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Christopher Kaeding M.D.

Outcomes & Predictors of ACL Surgery: Hamstring, BTB & Revision - What I T ell M y Patients -. 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

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Christopher Kaeding M.D.

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  1. Outcomes & Predictors of ACL Surgery: Hamstring, BTB & Revision - What I Tell My Patients - 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 and its contents

  3. Global Hypothesis MOON Evaluate PROGNOSIS & PREDICTORS of “Clinically Relevant Outcomes” of ACLR Aim 1: Activity Level (Marx) Aim 2: Patient-Oriented Outcomes (KOOS, IKDC, SF-36, WOMAC) Aim 3: Symptoms and Signs of Osteoarthritis Aim4: Recurrent Ligament disruption Aim 5: Additional arthroscopic surgery

  4. DEMOGRAPHIC PREDICTORS OF ACLR OUTCOMES Is AGE a risk factor for ACLR failure? YES Increased failures in younger patients

  5. DEMOGRAPHIC PREDICTORS OF ACLR OUTCOMES Is GENDER a predictor for activity level after ACLR? YES Females return to a lower Marx Activity level

  6. DEMOGRAPHIC PREDICTORS OF ACLR OUTCOMES Is Baseline Activity a predictor for future activity after ACLR? YES Higher Baseline activity predicts higher activity after ACLR

  7. DEMOGRAPHIC PREDICTORS OF ACLR OUTCOMES Is BMI a predictor for future activity and patient reported outcomes (PRO) after ACLR? YES Higher BMI predicts lower activity and worse PRO

  8. DEMOGRAPHIC PREDICTORS OF ACLR OUTCOMES Is Smoking a predictor for future activity and patient reported outcomes (PRO) after ACLR? YES Smoking predicts lower activity and worse PRO

  9. DEMOGRAPHIC PREDICTORS OF ACLR OUTCOMES Is Education a predictor of outcome after ACLR? YES Less Education predicts worse outcome after ACLR

  10. INJURY RELATED PREDICTORS OF ACLR OUTCOMES Is GRADE 1 OR 2 MCL a predictor for OUTCOME after ACLR? NO An associated incomplete MCL injury does NOT predict outcomeafter ACLR

  11. INJURY RELATED PREDICTORS OF ACLR OUTCOMES Is LCL Injury a predictor of outcomes after ACLR? YES More symptomsafter ACLR in patients with associated LCL injury

  12. INJURY RELATED PREDICTORS OF ACLR OUTCOMES Is Medial Meniscus Repair a risk factor for outcomes after ACLR? YES Worse outcomes with medial meniscus repair

  13. INJURY RELATED PREDICTORS OF ACLR OUTCOMES Is Lateral Meniscus Repair a risk factor for outcomes after ACLR? NO LM repair same as No LM tear

  14. INJURY RELATED PREDICTORS OF ACLR OUTCOMES Is Articular Cartilage Injury a risk factor for ACLR outcome? YES Worse outcomes with grade III / IV cartilage injuries present at ACLR

  15. RETURN TO SPORTS, ACTIVITY LEVELS, AND SPORT OUTCOME INSTRUMENTS (IKDC & KOOS) How many ACLRs return to American Football after surgery? 70% High School 70% College Of those who don’t, 50% site “Fear of Re-injury” as a primary factor

  16. RETURN TO SPORTS, ACTIVITY LEVELS, AND SPORT OUTCOME INSTRUMENTS (IKDC & KOOS) How many ACLRs return to Soccer after surgery? 70% With males more likely to return than females

  17. RETURN TO SPORTS, ACTIVITY LEVELS, AND SPORT OUTCOME INSTRUMENTS (IKDC & KOOS) • What will my future activity level be after ACLR - based on the Marx Activity Scale?

  18. Population Results: MARX Activity Scale IKDC For entire group: Slow decrease over 10 years

  19. RETURN TO SPORTS, ACTIVITY LEVELS, AND SPORT OUTCOME INSTRUMENTS (IKDC & KOOS) • What will be my future patient-reported outcome on the KOOS?

