Debate: 33-Year-Old Yoga Lover, Former Ballet Professional with an - PowerPoint PPT Presentation

Orthopaedic Summit 2017 Debate: 33-Year-Old Yoga Lover, Former Ballet Professional with an Isolated ACL Tear Pro: Hamstring Autograft is the Way to Go! Kevin F. Bonner, M.D. Jordan-Young Institute, Virginia Beach, VA Assistant Professor, Eastern Virginia Medical School

Kevin F Bonner MD Disclosures 1.Royalties : Zimmer / Biomet 2.Consulting : Smith & Nephew LifeNet Health Abyrx 3.Research and educational support : Depuy / Johnson & Johnson Zimmer / Biomet LifeNet Health

Overall Graft Trends: Campbell; ACL Study Group 2010 US: Hamstring > patellar tendon grafts in 2008 Worldwide: Hamstring>> Patellar tendon Source: iData Research Inc.

Scandinavian Registry: Graft Distribution By Year Gifstad et al. Am J Sports Med 2014

Graft Trends: US (Kaiser) 2007-14 HS Autograft PT Autograft Allografts Tibor et al. JBJS-Am 2016: 98

Graft Choice by NFL / NCAA Football Team Physicians Erickson et al. Arthroscopy 2014

Graft Selection: Risk Benefit Analysis

Patellar Tendon • Bone to bone healing • Reliable size & strength • Single strand • Tighter in some • Minimal tunnel lysis • Lower revision rates in young athletes • Greater morbidity

BTB: Worth it for everyone? Tendon Rupture Anterior knee pain Fracture

But there can be struggles for awhile after PT grafts

Hamstring Grafts • Became popular for a reason • Surgeons facile • Less stressful • Good graft for most • Less morbidity

Numerous Outcome Comparisons PT vs Hamstrings: Meta-analysis Functional outcomes: No Difference 1,2,3,4 Static stability testing: PT>HT 3,4 Increased morbidity: PT 1,2,3,4 1. Samuelsson et al. Arthroscopy 2009 2. Magnussen et al. Knee Surg Sports Tr Arthrosc 2011 3. Mohtadi et al. Cochrane Database Rev 2011 4. Li et al. Arch Orthop Trauma Surg 2012

Scandinavian Registry Revision Rates of Primary Graft Gifstad et al. Am J Sports Med 2014 “Difference more pronounced in patients involved in pivoting sports” Put in perspective 1.4%

US Community Based Registry Aseptic Revisions vs Age N=16,192 Maletis et al. Am J Sports Med 2013

MOON: Probability of Re-tear N=2,488 No sig difference (BTB 3.2% vs HS 4.6%) Kaeding et al. Am J Sports Med 2015;43(7)

Hamstring Graft Size Matters Ultimate Failure Load (N) 5000 4000 3000 Chance of revision 0.82 times 2000 lower with every 0.5 mm 1000 increase in diameter 0 Boniello, Bonner et al. Arthroscopy 2015 6mm 7mm 8mm 9mm Spragg et al. Am J Sports Med 2016: 44(6) Average Lowest

The Allograft Option Dr. Carter will I have a reaction to the allograft? Lynch et al. JAAOS 2015

Graft Selection Requires Assessing Risk Tolerance to: • Re-rupture / revision • Laxity in some • Graft Associated Problems & Morbidity • Postop struggle (pain, stiffness,….) • Knee pain that may never go away – Crepitation, stiffness…. • Extensor mechanism problems (fx, rupture, ….) • Cosmesis

I think we all go through “Graft Remorse”

I Try to Match Graft & Patient • Young athletes • Athletic goals vs Life goals? • Open Growth plates • Significant Medial sided injury • Pain tolerance? • Hx PF problems • Recreational athletes • Need to get back to work

Why is a hamstring graft a good choice for this patient? • Not a young pivoting athlete • Comparable results in most studies • Less assault on the knee • Patient preference • Less kneeling problems • Less phone calls • Lower chance of “graft remorse”

But in these 33 year old patients Dr. Carter my Dr. Provencher body is why does my reacting to this knee hurt allograft Hamstrings is probably a good way to go!

Thank you