2018 ACL Trends and Update Pearls and Tips - COA
Transcript of 2018 ACL Trends and Update Pearls and Tips - COA
2018 ACL Trends and Update Pearls and Tips
C. Benjamin Ma
Professor in Residence
Chief, Sports Medicine and Shoulder Service
University of California San Francisco
Department of Orthopaedic Surgery
Disclosures
• Research
– NIH, Arthritis Foundation, AANA, OREF
– Zimmer, Histogenics, Moximed, Samumed
• Consultant
– Conmed, Tornier, Medacta
What is a trend?
• “ a general direction in which something is developing or changing”
• “a fashion”
Latest Trends “Fashion” in ACL Reconstruction
• Really? Autograft and Allograft?
• How many bundles today?
• New ligament of the year – ALL
• Reconstruct or Repair or Augment?
• ACL and arthritis
Latest Trends in ACL Reconstruction
• Really? Autograft and Allograft?
• How many bundles today?
• New ligament of the year – ALL
• Reconstruct or Repair or Augment?
• ACL and arthritis
Autograft versus allograft
• Really?
– Only choice the patient really has
• Multiple studies performed on autograft versus allograft
• Allograft
– Faster recovery
– No morbidity with graft harvest
• Autograft
– ?better healing
– Morbidity from graft harvest
Suk et al, AJSM 2011, Sun et al Arthroscopy
2009, Poehling et al Arthroscopy 2005,
MOON Study: Auto vs Allo
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Spindler et al: J Orthop Res 2013 Jan 31(1)
18 yo – 22% failure for allograft
8% for autograft
Latest Trends in ACL Reconstruction
• Really? Autograft and Allograft?
• How many bundles today?
• New ligament of the year – ALL
• Reconstruct or Repair or Augment?
• ACL and arthritis
How many bundles today?
• Single
• Double
• Triple
• Parallelogram??
Description of two ACL bundles:
• 1938 Palmer (Acta Chir Scand)
• 1944 Abbott et al. (JBJS-Am)
• 1975 Girgis et al. (CORR)
AMB PLBPL
AM
Anatomy of ACL in Fetus
AMB
PLB
20th week
Courtesy of Dr. S. Arnoczky
PL
AM
Double bundle versus single bundle
• Improve rotational stability
• Improve pivot shift
10 years of Double Bundle “Fashion”
• No difference in clinical outcomes
• Few studies that show improvement in rotatory stability clinically
• No differences in developing of arthritis
Double bundle vs Single bundle
• Biomechnical advantage
• No difference in clinical outcomes and failure
Harner et al, Arthroscopy 2004
Too Vertical
15June 8,
2018
Anatomic single bundle ACL reconstruction
• Failure of ACL reconstructions
• MARS cohort
• Femoral tunnel malposition
– 35.9% too vertical
– 29.9% too anterior
– 26.5% too anterior and vertical
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Morgan et al, J Knee Surgery 2012
Lateral wall open
1
7
Anteromedial Drilling
• Need knee hyperflexion
• Caution around medial femoral condyle
Flexible Reamer
• Offers excellent flexibility
• No restriction in tunnel placement
• No need to hyperflex the knee
• Don’t know where it s heading
Outside in technique
• Reverse drilling – inside out
• Independent of knee flexion
• Extra incision – IT band or lateral quadriceps
Anatomic single bundle ACL
• No large comparison studies between techniques
• Smaller cohort studies
– Slight difference in knee kinematics
– Can be different related to tunnel aperture
Is this really anatomic?
Latest Trends in ACL Reconstruction
• Really? Autograft and Allograft?
• How many bundles today?
• New ligament of the year – ALL
• Reconstruct or Repair or Augment?
• ACL and arthritis
New Ligament
• New York Times report
• “People” magazine for orthopaedic surgery
• ALL – anterolateral ligament
ALL injury and reconstruction
• Recognition on MRI
– 26% by one radiologist
– 62% by second radiologist
• 10.7% ALL injury in conjuction with ACL
Segond Fracture
First described in 1879
ALL reconstructions
• Graft reconstruction
• Indications
– High Grade Pivot Shift
– Lateral sided injuries
How to grade pivot shift?
