What are the drawbacks of ACL reconstruction vs ACL repair or nonoperative treatment?

Issue: January 2017

Click here to read the Cover Story, "Options for nonoperative treatment of ACL injuries exist, but remain controversial."

Repair technology not available for all patients

At this point in time, if you have a complete ACL injury from a pivot mechanism and your exam demonstrates patholaxity from this injury, then reconstruction is the only way to make that knee stable in a predictable fashion. We do not yet have the repair technology to make that a viable treatment for everyone. While there are some interesting studies being done in small groups, we are clearly not there for mainstream treatment.

If you do nothing after the injury and simply let the injury heal, approximately one of every three patients may do “okay.” This okay patient would probably not return to high, level 1 sports on a weekly basis and would need to understand the risks of that decision. The risks accepted with this decision include further damage to the knee from another pivot event, including irreversible injury to the meniscus and articular cartilage.

Darren L. Johnson, MD — Darren L. Johnson

For example, if we look at children, for many years we treated the ACL-injured child by simply letting the knee heal and then slowly return the child to level 1 sports. What we have found in the last 5 years is these children were coming back to see us after another pivot event with significant meniscal and articular cartilage injuries that are not fixable. We cannot restore the knee to normal function. If we would have reconstructed the ACL the first time, then we would have saved that child from having an irreversible meniscus and articular cartilage injury.

That is a huge decision to make. My best chance to make a patient as normal as possible when performing an ACL reconstruction is to have normal articular cartilage and a repairable meniscus tear, even if I have to perform a small meniscectomy at the time of the ACL reconstruction; that is not as good as my ability to save the entire menisci.

Currently, if you have an active child with open growth plates who plays sports, and has a pivot event and tears the ACL, the recommendation is to do an ACL reconstruction as opposed to simply letting it heal on its own. The risks are simply too great to accept in the athletically active child. ACL reconstruction techniques have improved greatly during the last 10 years, and the inherent risks of the ACL surgery are small.

Darren L. Johnson, MD, is professor and chairman in the Department of Orthopedic Surgery at the University of Kentucky School of Medicine.
Disclosure: Johnson reports no relevant financial disclosures.

Variable revision rates

ACL reconstruction is a relatively reliable procedure that allows patients to return to function, but it is not without potential complications. Mohammad A. Yabroudi, PT, MS, PhD, and his colleagues reported that revision rates have ranged from 5% to 15%, depending on length of follow-up, graft choice and patient factors. Additional surgeries for postoperative arthrofibrosis (5.4%) and hardware-related procedures (2.4%) are also a possibility, according to Carolyn M. Hettrich, MD, MPH, and her colleagues. Furthermore, in the pediatric population, growth disturbances have resulted in lower extremity deformities, as reported by Mininder S. Kocher, MD, MPH, and his colleagues.

Alexis Chiang Colvin, MD — Alexis Chiang Colvin

Although there are numerous studies in the orthopedic literature on the technical aspects of ACL reconstruction and postoperative rehabilitation, there is scant literature on which patients truly need the surgery.

A recently published Cochrane review on operative vs. nonoperative treatment of ACL injuries found only one randomized trial that fit their criteria in addressing this question. The study by Richard B. Frobell, MD, MPH, compared young, active adults with an acute ACL injury with ACL reconstruction and rehabilitation vs. rehabilitation alone. The study found no difference between patient-reported knee scores at 2 years or 5 years between the two groups. In the nonoperative group, 39% chose to have delayed ACL reconstruction around 1 year after randomization. The significance of this study was that early reconstruction was not superior to early rehabilitation with the option for delayed ACL reconstruction. Furthermore, surgery was avoided in more than half of the patients in the latter group without adversely affecting outcomes.

It is also important to note that American Academy of Orthopaedic Surgeons Appropriate Use Criteria for ACL reconstruction takes into account the patient’s age, activity level, presence of arthritis, presence of a meniscal tear and history of nonoperative treatment measures in determining if a patient would benefit from surgery. Nonoperative treatment options can be considered in many of the clinical scenarios.

