Allograft Bone-Patellar Tendon-Bone (BPTB) Anterior Cruciate - - PowerPoint PPT Presentation

Allograft Bone-Patellar Tendon-Bone (BPTB) Anterior Cruciate Ligament Reconstruction in Patients <30 Years

a,dWest EJ, aPetterson SC, a-cPlancher KD

aOrthopaedic Foundation, Stamford, Connecticut; bClinical Professor, Albert

Einstein College of Medicine; cPlancher Orthopaedics & Sports Medicine, New York, New York;

dBrody School of Medicine at East Carolina University, Greenville, North

Carolina

• None

Disclosures

November 2017

Allograft BPTB ACLR in Patients <30

Recent Literature

• BPTB Autograft

 Functionally More Stable Than

Hamstring Autograft2

 Must Reproduce Mid-

substance Anatomical Position

 Greater Anterior Knee Pain3

• Allograft

 Less Anterior Knee Pain  Failure Rate 3-4x Greater Than

Autograft1,4-5

 Historically Higher in Young

• Ages 10-19

 Greater Knee Laxity5  Worse Functional Outcomesz

1) KaedingCC et al. Allograft Versus Autograft ACL Reconstruction: Predictors of Failure From a MOON Prospective Longitudinal Cohort. Sports Health. 2011. 3(1):73-81. 2) Freedman KB et al. Arthroscopic ACL reconstruction: A meta analysis comparing patellar tendon and hamstring tendon autografts. AJSM.

• 2003. 31(1):1-11.

3) Mohtadi NG et al. Patellar tendon versus hamstring tendon autograft for ACL rupture in adults. Cochrane Database Syst Rev. 2011 Sep 7;(9):CD005960. 4) MaletisGB et al. Reconstruction of the ACL: association of graft choice with increased risk of early revision. Bone Joint J. 2013. 95- B(5):623-8. 5) KraeutlerMJ et al. Bone-patellar tendon-bone autograft versus allograft in outcomes of ACLR: a meta-analysis of 5182 patients.

• AJSM. 2013 Oct;41(10):2439-48.

Allograft BPTB ACLR in Patients <30

Purpose of Investigation

• Purpose:

 Investigate Differences in Failure

Rates and Functional Outcomes Between BPTB Allograft and Autograft ACL Reconstructions in Patients Less Than 30 Years of Age

• Hypothesis:

 Patients < 30 Years Undergoing

Primary ACLR with BPTB Allograft or BPTB Autograft Will Have Equal Outcomes with Low Failure Rates

Allograft BPTB ACLR in Patients <30

Methods

Inclusion/Exclusion Criteria

• Primary ACL Reconstruction

 Cohort Study: 1998 – 2017  Single Surgeon (KDP)

 48 patients

 Allograft BPTB

 LifeNet (Virginia Beach, VA)  Musculoskeletal Transplant Foundation

(Edison, NJ)

 Autograft BPTB

• Exclusion Criteria

 Age

 <17 years old  >30 years old

 Follow-Up >2 years  Revision Surgery  Osteochondral Drilling  Multiligament Injury

Allograft BPTB ACLR in Patients <30

Methods

Surgical Technique - Transtibial

• Autograft Patellar Tendon

 Cancellous Bone Graft  1/3 Thickness Closure

• Allograft Patellar Tendon

 Under 40 years of age  Always 5+ Years Younger Than

Patient Age

 No Terminal Irradiation

• Bioabsorbable Interference Screw

 (ConMed Linvatec, Largo, FL)  Biphasic calcium phosphate  Poly-L D-lactide (PLDLA)

• Meniscal Repair

 All-Inside OR Inside-Out

Allograft BPTB ACLR in Patients <30

Methods

Post-Op Rehabilitation Protocol

• Conservative Rehab Program

 Home CPM: 2-3 Weeks  Knee Brace

 6 weeks: Post-Op Knee Brace

• Locked: Progress From 10o to 90o

 Weeks 6 to 12 Post-Op

• ACL Sport Specific Knee Brace

 Supervised Physical Therapy

 Month 5 Post-Op:

• Return To Sport Specific Brace
• Cut Workout Intensity In Half

 Cutting/Pivoting Sports

 Adequate Proprioception  Sport Test

• No Sooner Than 6 Months

5 Months S/P – ACLR Interstitial Revascularization

• Subjective Questionnaires

 Tegner Score  Lysholm Score (0-100)  IKDC Score (0-100)

• Physical Examination

 Pre & Post-Operative MRI/CT Scan  Ligamentous Laxity Testing  Lachman/Pivot-Shift  Range of Motion

 Flexion & Extension

 KT-1000

 5 lbs, 10 lbs, 20 lbs, Manual Max

Allograft BPTB ACLR in Patients <30

Methods

Data Collection

• Graft Failure Definitions

 Recurrent Subjective Knee Instability  Positive Lachman/Pivot Shift Test(s)  Imaging Positive For ACL Graft Rupture (MRI)

Allograft BPTB ACLR in Patients <30

Methods

Clinical Failure

BPTB ALLOgraft (n=13) BPTB AUTOgraft (n=35) P-Value Gender 5 males 8 females 27 males 8 females Patient Age (years) 23.8 + 3.9 22.0 + 4.4 p=0.187 Average Follow-Up (years) 6.7 + 3.7 8.7 + 5.2 p=0.155

Allograft BPTB ACLR in Patients <30

Results

Patient Demographics

• Overall Failure Rate

 Allograft: N=0 (0%)  Autograft: N=1 (2.9%)

 4 Years Post-op  Successful BPTB

Autograft Revision

 p = 0.324

• ALL Patients Returned To

Pre-Operative Sport

 ALL Patients Regained A

Tegner Score Of > 5

 Range 5-9

Allograft BPTB ACLR in Patients <30

Results

Return To Sport

Basketball 10.4% Other 29.2% Soccer 18.8% Baseball 20.8% Skiing 20.8%

10 20 30 40 50 60 70 80 90 100 Post-Op Lysholm Post-Op IKDC Functional Score ALLOGRAFT AUTOGRAFT 2 4 6 8 10 12 Post-Op KT-1000 Man. Max Anterior Tibial Translation (mm) ALLOGRAFT AUTOGRAFT

Allograft BPTB ACLR in Patients <30

Results

Functional Performance

• BPTB Allograft vs. BPTB Autograft
• NO Differences in Clinical Outcome (Significance p<0.05)
• Lysholm: p=0.380
• IKDC: p=0.324
• KT-1000 Manual Max: p=0.740

• Allograft BPTB ACLR is an

Excellent Option for Patients Under 30 Years of Age

 Allows for Return to Pre-Operative

Sport (ANY Sport, ANY Level)

 Equal Outcomes as Autograft BPTB

ACLR

 No Evidence of Increased Failure Rate

• Allograft Selection Important

 Age Always > 5 Years of Patient  No Terminal Irradiation

• Slow, Conservative Rehabilitation

is Required

Allograft BPTB ACLR in Patients <30

Conclusions

Thank You