ACL reconstruction surgery options and alternatives
Is ACL surgical repair the right option for every athlete? In this article Ross Hauser, MD reviews the latest medical research that can help the patient / athlete understand their ACL pre and post surgery challenges and how treatments that include Prolotherapy, PRP and stem cells may offer options and accelerated recovery
New research from Brown University presents the return to play reality: “Accelerated rehabilitation has made recovery for surgery more predictable and shortened the timeline for return to play. Despite success with and advancements in anterior cruciate ligament reconstructions, some athletes still fail to return to play.”1
Here is research that is scheduled for publication in March 2017 from a combined team of Italian and English researchers
- The number of patients undergoing revision surgery following failure of anterior cruciate ligament (ACL) reconstruction has increased over the recent pas
- Failure of primary ACL reconstruction can be attributed to technical errors, biological failures, or new traumatic injuries.
- Technical errors include tunnel malposition (see below), untreated associated ligaments insufficiencies (see below), uncorrected lower limb malalignment, and graft fixation failures (the graph re-ruptured). Candidates for revision surgery should be carefully selected, and the success of ACL revision requires precise preoperative planning to obtain successful results.2
What this means is that revision surgery is very difficult and should be carefully considered.
Patients expectations of excellent results in ACL reconstruction surgery not met
What are excellent results in ACL reconstruction surgery? That is hard to say. The problem is that orthopedic surgeons’ perspectives of excellent results are different than athletes’ perspectives.
One of the main reasons for having the ACL surgery was returning to sports. For many this was not achieved.
In one study patients saw no real choice between operative and non-operative treatment. Athletes perceived surgery as the only way to fully return to the pre-injury level of sports, and surgery was understood as the only way to become a completely restored “functional human being”.
A major source of frustration to the patients was that the progress during the ACL rehabilitation process did not match their expectations, fear of re-injury became common.
- Complications and knee problems after the surgery were common.
- Patients reported pain including behind the knee, knee swelling and knee popping
- Fear of re-injury was common.
- Other challenges were the commitment to staying with the ACL recovery timeline and demands of physical therapy.
Some participants because expectation of surgical success was not met decided not to return to their sports.3
So there is a question as to whether or not ACL reconstruction surgery is the best option
This question was further raised by researchers at Vanderbilt University Medical Center who noted the lack of data regarding the effect of anterior cruciate ligament (ACL) reconstruction on the ability of American high school and collegiate football players to return to play at the same level of competition as before their injury or to progress to play at the next level of competition..
- 43% of the players were able to return to play at the same self-described performance level.
- Approximately 27% felt they did not perform at a level attained before their ACL tear, and
- 30% were unable to return to play at all.
Although two thirds of players reported some “other interest” contributing to their decision not to return, at both levels of competition, fear of reinjury or further damage was cited by approximately 50% of the players who did not return to play.”4 Results that mimic those cited above.
Best ACL surgery options?
Recently researchers in the United Kingdom put together a paper on best practices of when and type of ACL surgery to consider.
Here is a summary: The aim of ACL surgery is to restore functional stability to the ACL deficient knee. ACL reconstruction can be performed using a variety of different surgical techniques as well as different graft materials.
The choice of whether to operate or not relies on many factors and is highly dependent on patient’s degree of symptoms and requirements in terms of activity level and participation in pivoting sports. Many patients can become symptom-free following a course of physical therapy and rehabilitation.
Timing of any ACL reconstruction is also crucial, it is commonplace to allow the acutely injured knee to settle, giving time for resolution of swelling, restoration of range of motion and recovery from of concomitant ligament injuries.
Furthermore a delayed reconstruction allows patients to try conservative therapy to see if surgery is indicated. (This is discussed at length below)
The three categories of commonly used grafts are:
- autograft, usually consist of either hamstrings tendons or Bone-patella tendon-bone (BPTB).
- allograft, Allografts are varied but can consist of tibialis posterior tendon, Achilles tendon, tibialis anterior tendon, BPTB and peroneus longus tendon.
- and Synthetic graft. Synthetic grafts have been developed over the years and are currently on their “third generation” but have encountered considerable problems in the past
The surgical technique used during ACL reconstruction varies widely. Different techniques include arthroscopic vs open surgery, intra vs extra-articular reconstruction, femoral tunnel placement, number of graft strands, single vs double bundle and fixation method. 5
ACL Reconstruction Complications
A fantastic summary of ACL complications can be found in the abstract of a classic lecture presentation from Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh. This lecture was delivered in 2000. Compare it to the research from 2017 we cited above – little has changed.
