Disclosure Consultant and receives royalties from Allograft ACL - - PowerPoint PPT Presentation

5/9/2014 1 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

Disclosure

• 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”

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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”

– KrychArthro 2008, LawhornArthro 2012, MarisculoAJSM 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

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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)

Patient Selection

12 Soccer 3 Football 1 Volleyball 1 Mountain Climbing 1 Baseball 1 Basketball

Evaluation

• 17 patients reported patient satisfaction,

function and ability to return to sport by filling

• ut 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

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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

Surgical Technique Technique Picture of XRAY

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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

Manual Max Exam

6 - 0 mm 2 - .5 mm 3 - 1-2mm AVE. 1.omm

1 - 7mm (f)

Satisfaction and Return to Sport

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

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Results

• Self satisfaction: 14 excellent/3 good
• Objective : 1 failure / 17 pts
• 16/17 pts able to return to sport
• Failure Rate <6%

Conclusions

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

ED CABAUD “one day we will use allograft tendons to reconstruct the anterior cruciate ligament”

The Cabaud Memorial Award

Thank You

• Special thanks to Laura Osorio M.A.