The question of how to identify the “copers” — those who are able to resume preinjury activity levels without experiencing instability from an ACL-deficient knee — is yet unanswered. There is some evidence that “non-copers” — those who opt for ACL reconstruction due to knee instability and functional limitations — have deficits in quadriceps strength, vastus lateralis atrophy, quadriceps activation deficits, altered knee movement patterns, reduced knee flexion moment and greater quadriceps/hamstring cocontraction. As research continues in establishing objective criteria that can be used to differentiate copers from non-copers, this information will be useful in identifying those patients who may not need early ACL reconstruction and may potentially be able to avoid surgery altogether.

References:
Frobell RB, et al. N Engl J M. 2010;doi:10.1056/NEJMoa0907797.
Hettrich C, et al. Am J Sports Med. 2013;doi:10.1177/0363546513490277.
Kaplan Y. J Orthop Sports Phys Ther. 2011;41(10):758-766.
Kocher M, et al. J Pediatric Orthopedics. 2002; 22(4):452-457.
Monk AP, et al. Cochrane Database Syst Rev. 2016 Apr 3;4:CD011166.
Yabroudi MA, et al. Orthop J Sports Med. 2016;doi:10.1177/2325967116666039.

Alexis Chiang Colvin, MD, is an associate professor in the Department of Orthopedic Surgery at Mount Sinai Hospital in New York City.
Disclosure: Colvin reports no relevant financial disclosures.

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Reconstruction does not prevent osteoarthritis

Orthopedics as a specialty will change more in the next 20 years than it has in the last 50 years. Why? Increasingly sophisticated cellular biologics, growth factors and cytokines delivered via precise injection will likely replace many elective surgeries. While this is a bold claim that many surgeons would scoff at today, perhaps a comparison of ACL reconstruction (ACLR) surgery and percutaneous ACL repair (Perc-ACLR, Regenexx) with high-dose bone marrow concentrate (HD-BMC) will provide a glimpse into what I believe will be the future.

Christopher Centeno, MD — Christopher Centeno

Despite being the current standard of care for high-grade ACL tears, ACLR is far from perfect. The graft is usually single bundle and is inserted at an artificially steep angle, leading to added compression in the joint to provide front-back stability and leaving the joint with possible rotational instability. Contrary to popular belief, the surgery does not prevent the onset of early osteoarthritis. Finally, other postoperative adverse events include muscle atrophy due to autologous tendon grafts and poor joint proprioception.

Repairing the ACL in-situ would be preferable to ACLR and may help eliminate some of these adverse events. While biologic augmentation with microfracture surgery to aid healing is gaining popularity, is it necessary? We have published on a small case series of patients with grades 1 to 3 ACL tears successfully treated with Percutaneous ACL repair with HD-BMC, showing evidence of repair on postoperative MRI. A new case series, which was recently submitted for publication, stretches the experience to 31 patients, with continued evidence of ACL healing with a precise fluoroscopically guided injection. For example, two of 24 grade 2 to 3 cases required ACLR despite the HD-BMC injection and no successfully treated patients had a retear injury. Based on these results, we are performing a randomized controlled trial that will include objective functional testing of ACL stability along with pre- and post-procedure MRI analyses.

We believe this procedure is effective because of the mesenchymal stem cell content of the injectate, and the precise placement into the origin/insertion of both bundles of the ACL. Furthermore, we believe the synovial membrane surrounding the ligament acts as a novel living biologic scaffold. However, it should be noted that to date we can only treat ACL tears with a maximum of 1 cm of retraction or a posterior femoral offset of no more than 5 mm. While we know we have much to prove to our surgical colleagues, we believe the experience to date shows glimpses of an interesting and less invasive future.

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Christopher Centeno, MD, is a pain management physician at Centeno Schultz Clinic. Matthew Hyzy, DO, is a physiatrist in Broomfield, Colo. Christopher J. Williams, MD, is a pain management physician at Centeno Schultz Clinic.
Disclosures: Centeno reports he is chief executive officer of Regenexx. Hyzy and Williams report no relevant financial disclosures.