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Moderator: Nick Mohtadi, MD MSc FRCSC DRCPSC | CANADA
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11:30 - 11:37
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Lecture
"Quad Speed": Examining the Evolution of the Quadriceps Autograft in the Skeletally-Immature ACL-injured Athlete (SQuASH Trial)
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Darren Lucien de SA, MD, MBA, FRCSC | CANADA
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Interest in the quadriceps tendon autograft, particularly in adult primary ACL reconstruction, has grown exponentially over the past 5 years. However, “children are not small adults”, and the challenges faced in managing the skeletally-immature athlete with an ACL-deficient knee within an industry exceeding $5 Billion have not gone unnoticed. ACL injuries in children are a significant global problem, with nearly 40-55% increases in the incidence of injuries over a period from 2005-2021. Despite continual technique and technological advances, outcomes in the skeletal-immature population leave much room for improvement, with approximately one-third of patients sustaining a second ACL injury, and 47% and 74% of graft re-ruptures occurring within the first and second post-operative years, respectively. Moreover, increasing evidence suggests that graft healing in this population may also be slower compared to adults. The 2018 International Olympic Committee (IOC) Consensus Statement on prevention, diagnosis, and management of pediatric ACL injuries suggests that the optimal graft for adults may not be ideal for pediatric patients and has made the study of the efficacy of different primary ACL graft options in the pediatric population a research priority - recommending only use of a soft-tissue autograft (not allograft) in patients with open physes.
The quadriceps autograft has demonstrated on par or better performance from a biologic and biomechanical perspective compared to traditional options in the adult population. As a member of the International Quadriceps Tendon Interest Group and having participated in several recent national and international sports medicine meetings (i.e. ESSKA 2024, Pittsburgh Panther Symposium 2024, Canadian Orthopedic Association/Arthroscopy Association of Canada 2024, etc.) it has been my experience that very little content, if at all, has been focused on the potential role and utility of the quadriceps autograft in the pediatric ACL population. This represents a unique opportunity for the Magellan Society 2024 Biennial Meeting.
This lecture is designed to briefly outline the historical use of the quadriceps autograft, its re-emergence and renewed interest in the adult population, and through sharing of my clinical and research experience in this field, its translation into the pediatric ACL armamentarium. Specifically, the lecture will present provocative data from several studies from our research group examining multiple facets of the quadriceps tendon autograft, including but not limited to: 1) graft harvest and preparation pearls in the pediatric population from pre-operative planning, to expected graft dimensions and analyses of clinical outcomes based on full vs. partial-thickness grafts, aperture vs. suspensory fixation, with or without patella bone blocks; 2) unique complication profiles especially arthrofibrosis, cosmesis, extensor mechanism disruption, etc.; 3) ideal knee flexion position for graft fixation; and 4) tenets of postoperative rehabilitation specific to this autograft. The lecture will contain case-based examples illustrating the application of our research findings and concludes by leading into presenting the SQuASH Study (Soft-tissue Quadriceps autograft ACL-reconstruction in the Skeletally-immature vs. Hamstrings), for which I am the Principal Investigator. Briefly, the SQuASH Study is a pilot, randomized controlled trial nearing complete recruitment of 100 patients from several centers in Canada and Japan, and has been funded by the Canadian Orthopedic Association and the Physician Services’ Incorporated Foundation. The primary research objective is to determine the effect of soft-tissue quadriceps versus hamstring autograft tendon during primary ACL reconstruction on rates of re-operation at 2 years. The secondary objectives are to determine the effect of soft-tissue quadriceps versus hamstring autograft tendon during primary ACL reconstruction on the following outcomes at 2 years: rate of return to sport; patient-reported knee function; range of motion; and incidence of contralateral ACL injury. As the first, global RCT in pediatric ACL reconstruction, with the pilot nearing complete recruitment, the intent is to present thought-provoking information on increasing use of this autograft in the skeletally-immature population, and to call upon the expertise of the attendees at the Biennial Meeting to debate this, its implications, and its future directions.
