Name: GraftLink® ACL Reconstruction Clinical Outcomes in Young Athletes
Uploaded: 2016-03-22T00:00:00Z
Channel: Arthrex

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VPT1-00634-EN | A | GraftLink® ACL Reconstruction Clinical Outcomes in Young Athletes

Frank A. Cordasco

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GraftLink® ACL Reconstruction Clinical Outcomes in Young Athletes

This study, published in GSM in 2014 by Emily Dodwell, Dan Green and others at HSN, mined the New York State Sparks database and demonstrated a nearly three fold increase in ACL reconstructions in this population under the age of 20 between 1990 and 2009. And this trend has led to scenes such as this one in my office, which I'm sure you've seen in your offices as well, where we have two athletes with ACL injuries, both football players. One plays in the NFL and one is in the second grade. Middle school, high school, collegiate and professional athletes represent a high risk group in this cohort. My my talk today will focus predominantly on the pediatric and adolescent population. We published our all epiphyseal technique in 2012. It's based upon Alan Anderson's landmark work over ten years ago, in which he described the epiphyseal technique with outside in tunnels. Ted Ganley and colleagues at Chop subsequently modified it with a RetroScrew and used intraoperative CT for imaging. Ours is an all inside approach. We use sockets and not tunnels with an inside out approach using FlipCutter as described and a hamstring or quad autograft, and we developed special pediatric guides as well to facilitate this. We evaluated this technique in our biomechanics lab. Maura McCarthy, one of our residents at the time, took the lead on this work, which was published in Ajsm in 2013, and the ACO compared favorably to the over the top and subsequently the complete TransFix in improving the kinematics and contact stress of the ACL deficient knee. So in our hands, we have found this to be an effective technique. We evaluated our first 25 athletes with MRI using a physical mapping technique coordinated by Dr. Daniel Nawabi, who was a fellow at that time. And our group found no significant growth disturbances. And we published our published our results in Agsm in 2014. And in our hands, it's been a safe technique. Recent instrumentation improvements have enhanced the efficiency. And Jake alluded to those a few minutes ago, but I'll just touch on a few issues that relate to this population. The short FlipCutter has been easier to handle. It's 3.5in shorter, and in these young athletes with a shorter tibia, it's easier to clear the O.R. table and it provides for more stability as well. In addition, the side release handle has improved efficiency. There's no need to slide the drill sheath back before securing it in the cortex and deploying the FlipCutter and the locking mechanism. As Jake mentioned on the drill sheath allows for one hand use and more stability. And finally, the longer housing combined with the shorter FlipCutter has increased stability. And again, in this young population, that's that's important. But what we're all really interested in are the clinical outcomes. We presented this work at Aossm in 2014 and should be published shortly. The purpose of this study was to Was to evaluate the quality of movement assessment to address modifiable risk factors related to neuromuscular mechanics in young athletes. Again, these are not collegiate or professional athletes, and there are developmental challenges here. We also wanted to determine the duration of time before the athletes were cleared for return to sport. And we hypothesized that this would be longer than the than in the skeletally mature or adult population. And our results did demonstrate that the quality of movement assessment provided a safe return to sport, and notably, at an average time 12.5 months following the injury and surgery. So we do believe the quality of movement assessment is an important tool to address these modifiable risk factors and provide a safe return. We also presented this work last summer at the Aossm. The purpose of this study was to evaluate the two year clinical outcomes of an all-inside all epiphyseal approach, with a primary focus upon return to sport and incidence of second surgery. Our group developed this guideline published in Jbj's JRPGs in 2013, and it really begins with determining skeletal age. We use the shorthand Bone Age Measurement scale, which is a validated scale and obviates the need for the GP Atlas. And then we can select from a menu of operations beginning with a modified Macintosh, the all epiphyseal, the partial transvaginal or hybrid technique, and the complete TransFix depending upon the skeletal age of the athlete. I'd like to add repair. We've heard a lot about repair and internal bracing at this meeting, and I think it's a very exciting area, and particularly in this cohort of young people, pediatric and young adolescent. There's a very good role for this, and I think it demands from all of us a more focused approach and attention to determining the selection of these patients. We'll hear more from this from my colleague Greg Defelice in the next session, who will talk specifically about repair and internal bracing. I also think there's a role for extra articular augmentation in the highest risk group of this, this population. And I'll touch on this in a few in a few moments and we'll hear more from this, more about this, I should say again in the next session from a Bertrand. And I had the pleasure of visiting him in his or in Lyon last summer at the Isakos meeting, and he's really a fabulous technician and I look forward to his talk. But for the moment I'm going to discuss predominantly the all epiphyseal approach and the results in this young cohort. So to provide some perspective of our first 100 cases in this prospective study over a four and a half year period, we performed 42 all Epiphyseal cases. And this presentation focuses on the first 23 to hit the two year minimum follow up mark. The mean age was 11.8, the mean bone age was 12.1. There were 17 males and six females. As you can see here, these are truly middle school students. The school grade distribution is shown and the predominant population was in the fifth through seventh grades. These were competitive athletes. 