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ACL Graft Choice
Michael B. Ellman, MDPanorama Orthopedics
Sports Medicine
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Disclosures
• Educational Consultant – Stryker Endoscopy and Sports Medicine
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ACL Graft Options
• Optimal ACL graft
– Structural and biomechanical characteristics of native ACL
– Allows for secure fixation
– Permits rapid biologic incorporation
– Limited donor site morbidity
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Graft Choices
Mall et al, 2012
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ACL Graft Options
• In residency, I thought there was only one great option…
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My Practice: ACL GRAFT USAGE
HAMSTRING AUTO61%
TA/TP ALLO22%
BTB AUTO15%
BTB ALLO1%
STAGE 1 REVISION
1%
ACL Graft Usage 2014‐15
61% Hamstring Auto15% BTB Auto22% Allograft
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Graft Options
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First Decision: Allograft vs Autograft?
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Allografts• Advantages
– No donor site morbidity
– Decreased pain
– Shorter OR times
– Better cosmesis
• Disadvantages– Cost
– Delayed tissue incorporation
– Safety?
– Clinical Outcomes?
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Cost
• Allografts are the most expensive option
• Nagda, CORR ‘10, Barrera Arthrosc ‘11:
– Allograft ACLRs more costly, despite surgical time savings
• But, are they “cost‐effective”???
– NO available studies showing clinical superiority of allo vs. auto OTHER than donor site morbidity benefits
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Safety
• Risk of Allograft Use
– Disease Transmission?
– Sterilization Process?
• Allograft Processing?
• Irradiated?
• Supercritical CO2?
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Safety
• Infection risk—NO DIFFERENCE– Williams et al. AJSM 1997
– Indelli et al. CORR 2002
– Barker et al. AJSM 2010
• Disease transmission
– Since 1985:
• 1 HIV infected donor
• 1 Hep C infected donor
– HIV risk = 1:8,000,000
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Sterilization: Effects of Irradiation
• Irradiation significantly compromises the biomechanical properties of allograft tissue
• Krych etal., Arthroscopy 2008; Sun et al., KSSTA2008;. Rappe et al., AJSM 2007; Mehta et al., Orthop 2010:– ***Sig biomechanical difference between irradiated
(>2.5mRad) and non‐irradiated allografts – ***NO SIG DIFF BETWEEN NON‐IRRADIATED
ALLOGRAFTS AND AUTOGRAFTS
– Yanke AJSM 2013: Low dose XRT (1.2mRad) no effect on biomechanical properties of BTB allograft, with exception of 20% decrease in graft stiffness
Conclusions: Avoid irradiation >2.2mRad; Non‐irradiated may be best option
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Sterilization
– Non‐irradiated allografts with Supercritical CO2
sterilization
• Alternative to standard irradiation + wash/cleanse technique
• Baldini KSSTA 2014: Supercritical CO2 sterilization decreases graft stiffness 27‐36%; ? Clinical impact
• Further studies warranted on optimal tissue processing technique
– Know your tissue bank!
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Clinical Outcomes: Allografts and Age
STUDY FINDING
Barrett Arthroscopy ’10, ‘11 < 40 yo: 2.6 – 4.2 x higher failure rate < 25 yo: allo failure 29%/ auto failure 11%
Pallis AJSM ‘12 7.7 x higher failure rate in military cadets
Steadman Arthroscopy ‘12 15 x higher revision rate in pts. ≤ 18yo
MOON cohort AJSM ’11,13 Allograft and younger age correlated with failure/reoperation rate
Fu AJSM ‘12 Younger age correlated with allograft failure
Mounting evidence that allograft failure rates are SIGNIFICANTLY higher in young, active patients• Age and Activity level RFs for failure with allograft
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CONCLUSION: Younger age and Allografts predict higher reoperation and revision rates
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***Factors associated with revision ACLR: younger age, allograft, teaching hospital
*** Risk factors for revision ACLR: allografts, hamstring autografts, younger age, males
***Allo failure rate: 29%, Auto failure rate 11%
***NCAA Div 1 athletes revision rate: 62% (ALLO) VS. 0% (AUTO), Higher revision rates in pts < 25 yo
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• Autograft vs Non‐irradiated Allograft: 6% vs 9% failure rate • Autograft vs Irradiated Allograft (2.5mRad): 6% vs 34% failure rate• Higher failure rates in young, active patients with allograft use
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Indications for Allograft (MBE)
• Select revisions
• Multi‐ligamentous injuries
• Unique co‐morbidities that are contraindications to autograft tissue – BTB: PFJ DJD, kneelers
– Hamstring: chronic hamstring issues, collagen disorders, require use of medial stabilizers
• Older patients: >35‐40
• In everyone else, Autograft…
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Autograft Options
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BTB Autograft• Advantages
– Rigid initial fixation
– Bone‐Bone healing
– “Gold Standard” for young athletes
• Disadvantages– Anterior knee pain / numbness
– Technical considerations – GT mismatch
– Patella fx / patellar tendon rupture
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Quadrupled Hamstring Autograft
• Advantages– Strongest graft (4000N)
– Improved cosmesis
– Decreased anterior knee pain
• Disadvantages– Soft tissue healing
– Decreased peak flexion strength
– Possible increased laxity over time
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Quadriceps Autograft
• Advantages– Largest x‐sectional area (62mm2)
– Bone – Bone fixation x1
– ? Less donor site morbidity vs BTB
• Disadvantages– Patella fracture = 2‐9%
– Anterior knee pain = 7‐22%
– Quad tendon rupture
– ? Loss of extension strength
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Graft Options
• No single right answer• Surgeon and Patient Choice
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Conclusions
• Limit use of allograft in young, active patients
– If using allograft, know your tissue bank
• Autograft recommended in patients <35
– No difference in outcomes between BTB and Hamstring
• Educate your patients to make the best choice for them!