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11:37 - 11:44
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Case Presentations
Restoring the Force Chain through Rotator Cuff Reconstruction for Ireparable Rotator Cuff Tear
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Jinzhong Zhao, MD | CHINA
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Though many techniques exist to treat irreparable rotator cuff tear, the optimal one is still being explored. Double-suspension bridging rotator cuff reconstruction aims to restore the force chain of the rotator cuff. Therefore, the technique will be introduced and the primary results will be presented.
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11:44 - 11:51
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Lecture
Return to Sport Testing in Football: Implementing Sportspecifity by a Mixed Reality Application
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Christian Fink, Prof. | AUSTRIA
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Introduction: In the professional ACL-rehabilitation return to sport process biomechanical measurements of standardized tests batteries are usually conducted. Usually test that contain strength, mobility, stability and dynamic tasks such as horizontal and vertical maximal jump task and cuttings manoeuvres are recommended. The prediction value of these tests with respect to the risk of potential further ACL-injury yet remains highly discussed.
Despite the possibility of high standardization and testing basic motor functions the test batteries might be improved by implementing more sport-specific tasks and tasks that also include the neurocognitive ability of the athlete by implementing tasks with external focus. Such tasks would stress the system from well planned and controlled movements to tasks in a shorter time domain and towards less controlled movements. Using Virtual reality and Mixed reality (MR) applications might help to overcome the difficulties usually coming with these tasks, such as e.g. space, standardization, including a ball and or opponents, and yet be able to test in laboratory conditions. MOTUM XR (MOTUM, Innsbruck, Austria) is a MR application, which enables the athlete to interact via an avatar, that he/she drives with the own movements, with a virtual surrounding displayed on a video wall in front of the motion capture area of the biomechanics lab. Capturing the motion data enables on the one hand side the real time interaction with the MR application and on the other hand side allows to collect data on the performed movement.
Methods: The purpose of this study was therefore to identify, if a mixed reality gaming application (MOTUM XR), can be used for return to sport testing. Of specific interest was the influence of the standing position of the virtual non-contact player (left or right from the goal), on the movement pattern of the performing athlete. Kinematic and kinetic data were collected from nine healthy football players, who performed countermovement jumps and headers according to the game specification.
Results: The data of this study showed indeed, that participants displayed altered movement strategies, despite a similar jump height. The findings of a preliminary study suggest that the jumping strategy was adapted to the task and that the head-ball situation in the MR environment may provide a more realistic test environment. Additionally, this movement pattern displayed strategies, that are generally associated to an increased ACL-injury risk mechanism, such a stiff knee movement combined with an increased vertical force.
Discussion: With respect to ACL-injury monitoring using tasks, which induce movement strategies that are closer to the identified risky movement strategies might improve the efficacy of screening tests. These results suggest that the MOTUM XR application has the potential to induce an external focus in a yet standardized testing scenario and might implement a more sport-specific testing.
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11:51 - 11:58
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Lecture
Second Look after Cartilage Transplantation Combined with HTO: Does Age Matters?
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Rainer Siebold, Prof. Dr. med. | GERMANY
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Clinical and second look follow-up study, age groups below and above 50 years are compared
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11:58 - 12:05
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Lecture
No Correlation Exists Between Tibial- and Femoral-Based Measurements of Patella Alta in a Population With Chronic Patellofemoral Pain or Instability Undergoing Patella Distalization
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Martyn Snow, FRCS | UNITED KINGDOM
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Purpose: To investigate whether the patellotrochlear index (PTI) predicts patella alta as determined by tibial-based methods of Insall-Salvati (IS) and Caton-Deschamp (CDI) indexes in a pathological population (with patellofemoral pain and/or instability), in addition to determining whether PTI and sagittal patellofemoral engagement (SPE) correlate with trochlea length as determined by lateral condyle index (LCI).
