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ACL Debate Chad J. Micucci, MD & Gregory J. Purnell, MD

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Presentation on theme: "ACL Debate Chad J. Micucci, MD & Gregory J. Purnell, MD"— Presentation transcript:

1 ACL Debate Chad J. Micucci, MD & Gregory J. Purnell, MD
Orthopedic Research of Virginia May 2010

2 Overview Introduction The Issues With ACL Injuries
Anatomic ACL Reconstruction Graft Selection Discussion

3 ACL Anatomy First described by Palmer 1938 Two fiber bundles
Anteromedial (AM) Tight in flexion Posterolateral (PL) Tight in extension Based on insertion into the tibia

4 Anatomy Avg length: 32 mm (range 22-41mm)
Avg Width: 11 mm Vascular supply: middle geniculate artery Nerve supply: primarily post. Articular nerve Mechanoreceptors Ruffini end-organ receptors (stretch) Free nerve endings (at insertion)

5 Femoral and Tibial Insertions
AM Bundle PL Bundle Flexion Extension PL AM An important concept to understand is the relative change of the ACL insertion sites throughout flexion and extension: Extension: two bundles are parallel Flexion: femoral insertion site of the PLB comes forward and the two bundles cross each other PL AM AM PL

6 AM and PL bundle have different length and diameter
7.0 mm 6.4 mm PL AM PL Studies of intraarticular length AMB significantly longer intraarticular length However, cross-sectional diameter not too different AM 38.5 (+/-3) 19.7 (+/-2) AM and PL bundle have different length and diameter

7 Natural History True natural history will probably never be known
Most studies look at symptomatic patients Numerous studies have implicated the ACL deficient knee in accelerated osteoarthritis 40-70% patients have x-ray evidence of DJD at 8-10 yrs Jones, Injury Clinic, 2003

8 Pathogenesis Most commonly via non-contact mechanism (70-80% of ACL injuries) Sports: football, basketball, soccer Classic mechanism Valgus, ER, twisting injury during deceleration Epidemiology 150,000 new injuries per year In given sport, females have 4-8 higher risk

9 Associated Injuries Meniscus tears common
Acute, lateral: 75% Chronic, medial: 91% Noyes, JBJS, 1980 Removal of as little as 15-30%→ ↑ contact forces up to 350% Baratz, Am J Sports Med, 1986 Meniscus is a secondary stabilizer to anterior translation in ACL deficient knee

10 Bone Bruises Middle portion of LFC; posterior portion of lateral plateau Graf, Am J Sports Med, 1993 Significance unknown Result of rotatory motion Second look arthroscopy at 6 years shows cartilage thinning in areas of bruising Clatworthy, Clin Sports Med, 1999

11 Pathophysiology Four categories: Environmental Anatomical Hormonal
Dry playing surfaces Increased fricition between shoes and surface Anatomical Larger X-sect area of ACL in males Narrower notch in females (? Significance?) Hormonal Conflicting data on estrogen and progesterone Biomechanical Differing patterns of knee motion may be associated with differences in neuromuscular control (i.e., females decrease hamstring firing, higher ant. Tibial shear force, greater knee valgus moment, smaller knee flexion angle have been noted in some studies)

12 Diagnosis History Exam Very important! Mechanism Effusion
Effusion, joint line tenderness, ROM Ligamentous exam (Lachman’s) KT 1000 (quantify laxity)

13 Radiologic studies X-rays AP, Lateral, Merchant

14 MRI High sensitivity and specificity for ACL tears
Overall accuracy approx. 95% Not mandatory for surgical intervention However, important for documenting associated injuries

15 Classification Grading ACL injuries I up to 5 mm II 6-10 mm
III mm IV > 15 mm Also note “firm” or “soft” end-point

16 Treatment Non-operative Operative Graft Selection
Usually based on lifestyle Rehabilitation Quad/Hamstring strengthening Operative Arthroscopic reconstruction Graft Selection BTB Hamstrings Allograft

17 ACL Reconstruction

18 Goals of ACL surgery Provide stable joint**
Delay osteoarthrosis Avoid further internal derangement Return to sport, work, recreational activities**

19 Success of the ACL surgery
Clinical success rates range from 69-95% Yunes, Arthroscopy, 2001 Freedman, Am J Sports Med, 2003 Studies include data from experienced, fellowship trained ACL surgeons 85% of surgeons performing ACL reconstruction do fewer than 10 per year Harner, Arthroscopy, 2004

20 Success?? Degenerative radiographic changes in 90% of patients 7 years after ACL single-bundle reconstruction 47% of patients returned to previous activity level after ACL single-bundle reconstruction Fithian et al, Am J Sports Med, 2005

