2018 ACL Trends and Update Pearls and Tips - COA

2018 ACL Trends and Update Pearls and Tips

C. Benjamin Ma

Professor in Residence

Chief, Sports Medicine and Shoulder Service

University of California San Francisco

Department of Orthopaedic Surgery

Disclosures

• Research

– NIH, Arthritis Foundation, AANA, OREF

– Zimmer, Histogenics, Moximed, Samumed

• Consultant

– Conmed, Tornier, Medacta

What is a trend?

• “ a general direction in which something is developing or changing”

• “a fashion”

Latest Trends “Fashion” in ACL Reconstruction

• Really? Autograft and Allograft?

• How many bundles today?

• New ligament of the year – ALL

• Reconstruct or Repair or Augment?

• ACL and arthritis

Latest Trends in ACL Reconstruction






Autograft versus allograft

• Really?

– Only choice the patient really has

• Multiple studies performed on autograft versus allograft

• Allograft

– Faster recovery

– No morbidity with graft harvest

• Autograft

– ?better healing

– Morbidity from graft harvest

Suk et al, AJSM 2011, Sun et al Arthroscopy

2009, Poehling et al Arthroscopy 2005,

MOON Study: Auto vs Allo

7

Spindler et al: J Orthop Res 2013 Jan 31(1)

18 yo – 22% failure for allograft

8% for autograft







How many bundles today?

• Single

• Double

• Triple

• Parallelogram??

Description of two ACL bundles:

• 1938 Palmer (Acta Chir Scand)

• 1944 Abbott et al. (JBJS-Am)

• 1975 Girgis et al. (CORR)

AMB PLBPL

AM

Anatomy of ACL in Fetus

AMB

PLB

20th week

Courtesy of Dr. S. Arnoczky

PL

AM

Double bundle versus single bundle

• Improve rotational stability

• Improve pivot shift

10 years of Double Bundle “Fashion”

• No difference in clinical outcomes

• Few studies that show improvement in rotatory stability clinically

• No differences in developing of arthritis

Double bundle vs Single bundle

• Biomechnical advantage

• No difference in clinical outcomes and failure

Harner et al, Arthroscopy 2004

Too Vertical

15June 8,

2018

Anatomic single bundle ACL reconstruction

• Failure of ACL reconstructions

• MARS cohort

• Femoral tunnel malposition

– 35.9% too vertical

– 29.9% too anterior

– 26.5% too anterior and vertical

16

Morgan et al, J Knee Surgery 2012

Lateral wall open

1

7

Anteromedial Drilling

• Need knee hyperflexion

• Caution around medial femoral condyle

Flexible Reamer

• Offers excellent flexibility

• No restriction in tunnel placement

• No need to hyperflex the knee

• Don’t know where it s heading

Outside in technique

• Reverse drilling – inside out

• Independent of knee flexion

• Extra incision – IT band or lateral quadriceps

Anatomic single bundle ACL

• No large comparison studies between techniques

• Smaller cohort studies

– Slight difference in knee kinematics

– Can be different related to tunnel aperture

Is this really anatomic?







New Ligament

• New York Times report

• “People” magazine for orthopaedic surgery

• ALL – anterolateral ligament

ALL injury and reconstruction

• Recognition on MRI

– 26% by one radiologist

– 62% by second radiologist

• 10.7% ALL injury in conjuction with ACL

Segond Fracture

First described in 1879

ALL reconstructions

• Graft reconstruction

• Indications

– High Grade Pivot Shift

– Lateral sided injuries

How to grade pivot shift?

• Indications of ALL Reconstructions

– High grade pivot shift

• Subjective evaluation

• “Glide” “Pivot” “Clunk”

• No objective measurement

Variability in measurements

• Europe

– Stefano Zaffagini

– Philippe Neyret

– Jon Karlsson

– Roland Becker

– Andreas Imhoff

– Timo Jarvela

• Africa

– Willem Vd Merwe

• South America

– Moises Cohen

• North America

– Freddie Fu

– Benjamin Ma

• Asia Pacific

– Masahiro Kurosaka

– Chen Shiyi

– Robert Smigielski

Results :wide variation of their preferred technique

Knee kinematics

• Besides ligament injuries

– ACL

– ALL

– Lateral capsule

• Bone shape have significant contribution to knee kinematics

Bone Shape MeasurementsStatistical Shape Modeling

• Landmarks identified with algorithm based

on local curvature features

• Principal component analysis performed on

matched 3D coordinates

• Modes of variation are extracted from PCA

– Describe unique, uncorrelated features

– Performed separately for tibia and femur

so not effected by knee position

– First 20 modes explain 90% of shape

variability

• Model knee constructed and individual

modes are adjusted to understand various

shape features

Avera

ge S

hape

+ 3SD

- 3SD

Results: Tibial Position Before ACL Reconstruction

-0.5

0

0.5

1

1.5

2

2.5

3

3.5

4

Extension Flexion

Sid

e-to

-Sid

e D

iffe

ren

ce in

Tib

ial

Posi

tio

n (

mm

)

Injured

Control

p = 0.0037 p = 0.026

Ziad and Ma; JOR 2015

Results: Tibial Position After ACL Reconstruction

-0.5

0

0.5

1

1.5

2

2.5

3

3.5

4

Extension Flexion

Sid

e-to

-Sid

e D

iffe

ren

ce in

Tib

ial

Posi

tio

n (

mm

)

Injured

Control

p = 0.048 p = 0.20

Femoral Bone Shape is Correlated with Tibial Position

-80

-60

-40

-20

0

20

40

60

80

-4 -2 0 2 4 6 8

Baseline Side-to-Side Difference in

Tibial Position in Flexion (mm)

