Ligament Laxity Leads To Worse ACL Reconstruction Outcomes

I was involved with a recent MOON (Multi-center Orthopaedic Outcomes Network) study that demonstrates that patients with loose ligaments and hyperextension have worse results and more frequent graft failures. Read details HERE

Surgical Predictors Of Revision ACL Reconstruction From The MARS Group

Surgical factors many of which are under the surgeon's control can help improve revision ACL reconstruction. Ask your surgeon about these when planning to undergo revision surgery. The article published by our MARS (Multi-center ACL Revision Study) recently became available in the public access system. Read it HERE

Does ACL Reconstruction Result In Arthritis

 In a meta-analysis of osteoarthritis following ACL reconstruction it has been noted in combined, pooled results of 4108 patients that at 5, 10 and 20 years results in osteoarthritis in 11.3%, 20.6%, and 51.6% respectively. These are devastating results, but we must keep in mind that patients treated nonoperatively without ACL reconstruction develop OA at similar rates. Read additional details of the study HERE

What Is the Risk Of Tearing My ACL During Sports?

This British Journal of Sports Medicine study demonstrated a 1.5 injuries per 10,000 athletic exposures for females and  0.9 injuries per 10,000 athletic exposures. Read details HERE

Opioid Use Around ACL Surgery

U Iowa study looking at opioid use surrounding ACL tears and surgery. 1/3 were using opioids before surgery and 5% were still using at 12 months after surgery. Get off of them presurgery if at all possible! ACL tears don't hurt once the swelling and bruising is gone. No one walks around and says my torn ACL is sore today. It is a functional injury. Remaining on opioids makes pain control after surgery difficult and increases risk of long term addiction. Read details HERE

Does An ACL Tear Result In Arthritis

Studies have demonstrated a risk of arthritis following an ACL tear with or without a subsequent ACL reconstruction. We have found in the MARS (Multi-Center ACL Revision Study) cohort that 90% have a meniscus tear or arthritis. ~ 70% have both. HERE are some details regarding the risk.

Why Revision ACL Grafts Are Chosen For Patients

Revision ACL grafts are chosen for a variety of reasons. Read our MARS study HERE to see the most important factors (Hint- It's the surgeon you choose)

MOON-MARS Revision ACL Graft Study Presented Toronto AOSSM Meeting

A combined MOON (Multi-Center Orthopaedic Outcomes Network)- MARS (Multi-Center ACL Revision Study) looked at patellofemoral (kneecap) cartilage changes after allograft or autograft primary ACL reconstruction as identified at the time of revision ACL reconstruction. This study presented by Robert Magnussen of Ohio St. at the Toronto AOSSM (American Orthopaedic Society for Sports Medicine) meeting in July. 134 patients had undergone MOON primary ACL reconstruction followed by MARS revision ACL reconstruction. Progression was identified as progression of one grade worse or a 25% increase in size of the lesion. 31 (23%) had worsening progression of arthritis. Results showed allografts had a 15.5 times higher risk of progression. Odds also increased 10% with each unit increase of BMI. Age, sex, activity level, meniscus status, injury mechanism had no impact. The association between graft choice and damage was surprising. Previously it was thought maybe a patellar tendon (BTB) autograft might be at more riskk. Allografts with more laxity may place more pressure on cartilage, but we cannot be sure. Further work will be necessary to sort this out.

MARS Predictors Of Patient Reported Outcomes After Revision ACL Reconstruction

MOON ACL Reconstruction Award Winning Study

At the AOSSM Annual Meeting the 10 year outcomes for the MOON Group were presented by Kurt Spindler MD. The study won the AOSSM O'Donoghue Award for best clinical study for 2017. The MOON Group is a 7 site study focusing on primary ACL reconstructions. 

Findings in this study of 1592 ACL reconstructions with 83% follow up showed several factors impacting the IKDC and KOOS Sports and Recreation and KOOS Quality of Life with worse scores. These included: Grade 3 and 4 cartilage wear in any compartment, previous medial meniscectomy, revision ACL reconstruction, higher BMI, smoking, reoperation or subsequent surgery and lower baseline scores. Factors not predicting worse scores included surgeon, medial and lateral meniscus surgery, sport played, graft chosen, MCL or LCL injury or higher laxity.

