ACL Flashcards
Benefits of suspensory fixation
Circumferential graft to tunnel healing. Can be used in cases of posterior wall blowout. Less graft slippage for all soft tissue grafts. May have better pull-out strength than aperture.
Downsides of suspensory fixation
Windshield wiper and Bungee cord effect which can lead to tunnel widening and graft stress and failure. lack of rigid aperture fixation.
Benefits for aperture fixation
Rigid fixation with lower risk for tunnel widening. Cheaper with metal screws. Compresses graft to bone.
Downsides for aperture fixation
Immune response to biocomposite screws leading to tunnel widening and graft failure. Screw breakage with biocomposite.
fixed loop vs adjustable loop suspension devices
Fixed loop is biomechanically superiorly
How common is windshield wipering
50-100% in ACL. Though the signfiicanti s unclear.
Downsides of tunnel expansion
Excssive shearing motion impedes biologic incorporation, bone loss comoplicates revision surgery. OR tunnel expansion is of no consequence
Root tear classification
Laprade. Type 1 is partial, 2 is complete, 3 is complete with bucket handle, 4 is complete but long oblique, 5 is root avulsion
meniscofemoral ligaments and posterior root
help preserve function of the laterla meniscus, limit extrusion
Donot site pain for the different grafts
8-18% QT, 22% hamstring, 40% BTB
Benefits of quadriceps tendon
Decreased kneeling pain and anterior numbness, preserved hamstring flexor tendon.
Downsides of quadriceps
Other than the surgical risks, extensor mechanism weakness, early extension deficits.
How common are Lat men psoterio rrot teras
7-14% incidence. Krych and laprade have separately noted their heigh incidence and occult nature on MRI, even when looking specifically for them.
So you did a procedure you didn’t ocnsent for?
Unfortunately that is how it is listed on the consent form, however I do discuss with patients and get their consent in the informed consent process to repair any meniscus tears that are present at the time of surgery. In my pre-op clinic note and day of surgery H&P I reiterated the plan to repai rany meniscus tears as possible, and listed the procedure as such. It was incorreclty transcirbed and I should have been more diligent in changing it to the broader wording.
Shelbourne KD, Roberson TA, Gray T. Long-term Evaluation of Posterior Lateral Meniscus Root Tears Left In Situ at the Time of Anterior Cruciate Ligament Reconstruction. The American Journal of Sports Medicine. 2011;39(7):1439-1443. doi:10.1177/0363546511398212
At a mean of 10 years’ follow-up of posterior lateral meniscus root tears left in situ, mild lateral joint-space narrowing was measured without significant differences in subjective or objective scores compared with controls. This study provides a baseline that can be used to compare the results of procedures used to treat these tears in other manners.
Benefit of lateral meniscus root repairs
Decreased degenerative joint disease, improved function, particularly rotational control (if they ask to specify)
BTB risks
Anterior knee pain in 17.4% of patients, kneeling pain. Patellar fracture 0-2%, patellar tendon rupture 0.25%, patellar tendinitis, 17.4% vs. 11.5 in HS autografts for anterior knee pain. INcreased risk of OA.
COntraindications for BTB
kneeling sports or activities like wrestlers, plumbers. Patients with pre-operative anterior knee pain
Benefits to BTB
GOld standard with longest clinical history, bone to bone healing in 6 weeks, higher return to sports than HA autografts and lower failure rate in young athletic patients. More consistent graft size especially in young
BTB re-rupture rates
1.9% to 6.6%
hamstring re-rupture rates
4.9-17.5%
Downsides of allograft
Expensive, infectious disease risk, delayed incorporation, higher failure ate (up to 25%), only use in patients >40 or multilig), lower return to sport compared to autograft 43% vs. 75%
benefits of allograft
No harvest site morbidity, deceased surgical time, predictable graft size
Freedman KB, D’Amato MJ, Nedeff DD, Kaz A, Bach BR. Arthroscopic Anterior Cruciate Ligament Reconstruction: A Metaanalysis Comparing Patellar Tendon and Hamstring Tendon Autografts. The American Journal of Sports Medicine. 2003;31(1):2-11
There were 1348 patients in the patellar tendon group (21 studies) and 628 patients in the hamstring tendon group (13 studies). The rate of graft failure in the patellar tendon group was significantly lower (1.9% versus 4.9%) and a significantly higher proportion of patients in the patellar tendon group had a side-to-side difference of less than 3 mm on KT-1000 arthrometer testing than in the hamstring tendon group (79% versus 73.8%). There was a higher rate of manipulation under anesthesia or lysis of adhesions (6.3% versus 3.3%) and of anterior knee pain in the patellar tendon group (17.4% versus 11.5%) and a higher incidence of hardware removal in the hamstring tendon group (5.5% versus 3.1%).
benefits of HS
Can be used in skeletally immature, but don’t use it in patients who require HS like sprinters, lower harvest site morbidity, less postop knee pain, smaller incision .
