ACL Graft Choice - Foundation for Orthopaedic Research and Education (FORE)
ACL Graft Choice
Michael B. Ellman, MD
Panorama Orthopedics Sports Medicine
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330033-2-23333-1-1222233
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
ACL Graft Usage 2014-15
BTB ALLO 1%
STAGE 1 REVISION
1%
BTB AUTO 15%
TA/TP ALLO 22%
HAMSTRING AUTO 61%
61% Hamstring Auto 15% BTB Auto 22% 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., KSSTA 2008;. 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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