From 2000: “Many factors influence the overall success or failure of anterior cruciate ligament reconstruction, including the integrity of the secondary restraints (that is the supporting structures of the knee the collateral ligaments, the mid-third capsular ligaments, the meniscus, and the iliotibial band), the preoperative laxity of the knee, the status of the articular and meniscal cartilage, the selection of the graft material, the surgical technique, the postoperative rehabilitation, and the motivation and expectations of the patient. (As discussed above).“6
As we noted in the research above untreated associated ligaments insufficiencies, in other words the other knee ligaments were too weak to support the new ACL, this caused failure.
The other knee may not be strong enough to support the new ACL – Contralateral anterior cruciate ligament injury
This is a ACL rupture of the other knee. There are many factors that doctors have explored including over-rehabbing one leg and creating an imbalance. Younger athletes under the age of 20 and female athletes are especially susceptible to this injury.
Tunnel placement complications
During the ACL reconstruction surgery a hole is drilled in the thigh bone and the shin bone, the donor tendon that is being used as the graft is then threaded through the holes, through the knee and fixed or screwed into place.
- Tunnel widening (the hole gets bigger),
- and tunnel misplacement (the tunnel was put in the wrong place),
- and fracture (the tunnel hole was too wide and caused a fracture of the bone) are the more common complications.
Image: Erickson B, et al. ORTHOPEDICS. 2016; 39: e456-e464.
Female athletes and ACL Ruptures
It’s been recognized for years that female athletes are more likely to suffer from ACL injures than their male counterparts. In fact in a 2015 paper, doctors said that the incidence of anterior cruciate ligament injuries is two to eightfold greater in female compared with male athletes. Reasons? Anatomic, hormonal, and neuromuscular factors.7
One study revealed that female soccer players are less likely to return to soccer than males after having ACL reconstruction surgery and that ACL reconstruction surgery on the non-dominant limb puts the dominant limb at risk of ACL injury.8 Because of this gender gap, many injury prevention programs were developed, yet many fall short.9 It has been reported that over 70% of anterior cruciate ligament (ACL) injuries occur in noncontact situations. Increased joint laxity and reduced knee stiffness in female knees have been suggested as possible explanations for the higher ACL injury rates in females.10
Other complications in both male and female patients include:
- graft rupture
- cystic degeneration of the graft, (cysts develop)
- postoperative infection of the knee
- Impingement syndrome, cyclops lesion or arthrofibrosis, which prevents the patient from achieving a full range of knee motion.
ACL Surgery and Revision Surgery Still Top Treatments
How important is ACL reconstruction to the medical community? In a recent paper citing the Top 100 Cited Articles in Clinical Orthopedic Sports Medicine, 15 of the 100 ( a very heavy influence) dealt with injury to the ACL.11
Why so much? Because the number of procedures done and the number of revision or secondary surgeries
- Nine percent of patients under 20 need a second anterior cruciate ligament (ACL) Reconstruction Therapy.12
- Single-stage transosseous revision ACL reconstruction in young, active, skeletally mature patients restores knee stability but returns only 52% of patients to their prior level of activity or sport.13
- The second ACL reconstruction was excellent or good in 70% of the cases, although meniscal and articular cartilage lesions were more frequent and more severe with recurrent laxity.14 Do these findings really merit an excellent?
- “Meniscectomy was performed in 65% of ACL tear procedures. This is concerning because studies have shown that, regardless of knee stability obtained after ACL reconstruction, meniscectomy accelerates degenerative joint changes. 15
- Researchers found that if you had to have a revision or secondary ACL reconstruction surgery you were at advanced risk for osteoarthritis, ligament damage and weakness, and loss of knee function. 16
- Research says that ACL injury following surgical repair results in worse patient outcomes in secondary repair and increases the risk of posttraumatic osteoarthritis.17
- Doctors in New Jersey write that Patellofemoral osteoarthritis is common following anterior cruciate ligament reconstruction and that post surgical lack of knee rotation may be sufficient to initiate or accelerate patellofemoral cartilage degeneration.18
In a study out of Norway, researchers compared 56 patients undergoing a revision reconstruction to 52 patients undergoing a primary reconstruction surgery. The results showed that the patients who had the second surgery had inferior results in almost every category of observation, including greater laxity, less muscle strength, and more severe radiological osteoarthritis.19
In other words, the more surgery, the weaker the knee becomes.
But is ACL reconstruction the only option?
Often a patient will come into our office and report that they have a complete or a partial ACL tear and they want a second opinion on whether ACL surgery is necessary.