21 In Vivo: Abnormal Rotational Knee Motion During Running After ACL Reconstruction
Tashman, AJSM, 2004 Using high speed stereoradiographic system AP stability restored in ACL reconstruction Rotatory instability persisted May contribute to long-term degeneration

22 Biomechanical analysis of anatomic ACL reconstruction. AJSM 2003
Fu and co-workers Demonstrated that a non-anatomic single-bundle reconstruction is biomechanically and kinematically inferior to an anatomic reconstruction (whether it is double- or single-bundle)

23 Femoral Tunnel Knee flexed 110- 120°
Femoral drilling guide through anteromedial accessory portal 10 or 2 o’clock position (right or left knee) Tunnel drilled over guide wire

24 Loh, et al, Arthroscopy, 2003 12 12 Femoral Tunnel 9 9

Your patient has already researched it on the INTERNET!!!!

26 Graft Selection Patellar tendon Hamstring tendons
Photos: Christina Allen, AAOS Patellar tendon Graft Selection Hamstring tendons

27 Goals of surgery Restore function Limit complications

28 What is the # 1 question on this athletes’ mind???
When can I come back and play, Doc?


30 Hamstrings INFERIOR Hamstring reconstructions:
1. Longer time to graft incorportation 2. Grafts loosen/Tibial fixation 3. Residual flexion weakness

31 Graft Healing Anterior Cruciate Ligament Replacement using Patellar Tendon. An evaluation of graft revascularization in the dog. Arnoczky JBJS 1982. 16 weeks showed near-completion of revascularization of the graft. Tendon-healing in a bone tunnel: a Biomechanical and histological study in the dog. Rodeo et al. JBJS 1993. Tendon healing to bone: 12 weeks Bone-tendon-Bone healing: 6 weeks

32 Failure of Osteointegration of Hamstring Tendon Autograft After Anterior Cruciate Ligament Reconstruction Eun Kyoo Song, M.D., et al Arthroscopy Report on 2 cases of failed osteointegration between the hamstring tendon and bone Concluded failed fixation methods

33 Graft Fixation Inadequate fixation is the most common cause of ACL failure in the first 2 months post-op Studies have indicated tibial fixation the weakest point in early post-op period (due to cancellous bone and screw divergence) Most common is Interference screw fixation Parallel fixation is crucial Area of screw compressing bone plug or soft tissue graft important

34 Graft loosening? BTB grafts heal faster
BTB fixation better construct than SMT [Adam AJSM 2004] BTB had lower side to side difference [Freeman AJSM 2003] BTB have less tunnel widening [Aglietti JBJS 2004]

35 Restoration of function
2003 JOURNAL “…Patellar tendon autografts had significantly lower rate of failure and resulted in better knee stability and increased patient satisfaction…”

36 Flexion weakness Theoretical in most activities
> 90% strength of contralateral knee [Spindler AJSM 2004] Weakness most significant at higher degrees of flexion (>90 degrees) [Nakamura Arthroscopy 2002] @ 18 months, 69-83% decrease in strength with 110 degrees of flexion [Tashiro AJSM 2003]

37 Hamstring Regeneration
Knee Surg Sports Traumatol Arthrosc Jun;14(6):542-5 Knee Surg Sports Traumatol Arthrosc Feb;15(2): (Review) Show regeneration of hamstrings both grossly and macroscopically (“closely resembles” normal tendon)……just like “hyaline-like” cartilage!!!!

38 Hamstrings Regenerate???
Really!?! With Seth and Amy on ACL graft selection

39 Hamstring use in ACL surgery Burks et al. Arthroscopy 2005
Hamstring strength testing revealed a 26% deficit at 6 months, 21% at 12 months Conclusions: At 1 year, the S.T.and gracilis muscles showed significant and persistent atrophy and frequent retraction of the S.T. muscle belly. Hamstring strength deficits persisting at 1 year after the use of the tendons for ACL reconstruction.