78% participated in a specific outside school teams, travel teams, etc.. Elite teams. And you can see the distribution of sports in that group. Predominantly soccer and lacrosse. Post-operatively. We began with a physical examination CT 1000 Arthroman three Isokinetic testing, single leg hop test, MRI and standing radiographs and validated outcome scores as you can see. We also developed, as I said, the quality of movement assessment as the first step in this return to sport program, specifically to target modifiable risk factors in this very vulnerable group. And the goal was to facilitate a safe return to pre-injury level of play and prevent a second injury, including contralateral and or ipsilateral injuries. The results as you can see, the outcome scores were respectable. Lockman and pivot were normal or nearly normal in all patients. Ct 1000 was one hop test 92%, and Isokinetic testing was greater than 9% 90% in the majority. Our MRI and MRI and standing radiograph results at two years demonstrated no significant growth disturbances and excellent graft incorporation. 21 of 23 athletes returned to sport at an average of 12.5 months post-op. You can see the final sports participation distribution here. Predominantly lacrosse and four athletes played more than one sport. Second surgery was required in two of 23 patients, or 9%. Three additional operations were required in these two patients. One patient had two surgeries, a revision ACL ten months post-op. He had not been released for return to sport and a contralateral ACL reconstruction at 18 months. An additional patient had a medial meniscus re repair with a graft intact at 18 months post op playing baseball, and then went on to return to high school baseball after re repair. So in summary, with respect to the all epiphyseal group, we found good to excellent subjective and objective clinical outcomes. No evidence of growth disturbance. Qma is an is an important tool to facilitate a safe return in our hands. Average time for return to sport in this young cohort was more than a year. 91% returned to sport. 9% required three additional surgeries, and long term follow up is clearly necessary, and we follow these young athletes out to skeletal immaturity. I'd like to touch on these non-modifiable risk factors, because I do think this is a critical component in this youngest group in particular. We published this paper last year in Ajsm. David Derr was the lead. He's a resident at our institution, and we looked at an MRI based case control study of 152 patients and found that increased lateral tibial slope was associated with ACL rupture in this pediatric and adolescent population, and in particular, the threshold value of greater than four degrees was found to be significant. Currently in this population, we are using an extra articular extra articular augmentation as a primary component of the ACL reconstruction at the time of the index operation for these higher risk patients, we Patients. We believe thus far that Beighton of greater than six excessive recurvatum valgus, increased lateral tibial slope and a narrow notch are candidates for this combined approach. Just a few preliminary observations from our first 100 cases. This is unpublished data. We had a 16% second surgery rate. I consider this a failure rate, and this includes both ipsilateral contralateral and meniscus injuries in this group. And I'd like to focus for the moment on the non-modifiable risk factors, which we identified really retrospectively when we looked at this group of failures because we were concerned. So as you can see, non-modifiable factors were associated with ipsilateral injury in four of the five partial knees and three of three complete TransFix. In addition, we found modifiable risk factors to be the component associated with failure in on the contralateral side in three of four complete transphasic patients. Nevertheless, the results of this study are consistent with the literature in this high risk group under the age of 20. And you can see across the board whether we look at the Boston Children's Report, moon cohort, Shelburne, a large group in Melbourne, a number of failures in this young population. I'd like to highlight this particular group. This is a paper that Emily Dodwell at our institution, presented last year at the Aossm, should be published shortly. Again, mining the New York State Sparks database. This represents one of the largest studies documenting surgery failure rates after ACL reconstruction in the under 20 population. Nearly 24,000 reconstructions between 1997 and 2010, with a 22% rate of second surgery. As Bill Garrett mentioned at dinner last night, we see too many injuries, too many revisions, and we need to do better. And I believe we can do better. And I'll just highlight these two issues before finishing. Again, I've you've heard me mention modifiable risk factors a few times here now. And they relate to strength, deficits, neuromuscular deficits, etc.. I think the onus is on us to identify these post-operatively before returning these young athletes to sport, and that that includes a strength and conditioning program and a quality of movement assessment. And as you can see, it goes beyond the three months, six months post-op period. We really have to follow these young athletes out for at least a year. And then on the Non-modifiable side, these are structural components that involve valgus alignment, recurvatum laxity, increased lateral tibial slope, and narrow notches. We tend not to see these in the elite collegiate and professional athletes. Again, this is a young cohort of patients and we need to identify these preoperatively. And my view is that we need to add something to the ACL at the time of the index operation, in the form of an extra articular augmentation. Our current preference is to use an ITB tenodesis a modified la mer technique.

GraftLink® ACL Reconstruction Clinical Outcomes in Young Athletes

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