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Thank you
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Autograft Options
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Then on to fellowship…
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Still only one option…
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Clinical Outcomes: Common Themes
• Non‐irradiated allografts may outperform irradiated grafts
– Low dose irradiation appears to be safe and effective
• Patient age and activity level correlated with increased risk of allograft failure use autograft!
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MOON Data 2011
WHY???
• Too early RTS?
• Increased activity level in younger pts?
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***No sig difference between allograft BTB vs. allograft tibialis posterior—trend toward higher failure rate with BTB allo
Rothman Institute group
For MBE
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Hettrich, C. M., Dunn, W. R., Reinke, E. K., MOON Group, & Spindler, K. P. (2013). The rate of subsequent surgery and predictors after anterior cruciate ligament reconstruction: two‐ and 6‐year follow‐up results from a multicenter cohort. The American Journal of Sports Medicine, 41(7), 1534–1540.
Spindler, K. P., Huston, L. J., Wright, R. W., Kaeding, C. C., Marx, R. G., Amendola, A., et al. (2011). The prognosis and predictors of sports function and activity at minimum 6 years after anterior cruciate ligament reconstruction: a population cohort study. The American Journal of Sports Medicine, 39(2), 348–359.
CONCLUSION: Younger age and Allografts predict higher reoperation and revision rates
MOON Data
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MOON Data
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BTB Autograft
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Questions?
• Safety?
• Clinical outcomes?
• Cost?
• Have things changed between 2009 and 2015???
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Stanford group
For JTJ
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MOON DATA2002‐15: 2683 patients
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Location
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Conclusions 2009‐13
• Allografts are safe but expensive
• Exercise caution when considering allografts for younger patients
• Non irradiated allografts outperform irradiated grafts
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2013 AND BEYONDThe trends continue…
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New MOON Data
***ACL retear odds 5.2x greater for allograft vs. autograft, risk ‘swith age and ‘s with increased activity level
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The outlier
***No difference between non‐irradiated allograft vs. autograft in pts. < 25 yo
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Meta‐analyses
StudyAuto Allo No
DifferenceNon‐irradiated grafts only
Kraeutler (CU) AJSM ‘13
Mariscalco (OSU) AJSM ‘14
Mascarenhas (Rush) Athros‘15
Cvetanovich (Rush) Arthros‘14
Lamblin (NM) Arthros ‘13
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2015 Conclusions:
• Mounting evidence against use of allografts in “younger” active patients
• Even low dose irradiation effects are still concerning
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Conclusions
• Unavailable data
– Any study that shows that allos outperform auto
– At best, outcomes are equivalent
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The Value Proposition
At what age do allografts become “cost‐effective”???
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Final Q
• Given available data, why would we choose to use an allograft as our first choice for primary isolated ACLR without relevant co‐morbidities in active young patients (< 40 years old)???
• CAG opinion at this point: I wouldn’t
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***Factors associated with revision ACLR: younger age, allograft, teaching hospital
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*** Risk factors for revision ACLR: allografts, hamstring autografts, younger age, males
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***Allo failure rate: 29%, Auto failure rate 11%
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***NCAA Div 1 athletes revision rate: 62% (ALLO) VS. 0% (AUTO), Higher revision rates in pts. < 25 yo
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***Younger age and used of allografts were risk factors for revision surgery.
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***In active pts < 40 yrs old, BTB allograft failure rates were 2.6 –4.2x higher than BTB autografts
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***In pts < 25 yo allograft failure rate (29%) vs. autograft BTB failure rate (11%)
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“All over the board…Trend to use hamstring. I like btb for the jumpers but they seriously mostly ask for allo…”
Anonymous knee surgeon 2013
Q: What graft do you prefer for your “pro” athletes?
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