Isolated ACL Tear Pro: Bone-Patella-Bone CAPT Matthew T. - - PowerPoint PPT Presentation

Isolated ACL Tear Pro: Bone-Patella-Bone

CAPT Matthew T. Provencher, MD, MC USNR Shoulder, Knee and Sports Surgery The Steadman Clinic & Steadman Philippon Research Institute Professor of Surgery, USUHS

Disclosures

• Royalties - Arthrex
• Stock - None
• Consultant - Arthrex; JRF
• Research Support -

AOSSM Grant (2005); AANA Research Grant (2008; 2006); OREF Grants (2002; 2004); BUMED (2009; 2012; 2014)

• Editorial Boards -

Elsevier (Arthroscopy - Asst. Editor in Chief; JSES), JBJS, JAAOS, SLACK (Orthopaedics, JKS), Sage (AJSM)

• Board Memberships -

AOSSM (Board of Directors, Research); SOMOS (Past Pres.); AAOS (Program; Annual Meeting); BOS/BOC (Research); ISAKOS (UE); AANA (Program/Education); ASES (Program; Membership; Technology)

Debate case

• A 33-Year-Old Yoga Lover
• Former Ballet Professional
• Isolated ACL Tear

• 127 patients - randomized study of three arthroscopically

assisted reconstruction techniques

• 125 f/u for mean 42 months
• semitendinosus-gracilis vs. two incision BTB vs. one incision

BTB

• KT-2000 and International Knee Documentation Committee
• Two incision BTB -
• returned to a greater level of athletic activity (p < 0.02)
• higher percentage of the pts in this group had a difference of

three millimeters or less on testing with the KT-2000 (p < 0.08)

1996

• BTB vs. Semi-T and gracilis w/ extra-articular procedure
• vs. Semi-T and gracilis alone
• 102 patients w/ mean 35 month f/u
• Assessed via International Knee Documentation

Committee knee evaluation and KT-1000

• Found increased laxity on instrumented testing in the non-

BTB groups

• Lesser Outcomes with Increased Laxity!

2001

• 56 patients - 28 randomized to BTB, 28 to semitendinosus-gracilis
• F/U for mean 39 months
• Evaluated in terms of clinical test findings, patient satisfaction, activity level,

functional status. and isokinetic muscle strength

• Hamstring graft - had an average of 4.4 mm of increased anterior knee

laxity, BTB - 1.1 mm of increased knee laxity

• 14% of hamstring pts had a mild pivot shift, 27% had a moderate pivot shift
• Only 14% of BTB had a mild pivot shift, and none had a moderate pivot shift
• Hamstring graft had been used had significantly lower peak knee-flexion

strength than BTB (p = 0.039)

2002

• Patients with patellar tendon grafts had greater Tegner activity

scores (P = .04)

• Single Assessment Numeric Evaluation scores:
• 88.5 - hamstring
• 90.1 - BTB (P = .53)
• Lysholm scores:
• 90.3 - hamstring
• 90.4 - BTB (P = .97)
• Postoperative graft rupture correlated with more horizontal tibial

tunnel orientation

2009

• 101 pts f/u for 24 months after ACLR w/ multiple-looped

semitendinosus

• 51 men and 50 women
• Postoperative differences in joint stability tested by KT2000
• Significant difference between post-op men, −2.3 to 4.1, and

women, −0.4 to 6.8 (P<0.01).

• >3 mm difference in 4% of men and 12% of women
• Increased failure rate in women compared with men with the

hamstring graft

In female pts specifically?

2004

• Prospectively followed 80 comparable athletes, 46 males, 32

females, after ACLR using either patellar tendon or hamstring graft for mean 36 months.

• BTB group - 26 males and 14 females
• Hamstring group - 22 males and 18 females
• Assessed by clinical evaluation, computerized knee laxity analysis,

isokinetic and functional strength tests, and standard knee scores

• Females in the hamstring group had significantly greater laxity,

and isokinetic tests at 1 year revealed a significantly higher deficit of peak torque at 60°/s in flexion and extension.

In female pts specifically?

2004

• Systematic review of sixteen meta-analyses
• The number of patients analyzed ranged from 361 to 3402 with a mean 1396

patients meeting eligibility criteria per study.

• Most studies found BPTB autografts to provide superior stability…
• but more postoperative complications, such as anterior knee pain and kneeling

pain.

• 5 studies found BPTB autograft had a significantly increased chance of

attaining a statically stable knee

• 6 studies found that patients with a BPTB autograft had a significantly lower

rate of positive pivot-shift test findings.

2017

What Do We Do in NFL?

ALCR 20 y.o. starting NCAA Division 1

• r NFL running back

ACLR for 25 y.o. recreational athlete

2014

Preferred graft choice for:

Op Plan

• ACL revision reconstruction of BTB

allograft

• FCL reconstruction with semitendinosus

allograft

Demonstration of technique in another case

ACL Harvest

Retrograde Drilling of Femoral Tunnel

Passing graft

What Would You DO?

• Evidence shows BTB Most Favorable in this Case!

Thank You!