Val

ues

for

Fem

ur

10 M

ode

+ More oval-shaped

medial femoral condyle

- More spherical medial

femoral condyle

Rho -0.52

P = 0.0007

Pedoia and Ma, OARSI 2015, 2016

-40

-30

-20

-10

0

10

20

30

-4 -2 0 2 4 6 8

Baseline Side-to-Side Difference in

Tibial Position in Flexion (mm)

Val

ues

for

Tib

ia 1

9 M

ode

+ Increased height of

anteromedial plateau

- Decreased height of

anteromedial plateau

Rho 0.034

P = 0.036

Tibial Bone Shape is Correlated with Tibial Position

Pedoia and Ma, OARSI 2015, 2016

ACL and Kinematics

• Knee kinematics can be related to bone shape differences, not just soft tissue injuries

• Same reconstruction can result in different outcome

• Clinical decision should not be dependent on subjective measurements

• Indication of ALL reconstruction is lacking







ACL – should we just shave them away?

ACL can heal!

• Steiner, Murray, Rodeo et al, Strategies to improve ACL healing and graft placement AJSM Jan 2008

• Zantop et al, Intraarticular rupture pattern of the ACL

– 122 consecutive ACL reconstructions

– 25% partial rupture of ACL

– 44% of patients AM and PL bundle rupture at different location

– Need to examine intact fiber bundles of ACL

ACL Preservation

• Closer analysis of the outcomes shows that location of the tear was important:

• More proximal tears did better: both short and long term

• Mid substance tears did poorly

40June 8,

2018

4

1

How about Augmentation?

4

2

Mackay technique

ACL Repair

4

3

• Wall Street Journal

• “Vogue” magazine for orthopaedic

surgery

Bridge-Enhanced ACL Repair (BEAR)

• Instead of using a graft to replace the torn ACL, we use a protein sponge placed between the torn ends of the tissue to stimulate healing.

Torn ACL Place sponge

in wound site,

holds blood in

wound site

ACL HealsPull ACL up

into sponge

with stitches

- Advantages of Bridge-Enhanced ACL Repair (BEAR)

- No need to heal in a graft harvest site

- Preclinical studies suggest it reduces post-ACL

arthritis

Clinical Studies: BEAR I and BEAR II

• BEAR I trial

– 20 patient FDA sponsored cohort study, opened 2/2015

– 10 BEAR vs 10 autograft HS

– No infection, inflammation, stiffness, failure

– All patients out one year, four are two years out

– All ten knees stable (Lachman, Pivot shift, KT-1000)

– MRIs promising

• BEAR II trial

– 100 patient RCT

– Autograft vs BEAR

– Opened May 2016, completed enrollment

– 96/100 surgeries completed

– Following patients Healed ACL at

one year in the

first BEAR

patient

STAY TUNED!!!

ACL augmentation and repair

• Early clinical trial

• ACL ligaments have been healing

– Just not to the right spot

– Can a sponge guide it?







ACL and Arthritis

• We are good getting patients back to play

– 82% return to sports

– 90% normal or near normal knee function

– Arden et al, Br J Sports Med 2011

• We are NOT good in preventing arthritis

– 50% radiographic OA 10 years out from ACL injuries

– Amin et al Osteoarthritis and Cartilage 2008

– Van der Hart et al J Orthop Surg 2008

Long-term outcomes of ACL injury

• 103 female soccer players with ACL injury > 12 years

• Mean age 31 (26-40yo)

• 82% had radiographic changes

• 51% fulfilled radiographic OA

• 60% had ACL recon

• Surgical reconstruction – no influence on knee symptoms

Lohmander et al, Arthritis Rheum 2004

Who are the at risk individuals?

Motion Difference and Cartilage DegenerationDrop jump test

✓ Vertical ground reaction force

✓ Sagittal biomechanics

✓ Frontal biomechanics

✓ Side to side difference

✓ = Ipsilateral - Contralateral knee

50Presentation Title

Early Detection

• Use of quantitative MR imaging

– T1rho and T2

60

45

30

15

0

(ms)

Baseline One year post ACL-

reconstructionDespite resolution of BMEL, cartilage shows persistent damage

Longitudinal landing biomechanicsAbnormal kinetics at 6 months but normalizes at 3 months


• Side to side differences in kinetics at 6M were associated with larger increases in T1ρ

value from baseline to 3Y


Conclusion

• 6M changes in knee kinetics can be predictable to cartilage degeneration

• Abnormal kinetics leading to more cartilage degeneration

• Intervention can focus on early rehabilitation and treatment

• At risk groups can be identified at 6M following ACL injury and reconstructions



Latest Trends in ACL Reconstruction• Really? Autograft and Allograft?

– Autograft > Allograft


– Less is more


– Not new and still don’t know when to do it


– Promising


– 6M kinetic differences can be risk factor for development of post traumatic osteoarthritis

57

Acknowledgments

▪ C. Benjamin Ma, MD

▪ Xiaojuan Li, PhD

▪ Brian Feeley, MD

▪ Richard Souza, PT PhD

▪ Sharmila Majumdar, PhD

▪ Tomohiro Shimizu, MD

▪ Drew Lansdown, MD

▪ Valentina Pedoia, PhD

▪ Nicholas Colyvas, MD

▪ Favian Su, BS

▪ Musa Zaid, MD

▪ Tomohiro Shimizu, MD

▪ Subburaj Karupppusamy, PhD

▪ UCSF Department of Orthopaedic Surgery

▪ Musculoskeletal Quantitative Imaging Group

▪ UCSF Department of Radiology

▪ The CTRFP TeamFunding:

• AOSSM Genzyme Osteoarthritis Grant for

Clinical Research

• NIH/NIAMS P50 AR060752

• CTSI/UCSF Clinical and Translational Research

Fellowship

Documents

2018 ACL Trends and Update Pearls and Tips - COA