Which Graft Leo P – Hamstrings Merv C – Patella tendon Americans Allograft Koreans Quads Tendon Footy show says Synthetic Graft ????????
Media LARS option: Fisher aims for fast return David Rodan back on training track two weeks after knee surgery Miracle op to melt down surgeons' phones Rodan surgery to become the norm Covell's career on knife's edge Moltzen plays it safe
WHICH GRAFT WOULD YOU HAVE? Autograft Allograft Synthetic
Lets look at some evidence
Allograft Allograft significantly lower normal stability rates than autograft Allograft abnormal stability rate 3 times greater than autograft.
Hamstrings Good Things Bad Things
Hamstrings Pros – Quick harvest – Reliable – Can use for double bundle – Small incisions
Hamstring Graft Cons – Subtle hamstring discomfort – Graft gets weaker intially as revascularises – Fixation to bone can takes longer than BTB – Stretches a little more than BTB – Graft size not predictable
Patella Tendon Good Things Bad Things
Patella Tendon Pros – Bone heals to bone quickly – Stiffer graft (doesnt seem to stretch as much) – No hamstring problems – Better if larger heavier patients and collision sports ligament lax individuals Known Hamstring problems
BTB graft Cons – Arguably anterior knee pain (Bone graft) – Longer to harvest graft – Larger incisions – uncomfortable initially – Risk of patella fracture and tendinopathy
Quads Tendon Good Things Bad Things
Quads Tendon Pros – 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
Great What does the literature tell us. Remember there is a lot of poor literature.
Patella vs Hamstrings
What about Quads? Currently performing Systematic review. No difference to BTB Quads strength? / less anterior knee pain ? /
Patient Specific Approach Choose graft that matches the patients needs. Discuss the pros and cons of each graft.
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.
As a result Long rehab that Lion opts for LARS 11/5/2010
LARS Whats good? Whats bad?
History Artificial Grafts 1918 silk sutures – failed 3 months First graft Proplast made of polytetrafluoroethylene (PTFE) Results with this system yielded an average time to breakage of just over 1 year.
Classification of Synthetic Grafts – Ligament Augmentation Devices (polypropylene, polyester) initial strength until revascularisation, stress shielding of autogenous tissue and prevented adequate strength. – Total Prosthetics permanent replacement with no revascularisation. Excellent short-term results, long-term efficacy results were poor due to wear and ensuing rupture of the prosthesis.
CARBON FIBRE PROSTHETICS Began late 70s carbon wear particles coated with collagen and absorbable polymers Good Early results longer term - unacceptable stretching and complete rupture as major complications.
DACRON tightly woven polyester strips. Early results were good however by 4 years about 50% had failed due to stretching of the graft.
LEEDS-KEIO ARTIFICIAL LIGAMENT a polyester mesh intended as a scaffold for soft tissue ingrowth Good early results. a large number of long-term graft ruptures despite excellent early results
KENNEDY LIGAMENT AUGMENTATION DEVICE (LAD) – 1980 Ligament Augmentation Device (LAD) in Idea - protect the autogenous tissue graft early Problem - Stress shielding resulted. Later - effusion and synovitis.
LIGAMENT ADVANCED REINFORCEMENT SYSTEM (LARS) ARTIFICIAL LIGAMENT polyethylene terephthalate (PET). intra-articular segment – Twist – PET Encourage ingrowth wear resistance of 22 million of cycles = 10 years of straining use.
Literature on LARS One case synovitis reported short term. Short term results in a handful of papers are good. Fast recovery and return to sport/activity. risk of rupture remain and must be addressed through long-term follow-up studies.
3 ruptures of synovitis
Longest Follow-up LARS ACL Reconstruction Using Artificial Ligament: Five Years Follow Up S.I.O.T. 2007; 33(suppl.1) : G. Cerulli et at. 25 patients older than 40 - Lars® artificial ligaments at a five-years follow-up with very good results.
