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Christopher Kaeding M.D.

Bioabsorbable vs Metal Screws : Want Some Facts?. Orthopaedic Summit 2018 Las Vegas, NV December 2018. Christopher Kaeding M.D. Judson Wilson Professor of Orthopaedics Executive Director, OSU Sports Medicine Medical Director, OSU Athletics The Ohio State University. Disclosure.

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Christopher Kaeding M.D.

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  1. Bioabsorbablevs Metal Screws: Want Some Facts? Orthopaedic Summit 2018 Las Vegas, NV December 2018 Christopher Kaeding M.D. Judson Wilson Professor of Orthopaedics Executive Director, OSU Sports Medicine Medical Director, OSU Athletics The Ohio State University

  2. Disclosure I have no financial interest or conflict of interest regarding this presentation.

  3. History Interference Screw fixation: • First description of use in 1983 • 30mm A-O 6.5 cancellous screw Lambert KL, CORR, 1983

  4. Metallic Interference Screws (MIS) Pros • Promote early integration into bone • Higher initial fixation strength than other methods Kurosaka M, AJSM, 1987 Pena F, AJSM, 1996

  5. Metallic Interference Screws (MIS) Cons • Artifact on MR imaging • Can make revisions more difficult • “in the way” • difficult to remove • leaves bone void • Advancement of graft • Graft laceration • Over advancement of screw into joint Matthews LS, Arthroscopy, 1989 Almazan A, Arthroscopy, 2006

  6. Bioabsorbable Interference Screws (BIS) • Resorb over time and replaced by bone • Typically takes 2-3 years • Incomplete resorption/ ossification may > 5 yrs • Varied composition • Polyglycolic acid (PGA) • Polylactic acid (PLA) • Polymer hybrids • Biocomposites developed to increase bone incorporation with increased osteoconductive properties • Polymer + calcium phosphate or hydroxyapatite Plominski J, OrthopTraumatolRehabil, 2008 Arama Y, AJSM, 2015

  7. Bioabsorbable Interference Screws (BIS) Pros • Easier revision • Decreased artifact on MRI Cons • Less fixation strength • May break during insertion • Incomplete resorption or incorporation into bone • May lead to tunnel widening or bony cysts • Migration of screw or fragments Watson JN, Knee, 2015 Baums MH, KSSTA, 2006 Almazan A, Arthroscopy, 2006

  8. Metal vsBioabsorbable • 2013 international survey of ACL fixation methods • 34% used BIS • 12% used MIS Usage Chechik O, IntOrthop, 2013

  9. Fixation: Metal vsBioabsorbable Nyland J, Knee, 2015 • Different bioabsorbable screws show similar fixation characteristics • Metal screws had higher mean insertion torque and mean load to failure • Both metal and polymer screws had similar mechanisms of failure Pena F, AJSM, 1996

  10. Complications: Metal vsBioabsorbable Laxdal G, AJSM, 2006 • BIS had significantly larger radiographic appearance of bone tunnels on femoral and tibial sides at 6 and 24 months • BIS had increased femoral tunnel width Myers P, Arthroscopy, 2008

  11. Metal vsBioabsorbable Tunnel Widening Cyst

  12. Complications: Metal vsBioabsorbable Papali R, Brit Med Bull, 2014 • 6 of 12 studies identified 29 intra-operative complications • 4.6% Incidence • 22 screw breakages, all in BIS • 5 of 6 graft damage occurred in BIS • 11 of 12 studies identified 62 post-operative complications • 6.7% Incidence • 43 (69%) occurred in BIS

  13. Complications Metal vsBioabsorbable • Meta-analysis of RCTs (Shen) • Prolonged effusion more common in BIS than MIS (RR 2.57) • No difference in incidence of deep infection • Meta-analysis of RCTs • Higher rate of post-op effusion in BIS (RR 2.81) • Early screw breakage in BIS (RR 12.81) • Less bony incorporation in BIS • Evidence of femoral tunnel widening in BIS (RR 3.78) Shen C, Arthroscopy, 2010 LaupattarakasemP, Arthroscopy, 2014

  14. Complications Metal vsBioabsorbable • Cochrane review by Debieux et al 2016. • Increased intra & post-op complications w/ BIS (RR 1.94) • Increased implant failure or breakage in BIS (RR 6.88) • No difference in infection • Systematic review by Mascarenhas et al 2015 • Showed BIS more commonly had • Prolonged knee effusion • Femoral tunnel widening • Implant breakage Debieux P, Cochrane, 2016 Mascarenhas R, Arthroscopy, 2015

  15. Metal vsBioabsorbable Outcomes

  16. Metal vsBioabsorbable Outcomes

  17. Metal vsBioabsorbable Outcomes Meta-Analyses and Cochrane review conclude: No difference in: • IKDC • Lysholm • KT arthrometry • Pivot-shift • Tegner Shen C, Arthroscopy, 2010 Emond CE, JBJS, 2011 Laupattarakasem P, Arthroscopy, 2014 Mascarenhas R, Arthroscopy, 2015 Debieux P, Cochrane, 2016

