Allows for secure fixation – Permits rapid biologic

8/10/2016

10

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

Autograft Options

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

Page 11: ACL Graft Choice...ACL Graft Options • Optimal ACL graft – Structural and biomechanical characteristics of native ACL – Allows for secure fixation – Permits rapid biologic

8/10/2016

11

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

Then on to fellowship…

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

Still only one option…

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

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!

Page 12: ACL Graft Choice...ACL Graft Options • Optimal ACL graft – Structural and biomechanical characteristics of native ACL – Allows for secure fixation – Permits rapid biologic

8/10/2016

12

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

MOON Data 2011

WHY???

• Too early RTS?

• Increased activity level in younger pts?

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

***No sig difference between allograft BTB vs. allograft tibialis posterior—trend toward higher failure rate with BTB allo

Rothman Institute group

For MBE

Page 13: ACL Graft Choice...ACL Graft Options • Optimal ACL graft – Structural and biomechanical characteristics of native ACL – Allows for secure fixation – Permits rapid biologic

8/10/2016

13

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

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), 1534–1540. 

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), 348–359. 

CONCLUSION:  Younger age and Allografts predict higher reoperation and revision rates

MOON Data

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

MOON Data

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

BTB Autograft

Page 14: ACL Graft Choice...ACL Graft Options • Optimal ACL graft – Structural and biomechanical characteristics of native ACL – Allows for secure fixation – Permits rapid biologic

8/10/2016

14

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

Questions?

• Safety?

• Clinical outcomes?

• Cost?

• Have things changed between 2009 and 2015???

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

Stanford group

For JTJ

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

MOON DATA2002‐15: 2683 patients 

Page 15: ACL Graft Choice...ACL Graft Options • Optimal ACL graft – Structural and biomechanical characteristics of native ACL – Allows for secure fixation – Permits rapid biologic

8/10/2016

15

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

Location

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

Conclusions 2009‐13

• Allografts are safe but expensive

• Exercise caution when considering allografts for younger patients

• Non irradiated allografts outperform irradiated grafts

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

2013 AND BEYONDThe trends continue…

Page 16: ACL Graft Choice...ACL Graft Options • Optimal ACL graft – Structural and biomechanical characteristics of native ACL – Allows for secure fixation – Permits rapid biologic

8/10/2016

16

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

New MOON Data

***ACL retear odds 5.2x greater for allograft vs. autograft, risk  ‘swith age and    ‘s with increased activity level

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

The outlier

***No difference between non‐irradiated allograft vs. autograft in pts. < 25 yo

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

Meta‐analyses

StudyAuto Allo No 

DifferenceNon‐irradiated grafts only

Kraeutler (CU) AJSM ‘13

Mariscalco (OSU) AJSM ‘14

Mascarenhas (Rush) Athros‘15

Cvetanovich (Rush) Arthros‘14

Lamblin (NM) Arthros ‘13

Page 17: ACL Graft Choice...ACL Graft Options • Optimal ACL graft – Structural and biomechanical characteristics of native ACL – Allows for secure fixation – Permits rapid biologic

8/10/2016

17

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

2015 Conclusions:

• Mounting evidence against use of allografts in “younger” active patients

• Even low dose irradiation effects are still concerning

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

Conclusions 

• Unavailable data

– Any study that shows that allos outperform auto

– At best, outcomes are equivalent

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

The Value Proposition

At what age do allografts become “cost‐effective”???

Page 18: ACL Graft Choice...ACL Graft Options • Optimal ACL graft – Structural and biomechanical characteristics of native ACL – Allows for secure fixation – Permits rapid biologic

8/10/2016

18

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

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

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

***Factors associated with revision ACLR:  younger age, allograft, teaching hospital

Page 19: ACL Graft Choice...ACL Graft Options • Optimal ACL graft – Structural and biomechanical characteristics of native ACL – Allows for secure fixation – Permits rapid biologic

8/10/2016

19

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

*** Risk factors for revision ACLR:  allografts, hamstring autografts, younger age, males

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

***Allo failure rate: 29%, Auto failure rate 11%

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

***NCAA Div 1 athletes revision rate: 62% (ALLO) VS. 0% (AUTO), Higher revision rates in pts. < 25 yo

Page 20: ACL Graft Choice...ACL Graft Options • Optimal ACL graft – Structural and biomechanical characteristics of native ACL – Allows for secure fixation – Permits rapid biologic

8/10/2016

20

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

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

Page 21: ACL Graft Choice...ACL Graft Options • Optimal ACL graft – Structural and biomechanical characteristics of native ACL – Allows for secure fixation – Permits rapid biologic

8/10/2016

21

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

***In active pts < 40 yrs old, BTB allograft failure rates were 2.6 –4.2x higher than BTB autografts

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

***In pts < 25 yo allograft failure rate (29%) vs. autograft BTB failure rate (11%)

Feel Better. Do More.303‐233‐1223        panoramaortho.com

Feel Better. Do More.303‐233‐1223      PanoramaOrtho.com

“All over the board…Trend to use hamstring.  I like btb for the jumpers but they seriously mostly ask for allo…”

Anonymous  knee surgeon 2013

Q: What graft do you prefer for your “pro” athletes?