40 More WEAKness… Evaluation of Active Knee Flexion and Hamstring Strength After Anterior Cruciate Ligament Reconstruction Using Hamstring Tendons Norimasa Nakamura, M.D., et al Arthroscopy Isokinetic testing showed decreased strength at 90 deg flexion angle on operative side The side-to-side ratio in mean maximum standing knee flexion angle was significantly lower in the ST/G group than in the ST group. Conclusions: This study suggests that the loss of knee flexor strength following the harvest of the hamstring tendons may be more significant than has been previously estimated. Furthermore, multiple tendon harvest may affect the range of active knee flexion

41 What He’s Going to tell you…

42 Hamstrings B-T-B Easier to harvest As strong or stronger than B-T-B
No anterior knee pain More difficult harvest Anterior knee pain Patella fractures

43 Prevalence of Saphenous Nerve Injury After Autogenous Hamstring Harvest
Brett Sanders, M.D., et al. Arthroscopy 2007 Results: Postoperative sensory disturbance was present in 74% of patients surveyed. Conclusions: The SBSN is at higher risk of injury during hamstring ACL reconstruction than has been previously reported.

44 Hamstrings B-T-B Easier to harvest As strong or stronger than B-T-B
No anterior knee pain More difficult harvest Anterior knee pain Patella fractures

45 Treatment of Anterior Cruciate Ligament Injuries With Special Reference to Graft Type and Surgical Technique: An Assessment of Randomized Controlled Trials (A systematic review) Kristian Samuelsson, M.D., et al. Arthroscopy 2009 The BPTB graft produces more anterior knee pain and kneeling pain than the HT graft, but the difference disappears with time.

46 How often do you kneel on a daily basis???
Plumber Wrestler Construction ……….

47 Hamstrings B-T-B Easier to harvest As strong or stronger than B-T-B
No anterior knee pain More difficult harvest Anterior knee pain Patella fractures

48 3 fellowship-trained sports medicine surgeons
The Incidence of Acute Patellar Tendon Harvest Complications for ACL Reconstruction Bach et al. Arthrscopy 2008 September 1986 to April 2006 1,725 consecutive patients primary ACL reconstruction using BPTB autograft 3 fellowship-trained sports medicine surgeons 3 acute complications (0.2%) related to patellar tendon harvest 2 patella fx (1 intra-op, 1 post-op); 1 patellar tendon rupture remains a safe and viable choice

49 Outcomes Central Third Bone–Patellar Tendon–Bone Anterior Cruciate Ligament Reconstruction: A 5-Year Follow-up Jig V. Patel, F.R.C.S., J. Sam Church, B.S.c., M.B., B.S., and Anthony J. Hall, F.R.C.S. All patients had knee flexion within 10 degrees of uninjured leg Only 3 patients had clinical signs of instability on 5 yr follow up Either + Lachman’s, pivot shift, or >3mm diff. on KT-1000

50 Outcomes Reconstruction of the anterior cruciate ligament: meta-analysis of patellar tendon versus hamstring tendon autograft. Goldblatt, Richmond, et al Arthroscopy 2005 Overall, incidence of instability is not significantly different between the BPTB and HT grafts. However, BPTB was more likely to result in normal Lachman, normal pivot-shift, KT-1000 side-to-side difference < 3 mm, and fewer results with significant flexion loss.

51 Outcomes Reconstruction of the anterior cruciate ligament in females: A comparison of hamstring versus patellar tendon autograft. Barrett et al. Arthroscopy 2002 CONCLUSIONS: Although not statistically significant, the hamstring group had more failures, more laxity on exam, and more pts with larger KT-1000 differences. These results indicate a trend toward increased graft laxity in female patients undergoing reconstruction with hamstring autograft compared with BTB


53 Thank you for playing…….
Here is your parting gift from our WINNER……


55 What I will tell you about….
Hamstrings YES, they are: -stronger -easier to harvest -smaller incision -no anterior knee pain -weakness not noticeable long term -outcomes equal B-T-B And YES, they are: More difficult harvest More risky complications Anterior knee pain Loss of ROM Larger incision No better outcomes

56 Complications of BTB grafts
Medscape Anterior knee pain Loss of extension Degenerative joint disease Extensor mechanism disruption

57 Anterior knee pain Spindler, AJSM, 2004 “When evaluating subjective anterior knee pain or kneeling pain, the results are reproducible and clear-cut.” Kneeling pain 50-65% BPTB unable to walk on yrs Ejerhed AJSM 2003 50% @ 7 yrs Roe AJSM 2005

58 Bach et al. Arthroscopy 2010 Femoral recession Graft rotation
Avoiding Mismatch in Allograft Anterior Cruciate Ligament Reconstruction: Correlation Between Patient Height and Patellar Tendon Length Bach et al. Arthroscopy 2010 Femoral recession Graft rotation Hybrid fixation

59 Extensor mechanism disruptions
3 acute complications related to patellar tendon harvest 2 patella fx (1 intra-op, 1 post-op); 1 patellar tendon rupture Bach et al. Arthrscopy 2008 Patellar Tendon Rupture 3 Years After Anterior Cruciate Ligament Reconstruction With a Central One Third Bone–Patellar Tendon–Bone Graft Phillip L. Mickelsen, M.D., et al. Arthroscopy 2001