Downsides of HS
donor site morbidity with knee flexion weakness, less predictable grat size, higher reupture rates (17.5% vs 6.4% than BTB), longer graft integration times, higher infection risk (0.6% vs. 0.07% with BTB)
Benefits of QT
Reliable graft size, can take with or without a bone block, lower infection risk, lower risk of numbness and injury to infrapatellar branch of saphenous nerve 1.5% vs. 53.3% with BTB), low donor site morbidity (0-15% vs 18-51% in BTB), less anterior knee pain (4.6% vs. 26.7% of BTB).
This limited variability is of particular importance because a fundamental aspect of the graft harvesting process in ACLR is the predictability of harvesting a graft with consistent volume, thickness, and size during each surgical case
Downsides of QT
porlonged quadriceps weakness (especially full thickness), donor site pain, fluid extravasation
QT revision rate
A recent registry study did show a higher revision rate for QT (4.7%) versus HS and BPTB (2.3% versus 1.5%. respectively), although QT patients in this study comprised only 3.2% of the patient sample and graft size, fixation technique, and bone block use were not available for analysis.29
How do you come about graft selection
My two grafts that I offer patients are patellar BTB and quadriceps tendon as they both have excellent outcomes and the decision is made with the patient with a discussion on their patient’s age, activity level, and occupation.
QT characteristics of graft
widest cross sectional area, even more than HT
PROMs examples
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BPTB vs. HT failure rate
A recent meta-analysis with 47,163 patients found 2.80% and 2.84% rupture rates for BPTB and HT, respectively, at a mean follow-up of 68 months.
Samuelsen, Brian T. MD, MBA1; Webster, Kate E. PhD2; Johnson, Nick R. BS1; Hewett, Timothy E. PhD1; Krych, Aaron J. MD1,3,a. Hamstring Autograft versus Patellar Tendon Autograft for ACL Reconstruction: Is There a Difference in Graft Failure Rate? A Meta-analysis of 47,613 Patients. Clinical Orthopaedics and Related Research 475(10):p 2459-2468, October 2017. | DOI: 10.1007/s11999-017-5278-9
Among six studies directly comparing QT with BPTB, there were 10/439 QT failures (2.28%) and 10/287 BPTB failures (3.48%)
Who do you do BTB for
High level young atheletes who are skeeltally mature, the bone to bone healing, the important clinical history, it is the gold standard
how often are root tears missed
A blinded review by LaPrade et al9 reported preoperative MRI detection of medial and lateral meniscus posterior root tears to have a sensitivity of only 82% and 60%, respectively.
In addition, Krych et al demonstrated that the rate of preoperatively identified posterior root tears on MRIs read by fellowship-trained musculoskeletal radiologists was only 33%, with only 50% of missed tears clearly evident when retrospectively reviewing known tears
root repair postop protocol
NWB x6 weeks, ROM 0-90 for 6 wks vs 2 weeaks. no deep squatting past 90 degrees for 4 months
Moon group
Allograft Versus Autograft Anterior Cruciate Ligament Reconstruction: Predictors of Failure From a MOON Prospective Longitudinal Cohort
Christopher C. Kaeding, MD Christopher.Kaeding@osumc.edu, Brian Aros, MD, […], and Kurt P. Spindler, MD
Patient age and ACL graft type were significant predictors of graft failure for all study surgeons. Patients in the age group of 10 to 19 years had the highest percentage of graft failures. The odds of graft rupture with an allograft reconstruction are 4 times higher than those of autograft reconstructions. For each 10-year decrease in age, the odds of graft rupture increase 2.3 times.
Anterior Cruciate Ligament Reconstruction in High School and College-Aged Athletes: Does Autograft Choice Influence Anterior Cruciate Ligament Revision Rates?
MOON Knee Group, Kurt P. Spindler, MD spindlk@ccf.org, […], and Rick W. Wright, MD
Moon group
Results:
A total of 839 patients were eligible, of which 770 (92%) had 6-year follow-up for the primary outcome measure of the incidence of subsequent ACLR. The median age was 17 years, with 48% female, and the distribution of BTB and hamstring grafts was 492 (64%) and 278 (36%), respectively. The incidence of subsequent ACLR at 6 years was 9.2% in the ipsilateral knee, 11.2% in the contralateral normal knee, and 19.7% for either knee. High-grade preoperative knee laxity (odds ratio [OR], 2.4 [95% confidence interval [CI], 1.4-3.9]; P = .001), autograft type (OR, 2.1 [95% CI, 1.3-3.5]; P = .004), and age (OR, 0.8 [95% CI, 0.7-1.0]; P = .009) were the 3 most influential predictors of ACL graft revision in the ipsilateral knee. The odds of ACL graft revision were 2.1 times higher for patients receiving a hamstring autograft than patients receiving a BTB autograft (95% CI, 1.3-3.5; P = .004). No significant differences were found between autograft choices when looking at the incidence of subsequent ACLR in the contralateral knee.
Conclusion:
There was a high incidence of both ACL graft revisions and contralateral normal ACL tears resulting in subsequent ACLR in this young athletic cohort. The incidence of ACL graft revision at 6 years after index surgery was 2.1 times higher with a hamstring autograft compared with a BTB autograft.