Factors that predicted worse Marx score can be seen in this slide. These findings can be used to better predict outcome and counsel patients as to expectations for ACL reconstruction.

Predictors of Outcome from the MARS Cohort: Surgical Factors

A Neuromuscular Warm Up Program May Help Prevent ACL Injuries

An old study, but still true. A neuromuscular based warm up program may help prevent ACL injuries. Read details HERE . Unfortunately, we don't know the exact dose, frequency etc. It is apparent that almost any program helps. Now we have to determine the easiest applied correct program. The Young Athlete's Center will be trialing programs locally with soccer teams. Stay tuned for results and recommendations

Revision ACL Reconstruction Predictors of Outcome: Meniscus and Cartilage

Revision ACL Reconstruction Predictors of Outcome: Graft Choice

ACL Reconstruction Graft Choice in Young Athletes

Anterior cruciate ligament (ACL) injuries currently require a reconstruction for active individuals desiring to return to activities that involve planting, cutting, turning, twisting or jumping. A reconstruction simply means a replacement of the ACL since repair currently does not work (see this link for exciting news regarding ACL repair). As part of the reconstruction a graft must be chosen and used. There are several options available, but young athletes and their families need to be careful in their graft decision process. Certain graft choices may not be the best for younger patients.

Broadly, there are two categories of graft: 1.) allograft (cadaver) and 2.) autograft (patient’s own tissue). There are advantages and disadvantages for both types. Allograft offers the advantage of no need to obtain a graft from the patient which may mean less pain and a quicker recovery. Unfortunately, the disadvantages include risk of disease transmission (HIV and Hepatitis 1/1,000,000), slower graft incorporation and a higher rerupture/failure rate. In an important study by the Multi-center Orthopaedic Outcomes Network (MOON) Group that we participated in at Washington University as an original MOON Group site cadaver grafts were noted to have a 4 times higher failure rate vs. autografts for patients of the same age and activity level. For example a 16 year old female high school team sport athlete has an ~5% ACL autograft failure rate in the first 2 years after surgery and ~20% failure rate over the same time period for an allograft. Read the study here: (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3445196/) Obviously, that is a rate of failure unacceptable for young athletes. Conversely, in a patient over the age of 40 the failure rate remains 4 times higher, but at 2% vs. 0.5% the relative risk is very close and allograft may be a reasonable choice for an older adult patient.

This has been confirmed also in the revision (redo) ACL reconstruction setting with a 2.78 times higher failure rate for allografts noted by a study performed by the Washington University coordinated MARS Group. Read the study here: (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4447184/ )

There are 2 types of autografts commonly used: hamstring or patellar tendon. Both have advantages

 and disadvantages. Hamstring grafts have a lower risk of kneeling pain, but less strong initial fixation and typically are ~1mm looser once healing is complete. Patellar tendon grafts have stronger initial fixation, heal a little tighter, but have a higher risk of kneeling pain. Data from Europe suggest the hamstring grafts may have a slightly higher (0.5—1.0%) risk of rupture, but this has not been duplicated in the US in similar studies. I typically recommend patients let their surgeons use the graft with which they are most comfortable. The small differences in the grafts typically do not matter clinically.

The 7 most common Sports Injuries

Sports Injuries are common every day occurrences in the general population. Follow this link to read a review of the 7 most common.
The 7 most common Sports Injuries

ACL Injury Video

Watch this video to learn more about ACL injuries

ACL Injury Video

Revision ACL Reconstruction

Revision (redo) ACL reconstruction which occurs when the original ACL reconstruction fails is not necessarily common, but is an important issue for those unfortunate patients and those of us that care for these patients. This began to be evident to us with the publication of one of the early ACL reconstruction studies that utilized patient reported outcome measures. These outcome scores ask patients how they are doing rather than surgeons declaring how well the patient was doing. While maybe intuitive that asking patients how they are functioning after an ACL reconstruction is the correct way to assess outcome it was an unusual approach at the time. These outcome measures are validated and can be as accurate as any outcome measure available. These patient reported outcome measures have formed the backbone of our approach in the Multi-center Orthopaedic Outcomes Network (MOON) group and the Multi-center ACL Revision Study (MARS).

