5/9/2014 Disclosure • Consultant and receives royalties from Allograft ACL Reconstruction in the Adolescent Biomet Sports Medicine and Zimmer • Editorial board of American Journal of Sports Steve J. Barad, MD and Stephen M. Howell, MD Medicine and Arthropaedia Private Practice Orthopedic Surgery, Sacramento, CA Professor of Mechanical Engineering, UC Davis UCSF Pioneered Research on Allograft ACL Reconstruction with Allograft ACL Reconstruction is Controversial – 1982: Effect of minus 80 degrees C on Viability of the • Some studies show 4-8 times higher risk of failure with Rhesus Monkey Patellar Tendon allograft than autograft – 1983: Effects of Cyclosporin A on Bone Allografts in the – Pallis AJSM 2012; Kaeding J Spts Health 2011,Kambien AJSM 2013, Barrett Artrhroscopy 2010 Rat Model • Allograft in adolescents is of greater concern – Presented Leroy C. Abbott Society Scientific Program – AANA 2013 “NEVER use an allograft for ACL S. Barad, J.Rodrigo and E.Cabaud reconstruction in the young athlete” 1
5/9/2014 Is Irradiation and Chemical Processing of ACL ALLOGRAFT Allograft Driving the Controversy? ADVANTAGES: • When allografts treated with irradiation and chemical save time in OR cleansing were excluded, the results with allografts were easier surgery easier recovery the same as autograft avoids harvest morbidity “no outcome difference” avoids weakness with flexion w Hamstring – KrychArthro 2008, LawhornArthro 2012, MarisculoAJSM avoids patellar pain w Patellar-Tendon-Bone 2013, Li AJSM 2013, Zang AJSM 2012 ACL Allograft Hypothesis Disadvantages • The use of fresh-frozen, non-irradiated and cost non-chemically processed allograft results in “immune response” high self-reported satisfaction, function, and delay graft incorporation return to sport (KOOS and Lysholm), a stable bacterial/viral transmission knee (KT-1000, pivot shift) and low failure “you are not using a dead person’s ligament in rate after ACL reconstruction in adolescents my child” 2
5/9/2014 Patient Selection METHODS AND MATERIALS • All patients 14-19 years of age treated with allograft ACL reconstruction from 2008-2013 were identified from searching our office and hospital database • 21 patients met the inclusion criteria • 4 were lost to follow-up • 17 patients, 10 female 7 male • F/u 9 month- 6 years ( mean 4 years) Patient Selection Evaluation 12 Soccer • 17 patients reported patient satisfaction, 3 Football function and ability to return to sport by filling 1 Volleyball out the KOOS and Lysholm questionnaires 1 Mountain Climbing • 12 pts had a physical examination including pivot 1 Baseball shift and KT-1000 (manual maximum test) and 1 Basketball single-leg hop test 3
5/9/2014 Surgical Technique Surgical Technique Fresh frozen, non- irradiated Posterior TibialisTendon Transtibial technique using a guide that helped prevent impingement in extension and flexion Cortical Locking device used for femoral fixation, screw and washer with bone graft used for tibial fixation Technique Picture of XRAY 4
5/9/2014 Results RESULTS PE: 10 pts normal exam with negative lachman and pivot shift test 1 pt had negative lachman with 1 plus pivot 1 pt had positive lachman with 2 plus pivot HOP test ave diff : 2.5 inches Satisfaction and Return to Sport KT -1000 Manual Max Exam KOOS range: 82-100 14 excellent 6 - 0 mm 3 good average 95 2 - .5 mm 80-90 good 3 - 1-2mm AVE. 1.omm Lysholm range: 86-100 90-100 excellent 14 excellent 1 - 7mm (f) 3 good average 95 5
5/9/2014 Results Conclusions Our experience with use of Allograft tendon in the young , athletic • Self satisfaction: 14 excellent/3 good population was favorable. • Objective : 1 failure / 17 pts We did not see the level of failure reported in many of the articles reviewed • 16/17 pts able to return to sport Unfortunately our sample size was small. Not all of the 17 pts were available • Failure Rate <6% for Physical Examination . Even with good satisfaction scores, their may have been laxity in this group detected by manual and KT evaluation “one day we will use allograft Thank You tendons to reconstruct the anterior cruciate ligament” • Special thanks to Laura Osorio M.A. ED CABAUD The Cabaud Memorial Award 6
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