February 6th, 2011
15 Year outcomes in Anterior Cruciate Ligament reconstructed patients
Leo Pinczewski’s study in the January 2011 edition of the AJSM has some interesting information.
In his article he followed 90 isolated ACL reconstructed patients over 15 years. 24% had a tear of the contra lateral ACL during that time and 8% ruptured their graft.
A vertically placed graft had a 10 times greater chance of an ACL graft rupture.
This is good news because in the last 5 years there has been a change in surgical technique where now surgeons are drilling the femoral tunnel through the medial portal so that the tunnel is more lateral than vertical. It is likely that this change in technique is resulting in fewer graft ruptures.
51% of patients had x-ray evidence of osteoarthritis at 15 years. The study showed
that the incidence of radiographic OA is lower in patients treated with ACL reconstruction compared with previous reports of patients with nonoperative treatment of ACL deficiency.
Younger patients are obviously more likely to have further trouble as they are more likely to continue to play at a higher level for longer. Patients did better after lateral meniscectomy compared with medial meniscectomy, with more patients progressing to OA after medial meniscectomy. Therefore, the effect of a less than one-third lateral meniscectomy on long-term functional and radiographic outcome is most likely minimal.
Of the 7 patients with meniscal repairs, only 1 patient who had medial meniscal repair required later meniscectomy, indicating that the other 6 patients had successful meniscal repair and were able to save their menisci.
All this is not bad news for this group of patients. However this represents only 90 of the 333 ACL reconstructions performed by Leo Pinczewski between January 1993 and April 1994. Exclusion criteria included any associated ligament injury requiring surgery, evidence of chondral damage or degeneration, previous meniscectomy or meniscal injury requiring
more than one-third meniscectomy at the time of reconstruction, abnormal radiograph results, abnormal contra lateral knee, patients seeking compensation for their injuries, and patients who did not wish to participate in a research study. Therefore, the study group consisted of
90 patients with an essentially isolated ACL injury.
To give a patient information before surgery I would like to know how the other 2/3 of patients do.
How does a total / near total meniscectomy affect outcome?
How does chondral damage affect outcome?
Tags: ACL reconstruction, ACL surgery
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September 28th, 2010
Another ACL graft option
Artificial ligaments in anterior cruciate ligament have had a bad reputation for a long time. So much so that they have been almost totally dismissed as an option in the USA and Europe. No reports at international meetings or in journals report on their outcomes. Until now that is and the April 2010 edition of the Arthroscopy journal.
A Chinese group Kai Gao et al report a multicentre 3 to 5 year follow up of ACL reconstruction using the Ligament Advanced Reinforcement System. LARS artificial ligament is a biomimic scaffold of artificial ligament made of polyester (polyethylene terephthalate [PET]) fibres. The intra-articular portion of LARS artificial ligament is composed of longitudinal external rotation fibres, and the left knee and right knee are separately designed, as clockwise or counter clockwise, respectively.
The graft is used as a scaffold when a stump of the torn ACL is present. The graft is placed through the retained stump. The study showed that LARS artificial ligament as a nondegradable scaffold in vivo could induce the growth of autologous collagen tissue and neoligament formation, which would increase the strength of LARS artificial ligament, avoid the abrasion of ligament fibres, and extend the longevity of the ligament. Basically a neoligament grows from the stump to surround the artificial graft.
This is not a controlled clinical trial. It is a therapeutic case series with a level 4 Level of Evidence. The results are similar to other case series using standard techniques. The femoral tunnel was drilled through the tibial tunnel unlike present techniques where the femoral tunnel is drilled through the anteromedial portal. There is not enough evidence in this article to change clinical practice.
Nevertheless it is an interesting study which should stimulate surgeons to have a second look at augmentation devices and see if they have a role. The obvious major advantage is they would avoid the need to take a graft from the patient, shortening operating time and reducing morbidity.
It is always interesting when someone challenges the accepted doctrine.
Tags: ACL reconstruction, ACL surgery
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May 14th, 2010
Platelet Rich Plasma and ACL graft healing
This is an area that will receive a lot of attention in the Sports Medicine journals over the next 2 years. The exciting question is can Platelet Rich Plasma (PRP) enhance the healing of the anterior cruciate ligament graft?
If it can then the time to return to full sport could be shortened. At the moment I think that it is best to wait for 12 months before a full return to sport as this gives time for the graft to become more like a ligament. In fact there is evidence that it takes 2 years for this process to be complete. If PRP could reduce the time for ligamentisation to 3 months then this would be a great advance.
I believe that a lot of failures are caused by a return to sport when the graft is not fully integrated with the bony tunnels and has not developed a proper blood supply and so has not become a ligament. The graft ruptures as it has not been given the time to develop fully. Of course tunnel placement is of great importance but I would like to emphasis the importance of graft integration.
