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Evidenced Based Approach to ACL Injuries

Evidenced Based Approach to ACL Injuries. Balmain Sports Medicine November 2011. Who am I?. References to Read. Handout. Epidemiology. Females have a 2-6x higher incidence ACL rupture compared to males in the same sport Overall Incidence over 4 year period Females 3.8% Males 3.5%

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Evidenced Based Approach to ACL Injuries

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  1. Evidenced Based Approach to ACL Injuries Balmain Sports Medicine November 2011

  2. Who am I?

  3. References to Read • Handout

  4. Epidemiology • Females have a 2-6x higher incidence ACL rupture compared to males in the same sport • Overall • Incidence over 4 year period • Females 3.8% • Males 3.5% • 67% men and 90% women rupture without contact

  5. Prevention • Neuromuscular Interventions • Hewett TE Am J Sports Med 2006 • Gilchrist Am J Sports Med 2008

  6. Pathophysiology • Isolated ACL in less than 10% • Meniscal injury in 60-75% • Bone Bruise on MRI in 80% • Collateral injury 5-24% • Articular cartilage damage 46%

  7. Diagnosis • History • Examination • Lachman 85% sensitive, 94% specific • Pivot 24% sensitive, 98% Specific • MRI • Sens 86% specific 95%

  8. Indications Surgery • Sensation of Instability in normal ADLs • Resume sports with cutting and pivoting • Particular jobs

  9. Indications for Surgery • Kanon/Frobell N Eng J Med 2010

  10. Delayed group • 37% went on to have ACL reconstruction • 20% chance requiring delayed meniscal surgery • Previously – at 2 years • Rate meniscal tear non operative 37% • Post Surgery 3%

  11. Graft Choice Autograft – Patients own tissue Allograft – someone else's tissue Synthetic - Artificial

  12. Autograft • The autograft source has a minimal effect on the outcome of patients undergoing anterior cruciate ligament reconstruction

  13. Bone Healing – BTB 4-6weeks • Soft Tissue Healing 9-12 weeks

  14. The Quadriceps Tendon: The Forgotten graft? Systematic Review of Primary ACL Reconstruction utilising Autograft Quadriceps Tendon Anterior knee pain 10 vs 35%(BTB) 3% failure rate S Hutchinson, J Mulford

  15. Quads Tendon • Pros • Strong graft • Good for revision graft • May be useful for double bundle • May have less morbidity then Patella and hamstrings • Cons • Quads weakness • Anterior knee pain • Not commonly used

  16. Allograft Allograft significantly lower normal stability rates than autograft Allograft abnormal stability rate 3 times greater than autograft. The graft failure rate was 4.7 +/- 0.5 per 100 for autograft reconstructions 8.2 +/- 2.1 per 100 allograft reconstructions

  17. Artificial Graft Have been used for over 30years Avoids the donor site morbidity, quicker recovery, cheat biology. Problem has been their durability – they have not matched autograft in this regard.

  18. Media Miracle op to melt down surgeons' phones

  19. 4 Comparison Papers • No difference in the 10 outcome measures at final follow up (15 – 49 months). • LARS patients reached full recovery sooner.

  20. Correspondence Dr Nicolas Duval • Best results are in early ACL repair augmented by LARS • Expect 80 to 90% good results at 10 years. • Chronic ACL tear - 50% failure at 10 years • Revision ACL surgery - 40% failure at 10 years.

  21. Electron Microscopy

  22. Pittsburgh Group

  23. The future – Scaffolds and Growth Factors with Repair. • tissue engineering techniques • Grafts that regenerate a mechanically robust and natural ACL • cell-specific growth factors that influencing the maturation and healing response of ligament tissue will also be available.

  24. Patient Specific Approach • Choose graft that matches the patients needs. • Discuss the pros and cons of each graft.

  25. Rehabilitation • CPM – no substantial advantage • Weight bearing – standard practice • Post op bracing – not necessary

  26. Neuromuscular stimulation – high-intensity early post-op period. Not required to achieve successful outcome. • Accelerated rehab - minimal evidence for safe return to sport.

  27. Closed vs Open • Closed chain safe • Concern open chain results in increased laxity • Open chain excercises from 6 weeks may be safe and improve patient outcome (Mikkelsen) • Glass – systematic review

  28. LIPUS

  29. Evidence of Expected Outcome • Predictors of poorer outcome • Smoker • female • higher body mass index • older age.

  30. Complications Reconstruction • Graft Failure – 3.6% • Infection 1% • Additional Arthroscopic Surgery – 15% • DVT – low • Nerve injury low

  31. Risk Arthritis • Oiestad -Systematic Review • Isolated injury – prevalence 0-13% at 10 years • ACL + Meniscus – 21-48% at 10 years

  32. Expected Outcome • ROM normal • Laxity 1-2 mm • Isokinetic strength Av > 90% • Marx Activity reduced by 4 • IKDC Score < 40% normal • Contralateral ACL tear 3% • Graft Failure 3%

  33. Thankyou

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