  18. Conclusions • Both provide good fixation • Increased risk of complications in BIS • Implant failure • Knee effusion • Tunnel widening • No difference between MIS and BIS in: • patient-reported outcomes • or functional outcomes

  19. “Leave no footprint behind” OR

  20. “Leave no footprint behind” Personally, I use Bioscrews in the Tibia With careful technique, screw breakage has not been a problem Avoid intra-articular exposure of the screw Do not use them for retrograde femoral fixation Have had the rare subcutaneous cyst

  21. Thank You

  22. References 1: Almazán A, Miguel A, Odor A, Ibarra JC. Intraoperative incidents and complications in primary arthroscopic anterior cruciate ligament reconstruction. Arthroscopy. 2006 Nov;22(11):1211-7. PubMed PMID: 17084299. 2: Arama Y, Salmon LJ, Sri-Ram K, Linklater J, Roe JP, Pinczewski LA. Bioabsorbable Versus Titanium Screws in Anterior Cruciate Ligament Reconstruction Using Hamstring Autograft: A Prospective, Blinded, Randomized Controlled Trial With 5-Year Follow-up. Am J Sports Med. 2015 Aug;43(8):1893-901. doi: 10.1177/0363546515588926. Epub 2015 Jun 24. PubMed PMID: 26109611. 3: Baums MH, Zelle BA, Schultz W, Ernstberger T, Klinger HM. Intraarticular migration of a broken biodegradable interference screw after anterior cruciate ligament reconstruction. Knee Surg Sports TraumatolArthrosc. 2006 Sep;14(9):865-8. Epub 2006 Feb 15. Review. PubMed PMID: 16479410. 4: Benedetto KP, Fellinger M, Lim TE, Passler JM, Schoen JL, Willems WJ. A new bioabsorbable interference screw: preliminary results of a prospective, multicenter, randomized clinical trial. Arthroscopy. 2000 Jan-Feb;16(1):41-8. PubMed PMID: 10627344. 5: Chechik O, Amar E, Khashan M, Lador R, Eyal G, Gold A. An international survey on anterior cruciate ligament reconstruction practices. IntOrthop. 2013 Feb;37(2):201-6. doi: 10.1007/s00264-012-1611-9. Epub 2012 Jul 11. PubMed PMID: 22782378; PubMed Central PMCID: PMC3560905. 6: Debieux P, Franciozi CE, Lenza M, Tamaoki MJ, Magnussen RA, Faloppa F, Belloti JC. Bioabsorbable versus metallic interference screws for graft fixation in anterior cruciate ligament reconstruction. Cochrane Database Syst Rev. 2016 Jul 24;7:CD009772. doi: 10.1002/14651858.CD009772.pub2. Review. PubMed PMID: 27450741. 7: Drogset JO, Straume LG, Bjørkmo I, Myhr G. A prospective randomized study of ACL-reconstructions using bone-patellar tendon-bone grafts fixed with bioabsorbable or metal interference screws. Knee Surg Sports TraumatolArthrosc. 2011 May;19(5):753-9. doi: 10.1007/s00167-010-1353-4. Epub 2011 Jan 14. PubMed PMID: 21234545; PubMed Central PMCID: PMC3076560. 8: Drogset JO, Grøntvedt T, Tegnander A. Endoscopic reconstruction of the anterior cruciate ligament using bone-patellar tendon-bone grafts fixed with bioabsorbable or metal interference screws: a prospective randomized study of the clinical outcome. Am J Sports Med. 2005 Aug;33(8):1160-5. Epub 2005 Jul 6. PubMed PMID: 16000666.

  23. References  9: Emond CE, Woelber EB, Kurd SK, Ciccotti MG, Cohen SB. A comparison of the results of anterior cruciate ligament reconstruction using bioabsorbable versus metal interference screws: a meta-analysis. J Bone Joint Surg Am. 2011 Mar 16;93(6):572-80. doi: 10.2106/JBJS.J.00269. PubMed PMID: 21411708. 10: Fink C, Benedetto KP, Hackl W, Hoser C, Freund MC, Rieger M. Bioabsorbablepolyglyconate interference screw fixation in anterior cruciate ligament reconstruction: a prospective computed tomography-controlled study. Arthroscopy. 2000 Jul-Aug;16(5):491-8. PubMed PMID: 10882444. 11: Järvelä T, Moisala AS, Sihvonen R, Järvelä S, Kannus P, Järvinen M. Double-bundle anterior cruciate ligament reconstruction using hamstring autografts and bioabsorbable interference screw fixation: prospective, randomized, clinical study with 2-year results. Am J Sports Med. 2008 Feb;36(2):290-7. Epub 2007 Oct 16. PubMed PMID: 17940145. 12: Kaeding C, Farr J, Kavanaugh T, Pedroza A. A prospective randomized comparison of bioabsorbable and titanium anterior cruciate ligament interference screws. Arthroscopy. 2005 Feb;21(2):147-51. PubMed PMID: 15689862. 13: Kurosaka M, Yoshiya S, Andrish JT. A biomechanical comparison of different surgical techniques of graft fixation in anterior cruciate ligament reconstruction. Am J Sports Med. 1987 May-Jun;15(3):225-9. PubMed PMID: 3303979. 14: Lambert KL. Vascularized patellar tendon graft with rigid internal fixation for anterior cruciate ligament insufficiency. ClinOrthopRelat Res. 1983 Jan-Feb;(172):85-9. PubMed PMID: 6822009. 15: Laupattarakasem P, Laopaiboon M, Kosuwon W, Laupattarakasem W. Meta-analysis comparing bioabsorbable versus metal interference screw for adverse and clinical outcomes in anterior cruciate ligament reconstruction. Knee Surg Sports TraumatolArthrosc. 2014 Jan;22(1):142-53. doi: 10.1007/s00167-012-2340-8. Epub 2012 Dec 14. PubMed PMID: 23238925. 16: Laxdal G, Kartus J, Eriksson BI, Faxén E, Sernert N, Karlsson J. Biodegradable and metallic interference screws in anterior cruciate ligament reconstruction surgery using hamstring tendon grafts: prospective randomized study of radiographic results and clinical outcome. Am J Sports Med. 2006 Oct;34(10):1574-80. Epub 2006 May 9. PubMed PMID: 16685087.