There is quite a way to go yet with PRP and ACL recon. With many different concentrations and systems of PRP and different ways they are used with ACL surgery it is very difficult to nail down what system is best. Some studies have shown a decrease in tunnel widening which I believe is a good thing. The South American experience with PRP and ACL reconstruction has been led by Radice et al. in Chile. The authors found that the time to complete homogeneity of the ACL graft on MRI was 177 days for the group with surgery plus PRP, whereas the group with surgery alone required 369 days to acquire a matured graft. Moreover, when the subgroup of BTB autograft was analyzed, the maturation time in the PRP group was 109 days versus 363 days. In light of these results, Radice et al. concluded that the use of PRP accelerates graft maturation by half of the expected time, with an additional reduction in maturation time from 12 months to 3.6 months in the BTB graft and PRP group. These results are especially significant in light of the accelerated recovery time desired in sports medicine.
This is exciting stuff. It is probably the most promising advance in ACL reconstructive surgery in the last 10 years. Together with double bundle grafts this is where the future of reconstructive ACL surgery is going. First there was anatomical positioning and now the use of biologics to speed up healing. Let’s hope that the studies will prove that the hope is real.
Tags: ACL injury, ACL reconstruction surgery, Anterior Cruciate Ligament Injury
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January 7th, 2010
Chronic Tendon Injuries
The biggest change I have noticed in the treatment of chronic tendon injuries over the last 10 years is the understanding of the pathology involved. I am talking about rotator cuff tendon problems, tennis elbow, patellar tendinopathy and Achilles tendinopathy. Whereas in the past people believed that this was an inflammatory condition now it is proven that this is a disease caused by micro tearing. All tissues have their breaking point and when this is reached fibres will start to tear. For some of the fibres in the tendon this breaking point is reached sooner and so some of these fibres break down leading to micro tearing.
The important point is that this injury does not produce an inflammatory reaction and without inflammation there is no healing response. Tendons have a poor blood supply and therefore their capacity to heal is poor. These injuries do not adequately heal because there is not a proper inflammatory response produced. It takes a bit of a leap to get away from the idea that these tissues are inflamed and need to be rested, cooled and anti-inflammatories should be taken to instead going for a supervised rehab programme with possible extracorporeal shock wave therapy and possible autologous platelet injections to promote the inflammatory response and healing.
Non steroidal anti inflammatory drugs are used to get rid of the dreaded inflammation that so many people are keen to treat. Instead people should start to see inflammation as the body’s reaction to injury and is essential to healing. Sometimes inflammation can get out of control and needs to be reduced but we should be careful not to be so fast to reach for the tablets. The same goes of course for the steroid injections.
Even surgery can be required to promote healing. All forms of treatment seek to produce more of a response from the body.
So the message in chronic tendon injury is that we need to help the body to heal itself. That means promoting the natural inflammatory response and getting a new mindset in thinking about these injuries.
Tags: Achilles tendon, ESWT, Platelets
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November 23rd, 2009
Growth Factors
There has been a recent surge in interest in the use of growth factors to promote natural healing of bone and soft tissue injuries. A variety of products have been developed to help stimulate biologic factors and promote healing. Platelet rich plasma (PRP) has received a lot of publicity recently. Platelets contain proteins, cytokines and other biologic factors that promote healing. PRP is produced by centrifuging a sample of anti-coagulated blood taken from the patient. It therefore has a 3 to 5 fold increase in the concentration of growth factors. The PRP is then clotted before it is used. About 30 to 60mls of blood will produce 3 to 6mls of platelet aggregate.
Some patients will get an immediate inflammatory reaction to the injection with pain and swelling. Patients can use ice and elevation to control the pain. Non steroidal anti-inflammatory drugs are not given for 2 weeks after the injection as they reduce the effectiveness of the treatment. PRP depends on the inflammatory healing cascade.
The indications for treatment have not yet been clearly established. It is showing some good results in patellar tendinopathy, Achilles tendinopathy, tennis elbow and even acute muscle tears. The exact indications and the technique of injection have yet to be defined. It is however an exciting development where the patient’s own blood is used to treat the condition with no risk from drugs or outside agents. There is no doubt that it is in the field of biologics where the next developments in the treatment of orthopaedic injuries is happening. We have to be careful with any new treatment as there have been false dawns in the best. I am also a little wary of any treatment that is the cure-all for all diseases. However platelet rich plasma makes sound scientific sense, is a very safe procedure and appears to work. We await the specific double blind trials that will define its role.