Generally with a documented complete rupture, the patient has a choice of reconstruction surgery or non-surgical options. The non-surgical options would include first: A realistic assessment of future activities on an ACL-deficient knee. Some patients exhibit little or no symptoms when they play low-demanding sports or activities.
Here are the surgical proponent’s arguments for operating on a partial ACL tear:
The optimal treatment for a partial anterior cruciate ligament (ACL) tear continues to be a subject of considerable debate.
A question remains whether it is advantageous to preserve the ACL remnant and augment it with a graft, or get rid out it and start all over. Clinical outcomes of ACL preserving surgery are promising. An increasingly large body of scientific evidence suggests that augmenting the intact bundle is beneficial in terms of vascularity, proprioception and kinematics.20
THEN WHY DO SURGERY IF IT IS BETTER TO REPAIR THE PARTIAL TEAR? Especially when non-surgical options are available?
Patients should always take caution when any type of joint surgery is recommended, and reconstruction of the anterior cruciate ligament (ACL) is no different. It is widely known that many patients who undergo ACL reconstruction experience a chronic “giving way” feeling after the surgery and some encounter a re-rupture of the tendon.21
Stem Cells – Non-surgical ACL reconstruction?
This research suggests that one day doctors will be able to grow a new ACL in the laboratory and implant it into a knee. That is fantastic news for the people of the future but what about today? Is there a way today to non-surgically repair a damaged ACL.
Another team of Chinese researchers noted that the ACL has certain self-healing abilities after acute injury. These self-healing abilities have to do with stem cells (for a detailed discussion on how stem cells work please see may article on stem cell therapy). The Chinese team suggested that leaving behind part of the ruptured ACL remnant would release native stem cells into the new graft and augment healing. In addition, taking stem cells from the remnant ACL may be a potential source of seeding cells for ligament regeneration.23
This research found agreement in the work of Korean doctors who wrote: Recent developments in mesenchymal stem cell (MSC)-based approaches for treating musculoskeletal injuries have led to the application of MSCs for enhancing healing after ACL injuries. Stem cells are thought to be promising treatment options for enhancing biologic healing of ACL grafts and restoring the functional properties to the levels of the native ACL, and ultimately improving clinical outcomes.24
In 2009, Prolotherapy doctors published a case history of an 18-year old female patient who returned to sports after a high-grade partial (possibly complete) ACL rupture.25
Would you like to talk to us about your ACL problems – here is how to email us.
References for this article
1 Morris RC, Hulstyn MJ, Fleming BC, Owens BD, Fadale PD. Return to Play Following Anterior Cruciate Ligament Reconstruction. Clin Sports Med. 2016 Oct;35(4):655-68. [Pubmed]
2 Osti L, Buda M, Osti R, Massari L, Maffulli N. Preoperative Planning for ACL Revision Surgery. Sports Med Arthrosc. 2017 Mar;25(1):19-29. [Pubmed]
3. Heijne A, Axelsson K, Werner S, Biguet G. Rehabilitation and recovery after anterior cruciate ligament reconstruction: patients’ experiences. Scand J Med Sci Sports. 2008 Jun;18(3):325-35. Epub 2007 Dec 7. [Pubmed]
4. McCullough KA, Phelps KD, Spindler KP, Matava MJ, Dunn WR, Parker RD; MOON Group, Reinke EK. Return to High School- and College-Level Football After Anterior Cruciate Ligament Reconstruction: A Multicenter Orthopaedic Outcomes Network (MOON) Cohort Study. Am J Sports Med. 2012 Aug 24. [Pubmed]
5. Shaerf DA, Pastides PS, Sarraf KM, Willis-Owen CA. Anterior cruciate ligament reconstruction best practice: A review of graft choice. World Journal of Orthopedics. 2014;5(1):23-29. doi:10.5312/wjo.v5.i1.23. [Pubmed]
6 Harner CD, Giffin JR, Dunteman RC, Annunziata CC, Friedman MJ. Evaluation and treatment of recurrent instability after anterior cruciate ligament reconstruction. Instr Course Lect. 2001;50:463-74.
7. Johnson JS, Morscher MA, Jones KC, et al. Gene expression differences between ruptured anterior cruciate ligaments in young male and female subjects. J Bone Joint Surg Am. 2015 Jan 7;97(1):71-9. doi: 10.2106/JBJS.N.00246.