Methods: Patients with confirmed patella alta (IS/CDI ratio >1.2) undergoing tibial tubercle osteotomy for patellofemoral pain/instability with an available magnetic resonance imaging (MRI) scans were included. Patients who had undergone previous soft-tissue realignment, previous surgery, or trauma to the extensor mechanism were excluded. Two raters measured the IS, CDI, PTI, SPE, LCI, and knee flexion angle (KFA) on MRI. Interobserver reliability and correlation between measurements were calculated.
Results: In total, 71 knees were included. PTI (0.73), SPE (0.836), LCI (0.701), and KFA (0.8) demonstrated good- to near-excellent interobserver reliability. IS (0.65) and CDI (0.66) demonstrated moderate interobserver reliability. PTI and SPE showed the strongest significant correlation (0.8112, P = 2.2 × 10-16). IS and CD (0.39, P = .0007) showed a moderate significant correlation. PTI and KFA (0.53, P = 1.685 × 10-6) and SPE and KFA (0.61, P = 1.991 × 10-8) had a significant moderate correlation. LCI and KFA (-0.37, P = .0017) showed a significant moderate negative correlation. All other measurement indices correlated poorly and were insignificant. A total of 94.4% of the knees were defined as having patella alta using IS, with the remaining 5.6% having a raised CDI. Only 14% of cases had an IS of >1.2, a CDI >1.2, and a PTI <0.125, which increased to 39% (28/71) when the threshold for PTI was increased to <0.28.
Conclusions: There was no correlation between tibial (IS and CD) and femoral methods (PTI and SPE) of quantifying patella alta. PTI and SPE did not correlate with trochlea length as measured by LCI. PTI, SPE, and LCI are significantly affected by the KFA during MRI.
Level of evidence: Level IV, retrospective diagnostic radiographic investigation.
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12:05 - 12:12
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Lecture
When is a Graft "healed", and What Does that Actually Mean?
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Brett Andrew Fritsch, MBBS BSc(Med) FRACS FAOrthA | AUSTRALIA
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The goal of treatment of ACL injuries is a normal, healed graft. But what does that mean and how well can we measure it ? Subjective patient experience with PROMS, stability measurements both subjective (clinical exam) and objective (GNRB/KT-1000) findings, and MRI analysis are all useful tools for assessing healing from different perspectives. I present a series of ACLR with and without internal brace (see below) to highlight the challenges they present in assessing graft healing, and to act as a starting point for discussion around “what constitutes a healed graft”. In Australia recently there is a sports physician and physiotherapist driven push for non-operative treatment of ACL injuries and proposed bracing protocols to enhance it, with much discussion about what “healing” actually means, and when it has been achieved. The Magellan forum of discussion would seem a timely place to try and answer this question.
Title
The effect of Internal brace on graft healing in single bundle ACLR using hamstring autograft
Background
The Internal brace has been proposed as an adjunct to biological ACLR. Biomechanical data is encouraging though there is a paucity of clinical data about its outcomes on graft healing or clinical effects.
Objective
To determine the influence of an internal brace on the healing of a primary single bundle ACL graft.
Methods
A case series of 70 patients who had a single bundle ACL reconstruction by two surgeons using hamstring autograft with bicortical suspensory fixation and addition of a FiberTape Internal Brace were compared to an age and sex matched cohort of patients with the same technique but no internal brace (matched cohort study). Graft healing was assessed at 12 months via standardised MRI scans using a previously published protocol analysing graft signal/noise quotient (SNQ) across three sites of the graft. Patient reported outcomes (PROMS) with IKDC, Tegner and Lysholm scores were also recorded, and stability assessed via KT-1000.
Results
At 12 months there was no reruptures in either group and no difference between groups for IKDC, Tegner, Lysholm, or stability (KT-1000).
SNQ measurements as a proxy for graft healing on MRI comparing the IB and no-IB groups at proximal, midsubstance, distal regions of interest (ROI), and overall average signal were significantly different between 2 well trained observers. Observer A reported a significant difference at all 3 ROI (SNQ 3.6 ± 3.7 Vs 2.3 +/- 1.5, 5.7 ± 5.1 Vs 3.26 +/- 2.1, 2.6 ± 3.4 Vs 1.7 +/- 1.7, respectively), whereas observer B showed no significant difference at any ROI (SNQ 3.5 +/-3.8 Vs 4.1 +/1 10.4, 4.65 +/- 4.7 Vs 5.4 +/- 11/1, 3.36 +/- 3.15 Vs 5.39 +/ 11.7 respectively).
