ACL Reconstruction in
Patients Over Age 25:
Allograft is a Good Option and will
ensure less morbidity!
Orthopedic Summit 2014
Annual Meeting
December 4, 2014
Mark H. Getelman, MD
Disclosures
Consultant
Depuy Synthes Mitek Sports Medicine
Director
So. California Orthopedic Research and Education
Fellowship Support
Depuy Synthes Mitek Sports Medicine
Smith Nephew
Ossur Medical
DJO
AANA, Enduring Materials Committee Chairman
Member-Board of Directors
Background
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Many technical advances have occurred in
ACL surgery
Soft tissue grafts have gained in popularity
particularly with the benefits of AMP drilling
double bundle and all inside techniques.
Several studies have shown similar
outcomes for BTB and hamstrings
autografts and allografts as well
Autograft vs Allograft
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Allograft ACL eliminates
 donor site morbidity
 anterior knee pain
 knee flexion weakness
 patella tendonitis or fracture
 altered quadriceps function
 saphenous nerve injury
Autograft vs Allograft
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Debate exists regarding optimal graft selection
Systematic reviews have shown no difference in
clinical outcomes
Studies have questioned durability of allograft
reconstruction in young patients…
But is it really the graft??
…or just higher risk of failure in young athletes
…REGARDLESS of Graft.
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5.6% failure rate
8.8% failure in patients under 25
5.7% failure in patients 26-40
0% failure in patients over 40
Did not reach statistical significance
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23.1% required revision surgery
Failure or reoperation in 17/31 patients
under age 25 (55%)
Mean age of patients who failed was 22.8
Advised against use of tibialis anterior
allograft in young competitive athletes
Used an accelerated rehab and limited data
about graft sourcing and age of donor
Hamstring Autograft
This Just
In…from
leading
expert ACL
expert
Stephen
Colbert
Hamstring
Autograft
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Magnussen reported on 256
pts
1.7% pts with grafts > 8mm
failed
13.6% pts with grafts < 7mm
failed
<1% pts over age 20 failed
14.3% pts under age 20
failed
Systematic Review
Arthroscopy 2013
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Auto vs Allo
No Statistically Significant Difference:
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Lysholm
IKDC
Lachman
Pivot-shift
KT-1000
Failure Rate
Allograft is the way to go!
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HT Failure rate is at least 13.6-18.6%!
I would recommend a 9 mm Tibialis
Anterior allograft all day long instead ESP
in patients over the age of 25!
We have data to support it
Presented at AANA Annual Meeting 2013
by Kyle Stuart, MD and myself and
submitted for publication
Methods
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Failure defined as persistent or recurrent
subjective knee instability in addition to
objective findings of positive Lachman
and/or pivot shift test—not only revisions!
Failure Rates by Age
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Oldest pt to fail: 21 years old
3 male failures: ages 18-20
9/10 female failures < 17 years old
Overall 12/13 failures < 21 years old
Summary
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Lowest failure rates for BTB…gold std!
Highest failure rates for HT AUTO
Higher failure rates in women under 21
All failures in patients aged 21 and under
Highest outcome scores AT Allograft
Lowest outcome scores HT Autograft
So Now What?
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Must accept that not all who
tear their ACL are going to
be D I or Pro athletes
The return to sport with BTB
can be delayed
Not all our patients are the
same and we have to
individualize our graft
selection
Tough Cases…
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What if physes are not fully closed?
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BTB?
5’3” girl with…7mm at best hamstrings
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Is that your best option!
Tough Cases…Demand Tough
Choices
Courtesy Kevin Bonner, MD
Not all patients are the same…even
for our Panelists!!
U Conn Clinic
Boston
So Now What?
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In SoCal…many are not willing to
accept the incision, morbidity of BTB
Bottom Line…even in Under 25
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Failure rates are higher for all graft options
particularly in Females and under age 21
Most Males will go with BTB and do well
MANY females don’t want BTB and I use
Allograft over Hamstring Auto
Need to counsel the patient and family of
the higher risk if under age 21
No Difference with less Morbidity > age 21
Conclusion
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Allograft ACL reconstruction
is a excellent option and
viable for young patients
Caution is advised for
hamstring autograft,
especially in young,
competitive female athletes
with marginal graft size
Come on Mr. Moderator
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Show some support:
We have ties to UF
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UF MD ’89
Watched you do many
allografts…even in the
athletes < 22.
Maybe next year!
What do panelists really use…
Allograft is
best for
you!
Sure bet you are REALLY closet ALLOGRAFT Guys?
Thank You
THANK
YOU