Evidenced Based Approach to ACL Injuries Balmain Sports Medicine November 2011

Who am I?

References to Read Handout

Epidemiology Females have a 2-6x higher incidence ACL rupture compared to males in the same sport Overall Incidence over 4 year period Females 3.8% Males 3.5% 67% men and 90% women rupture without contact

Prevention Neuromuscular Interventions Hewett TE Am J Sports Med 2006 Gilchrist Am J Sports Med 2008

Pathophysiology Isolated ACL in less than 10% Meniscal injury in 60-75% Bone Bruise on MRI in 80% Collateral injury 5-24% Articular cartilage damage 46%

Diagnosis History Examination MRI Lachman 85% sensitive, 94% specific Pivot 24% sensitive, 98% Specific MRI Sens 86% specific 95%

Indications Surgery Sensation of Instability in normal ADLs Resume sports with cutting and pivoting Particular jobs

Indications for Surgery Kanon/Frobell N Eng J Med 2010

Delayed group Previously – at 2 years 37% went on to have ACL reconstruction 20% chance requiring delayed meniscal surgery Previously – at 2 years Rate meniscal tear non operative 37% Post Surgery 3%

Graft Choice Autograft – Patients own tissue Allograft – someone else's tissue Synthetic - Artificial 13

Autograft The autograft source has a minimal effect on the outcome of patients undergoing anterior cruciate ligament reconstruction

Bone Healing – BTB 4-6weeks Soft Tissue Healing 9-12 weeks

Primary ACL Reconstruction utilising The Quadriceps Tendon: The Forgotten graft? Systematic Review of Primary ACL Reconstruction utilising Autograft Quadriceps Tendon Anterior knee pain 10 vs 35%(BTB) 3% failure rate S Hutchinson, J Mulford

Quads Tendon Pros Cons Strong graft Good for revision graft May be useful for double bundle May have less morbidity then Patella and hamstrings Cons Quads weakness Anterior knee pain Not commonly used 18

Allograft Allograft significantly lower normal stability rates than autograft Allograft abnormal stability rate 3 times greater than autograft. The graft failure rate was 4.7 +/- 0.5 per 100 for autograft reconstructions 8.2 +/- 2.1 per 100 allograft reconstructions 19

Artificial Graft Have been used for over 30years Avoids the donor site morbidity, quicker recovery, cheat biology. Problem has been their durability – they have not matched autograft in this regard. 20

Media Miracle op to melt down surgeons' phones 21

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4 Comparison Papers No difference in the 10 outcome measures at final follow up (15 – 49 months). LARS patients reached full recovery sooner.

Correspondence Dr Nicolas Duval Best results are in early ACL repair augmented by LARS Expect 80 to 90% good results at 10 years. Chronic ACL tear - 50% failure at 10 years Revision ACL surgery - 40% failure at 10 years.

Electron Microscopy

Pittsburgh Group

The future – Scaffolds and Growth Factors with Repair. tissue engineering techniques Grafts that regenerate a mechanically robust and natural ACL cell-specific growth factors that influencing the maturation and healing response of ligament tissue will also be available. 32

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Patient Specific Approach Choose graft that matches the patients needs. Discuss the pros and cons of each graft.

Rehabilitation CPM – no substantial advantage Weight bearing – standard practice Post op bracing – not necessary

Neuromuscular stimulation – high-intensity early post-op period Neuromuscular stimulation – high-intensity early post-op period. Not required to achieve successful outcome. Accelerated rehab - minimal evidence for safe return to sport.

Closed vs Open Closed chain safe Concern open chain results in increased laxity Open chain excercises from 6 weeks may be safe and improve patient outcome (Mikkelsen) Glass – systematic review

LIPUS

Evidence of Expected Outcome Predictors of poorer outcome Smoker female higher body mass index older age.

Complications Reconstruction Graft Failure – 3.6% Infection 1% Additional Arthroscopic Surgery – 15% DVT – low Nerve injury low

Risk Arthritis Oiestad -Systematic Review Isolated injury – prevalence 0-13% at 10 years ACL + Meniscus – 21-48% at 10 years

Expected Outcome ROM normal Laxity 1-2 mm Isokinetic strength Av > 90% Marx Activity reduced by 4 IKDC Score < 40% normal Contralateral ACL tear 3% Graft Failure 3%

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