8. Lohmander, L. S., Östenberg, A., Englund, M. and Roos, H. (2004), High prevalence of knee osteoarthritis, pain, and functional limitations in female soccer players twelve years after anterior cruciate ligament injury. Arthritis & Rheumatism, 50: 3145–3152. doi: 10.1002/art.20589
9. Brophy RH, Schmitz L, Wright RW, et all. Return to play and future ACL injury risk after ACL reconstruction in soccer athletes from the multicenter orthopaedic outcomes network (MOON) group. Am J Sports Med November 2012 vol. 40 no. 11 2517-2522.
10. Boguszewski DV, Cheung EC, Joshi NB, Markolf KL, McAllister DR. Male-Female Differences in Knee Laxity and Stiffness: A Cadaveric Study. Am J Sports Med. 2015 Oct 13.
11. Nayar SK, Dein EJ, Spiker AM, Bernard JA, Zikria BA. The Top 100 Cited Articles in Clinical Orthopedic Sports Medicine. Am J Orthop (Belle Mead NJ). 2015 Aug;44(8):E252-61.
12. Lind M, Menhert F, Pedersen AB, Incidence and Outcome After Revision Anterior Cruciate Ligament Reconstruction. Am J Sports Med July 2012 vol. 40 no. 7 1551-1557
13. Reinhardt KR, Hammoud S, Bowers AL, Umunna BP, Cordasco FA. Revision ACL reconstruction in skeletally mature athletes younger than 18 years. Clin Orthop Relat Res. 2012 Mar;470(3):835-42.
14. Wegrzyn J, Chouteau J, Philippot R, Fessy MH, Moyen B. Repeat revision of anterior cruciate ligament reconstruction: a retrospective review of management and outcome of 10 patients with an average 3-year follow-up. Am J Sports Med. 2009 Apr;37(4):776-85.
15. Battaglia MJ 2nd, Cordasco FA, Hannafin JA, Rodeo SA, O’Brien SJ, Altchek DW, Cavanaugh J, Wickiewicz TL, Warren RF. Results of revision anterior cruciate ligament surgery. Am J Sports Med. 2007 Dec;35(12):2057-66. Epub 2007 Oct 11.
16. Grassi A, Ardern CL, Marcheggiani Muccioli GM, Neri MP, Marcacci M, Zaffagnini S. Does revision ACL reconstruction measure up to primary surgery? A meta-analysis comparing patient-reported and clinician-reported outcomes, and radiographic results. Br J Sports Med. 2016 Jan 25.
17. Kaeding CC, Pedroza AD, Reinke EK, Huston LJ; MOON Consortium, Spindler KP. Risk Factors and Predictors of Subsequent ACL Injury in Either Knee After ACL Reconstruction: Prospective Analysis of 2488
18. Culvenor AG, Schache AG, Vicenzino B. Are knee biomechanics different in those with and without patellofemoral osteoarthritis after anterior cruciate ligament reconstruction? Arthritis Care Res (Hoboken). 2014 Oct;66(10):1566-70.
19. Gifstad T, Drogset JO, Viset A, Grontvedt T, Hortemo GS. Inferior results after revision ACL reconstructions: a comparison with primary ACL reconstructions. Knee Surg Sports Traumatol Arthrosc. 2012 Dec 14
20. Makhni EC, Padaki AS, Petridis PD, Steinhaus ME, Ahmad CS, Cole BJ, Bach BR Jr. High Variability in Outcome Reporting Patterns in High-Impact ACL Literature. J Bone Joint Surg Am. 2015 Sep 16;97(18):1529-42. doi: 10.2106/JBJS.O.00155.
21. Judge A, Arden NK, Cooper CC, Javaid MK, Carr AJ, Field RE, Dieppe PA. Predictors of outcomes of total knee replacement surgery. Rheumatology. 2012;51(10):1804-1813. These re-ruptures often lead to a second ACL reconstruction surgery.
22. Sun Z, Li J. Research progress of tissue engineered ligaments Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2015 Sep;29(9):1160-6. Chinese.
23. Fu W, Li Q, Tang X, Chen G, Zhang C, Li J. Mesenchymal stem cells reside in anterior cruciate ligament remnants in situ. Int Orthop. 2015 Jul 31. [Epub ahead of print]
24. Jang KM, Lim HC, Bae JH. Curr Stem Cell Res Ther. 2015;10(6):535-47. Mesenchymal Stem Cells for Enhancing Biologic Healing after Anterior Cruciate Ligament Injuries.
25. Grote W, Delucia R, Waxman R, Zgierska A, Wilson J, Rabago D. Repair of a complete anterior cruciate tear using prolotherapy: a case report.Int Musculoskelet Med. 2009 Dec 1;31(4):159-165