  24. References 17: Mascarenhas R, Saltzman BM, Sayegh ET, Verma NN, Cole BJ, Bush-Joseph C, Bach BR Jr. Bioabsorbable versus metallic interference screws in anterior cruciate ligament reconstruction: a systematic review of overlapping meta-analyses. Arthroscopy. 2015 Mar;31(3):561-8. doi: 10.1016/j.arthro.2014.11.011. Epub 2014 Dec 31. Review. PubMed PMID: 25557919. 18: Matthews LS, Soffer SR. Pitfalls in the use of interference screws for anterior cruciate ligament reconstruction: brief report. Arthroscopy. 1989;5(3):225-6. PubMed PMID: 2673257. 19: McGuire DA, Barber FA, Elrod BF, Paulos LE. Bioabsorbable interference screws for graft fixation in anterior cruciate ligament reconstruction. Arthroscopy. 1999 Jul-Aug;15(5):463-73. PubMed PMID: 10424549. 20: Moisala AS, Järvelä T, Paakkala A, Paakkala T, Kannus P, Järvinen M. Comparison of the bioabsorbable and metal screw fixation after ACL reconstruction with a hamstring autograft in MRI and clinical outcome: a prospective randomized study. Knee Surg Sports TraumatolArthrosc. 2008 Dec;16(12):1080-6. doi:10.1007/s00167-008-0593-z. Epub 2008 Sep 2. PubMed PMID: 18762911. 21: Myers P, Logan M, Stokes A, Boyd K, Watts M. Bioabsorbable versus titanium interference screws with hamstring autograft in anterior cruciate ligament reconstruction: a prospective randomized trial with 2-year follow-up. Arthroscopy. 2008 Jul;24(7):817-23. doi: 10.1016/j.arthro.2008.02.011. Epub 2008 Apr 14. PubMed PMID: 18589271. 22: Nyland J, Krupp R, Greene J, Bowles R, Burden R, Caborn DN. In situ comparison of varying composite tibial tunnel interference screws used for ACL soft tissue graft fixation. Knee. 2015 Dec;22(6):554-8. doi: 10.1016/j.knee.2015.03.009. Epub 2015 Jun 16. PubMed PMID: 26092113. 23: Papalia R, Vasta S, D'Adamio S, Giacalone A, Maffulli N, Denaro V. Metallic or bioabsorbable interference screw for graft fixation in anterior cruciate ligament (ACL) reconstruction? Br Med Bull. 2014;109:19-29. doi: 10.1093/bmb/ldt038. Epub 2013 Dec 18. Review. PubMed PMID: 24357733.

  25. References 24: Pena F, Grøntvedt T, Brown GA, Aune AK, Engebretsen L. Comparison of failure strength between metallic and absorbable interference screws. Influence of insertion torque, tunnel-bone block gap, bone mineral density, and interference. Am J Sports Med. 1996 May-Jun;24(3):329-34. PubMed PMID: 8734884. 25: Płomiński J, Borcz K, Kwiatkowski K, Zabicka M. Fixation of patellar tendon bone graft in reconstruction of patellar ligaments. Comparison of bioabsorbable and metal interference screws--results of treatment. OrtopTraumatolRehabil. 2008 Jan-Feb;10(1):44-53. PubMed PMID: 18391905. 26: Shen C, Jiang SD, Jiang LS, Dai LY. Bioabsorbable versus metallic interference screw fixation in anterior cruciate ligament reconstruction: a meta-analysis of randomized controlled trials. Arthroscopy. 2010 May;26(5):705-13. doi: 10.1016/j.arthro.2009.12.011. Review. PubMed PMID: 20434671. 27: Watson JN, McQueen P, Kim W, Hutchinson MR. Bioabsorbable interference screw failure in anterior cruciate ligament reconstruction: A case series and review of the literature. Knee. 2015 Jun;22(3):256-61. doi: 10.1016/j.knee.2015.02.015. Epub 2015 Mar 17. Review. PubMed PMID: 25795545.

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