  20. Population Results: KOOS IKDC 2,6,10 yr Baseline Improved Improvement stable through at least 10 years

  21. RETURN TO SPORTS, ACTIVITY LEVELS, AND SPORT OUTCOME INSTRUMENTS (IKDC & KOOS) • What will my IKDC patient-reported outcome be after ACLR?

  22. Population Results: IKDC IKDC Improved Improvement stable through at least 10 years

  23. RISK FACTORS FOR ADDITIONAL SURGERY • What is my risk of meniscal repair failure? 4-6% at 2 years Much higher for younger and more active

  24. RISK FACTORS FOR ADDITIONAL SURGERY What is my infection risk after ACLR? 0.4% Somewhat higher in hamstring grafts

  25. Hamstring Grafts: Under Assault? Orthopaedic Summit 2018 Las Vegas, NV December 2018 Christopher Kaeding M.D. Judson Wilson Professor Executive Director Sports Medicine Center Head Team Physician The Ohio State University Sports Medicine

  26. Hamstring Grafts Traditionally: - Semi-tendinosus+gracilis tendons doubled to create 4 strand graft - Some use only doubled Semi-tendinosus Mechanical Properties TissueStrength (N) Stiffness (KN/m) Native ACL 2160 292 BPTB 2977 620 Quad HS 4590 861

  27. Hamstring Grafts Increasing in popularity - in early 1990’s 90% of ACLR grafts were BPTB - as we began to attain consistent results with PT: “Can we get same results more easily for patient?”

  28. Hamstring Grafts Advantages (vs PT): - Less post-operative pain - Less quadriceps inhibition - No risk of patella fracture - Less kneeling pain - Less ROM issues Easier Recovery Fewer Complications Better fixation techniques: Soft-threaded Screws Cross Pins Suspension “Buttons” Whip stitch tied over a post

  29. Hamstring Grafts Increasing in popularity - in early 1990’s 90% of grafts were PT - More recent hamstring use: - 84% in Denmark + Sweden - 60% in Norway - 44% in USA (vs 42% PT) Most commonly used ACLR graft in the world

  30. Hamstring ACLR Grafts Clinical Outcomes (vs PT) - Laxity: < 1mm difference in SSD - Patient reported outcomes: Equal - no difference except for kneeling pain - Retear: historically no statistical difference • If outcomes equal, why not use the graft with: • easier recovery • lower morbidity ...... but the discussion continues …….

  31. Hamstring Grafts Recent concern over increased risk of retear in HS ACLR: - Revisions at 5 years: - Danish registry: HS 4.5% vs PT 3.0% - Norwegian registry: HS 5.1% vs PT 2.1% For all groups: 95% or greater chance of not needing a revision at 5 years

  32. Hamstring Grafts If small increase in retear risk is true…….. Why? - Were the grafts smaller?

  33. Hamstring Grafts If small increase in retear risk is true…….. Why? - Were the grafts smaller? - Is small loss of remaining HS function contributing?

  34. Hamstring Grafts If small increase in retear risk is true…….. Why? - Were the grafts smaller? - Is small loss of remaining HS function contributing? - More rehab & time for compensation = benefit?

  35. Hamstring Grafts If small increase in retear risk is true…….. Why? - Were the grafts smaller? - Is small loss of remaining HS function contributing? - More rehab & time for compensation = benefit? - Quadruple Semi-T, preserve gracilis= benefit?

  36. Hamstring Grafts If small increase in retear risk is true…….. Why? - Were the grafts smaller? - Is small loss of remaining HS function contributing? - More rehab & time for compensation = benefit? - Quadruple Semi-T, preserve gracilis= benefit? - Is HS tissue biologically different than PT? - Does it require more time to mature?

  37. Hamstring Grafts If small increase in retear risk is true…….. Is there a population where HS grafts are more / less appropriate? Is the price of a 95 vs 97% non-revision rate worth the other advantages of HS graft?

  38. Hamstring Grafts Having said all that …… I currently use PT grafts on committed cutting sport athletes.

  39. ACL Grafts More work needs to be done…… Ideal graft for ACLR has not yet been identified.

  40. Thank You

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