Graft choice for ACL reconstruction: what are the evidences

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Graft choice for ACL reconstruction what are the
evidences?

• P. DJIAN, Paris France

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ACL reconstruction

• Were abandoned
• ACL suture
• Prosthesis and Augmentation
• Isolated Lateral extra art. tenodesis
• Autografts
• Allografts

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The different grafts
BPTB
Quad T
Hamstring
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Mechanical constraints supported by the native
ACL or the grafts

• The mechanical resistance of a graft must be
  considered compared to the constraints undergone
  by the ACL during the daily activities,
  rehabilitation and the sport activity.

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Biomechanics properties of normal ACL
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Biomechanics properties of normal ACL
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BPTB vs Hamstring

• Hamstring x4 BPTB
• Non equal Tension / Equal Tension (10 mm)
• Ultimate Load N 1550 369 4590
  674 2977 51
  
• Stiffness N/mm 455 39 871 186
  455 57

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Cross-sectional area of the tendons
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Mechanical properties of the different grafts
compared to the native ACL

• of ACL
• 1/3 central BPTB (10 mm) 168
• Semitendinosus (DT) 70
• Gracilis (DI) 49
• Iliotibiale tract (18mm)
  44
• Hamstring 4 Bundles 200
• 1/3 Quad Tendon 150

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Comparison of the diameter of collagen fibers

A
B. Oakes 1993
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Literature Autografts

• In an Evidence-Based Medecine hierarchy, we must
  based consideration on Randomized Controlled
  Trials (RCTs) or controlled prospective
  comparative study.
• Meta analysis and systematic reviews.
• Meta analyses provide a useful tool to give us
  up-to-date knowledge in order to help them in
  clinical decision making (Guyatt GH et al. 2002
  AMA press)

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Literature

• But there are some differences in the systematic
  reviews related to the quality of the
  systematic review themselves.
• QUORUM is the Quality of Reporting of Meta
  analysis statement. Moher et al Lancet 1999.

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Literature

• Overlapping systematic reviews of ACL
  reconstruction comparing Hamstring autograft with
  BPTB autograft why are they different ?
• Poolman RW, Abouali JAK, Conter HJ, Bhandari M.
  JBJS 2007, 89 1542-52

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literature

• Search in Medline, Cochrane and Embase
• 11 studies overlapping systematic reviews.

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Literature

• 3 reviews favored the BPTB for stability one
  favored Hamstring graft.
• 6 reviews favored the HT graft to prevent
  anterior knee pain and the rest are inconclusive

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literature

• The quality of reporting ranged from 5 to 18
  (median 12)
• The internal validity ranged from 1 to 7 (median
  2)
• Formal sensitivity analysis was utilized
  unfrequently.
• The highest-quality review favored HT grafts to
  prevent AKP and showed weak evidence that BPTB
  grafts yielded better stability

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literature conclusion

• Hamstring Tendons autografts are superior to
  prevent Anterior Knee Pain (AKP)
• Limited evidence that BPTB autografts provide
  better stability

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literature conclusion

• Mobility
• No difference between the two grafts
• Isokinetic strength
• No statistical difference between the two grafts
• Activity and sport IKDC, Tegner
• No statistical difference between the two grafts

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Literature Allografts

• BPTB autograft vs BPTB allograft
• Meta analysis . Krych A J, Jackson JD, Hoskin TL,
  Dahm DL
• Arthroscopy, 2008 292-298

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Literature

• Medline, Embase, Scopus between Jan 1985 to April
  2006
• Inclusion criteria
• Comparative studies BPTB auto vs BPTB allo
• a min 2 Year FU
• Identical rehab protocols
• Subjective and Objective assessment

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Literature

• 6 studies / 548 fulfilled the inclusion criteria
• 534 patients 256 with BPTB autograft and 278
  allografts
• No significant difference between the two groups
  in terms of age, gender, laxity in preop status.

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Literature

• Graft failure OR 5.03 S more graft ruptures in
  the allograft group
• Rate of reoperation N.S
• Lachman evaluation N.S
• Pivot shift evaluation N.S
• Patellofemoral crepitus N.S

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Literature

• Return to pre injury activity N.S
• Hop test OR 5.66 In favor of the BPTB
  autografts
• IKDC Scores N.S

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Discussion

• Studies in literature have shown allografts
  rupture from 7 to 13 and autografts rupture
  from 5 to 7
• Sterilization process with irradiation and
  chemical processing
• When these grafts are excluded there is non
  significant difference between the two groups

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CONCLUSION

• All these findings suggest that graft type may
  not be the primary determinant for successful
  outcomes after ACL reconstruction.
• Improvements
• In surgical technique (tunnels and fixations),
• The injuries to the meniscus and cartilage and
  their treatment

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Thank You for your attention