ACL reconstruction alternatives and options
Ross Hauser, MD
Is surgical repair the right option for every athlete seeking ACL tear treatment? Read what some recent medical research suggested:
- Nine percent of patients under 20 need a second anterior cruciate ligament (ACL) Reconstruction Therapy1
- 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.2
- 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.3
- “Meniscectomy was performed in 65% of meniscus tears. This is concerning because studies have shown that, regardless of knee stability obtained after ACL reconstruction, meniscectomy accelerates degenerative joint changes.”4
- Revision ACL surgery allowed approximately 60% of patients to go back to sports, most of them at lower levels than their pre-revision function. Instrumented laxity of <3 mm was associated with a better result. Patients who undergo revision ACL surgery should be counseled as to the expected outcome and cautioned that this procedure probably represents a salvage situation and may not allow them to return to their desired levels of function.5
In the surgical mode of options, the best case scenario for a torn ACL is one year of recovery from a ligament replaced with a tendon.3 Perhaps then, the athlete will be able to compete again at a later date. The other option of course in this mode of options is to do nothing, rest the injury to see if the ACL responds.
Don’t bother fixing the ACL if you remove the meniscus
Writing in the medical journal Athroscopy, researchers said they were concerned about the number of patients who had both ACL reconstruction and Meniscectomy, here is what they said “this study found that meniscectomy was performed in 65% of meniscus tears. This is concerning because studies have shown that, regardless of knee stability obtained after ACL reconstruction, meniscectomy accelerates degenerative joint changes.”
So what is best? Left untreated, ACL injuries have terrible consequences and, if treated with surgery there are also bad consequences. Unfortunately for the athlete unaware of surgery alternatives such as Prolotherapy, Platelet Rich Plasma Therapy, or stem cell injection therapy, they must choose between the lesser of two evils.6
The Untreated ACL
Studies have shown:
- up to 86% of these knees “gave way” within four years.
- only 14% of athletes were able to return to unlimited athletic activities.
- after ten years, up to 78% of the knees treated without surgery showed osteoarthritis.
- ACL deficient knees are plagued by long-term swelling and stiffness.
Realize that the conservative treatments the athletes received in the above studies were Rest, Ice, Compression, and Elevation (RICE treatment), anti-inflammatories, cortisone, physical therapy, and other conservative therapies. They did not receive Prolotherapy.
Surgery as ACL tear treatment
There are various surgical techniques employed in ACL reconstruction: repair through the patellar defect, arthroscopically-assisted techniques, and the mini-arthrotomy technique. The problem is that orthopedic surgeons’ perspectives of excellent results are different than athletes’ perspectives.
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 was that the meaning of and progress during the rehabilitation did not match their expectations…Fear of re-injury was common; however, some participants decided not to return to their pre-injury level of sports due to reasons other than physical limitations or fear of re-injury. From a patient perspective, it seems important that the choice of operative or non-operative treatment should be discussed in terms of the meaning and extent of the post-operative rehabilitation and the expected outcomes. There also seems to be a need for more guidance in realistic goal setting and coaching throughout the rehabilitation process.”7
Prolotherapy and ACL Tears. What is Realistic?
So there is a question whether or not ACL reconstruction surgery is the best option. This question was further raised by researchers at Vanderbilt University Medical Center who noted “There is a relative paucity 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.”8
Most Prolotherapy clinics see many young athletes with ACL injury. The first step is to determine if the ACL is truly ruptured. Many times the MRI is not accurate. “The true positive rate for complete ACL tear diagnosis with MR imaging was 67%, making the possibility of a false-positive report of “complete ACL tear” inevitable with MR imaging.”9
Prolotherapists can speculate that one out of three who come in with a diagnosis of complete tear do not have a complete tear. As noted above, in the surgical mode of options, the best-case scenario for a torn ACL is that a partial number of them will return to the sport after a lengthy rehabilitation. A better option is to seek out surgery alternatives such as Prolotherapy, Platelet Rich Plasma Therapy, or stem cell injection therapy that will cure and allow athletes to return to sport at the same pre-injury level.
1. 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
2. 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.
3. 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.
4. 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.
5. Noyes FR, Barber-Westin SD.Treatment of meniscus tears during anterior cruciate ligament reconstruction. Arthroscopy. 2012 Jan;28(1):123-30. Epub 2011 Nov 9.
6. 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.
7. Noyes FR, Barber-Westin SD. treatment for meniscus tears during anterior cruciate ligament reconstruction. Arthroscopy. 2012 Jan;28(1):123-30. Epub 2011 Nov 9. See Abstract Below
8. 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. [Epub ahead of print]
9. Tsai K-J, Chiang H, Jiang CC. Magnetic resonance imaging of anterior cruciate ligament rupture. Published online 2004 July 8. doi: 10.1186/1471-2474-5-21