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Evidenced Based Approach to ACL Injuries Balmain Sports Medicine November 2011.

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Presentation on theme: "Evidenced Based Approach to ACL Injuries Balmain Sports Medicine November 2011."— Presentation transcript:

1 Evidenced Based Approach to ACL Injuries Balmain Sports Medicine November 2011

2 Who am I?

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5 References to Read Handout

6 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

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

8 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%

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

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

11 Indications for Surgery Kanon/Frobell N Eng J Med 2010

12 Delayed group – 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%

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

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

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

17 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

18 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

19 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

20 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.

21 Media Miracle op to melt down surgeons' phones

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25 4 Comparison Papers No difference in the 10 outcome measures at final follow up (15 – 49 months). LARS patients reached full recovery sooner.

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28 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.

29 Electron Microscopy

30 Pittsburgh Group

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32 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.

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

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

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

37 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

38 LIPUS

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

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

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

42 Expected Outcome ROM normal Laxity 1-2 mm Isokinetic strength Av > 90% Marx Activity reduced by 4 IKDC Score < 40% normal Contralateral ACL tear3% Graft Failure3%

43 Thankyou


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