There was no differences between males and females in either group.
Conclusion
The use of an internal brace in a single-bundle hamstring ACL reconstruction using hamstring autograft and bicortical suspensory fixation shows equivalent clinical results at 1 year compared to a matched cohort without internal brace. When healing is assessed using MRI there is a significant difference between observers, with one reporting increased signal in the graft tissue of the internal brace group at 3 ROI along the graft raising the possibility of less complete healing or graft quality at 1 year in the internal brace group, and the next showing no difference.
This highlights the challenge in assessing what is meant by a “healed graft”, how to measure it, and what we should be telling our patients.
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12:12 - 12:19
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Lecture
Pediatric ACL Injuries - an Update on Diagnosis, Management and Treatment
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Guri Ranum Ekas, MD, PhD | NORWAY
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The aim of this lecture is 1) to present the increasing trend of ACL reconstructions in girls younger than 15 and boys younger than 17 based on numbers from the Norwegian Knee ligament registry and 2) to present a clinical update on pediatric ACL injuries in Norway based on inclusion in the Pediatric ACL Monitoring Initiative.
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12:19 - 12:26
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Lecture
Can chronicity of anterior cruciate ligament rupture influence morphologic changes of the posterior cruciate ligament and its alignment?
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Shahbaz Malik, BSc (Hons), MB BCh, MSc (Orth Engin), LLM, FRCS | UNITED KINGDOM
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please add notes/abstract here.
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12:26 - 12:33
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Lecture
Smaller Defects and Lower Cell Density Associated with Improved Functional Recovery after ACI in Patients with Isolated Femoral Cartilage Defects
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Martyn Snow, FRCS | UNITED KINGDOM
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Background: There has been an accumulation of high-level evidence demonstrating good clinical outcomes for the use of Autologous Chondrocyte Implantation (ACI) in articular cartilage repair in the short and mid-term. Long-term evidence, however, remains limited.
Purpose: To report the long-term outcomes and identify predictors of success and failure following ACI in the knee for isolated femoral condyle articular cartilage defects.
Study design: Case series; Level of evidence, 4.
Methods: A review of prospectively collected data on 40 patients (mean age 36.4 years [range, 18-52]) undergoing ACI for isolated lesions of the medial or lateral femoral condyle was conducted with a mean follow-up of 11 years (SD 5yrs). No concomitant procedures were performed at the time of ACI surgery. The median defect size was 4.0cm2 [IQR 2.4-6.5] and the mean number of cells implanted was 5.4 million with a median density of 1.4 million cells/cm2defect area. Kaplan-Meier survival analysis was performed, and clinical outcome was determined using the modified Lysholm score. Multilevel modelling was used to identify predictive factors.
Results: The mean baseline pre-operative Lysholm score was 42.8 (SD 17.5, range: 11-74). A mixed effects model demonstrated a mean increase during the 1st post-operative year of 17.6 (p<0.001). Eight patients failed to reach the minimum detectable change of 10.1 at any stage during the follow-up period. Functional improvement was maintained in 44% (95%CI 8-57%) at 20 years with Lysholm score sustained above baseline. A higher baseline Lysholm score was associated with a larger risk of losing clinical benefit even when adjusted for other independent variables. Eight (20%) knees underwent total knee arthroplasty at a mean time of 8.1 years (SD 3.1). Higher age was associated with a higher risk of knee arthroplasty. Mixed effects modelling identified that larger defect size and higher density of implanted cells were associated with a lower 12-month Lysholm score.
Conclusion: ACI for isolated femoral condyle articular cartilage lesions allows for the maintenance of functional improvement in 44% of patients and avoidance of total knee arthroplasty in 79% for 20 years. However, increasing cell density and larger defects were found to have a negative effect on clinical outcome at 1-year.
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