• Indications of ALL Reconstructions
– High grade pivot shift
• Subjective evaluation
• “Glide” “Pivot” “Clunk”
• No objective measurement
Variability in measurements
• Europe
– Stefano Zaffagini
– Philippe Neyret
– Jon Karlsson
– Roland Becker
– Andreas Imhoff
– Timo Jarvela
• Africa
– Willem Vd Merwe
• South America
– Moises Cohen
• North America
– Freddie Fu
– Benjamin Ma
• Asia Pacific
– Masahiro Kurosaka
– Chen Shiyi
– Robert Smigielski
Results :wide variation of their preferred technique
Knee kinematics
• Besides ligament injuries
– ACL
– ALL
– Lateral capsule
• Bone shape have significant contribution to knee kinematics
Bone Shape MeasurementsStatistical Shape Modeling
• Landmarks identified with algorithm based
on local curvature features
• Principal component analysis performed on
matched 3D coordinates
• Modes of variation are extracted from PCA
– Describe unique, uncorrelated features
– Performed separately for tibia and femur
so not effected by knee position
– First 20 modes explain 90% of shape
variability
• Model knee constructed and individual
modes are adjusted to understand various
shape features
Avera
ge S
hape
+ 3SD
- 3SD
Results: Tibial Position Before ACL Reconstruction
-0.5
0
0.5
1
1.5
2
2.5
3
3.5
4
Extension Flexion
Sid
e-to
-Sid
e D
iffe
ren
ce in
Tib
ial
Posi
tio
n (
mm
)
Injured
Control
p = 0.0037 p = 0.026
Ziad and Ma; JOR 2015
Results: Tibial Position After ACL Reconstruction
-0.5
0
0.5
1
1.5
2
2.5
3
3.5
4
Extension Flexion
Sid
e-to
-Sid
e D
iffe
ren
ce in
Tib
ial
Posi
tio
n (
mm
)
Injured
Control
p = 0.048 p = 0.20
Femoral Bone Shape is Correlated with Tibial Position
-80
-60
-40
-20
0
20
40
60
80
-4 -2 0 2 4 6 8
Baseline Side-to-Side Difference in
Tibial Position in Flexion (mm)
Val
ues
for
Fem
ur
10 M
ode
+ More oval-shaped
medial femoral condyle
- More spherical medial
femoral condyle
Rho -0.52
P = 0.0007
Pedoia and Ma, OARSI 2015, 2016
-40
-30
-20
-10
0
10
20
30
-4 -2 0 2 4 6 8
Baseline Side-to-Side Difference in
Tibial Position in Flexion (mm)
Val
ues
for
Tib
ia 1
9 M
ode
+ Increased height of
anteromedial plateau
- Decreased height of
anteromedial plateau
Rho 0.034
P = 0.036
Tibial Bone Shape is Correlated with Tibial Position
Pedoia and Ma, OARSI 2015, 2016
ACL and Kinematics
• Knee kinematics can be related to bone shape differences, not just soft tissue injuries
• Same reconstruction can result in different outcome
• Clinical decision should not be dependent on subjective measurements
• Indication of ALL reconstruction is lacking
Latest Trends in ACL Reconstruction
• Really? Autograft and Allograft?
• How many bundles today?
• New ligament of the year – ALL
• Reconstruct or Repair or Augment?
• ACL and arthritis
ACL – should we just shave them away?
ACL can heal!
• Steiner, Murray, Rodeo et al, Strategies to improve ACL healing and graft placement AJSM Jan 2008
• Zantop et al, Intraarticular rupture pattern of the ACL
– 122 consecutive ACL reconstructions
– 25% partial rupture of ACL
– 44% of patients AM and PL bundle rupture at different location
– Need to examine intact fiber bundles of ACL
ACL Preservation
• Closer analysis of the outcomes shows that location of the tear was important:
• More proximal tears did better: both short and long term
• Mid substance tears did poorly
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2018
4
1
How about Augmentation?
4
2
Mackay technique
ACL Repair
4
3
• Wall Street Journal
• “Vogue” magazine for orthopaedic
surgery
Bridge-Enhanced ACL Repair (BEAR)
• Instead of using a graft to replace the torn ACL, we use a protein sponge placed between the torn ends of the tissue to stimulate healing.
