ACL Reconstruction - Update 2012

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Update on ACL reconstruction, with information on current direction of demineralized bone matrix (DBM) use in bone tunnels and biocartilage on chondral lesions

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ACL Reconstruction - Update 2012

  1. 1. Update on the ACL Alan M. Hirahara, M.D., FRCS(C) Board Certified in Orthopaedic Surgery & Orthopaedic Sports Medicine Specializing in arthroscopic shoulder surgery Medical Director Team Physician ConsultantSacramento State Athletics Sacramento River Cats Oakland A’s MiLB - AAA
  2. 2. Anterior Cruciate Ligament Mechanisms of Injury• Hyperextension• Hyperflexion• Valgus-Rotation
  3. 3. Instability Tests• Examine contralateral leg• Relax the patient – Difficult with acute injuries / Re-examine• Gentle then repeat several times to determine maximum stress tolerated• Degree of instability• Quality of instability (“End Point”)
  4. 4. Anterior DrawerEven with anesthesia, only accurate 50%
  5. 5. Lachman TestMost sensitive test and diagnostic 95% of time
  6. 6. Pivot Shift • Anterolateral instability • Lateral tibial plateau subluxes in extension • Reduces in flexion by IT band Grade I – Glide into place Grade II – Pops into place Grade III – Doesn’t reduce
  7. 7. Associated Pathology• Meniscal tears (62%) – Acutely – Lateral – Chronic – Medial• Osteochondral fractures (10 - 20%)• Other ligamentous injuries (19%)
  8. 8. Xray• Segund sign – Lateral capsular sign – Avulsion fracture, indicating lateral capsular injury associated with ACL rupture
  9. 9. MRI
  10. 10. Partial ACL TearEmpty Lateral Wall Sign
  11. 11. Treatment• Conservative management – Build up quads & hams – ACL Brace – Avoid pivot sports• Reconstruction – No meniscal repair without reconstruction
  12. 12. Fixation for ACL: Soft Tissue
  13. 13. Fixation for ACL: Bone & Soft TissueInterference Screws – Metal vs. Bioabsorbable vs. BioComposite
  14. 14. ACL Reconstruction:Hamstrings / Transfix
  15. 15. ACL Reconstruction:Animation of All-Inside TightRope
  16. 16. Results of ACL Recon• Meta-analysis • Allograft comparable to demonstrates newer autograft for long term techniques with 4HS vs. stability BTB produces higher – But debatable whether less stability rates and are morbidity – 1 : 1.5 to 4 million risk of fixation dependent disease transmission – 77 – 80% Normal stability – 4.4 – 5.9% Instability rates Prodromos et al, Arthroscopy, 21(10) 2005. Sherman et al, Arthroscopy, 20(9) 2004.
  17. 17. STIMUBLAST
  18. 18. Demineralized Bone Matrix• Allograft bone with inorganic mineral removed, leaving only organic collagen matrix• Increased osteoinductivity – Exposed growth factors (BMP’s)• Requires a carrier• Many clinical studies showing efficacy but each product has different characteristics
  19. 19. DBM Osteoinduction Carrier Terminal Product Distributor Assay – Test % DBM (by wt) Sterility? Every Lot? RPM Yes In VivoStimuBlast Arthrex (36) E-Beam Yes Wright CaSO4 Yes In VitroAlloMatrix Medical (40) E-Beam Yes Na Hyaluronate In Vivo / In Vitro DBX Synthes No (32) Yes Glycerol In Vivo Grafton Medtronic No (17) No
  20. 20. Reverse Phase Medium (RPM)• Mod Pluronic F127 (Poloxamer PPO PEO) 5 min• More viscous at body temp• Resists irrigation, can use arthroscopically• Permeable to blood, resorbed• Metabolized readily RPM Glycerol
  21. 21. The Problem
  22. 22. Etiology of ACL Tunnel Widening Biological Mechanical• Synovial fluid propagation • Graft position• Increased cytokine levels • Fixation method• Sterilization methods• Implant material• Graft type• Graft donor Maak et al. JAAOS. 2010; 18: 695-706. Fauno et al. Arthoscopy. 2005; 21(11): 1337-41. Wilson et al. AJSM. 2004; 32(2): 543-9. Darabos et al. Knee Surg Sports Traum Arthrsc; 2011; 19: S36-46. Rodeo et al. AJSM. 2006; 34(11): 1790-800.
  23. 23. Potential Consequences• Delaying incorporation of the soft tissue graft into bone• Decreasing graft stability• Causing difficulty with future revision surgery
  24. 24. Saw Bones Testing
  25. 25. A Pilot Study:Effect of DBM on tunnel size in ACL reconstruction Alan M Hirahara, MD, FRCSC
  26. 26. Study DesignStudy Control• 14 patients • 6 patients – 7 male / 7 female – 3 male / 3 female – Age mean: 28.9 (15 – 45 yo) – Age mean: 26.6 (16 – 48 yo)• 5 revisions – 2 staged / 3 primary • No revisions• Associated pathology • Associated pathology – 2 meniscus repair – 2 menisectomy – 5 menisectomy – 3 chondroplasty – 2 microfx chondroplasty
  27. 27. VAS Results6.05.04.03.02.01.00.0 Pre-op Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Study Control
  28. 28. Technique
  29. 29. 3 Months Post-op
  30. 30. The effect of biologic treatments onACL reconstruction tunnel widening – a randomized clinical trialInvestigators:Alan Hirahara MD, FRCSC, Private Practice, Sacramento CAThomas M. DeBerardino, MD, U of Connecticut Health Center
  31. 31. BIOCARTILAGE
  32. 32. Micronized Cartilage ECM• Potential augment for Microfracture – Provides cartilage ECM scaffold – Allows for BM MSC attachment and growth – Stem Cells exposed to ECM will differentiate based on factors present within the matrix – Glycoproteins/Proteoglycans – Simple / inexpensive• Cheng et al (Tissue Engineering 2009) – Adult stem cells seeded onto the lyophilized cartilage scaffold – Chondrogenesis of ASCs evident by PCR & immunohistochemical examination – Resembled native articular cartilage Cheng N et al. Tissue Engineering 2009.
  33. 33. Relative CostsCompetition BioCartilage (Arthrex)• ACI (Genzyme) • $750 – Morselized, freeze- – $10,000 – Cost for cultured dried cartilage cells – + Costs of two surgeries• DoNovo (Zimmer) – $4,000 – Live cells
  34. 34. BioCartilage: Trochlea (Knee)
  35. 35. Thank You!

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