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

2. Who am I?

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 MRI Lachman 85% sensitive, 94% specific
Pivot % 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 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%

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

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

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

17. 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

18. 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

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

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. 20

21. Media
Miracle op to melt down surgeons' phones 21

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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.

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

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. 32

33. 33

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
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 tear 3%
Graft Failure 3%

43. Thankyou