Torn ACL Place sponge
in wound site,
holds blood in
wound site
ACL HealsPull ACL up
into sponge
with stitches
- Advantages of Bridge-Enhanced ACL Repair (BEAR)
- No need to heal in a graft harvest site
- Preclinical studies suggest it reduces post-ACL
arthritis
Clinical Studies: BEAR I and BEAR II
• BEAR I trial
– 20 patient FDA sponsored cohort study, opened 2/2015
– 10 BEAR vs 10 autograft HS
– No infection, inflammation, stiffness, failure
– All patients out one year, four are two years out
– All ten knees stable (Lachman, Pivot shift, KT-1000)
– MRIs promising
• BEAR II trial
– 100 patient RCT
– Autograft vs BEAR
– Opened May 2016, completed enrollment
– 96/100 surgeries completed
– Following patients Healed ACL at
one year in the
first BEAR
patient
STAY TUNED!!!
ACL augmentation and repair
• Early clinical trial
• ACL ligaments have been healing
– Just not to the right spot
– Can a sponge guide it?
Latest Trends in ACL Reconstruction
• Really? Autograft and Allograft?
• How many bundles today?
• New ligament of the year – ALL
• Reconstruct or Repair or Augment?
• ACL and arthritis
ACL and Arthritis
• We are good getting patients back to play
– 82% return to sports
– 90% normal or near normal knee function
– Arden et al, Br J Sports Med 2011
• We are NOT good in preventing arthritis
– 50% radiographic OA 10 years out from ACL injuries
– Amin et al Osteoarthritis and Cartilage 2008
– Van der Hart et al J Orthop Surg 2008
Long-term outcomes of ACL injury
• 103 female soccer players with ACL injury > 12 years
• Mean age 31 (26-40yo)
• 82% had radiographic changes
• 51% fulfilled radiographic OA
• 60% had ACL recon
• Surgical reconstruction – no influence on knee symptoms
Lohmander et al, Arthritis Rheum 2004
Who are the at risk individuals?
Motion Difference and Cartilage DegenerationDrop jump test
✓ Vertical ground reaction force
✓ Sagittal biomechanics
✓ Frontal biomechanics
✓ Side to side difference
✓ = Ipsilateral - Contralateral knee
50Presentation Title
Early Detection
• Use of quantitative MR imaging
– T1rho and T2
60
45
30
15
0
(ms)
Baseline One year post ACL-
reconstructionDespite resolution of BMEL, cartilage shows persistent damage
Longitudinal landing biomechanicsAbnormal kinetics at 6 months but normalizes at 3 months
52Presentation Title
• Side to side differences in kinetics at 6M were associated with larger increases in T1ρ
value from baseline to 3Y
53Presentation Title
Conclusion
• 6M changes in knee kinetics can be predictable to cartilage degeneration
• Abnormal kinetics leading to more cartilage degeneration
• Intervention can focus on early rehabilitation and treatment
• At risk groups can be identified at 6M following ACL injury and reconstructions
54Presentation Title
Latest Trends in ACL Reconstruction
Latest Trends in ACL Reconstruction• Really? Autograft and Allograft?
– Autograft > Allograft
• How many bundles today?
– Less is more
• New ligament of the year – ALL
– Not new and still don’t know when to do it
• Reconstruct or Repair or Augment?
– Promising
• ACL and arthritis
– 6M kinetic differences can be risk factor for development of post traumatic osteoarthritis
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Acknowledgments
▪ C. Benjamin Ma, MD
▪ Xiaojuan Li, PhD
▪ Brian Feeley, MD
▪ Richard Souza, PT PhD
▪ Sharmila Majumdar, PhD
▪ Tomohiro Shimizu, MD
▪ Drew Lansdown, MD
▪ Valentina Pedoia, PhD
▪ Nicholas Colyvas, MD
▪ Favian Su, BS
▪ Musa Zaid, MD
▪ Tomohiro Shimizu, MD
▪ Subburaj Karupppusamy, PhD
▪ UCSF Department of Orthopaedic Surgery
▪ Musculoskeletal Quantitative Imaging Group
▪ UCSF Department of Radiology
▪ The CTRFP TeamFunding:
• AOSSM Genzyme Osteoarthritis Grant for
Clinical Research
• NIH/NIAMS P50 AR060752
• CTSI/UCSF Clinical and Translational Research
Fellowship