Breandán Long
Tags: Biologics, Growth Factors
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October 3rd, 2009
Are there engineers out there who can manufacture relatively simple arthroscopic surgery devices that are used on a single use or limited re-use basis?
A single use radiofrequency probe can cost €150 euro. These devices are used to ablate degenerative articular cartilage in joints. They may be used for only 30 seconds during an arthroscopic operation on the knee and then thrown out. The device itself appears to be a simple product that conducts electricity across its electrodes. I would expect if there was a similar device to be used in the home for any reason you would expect to pay between €5 and €15 for it. It might even be 50 cents such is the simplicity of it.
It is similar with arthroscopic shavers and burrs. They are used to remove cartilage, meniscal tissue and bone from joints. These can cost from €60 to €150 for a relatively simple metal and plastic device which you would expect to pay a few euros for if it was not used in an operation.
There are safety issues and standards to be achieved but nothing as onerous as with a drug.
These devices are not left in the body so they do not have the safety issues that implants have.
It is not that the quality of the product has to be extra, extra special or that the testing can be particularly difficult. I know that sterilising these products has to be of the very highest standard but this is well established in all areas of medical equipment. I can’t see how a medical device can justify such a mark up.
So where are the start-ups that will take this on? Is there a whole business waiting to be developed in providing high quality, reasonably priced arthroscopic medical devices. Most of these devices have little or no electronics and no micro circuitry. Can they be so difficult to manufacture?
Tags: arthroscopy surgery
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September 22nd, 2009
After 12 years doing ACL reconstructive surgery this is still a difficult question for me to answer. It sounds logical. Something is broken – get it fixed. But it is not that simple. There is no doubt that there is a lot of hassle involved. On average a patient involved in physical work will be off for 3 months. Rehab will last for 6 months at least and then there is a commitment to continue a programme to maintain the strength in the knee.
What is gained by a reconstruction?
Definitely in 80% of patients the knee will feel more stable. You could argue with an intensive physio programme a lot of people would achieve this stability anyhow. It may protect the knee from further injury by preventing the knee from giving way. Against this is that patients after ACL surgery have double the chance of a meniscus injury than people who have not injured their ACL.
So does surgery reduce the risk of osteoarthritis?
Possibly is about all we can say. It reduces giving way and helps knee kinematics but kinematics are not normal after surgery. Patients who tear their ACLs have an increased risk of arthritis whether they have surgery or not. Of course we cannot even agree on what osteoarthritis is. Is it when the x-ray shows it or when the patient’s symptoms are at a certain level? And how do we measure it. Not very well it seems. Patients’ symptoms bear a poor relationship to their x-rays.
So should I get my ACL reconstructed?
If you want to play sport at a high level then the answer is yes. Be aware though that there is an argument that says that if you want to reduce the risk of further injury you might think of calling it a day.
I cannot dismiss the psychological value of ACL surgery. If it is broken fix it. I can understand that a lot of patients want this certainty in their lives.
So the answer is get as much relevant information as you need, discuss it with those that had it done (but don’t take everything to heart), talk to your surgeon and make full use of your consultation. Then make your mind up. Take some time to do this if you need it. There is no great rush.
Tags: ACL reconstruction surgery
Posted in ACL Injuries | No Comments »
August 22nd, 2009
This is a much debated subject. A study in the American Journal of Sports Medicine in July 2009 shows that there are anthropometric differences between the knees of subjects with a non contact ACL injury and those without an ACL injury, suggesting that ACL volume may play a direct role in non contact ACL injury.
The study showed that the volume of the ACL on the uninjured side as measured on MRI was significantly smaller in subjects who tore their ACLs than in subjects who had no injury.
With up to 70% of ACL injuries non-contact in nature this new information is enlightening. Previous studies have shown that women have smaller ACL volume than men when subjects of the same height are compared. This study shows that the ACL volume in subjects who injure their ACLs is less than in non-injured subjects. It provides the strongest evidence to date of a link between ACL size and injury risk because it directly compares injured subjects to matched controls.
It may be possible to pre-screen individuals and direct them in neuro-muscular training where proprioception would be improved. Such programmes have already been shown to decrease injury rates in the ACL. There is a gradual movement away from concentrating on pure strength and stretching to prevent injury and a greater understanding of the importance of proprioceptive training.
It may also be possible to use growth factors in relatively small ACLs to increase volume and prevent injuries. This area needs more research and it is unlikely that growth factors will be used on a widespread basis in the next 5 years to promote growth of the ACL. However there is no doubt that growth factors is where the next big break through in ACL injury will be. They will be used in normal ligaments to make them stronger, partially torn ligaments to make them heal and reconstructed grafts to integrate faster.
Breandán Long
Tags: ACL injury, ACL surgery, Anterior Cruciate Ligament Injury
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