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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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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