Ross Hauser, MD
Is surgical repair the right option for every athlete seeking ACL tear treatment? In this article Ross Hauser, MD reviews the latest medical research that can help the patient / athlete understand their ACL challanges pre and post surgery and how treatments that include Prolotherapy, Platelet Rich Plasma, and Stem Cell Therapy may offer options.
Further that evidence suggests that not all ACL tears are complete disintegration ruptures and that non-surgical options may provide higher patient expectation outcomes.
January 2015 – Researchers say that the recent advancements in the field of musculoskeletal tissue engineering (Stem Cell Therapy, Platelet Rich Plasma Therapy and others) have raised an increasing interest in the regeneration of the anterior cruciate ligament (ACL). These researchers say that scaffolds (a platform to rebuild the ACL from biological materials (blood), biodegradable polymers and composite materials are used. The main cell sources are mesenchymal stem cells and ACL fibroblasts (collagen). In their paper the they conclude:
We expect considerable progress in the near future that will result in a realistic option for ACL surgery soon.1
ACL reconstruction revision: poor outcomes with the second surgery
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 “giving way” feeling after the surgery and some encounter a re-rupture of the tendon.2 These re-ruptures often lead to a second ACL reconstruction surgery.
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 osteoarthritis3.
In other words, the more surgery, the weaker the knee becomes.
Why would the first reconstruction fail in the first place? In an ACL reconstruction, the tendon (often taken from the kneecap tendon or the hamstring tendon) that is supposed to function as the ACL inevitably weakens and can no longer function in the way that the ACL is supposed to. Therefore the knee joint loses stability. Further surgery just weakens the joint even more. An alternative to knee surgery is needed in these cases.
- Nine percent of patients under 20 need a second anterior cruciate ligament (ACL) Reconstruction Therapy.4
- 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.5
- 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.6
- Revision or second ACL surgery allowed approximately 60% of patients to go back to sports, most of them at lower levels than their pre-revision function.7
- “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.”8
What athletes are at risk for needing a second ACL surgery?
Swedish doctors identified:
- younger age,
- having ACL reconstruction early after the primary injury,
- and incurring the primary injury while playing (soccer) as the main predictors for revision and contralateral ACL reconstruction.
This suggests that the rate of additional ACL reconstruction is increased in a selected group of young patients aiming to return to strenuous sports after primary surgery and should be taken into consideration when discussing primary ACL reconstruction, return to sports, and during post-surgery rehabilitation.9
ACL surgery and patellofemoral osteoarthritis
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.10
Much of this research agrees that 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. 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 if it is not a complete disintegration tear.
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 they must choose between the lesser of two evils.
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. “11
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.”12
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.”13
Doctors 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.
Prolotheray treatment guidelines for ACL Tears
The first step in examination to help determine the extent of the ACL tear. Once determined and after examining the supporting structures, namely teh cartilage and meniscus, a treatment plan is developed.
Because of the poor outcome of ACL injury treatment options, especially reconstruction surgery, much of the literature over recent years have focused on prevention programs. While these may help, they cannot completely eliminate ACL injury in the athlete population. Sports injuries are unfortunately common and what is needed is an alternative treatment that allows the athlete to completely heal, rehab and return to top performance.
Prolotherapists commonly treat sports injuries in athletes of all ages and levels. Prolotherapy is a regenerative injection technique that stimulates the healing of tendon and ligament injuries. In the case of incomplete ACL tears, Prolotherapy is an excellent option for the injured athlete because it decreases pain and instability while allowing the athlete to rehab and maintain fitness throughout the course of treatment. Listen as Prolotherapist, Ross Hauser, MD explains why Prolotherapy is an excellent treatment option for ACL injury.
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References for this article
1. Nau T Teuschl A. Regeneration of the anterior cruciate ligament: Current strategies in tissue engineering. World J Orthop. 2015 Jan 18;6(1):127-36. doi: 10.5312/wjo.v6.i1.127. eCollection 2015.
2. 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.
3. 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 [Epub ahead of print].
4. 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
5. 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.
6. 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.
7. 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.
8. 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.
9. Fältström A1, Hägglund M, Magnusson H, Forssblad M, Kvist J. Predictors for additional anterior cruciate ligament reconstruction: data from the Swedish national ACL register. Knee Surg Sports Traumatol Arthrosc. 2014 Nov 1. [Epub ahead of print]
10. 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.
11. 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.
12. 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]
13. 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