60 Technical Note Management of Patella Fractures Associated With CentralThird Bone-Patella Tendon-Bone Autograft ACLReconstructions Eugene E. Berg, M.D. Arthroscopy: The Journal of Arthroscopic and Related Surgery. Vol 12, No :


62 Reconstruction of the anterior cruciate ligament: meta-analysis of patellar tendon versus hamstring tendon autograft Goldblatt, Richmond, et al Arthroscopy 2005 HT grafts had a reduced incidence of patellofemoral crepitance, kneeling pain, and extension loss

63 What healing problems??? Comparison of Clinical Results and Second-Look Arthroscopy Findings After Arthroscopic Anterior Cruciate Ligament Reconstruction Using 3 Different Types of Grafts Jung Hwan Lee, M.D., et al. Arthroscopy 2010 Hamstring autograft group better synovial coverage on second-look arthroscopy Better synovial coverage on second-look arthroscopy presented better clinical results on the IKDC objective examination form.

64 Graft loosening? Fixation method, not graft type, cause of slippage
The truth… PT tendons heal faster Transfixation better than interference for hamstring grafts??? Ahmad AJSM 2004 Tranfixation of STG may be better than interference PT Rowden AJSM 1997 Fixation method, not graft type, cause of slippage

65 The Incision

66 Hamstring strength NOT an issue
GRAFT TENSILE LOAD (N) STIFFNESS (N/mm) CROSS SECTIONAL AREA (mm2) Native ACL 2160 242 44 Patellar Tendon Autograft 2977 620 35 Quadrupled Hamstrings 4090 776 53 West and Harner JAAOS 2005

67 What would you want for your daughter????

68 Outcomes Anterior cruciate ligament reconstruction, hamstring versus bone-patella tendon-bone grafts: a systematic literature review of outcome from surgery. Herrington, et al. Knee 2005 The results of the 13 studies included in this review suggest that there is no significant evidence to indicate that one graft is superior. Both the PT and HT grafts appear to improve patients' performance, and therefore both would be good choices for ACL reconstruction

69 Outcomes Patellar tendon or four-strand hamstring? A systematic review of autografts for anterior cruciate ligament reconstruction Forster, et al. Knee 2005 Overall, there was a greater chance of extension loss (p=0.007) and a trend towards increased PFJ pain (p=0.09) with BTB There was no difference with Lachman testing, chance of returning to the same level of sport, clinical knee scores, graft ruptures or other complications.

70 Outcomes A prospective, randomized comparison of semitendinosus and gracilis tendon versus patellar tendon autografts for anterior cruciate ligament reconstruction: five-year follow-up Sajovic, et al. AJSM 2006 CONCLUSION: Both provided good subjective outcomes and objective stability at 5 years. No significant differences in the rate of graft failure were identified. Patients with patellar tendon grafts had a greater prevalence of osteoarthritis at 5 years after surgery.

71 Outcomes Hamstring tendon versus patellar tendon anterior cruciate ligament reconstruction using biodegradable interference fit fixation: a prospective matched-group analysis. Wagner et al. AJSM 2004 Hamstring tendon graft was superior in knee stability and function. These findings are partially contrary to previous studies and might be attributable to the use of an anatomical joint line fixation for hamstring tendon grafts.

72 Outcomes No difference in knee function or prevalence of osteoarthritis after reconstruction of the anterior cruciate ligament with 4-strand hamstring autograft versus patellar tendon-bone autograft: a randomized study with 10-year follow-up Homi et al. AJSM 2010 No statistically significant differences in clinical outcome at 10 years Prevalence of OA significantly higher in operated leg No significant differences between the 2 groups

73 Regardless…………..Educate
Factors Affecting Patient Selection of Graft Type in Anterior Cruciate Ligament Reconstruction Cohen et al. Arthroscopy 2009 Most important factor for a patient choosing a graft for ACL reconstruction is physician recommendation Increasing trend toward the use of allograft materials for ACL reconstruction 63.3% of all graft materials selected

74 J. Richmond. AANA 2010 Author’s Current Surgical Treatment Algorithm
“High demand”: eg. Competitive athlete  Autologous B-PT-B “Moderate demand”: eg. Recreational athlete  Autologous Q-ST&G “Lower demand” or other modifying circumstance (age, autologous tendon issues, revision)  Allograft (tibialis or B-PT-B)

75 Where do you want to go?

76 Thank You

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