Sports Knee Surgery ACL Graft Choice

Dr Jonathan Mulfordmyorthopod.com.au

Who am I?

ACL Surgery

• What do you think of the LARS?

What Are you asking me?

• What is the best graft? What would you have?

Graft Choice

• Autograft – Patients own tissue

• Allograft – someone else's tissue

• Synthetic - Artificial

Which Graft• Leo P – Hamstrings

• Merv C – Patella tendon

• Americans Allograft

• Koreans Quads Tendon

• Footy show says Synthetic Graft

• ????????

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

WHICH GRAFT WOULD YOU HAVE?

• Autograft

• Allograft

• Synthetic

Lets look at some evidence

Allograft

Allograft significantly lower normal stability rates than autograft

Allograft abnormal stability rate 3 times greater than autograft.

Autograft

Hamstrings

• Good Things

• Bad Things

Hamstrings

• Pros– Quick harvest– Reliable– Can use for double bundle– Small incisions– Early rehab not too bad.

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

Patella Tendon

• Good Things

• Bad Things

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

BTB graft

• Cons– Arguably anterior knee pain

(Bone graft)– Longer to harvest graft– Larger incisions– uncomfortable initially– Risk of patella fracture and

tendinopathy

Quads Tendon

• Good Things

• Bad Things

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

Great

• What does the literature tell us.

• Remember there is a lot of poor literature.

Patella vs Hamstrings

What about Quads?

• Currently performing Systematic review.

• No difference to BTB• Quads strength? / • less anterior knee pain ? /

Patient Specific Approach

• Choose graft that matches the patients needs.

• Discuss the pros and cons of each graft.

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.

As a result Long rehab that

• Lion opts for LARS 11/5/2010

LARS

• What’s good?

• What’s bad?

History Artificial Grafts

• 1918 silk sutures – failed 3 months

• First graft 1973 - Proplast made of polytetrafluoroethylene (PTFE)

• Results with this system yielded an average time to breakage of just over 1 year.

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.

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.

DACRON

• tightly woven polyester strips.

• Early results were good

• however by 4 years about 50% had failed due to stretching of the graft.

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

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.

LIGAMENT ADVANCEDREINFORCEMENT 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.

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.

• 3 ruptures of 159• 1 synovitis

Longest Follow-up LARS• ACL Reconstruction Using Artificial Ligament:

Five Years Follow Up

• S.I.O.T. 2007; 33(suppl.1) : 8238-8242G. Cerulli et at.

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

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.

Why is rehab “Faster”

• No Donor site Morbidity

• Graft not going to weaken early.

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.

Patient Specific Approach• Choose graft that matches the patients

needs.• Discuss the pros and cons of each graft.

• LARS concept is good but not quite right

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.

Platelet Rich Plamsa - Injections