Evidenced Based Approach to ACL Injuries

Balmain Sports Medicine

November 2011

Who am I?

References to Read

• Handout

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

Prevention

• Neuromuscular Interventions

– Hewett TE Am J Sports Med 2006– Gilchrist Am J Sports Med 2008

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%

Diagnosis

• History

• Examination– Lachman 85% sensitive, 94% specific– Pivot 24% sensitive, 98% Specific

• MRI– Sens 86% specific 95%

Indications Surgery

• Sensation of Instability in normal ADLs

• Resume sports with cutting and pivoting

• Particular jobs

Indications for Surgery

• Kanon/Frobell N Eng J Med 2010

• 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%

Graft Choice

• Autograft – Patients own tissue

• Allograft – someone else's tissue

• Synthetic - Artificial

Autograft

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

• Bone Healing – BTB 4-6weeks

• Soft Tissue Healing 9-12 weeks

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

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

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

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.

Media

• Miracle op to melt down surgeons' phones

4 Comparison Papers

• No difference in the 10 outcome measures at final follow up (15 – 49 months).

• LARS patients reached full recovery sooner.

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.

Electron Microscopy

Pittsburgh Group

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.

Patient Specific Approach

• Choose graft that matches the patients needs.• Discuss the pros and cons of each graft.

Rehabilitation

• CPM – no substantial advantage

• Weight bearing – standard practice

• Post op bracing – not necessary

• Neuromuscular stimulation – high-intensity early post-op period. Not required to achieve successful outcome.

• Accelerated rehab - minimal evidence for safe return to sport.

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

LIPUS

Ultimate load

0

100

200

300

400

500

600

26 wks Control 26 wks Ultrasound

N p=0.046

Evidence of Expected Outcome

• Predictors of poorer outcome

– Smoker– female– higher body mass index– older age.

Complications Reconstruction

• Graft Failure – 3.6%

• Infection 1%

• Additional Arthroscopic Surgery – 15%

• DVT – low• Nerve injury low

Risk Arthritis

• Oiestad -Systematic Review

• Isolated injury – prevalence 0-13% at 10 years

• ACL + Meniscus – 21-48% at 10 years

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 Failure 3%

Thankyou