1. Sports Knee Surgery What’s New & What’s Coming
Dr Jonathan Mulford
myorthopod.com.au

2. Who am I?

4. ACL Surgery
What do you think of the LARS?

5. What Are you asking me?
What is the best graft?

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

7. Which Graft Leo P – Hamstrings Merv C – Patella tendon
Americans Allograft
Koreans Quads Tendon
Footy show says Synthetic Graft
????????

8. 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

9. WHICH GRAFT WOULD YOU HAVE?
Autograft
Allograft
Synthetic

10. Lets look at some evidence

11. Allograft
Allograft significantly lower normal stability rates than autograft
Allograft abnormal stability rate 3 times greater than autograft.

12. Autograft

13. Hamstrings
Good Things
Bad Things

14. Hamstrings Pros Quick harvest Reliable Can use for double bundle
Small incisions

15. 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

16. Patella Tendon
Good Things
Bad Things

17. Patella Tendon Pros Bone heals to bone quickly
Stiffer graft (doesn’t seem to stretch as much)
No hamstring problems
Better if
larger heavier patients and
collision sports
ligament lax individuals
Known Hamstring problems

18. BTB graft Cons Arguably anterior knee pain (Bone graft)
Longer to harvest graft
Larger incisions
uncomfortable initially
Risk of patella fracture and tendinopathy

19. Quads Tendon
Good Things
Bad Things

20. 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

21. Great What does the literature tell us.
Remember there is a lot of poor literature.

22. Patella vs Hamstrings

24. What about Quads? Currently performing Systematic review.
No difference to BTB
Quads strength? /
less anterior knee pain ? /

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

26. 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.

28. As a result Long rehab that
Lion opts for LARS 11/5/2010

29. LARS
What’s good?
What’s bad?

30. 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.

31. 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.

32. 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.

33. DACRON tightly woven polyester strips. Early results were good
however by 4 years about 50% had failed due to stretching of the graft.

34. 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

35. KENNEDY LIGAMENT AUGMENTATION DEVICE (LAD) – 1980
Ligament Augmentation Device (LAD) in 1980.
Idea - protect the autogenous tissue graft early
Problem - Stress shielding resulted.
Later - effusion and synovitis.

36. 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.

37. 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.

39. 3 ruptures of 159
1 synovitis

41. 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 patients older than 40 - Lars® artificial ligaments at a five-years follow-up with very good results.

42. 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.

43. Why is rehab “Faster” No Donor site Morbidity
Graft not going to weaken early.

44. 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.

45. LARS concept is good but not quite right

46. 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.

47. Platelet Rich Plamsa - Injections

50. Other ACL controversy

51. Graft Tunnel Placement
Many papers recently.
Femur – medial portal better than trans-tibial.
Tibia – place posterior aspect foot print.

52. Double bundle – double trouble?
Meta-analysis – No significant difference clinically between double bundle and single bundle.

55. ACL Navigation Has been available since 1995.
Overall gives more reliable positioning of the tunnels
No clinical benefit shown
there is still debate over positioning of the tunnels.

56. Patellofemoral Joint
Instability
MPFL

59. Trochlea Dysplasia

62. Trochleoplasty

76. CARTILAGE LESIONS
Bottom Line – at present no technique has clinically shown to be superior than another.

77. 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

78. Non Surgical
Chondrotin Sulphate
Synvisc One

79. Surgical Options Options Marrow stimulation techniques
Osteochondral transplant techniques
Cell based repair techniques
Future - Use of Stem Cells and Growth Factors

80. 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

81. Enhanced Microfracture
Try to enhance chondrogenic differentiation
Addition growth factors (TGF-B3, BMP-7)
Still in the lab

84. Osteochondral
OATS

85. Cell based repair techniques
MACI
Cartilage taken – grown in lab and then reinserted.

86. Stem Cells
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87. Mesenchymal Stem Cells
MSC found in bone marrow, skeletal muscle, synovial membrane, adipose tissue and umbilical cord blood.

88. Problems MSC Selection Cell Delivery to site
3D Scaffold ideal (synthetic or polymer)
Synthetic issues retention and degradation
Biological – disease transmission, immunological reaction, precision.

89. 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.

91. Additional Surgery

92. Partial Resection Repair Replacement -
Meniscus
Partial Resection
Repair
Replacement -

93. Meniscal Lesions Different populations
Young high energy sports injury.
Middle aged sports injury with previous recon
Low energy associated with OA

94. Meniscal Repair

95. 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.

96. Meniscus replacement - Allograft
Problems are availability, logistics, costs, and varying results

97. Future - Stem Cell Therapy
Goats – MSC injected into knees that where OA due to ACL deficiency,
A new meniscus like regenerative type tissue formed

98. 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!

99. Thankyou
Jonathan Mulford
Myorthopod.com.au