The study Kurt Spindler and I wrote and published was a minimum 5 year outcome analysis of ACL

reconstruction. Read the study Here In that study we found that gaining weight(> 15 lbs) and failing to advance your educational status following ACL reconstruction resulted in worse patient reported outcomes (PROs) at 5 years. Interestingly, the strongest predictor for a worse outcome was if the reconstruction was a revision ACL reconstruction. The journal (Journal of Bone and Joint Surgery) did not want or allow us to include the revision reconstructions and so we published a paper of just first time (primary) reconstructions. This made us curious and we began to pay more attention to the outcomes of revision ACL reconstructions. We noted following the formation of the MOON Group similar findings with worse results with the revision ACL reconstructions. Revisions made up only ~10% of our reconstructions and that even with 17 surgeons in the group we could not accumulate enough patients quickly enough to do the sophisticated statistical analysis and modeling to answer the question of “Why do these patients do worse?”.

It was not intuitive why they necessarily would have worse function, more pain and lower activity levels compared to primary reconstructions. For this reason we knew we needed at least 50 surgeons contributing patients and thus formed the nationwide Multi-center ACL Revision Study (MARS). MARS is an 83 surgeon, 52 site study for which Washington University Sports Medicine Division is the coordinating center and I serve as principle investigator for the study. The American Orthopaedic Society for Sports Medicine supported the concept and offered participation to its members. We enrolled 1215 patients and obtained NIH funding to support 2 year follow up. The demographics of the study and our initial study can be found HERE. Future blogs will discuss our findings that are changing and shaping the care of the revision ACL reconstruction patient. We recently submitted a competitive renewal grant to the NIH to support 10 year follow up analysis of these 1215 patients. See the MARS Facebook page for additional information. MARS

ACL Injuries

The anterior cruciate ligament (ACL) is one of the four main ligaments of the knee. It is the primary restraint that provides rotational stability to the joint. It is often injured during cutting, twisting, jumping, change of direction or pivoting-type maneuvers. In addition, it is often associated with meniscal or articular cartilage injuries in greater than 50% of patients. Females are up to 3-6 times more likely to be injured than males, given the same athletic performance. Once the ACL tears, it is not able to heal itself. Repair of the torn ends does not work either. Anterior cruciate ligament reconstruction is one of the most common operations performed in orthopaedic sports medicine with more than 200,000 reconstructions performed in the U.S. annually.

Treatment options consist of either conservative (non-surgical) or surgical treatment. Conservative treatment involves modification of those activities that involve cutting, twisting, jumping, or pivoting. In-line activities can typically be resumed once pain and swelling subsides. A physician may prescribe anti-inflammatory medication and physical therapy to regain normal knee motion and strength. Bracing may also be prescribed for certain at-risk activities. Some patients may be willing to reduce or eliminate those activities that may cause instability episodes.

Surgical treatment consists of reconstruction of the ligament as its direct repair is not feasible due to the inability of the torn ligament to heal. This surgery involves the placement of a reconstructive graft taken from the patient’s knee’s patellar tendon (the tendon located beneath the knee cap) or from the hamstring tendons. Alternatively, your surgeon may choose to use a donor graft, known as an allograft, to reconstruct the ACL. The surgery itself takes approximately one hour and is performed on an out-patient basis with less than 1% percent risk of complications. Allograft reconstruction is not advised for younger, active patients.

Extensive physical therapy is required for a successful recovery from ACL reconstructive surgery. It is necessary following the surgery in order to regain full knee motion and strength, and to return to athletic activity. Most patients are able to return to play following ACL reconstruction approximately 6 months postoperatively. The overall success rate of ACL reconstruction using present-day surgical techniques is well over 90%.

Future posts will give additional detail regarding the treatment and outcome of these injuries.