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Anterior Cruciate Ligament Reconstruction Using Platelet Rich Plasma and Tenomend™

Paul R. Fleissner, Jr., MD

Crystal Clinic Orthopaedic Center

This article has been modified by the author for length to facilitate inclusion in Innovations. The original article,“ Outcomes of Anterior Cruciate Ligament Reconstruction Using Biologic Augmentation in Patients 21 Years of Age and Younger,” is available at www.sciencedirect.com.

INTRODUCTION

Anterior cruciate ligament (ACL) injuries are commonly encountered in the practice of sports medicine with current literature estimating an incidence of 100,000 to 200,000 cases per year.1,2 Among adolescent populations, these injuries are becoming more prevalent. Recent reports have suggested that the numbers are steadily growing, with an incidence of 0.1 to 2.4 patients per 100,000 annually.

Regardless of graft and technique, reports have shown an increased risk of graft failure in the younger population compared with the adult population. Graft failure after successful anterior cruciate ligament reconstruction (ACLR) in patients 21 years of age or younger is as high as 25% or more in some studies.1,3 The use of biologic agents, such as platelet-derived growth factors, remains an area of interest as surgeons explore new means to improve healing. In cases of ACLR, this adjunct is thought to enhance the overall integrity of the reconstructed ligament.4

Although a certain amount of fibrin clot forms in vivo after post-surgical trauma, concentrating specific growth factors that are found within a clot, (e.g., PRP), may have unrealized potential. Plasmin, which is also found with increased intra-articular concentrations after athletic or post-surgical trauma, has been shown to degrade fibrin and may prevent effective delivery of beneficial growth factors.5 With this in mind, collagen scaffolds represent an intriguing adjunct, as soluble collagen can slow plasmin-mediated degradation of fibrin.6

Figure 1. Intraoperative arthroscopic photograph of a left knee from a standard anterolateral viewing portal demonstrating final anterior cruciate ligament graft placement. An overlying porous collagen carrier has been sutured to circumferentially cover the hamstring autograft, and platelet rich plasma has been injected into the graft.

Figure 1. Intraoperative arthroscopic photograph of a left knee from a standard anterolateral viewing portal demonstrating final anterior cruciate ligament graft placement. An overlying porous collagen carrier has been sutured to circumferentially cover the hamstring autograft, and platelet rich plasma has been injected into the graft.

METHODS

Institutional review board approval was obtained. Patients 21-years of age or younger who underwent ACLR utilizing autologous hamstrings and biologic augmentation (PRP and porous bovine collagen membrane, TenoMend, Collagen Matrix, Ramsey, NJ), with a minimum of two years follow-up were enrolled. All patients completed physical therapy and answered outcome questionnaires, including IKDC, Lysholm, Tegner and SANE. They also answered questions concerning whether they had sustained an ipsilateral or contralateral ACL injury since their initial ACLR, positive family history for ACL injury, return to the same sport after ACLR that they had played previously and subsequent surgery on the reconstructed knee since the ACLR (Figure 1).

Patients were rehabilitated using the protocol developed by the MOON study group. Patients were required to complete all 5 phases of the protocol and pass functional testing prior to returning to sports. Serial Lachman testing was performed postoperatively and at final follow-up. Patients were tested at final follow-up for pivot shift phenomenon and by KT-1000 arthrometer.

RESULTS

Initially, there were 194 patients eligible for this study; 143 patients involving 151 knees met the inclusion criteria and completed follow up questionnaires. The mean patient age was 16 years, range 8 to 21 years. The average time to complete physical therapy was 22 weeks, range 12 to 41 weeks. After completion of physical therapy, 132 patients (92%) returned to their preinjury level of activity. The average total follow-up duration was 52 months, range 25 to 94 months. Seven cases (5%) of ipsilateral ACL injury occurred that required revision surgery, with an average time to injury of 17 months. There were 23 contralateral ACL injuries (15%) at an average time of 28 months from the initial surgery.

Mean IKDC and Lysholm scores were 91 and 91, with a range of 55 to 100 and 57 to 100, respectively. Tegner scoring was the same both preoperatively and postoperatively in 138 of 151 knees; 11 scores were lower postoperatively than preoperatively, whereas 4 scores were higher postoperatively. The mean Tegner score preoperatively was 9, range 5 to 10, whereas the mean Tegner postoperative score was 9, range 4 to 10. The average SANE score was 94, range 60 to 100.

Figure 2. The same patient as in Fig 1, 7 months after the initial procedure. Patient was reevaluated with diagnostic and operative arthroscopy after sustaining a new injury while playing basketball. The reconstructed ACL has fully incorporated, with demonstrated ligamentization and neovascularization, again visualized from a standard anterolateral viewing portal.

Figure 2. The same patient as in Fig 1, 7 months after the initial procedure. Patient was reevaluated with diagnostic and operative arthroscopy after sustaining a new injury while playing basketball. The reconstructed ACL has fully incorporated, with demonstrated ligamentization and neovascularization, again visualized from a standard anterolateral viewing portal.

DISCUSSION

Mean IKDC and Lysholm scores were 91 and 91, with a range of 55 to 100 and 57 to 100, respectively. Tegner scoring was the same both preoperatively and postoperatively in 138 of 151 knees; 11 scores were lower postoperatively than preoperatively, whereas 4 scores were higher postoperatively. The mean Tegner score preoperatively was 9, range 5 to 10, whereas the mean Tegner postoperative score was 9, range 4 to 10. The average SANE score was 94, range 60 to 100.

CONCLUSIONS

This study using biologic augmentation (PRP with porous bovine collagen membrane, TenoMend), with hamstring autograft in ACL reconstruction in patients 21-years of age or younger shows a decreased rate of second ACL injury, specifically regarding ACL revision surgery. The patients in this study also show a higher return to preinjury level of competition at a faster rate than other studies have shown.

REFERENCES

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