Dr Nicolas Duval using LARS since 1993 Best results are in early ACL repair augmented by LARS In older patients (more than 50) I use the LARS in any condition because of the low morbidity and easy rehab.
Why is rehab Faster No Donor site Morbidity Graft not going to weaken early.
LARS Indications Sportsmen who have acute injury require fast recovery for particular target time AND prepared to take the risks possible long term failure. Older patients with less demands however functional instability and want less involved rehab.
LARS concept is good but not quite right
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.
Platelet Rich Plamsa - Injections
Other ACL controversy
Graft Tunnel Placement Many papers recently. Femur – medial portal better than trans-tibial. Tibia – place posterior aspect foot print.
Double bundle – double trouble? Meta-analysis – No significant difference clinically between double bundle and single bundle.
ACL Navigation Has been available since Overall gives more reliable positioning of the tunnels No clinical benefit shown there is still debate over positioning of the tunnels.
Patellofemoral Joint Instability MPFL
CARTILAGE LESIONS Bottom Line – at present no technique has clinically shown to be superior than another.
Emerging Options for Treatment Articular Cartilage Injury in the Athlete Very controversial!!! Treatment articular cartilage injuries is a therapeutic challenge. Cartilage not good at repairing due to avascular surroundings and unique matrix organisation
Non Surgical Chondrotin Sulphate Synvisc One
Surgical Options Options – Marrow stimulation techniques – Osteochondral transplant techniques – Cell based repair techniques Future - Use of Stem Cells and Growth Factors
Marrow Stimulation Techniques Microfracture – Minimally invasive, low morbidity, relative short rehab. – Micropenetration of subchondral plate creates blood clot containing pluripotent marrow derived mesenchymal stem cells. – MSC produce fibro-cartilage repair tissue. – Time from injury to micro-fracture is important – Best lesion size <200mm sq
Enhanced Microfracture – Try to enhance chondrogenic differentiation – Addition growth factors (TGF-B3, BMP-7) – Still in the lab
Cell based repair techniques MACI Cartilage taken – grown in lab and then reinserted.
Stem Cells The Regenexx procedure as an alternative to traditional knee surgery is non-invasive, resulting in faster healing and less recovery time. Read more about our knee surgery alternative, or fill out our form below to find out right now if you are a candidate.knee surgery alternative Banking Stem Cells
Mesenchymal Stem Cells MSC found in bone marrow, skeletal muscle, synovial membrane, adipose tissue and umbilical cord blood.
Problems MSC Selection Cell Delivery to site 3D Scaffold ideal (synthetic or polymer) – Synthetic issues retention and degradation – Biological – disease transmission, immunological reaction, precision.
Tissue Engineered Construct - TEC Synovial tissue cultured with ascorbic acid – sheet collagen produced 3D tissue is produced with cartilage cells interwoven in extracellular matrix Culture in medium with growth factors known to stimulate cartilage and type II collagen More Fibrous than Hyaline Testing with different GF and gene modification with viruses.
Meniscal Lesions Different populations Young high energy sports injury. Middle aged sports injury with previous recon Low energy associated with OA
Meniscus Replacement Partial menisectomy Replacement with a Collagen Meniscal Implant (CMI) is an option. CMI is approved in Europe for medial meniscus. CMI is a collagen-based implant that acts as a scaffold for tissue infiltration. They are like a sponge made from bovine achilles tendons, GAGs are added, they are deg\hydrated and orietated in a mold then chemically crosslinked with formaldehyde.
Meniscus replacement - Allograft Problems are availability, logistics, costs, and varying results
Future - Stem Cell Therapy Goats – MSC injected into knees that where OA due to ACL deficiency, A new meniscus like regenerative type tissue formed
CONCLUSION Lots of exciting advances happening in sports knee injuries. Many advances are still some way off clinical application. Balance of biology, synthetics, growth factors and gene manipulation. Watch this space!