Transcript Slide 1

Sports Knee Surgery
ACL Graft Choice
Dr Jonathan Mulford
myorthopod.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
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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
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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 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.
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) : 8238-8242
G. 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