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

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.

Meniscus Repair in the Setting of a Revision ACL Reconstruction: ISAKOS Presentation Shanghai

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.

Meniscal and Chondral Predictors of ACL Revision Reconstruction Outcomes

Revision ACL reconstruction is known to result in worse outcomes. Meniscus and cartilage damage may contribute to these worse outcomes. With the MARS (Multi-center ACL Revision Study) Group we looked 1215 revision ACL reconstructions to analyze the impact of meniscus and articular cartilage damage on patient results We found that a previous lateral meniscectomy and femoral groove/trochlear groove cartilage damage most strongly contributed to worse patient outcomes. Read further details HERE

MARS (Multicenter ACL Revision Study) Rehabilitation Predictors of Surgical Outcomes

ACL Reconstruction Rehabilitation Part 3

Postoperative rehabilitation remains critical to the outcome for the patient undergoing ACL reconstruction. If the physical therapy following surgery does not go well then it does not matter how well the surgery was performed. When the

MOON group began enrolling ACL reconstruction patients we decided to develop a standardized physical therapy protocol to use for our patients and to have consistency for our patients’ recovery. I was tasked with developing an evidence based review of ACL reconstruction rehabilitation and then using it in conjunction with our physical therapists to develop a practical protocol. Ultimately, we developed what has been a very popular protocol that is more milestone based than time based and has been easy to implement across our several sites. We have subsequently published the protocol in the AOSSM journal Sports Health so that others can utilize it also. You can read the description and find the protocol HERE.

We based the protocol on a series of Systematic Reviews we performed to establish the evidence for best practice ACL rehabilitation. Previously we discussed the first 2 reviews. Here we will review the findings in our 3rd review which was an update of the original 2. It can be found HERE. In this study we discussed an additional study evaluating the use of Continuous Passive Motion machines which once again showed no advantage. Several additional studies had been published evaluating bracing and none demonstrated any advantage in the postoperative rehabilitation period. Additional studies evaluated early ROM and quad strengthening without any increase in laxity. Eccentric strengthening was safe and showed improved strength gains compared to concentric strengthening when initiated at 3 weeks and continuing for 12 weeks. Accelerated rehab shortening to 5 months the recovery did not result in worse outcomes  or safety issues. Additional electrical stimulation studies showed safety, but no significant efficacy in ACL rehabilitation.

Most additional studies performed since our last review reiterated our additional findings. I will be presenting specific findings for revision ACL reconstruction rehabilitation at the July 2016 American Orthopaedic Society for Sports Medicine and we will blog those results when available next week.

ACL Reconstruction Rehabilitation Part 2

Postoperative rehabilitation remains critical to the outcome for the patient undergoing ACL reconstruction. If the physical therapy following surgery does not go well then it does not matter how well the surgery was performed. When the
MOON group began enrolling ACL reconstruction patients we decided to develop a standardized physical therapy protocol to use for our patients and to have consistency for our patients’ recovery. I was tasked with developing an evidence based review of ACL reconstruction rehabilitation and then using it in conjunction with our physical therapists to develop a practical protocol. Ultimately, we developed what has been a very popular protocol that is more milestone based than time based and has been easy to implement across our several sites. We have subsequently published the protocol in the AOSSM journal Sports Health so that others can utilize it also. You can read the description and find the protocol HERE.

We published the systematic review evidence we based the protocol on in 3 separate studies. in Part 1 I reviewed the findings in our first publication. The second publication can be found HERE. Findings in this study included a review of open (isokinetic) vs. closed chain exercises. Closed chain exercises occur when the foot is planted on the floor or on a firm surface such as a leg press machine. These type of exercises may be more protective for the healing ACL graft,  but it appears open chain exercises are safe 6 weeks after ACL reconstruction.

Neuromuscular stimulation has been extensively studied utilizing a variety of parameters and has not been shown to be critically important. It is safe and can be utilized at the therapist's discretion most commonly when the patient is struggling to recruit the quadriceps muscle for strengthening.

Accelerated rehabilitation has gained much attention, but there remains little evidence that it can be truly lowered below the 4 month time frame safely. One randomized study looked at 8 vs. 5 months and found no problems with this length of rehabilitation, but to many of us this doesn't represent significant acceleration. Future research will be necessary to address this further.

Water exercise may decrease swelling and appears to be safe. Slide board exercises can be incorporated at 6 weeks without harm. Stair climber is as safe as stationary cycling at 4 weeks.

Additional principles will be reviewed in Part 3 reviewing our 3rd study evaluating ACL rehab PT

ACL Reconstruction Rehabilitation Part 1

Postoperative rehabilitation remains critical to the outcome for the patient undergoing ACL reconstruction. If the physical therapy following surgery does not go well then it does not matter how well the surgery was performed. When the
MOON group began enrolling ACL reconstruction patients we decided to develop a standardized physical therapy protocol to use for our patients and to have consistency for our patients’ recovery. I was tasked with developing an evidence based review of ACL reconstruction rehabilitation and then using it in conjunction with our physical therapists to develop a practical protocol. Ultimately, we developed what has been a very popular protocol that is more milestone based than time based and has been easy to implement across our several sites. We have subsequently published the protocol in the AOSSM journal Sports Health so that others can utilize it also. You can read the description and find the protocol HERE.

We published the principles that it was based upon in a series of evidence based systematic reviews. The study can be found HERE  I will summarize our findings in this and subsequent blogs. Continuous passive motion CPM has been anecdotally advocated as a way to improve range of motion (ROM) following ACL reconstruction. It has become increasingly difficult to get insurance to pay for this and fortunately 6 randomized controlled trials demonstrated no advantage for the use of CPM. Based on this we did not utilize or advocate for its use in our protocol.

Immediate weight bearing and early ROM has been shown to improve outcome with less patellofemoral pain postoperatively. More than 15 randomized trials have evaluated using braces during the recovery phase following ACL reconstruction. No study demonstrated an advantage for safety, swelling, graft function or ROM with the use of the brace. Given the cost and inconvenience of braces we do not require or advocate bracing after ACL reconstruction.

Home based vs. outpatient rehabilitation has been evaluated in several studies. In the motivated patient appropriate outcomes can be achieved with minimal outpatient therapist guidance. This should be individualized for each patient.

Read future blogs for a review of further studies guiding our protocol’s development.

ACL Injury Video

Watch this video to learn more about ACL injuries

ACL Injury Video