Antwerpen Endobutton Meeting December 2013

1. Graft Selection in 2013:
What are the advantages, disadvantages and issues to consider ?
A. Busilacchi M.D.
Clinical Orthopedics – Università Politecnica delle Marche –Ancona- ITA
Ph.D. Clinical and Molecular Science
Fellow in Knee & Sports Surgery – Az Monica

2. How are we doing with ACL surgery in 2013?
… perhaps not as good as we think.
2 Years after ACLR
72% return to sports
24 % : fear to practice .
(R. Brophy, MOON Group – AJSM 2012)
Still have the same issues
over the last 30 years,

3. GRAFT SELECTION
…and the best is…?

4. What do we “ask to our graft” ?
1.
2.
3.
4.
Be strong enough
Low or absent morbidity
Good primary stability
Good collagen to favour integration and “ligamentization”
… practically, TO BE AS PERFECT AS THE NATIVE ACL…
or rather even BETTER:
if we choose a graft, we wish it will never changes (or vanishes) !!

5. What should we consider when
choosing the graft in
PRIMARY SURGERY?
1. Patient’s demand
2. Morbidity of the donor site (autograft)
3. Anatomy of ACL origin and insertion
4. Biological factors in favour of graft integration and ligamentization.
5. Costs

6. What should we consider when
choosing the graft in REVISIONS?
1.
2.
3.
4.
5.
Patient’s demand
Investigate risk factors predisposing to re-rupture
If possible, reduce further morbidity of another graft
Stimulate graft integration and ligamentization
Costs

7. Patient’s Demand
To know prior to surgery:
① Kind of sport
② Intensity of physical activity
1. Low demanding:
2. Amateur
3. Professional player:
a) Young
b) End of career

8. Morbidity of the donor site
BTB:
 Large surgical approach: Scar complications
How to solve it: Mini invasive approach (Beaufils): preservation of nerves
 Anterior pain from neuroma of the infrapatellar branch of s.n.
 Fill the BTB Gap? Scaffold (Woo et al.) PrP (Cervellin et al.)
Prof M. Martens, 2009
.
Milan youth team player 16 y.o
Proximal Part incision &
Lat portal (oblique 2cm)

9. Morbidity of the donor site
Hamstrings:
 Advantages in smaller approach & potential regeneration
 Careful Semi T isolation prevents from s.n or s.v. injury
 Posterior approach or classic anterior?
 Vertical or oblique incision?

10. Integration & Ligamentization

11. Graft Shape: Miming the insertions anatomy
“One size fits all” : old fashioned principle
Courtesy of Dr. Smigielski
Sometimes native ACL insertions are more” ribbon-like”.
An ideal graft should reproduce the native ACL shape.

12. Is it possbile to make a preop- planning for
a “tailored” graft ?

13. GRAFT CHOICE:
Consider Re-Rupture Risk factors
NON-MODIFIABLE
 Sex:
 Age:
 Collagenopathies
 Notch/ Insertions anatomy
 Hormonal patterns
MODIFIABLE
 Smoke
 BMI
 Contact sports
 Pharmacological Therapies

14. BTB
Hamstrings
In 2013

15. Patellar tendon versus hamstring tendon autografts
for reconstructing the anterior cruciate ligament: a
meta-analysis based on individual patient data.
Pooled data of 6 RCTs
423 patients
Postoperative knee instability
was less common after ACL
reconstruction
with
patellar
tendon autograft than with
hamstring tendon autograft.

16. ALLOGRAFT
NO donor site MORBIDITY
BUT
Issues of sterilization
Higher costs
Failure rate higher than autografts.
•
•
•
Prodromos 2007: Autograft failure 5% - Allograft failure 14%
Singhal & D. Johnson 2007: Autograft 23.1% failure
Krych 2008: BTB Allograft has 5.01 higher odds of failure than BTB autograft

17. L.A.R.S & Co
NO donor site MORBIDITY
BUT
Issues of cells viability
Foreign body reactions- necrosis
Long term follow-up?
1 Failure on 26 cases at 10 years
5.6% complication Rate (159 cases)
Parchi, Int J Orthop 2013
Gao, Arthroscopy 2012

18. BIOSCAFFOLDS
 Promising reality: BUT NOT A GRAFT CHOICE
 Human or animal derived medical device
 Still weak: cannot replace human or synthetic graft (due to deantigenation and sterilization issues):
Inappropriate for poor primary stability & poorer streght during remodeling
 FDA approved as “AUGMENTATION” in tendon repair Gigante & Busilacchi JOR 2009, JOR 2012
 Perhaps suitable to fill the BTB gap after harvest - Karaglou & Woo 2008
Future direction:
Mixed biomaterial, with synthetic inner structure
and collagenic surface (biomiming)
Busilacchi (in progress)

19. GFs (PRP / PRFM)
CONTROVERSIAL “Fashion” Therapy to stimulate the integration / ligamentization
REALLY NO EVIDENCES of strenght improvements by its intraop- administration in primary
or revision (allograft)
Magnussen (MOON), Knee, Aug 2013
Apparently in MRI it enhances tunnels bone regrowth
PRP does not reduce widening of tunnels
Reduces donor site morbiity in BTB harvest
(Rupreth 2013)
(Vadalà 2013)
(Cervellin 2012)
Issues of reimbursement in several countries (Be- Ita – US …)
Intra-articular administration during the remodeling phase of the
“ligamentization”?? : (10-16 weeks postop)
Animal experimental model: 1 administration of PRFM (Cascade) releases GFs till 72h but no influences on
tendon/ligament healing apart from an earlier revascularization
Busilacchi & Gigante, in progress

20. Let’s Talk about MONEY
(Health has no price but Healtcare has costs)
Conclusions:
Hamstring autograft for ACL reconstruction is the most cost-effective
method of surgery for the average patient with ACL deficiency.

21. COST – EFFECTIVENESS :
GRAFTS
Complications
Hamstrings Autograft:
cheapest and the most (cost)effective graft

22. IN SUMMARY
Morbidity
Failure %
Procedure
Costs
Semi-T
M4
lower
5-9%
$
Semi-T /
GracilisM
5-M6
low
3.5-7 %
$
BTB
higher
< 5%
$$
Quad
high
n.d.
$$
Allograft
No
14-23 %
$$$
Synthetic
No
5-6 %
$$$$
Primary
Selected
cases
Revision

23. TAKE HOME
• Hamstrings: low morbidity, reliable, M4 to M6 strong but probably too
stiff.
• BTB: best integration and ligamentization. OLDIE BUT GOLDIE???
• Allograft: in revision cases only and low demanding (higher failure)
• LARS & Co: quick solution for quick recovery (athletes requiring a
extra-fast return to competition.)
• Collagenic scaffold: only as augmentation.
EBM is supporting the Hamstrings bestcosteffectiveness profile:
May it influence companies and insurance strategies,
the the surgeon??

24. EBM
vs
EBM
Nowadays Evidence Based Medicine is not really univocal in declaring
one graft better than others.
Experience Based Medicine highlights the effectiveness of Hamstrings
(quicker, cheaper, 1 or 2 tendons, M4-5-6, …) but BTB is performed if
the surgeon doesn’t really want any surprise.