Encouraging Evidence in Support of ACL Preservation

Celebrating about a decade of advanced orthopedic treatment resulting in ACL tear regrowth and results. About a year ago I participate in this study to help contribute results.  

It’s amazing public health is still not offering this, and much of the the orthopedic community is a decade behind current practices.

I’m border line starting a petition for to get Alberta Health to stop unnecessary body part removal and protect orthopedic surgeons from a class action lawsuit from the 1100 or so patients a year receiving the wrong procedure.

Follow up MRI 1 - InternalBrace ACL Regrowth

Aug. 24, 2019 - 1 year, 3 months post surgery

Follow up MRI completed at Foothills Medical Center, Richmond Road Diagnostic, AHS, Calgary Alberta

Radiologist interpretation influenced by lack of exposure to this type of repair and therefore may not accurately reflect actual condition in tissue remodeling.

This is a general problem, despite ACL regrowth being practiced for 10 years most orthopedic surgeons are not practicing current method, and as a result radiologists do not have exposure they otherwise would have.

May 21, 2018 call, timeline

Wait time: 61 days

time to avoid removal: 4.1 weeks remaining

Monday after May ‘2-4’ Long Weekend

On a call to Scotland speak with Prof Mackay in the morning, who mentioned he’s done 300 over 7 years. He was personable and his depth of knowledge on orthopedic practice far beyond any of the doctors I'd spoken to so far. He mentioned there are more professional football (a.k.a. soccer) & rugby players opting for this, also some pro skiers and skiers from the USA who traveled specifically to keep their ACL.

A consult could be scheduled as soon as Wednesday afternoon and surgery Friday. He suggested to plan at least 2 weeks there up to 6 weeks after, and to approach it like a vacation where I won’t be doing anything. It was also clarified when identified to be an InternalBrace candidate according to MRI (in previous post), a surgeon won’t know for sure until they’re inside the knee to examine the tissue, so depending on what he actually finds, a graft ACLreconstruction may turn out to be the best option, however he’s fairly optimistic; if needed we may do a hybrid: smaller graft & internal graft + keep ACL. For the ACL it depends on disruption of continuity.

An additional 20-30 min may be added to the procedure depending on the MCL (slight slack can move tension to ACL; spoke about the remodeling phase – laxity of system) and retention to natural length, so procedure may be 2-3 hours.

The timeline sensitivity was explained: preference for procedure is 3 – 6 weeks; we’re at 9. Briefly talks about some graft & stats on hamstring show some problems after.

Surgery will be somewhere called BMIRossHall in Glasgow Scotland. I’m fine with this,

I just want my sportsmedicine doctor to be giving me the option not to rip out healing body parts when it’s not needed, which isn’t happening in Canada. Or the USA. Or the UK.

timeline in pic

Regeneration of the anterior cruciate ligament: current strategies in tissue engineering

Which led me to search for this researchers more current work; here’s a publication:

Regeneration of the anterior cruciate ligament: Current strategies in tissue engineering

World Journal of Orthopedics

2015

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4303781

“The worldwide estimation of young sports players that require surgery following a knee injury lies between 17%-61%. The anterior cruciate ligament (ACL), a main stabilizing structure of the knee, is one of the most commonly injured ligaments. In the USA alone, around 350,000 reconstructive surgeries of the ACL are performed annually. According to the National Center for Health Statistics, the annual costs for the acute care of these injuries are around $6 billion”

“relatively high failure rates of ACL reconstruction, especially in young and active patients, have been reported for allografts. An incidence of osteoarthritis as high as 50% within 7-14 years after injury and reconstruction of the ACL is still the main drawback of this surgical strategy. The development of osteoarthritis following ACL injury is not fully understood and may be caused not only by the limitation of the current grafts, but also by the initial joint trauma and the trauma caused by the surgeon.”

and the most recent thing I came across from last year next post…

Anterior Cruciate Ligament Repair Revisited. Preliminary Results of Primary Repair with Internal Brace Ligament Augmentation: A Case Series

The next report I came across really put the it into perspective the need for alternatives given complications and lower than toted outcomes of ACL reconstruction, and how InternalBrace initially measured up within the first 3 months – back in 2015.

Anterior Cruciate Ligament Repair Revisited. Preliminary Results of Primary Repair with Internal Brace Ligament Augmentation: A Case Series

https://www.omicsonline.org/open-access/anterior-cruciate-ligament-repair-revisited-preliminary-results-of-primary-repair-with-internal-brace-ligament-augmentation-a-case-series-2161-0533-1000188.php?aid=52900

“estimates suggest that in the United States alone 400,000 ACL reconstructions are carried out each year. As the majority of ACL injuries occur in patients of working age, the economic burden to both patients and society is considerable”

“ACL reconstruction. The technique either involves removing or bypassing residual ACL tissue, without any attempt to repair the ligament”

“In the majority of cases, sufficient tissue remains for a repair to be considered, particularly if surgery is carried out within 6 weeks of injury”

*What really strikes me – perhaps from my continuous improvement background – is removal & reconstruction is a work around to the problem*

“A number of problems have been identified with ACL removal however, with autograft harvest associated with a degree of morbidity from tissue loss. Hamstring muscle weakness following harvesting averages 10% in most studies with anterior knee pain common with patellar tendon grafts”

“loss of proprioception a particular problem. Not surprisingly therefore the majority of studies of gait after ACL reconstruction show abnormal gait patterns and altered knee kinematics which may be linked to the higher rate of early Osteoarthritis”

Orthopedic & Muscular System: Current Research ISSN:2161-0533

“68 consecutive patients who underwent Anterior Cruciate Ligament repair with IBLA were followed for a minimum of 1 year following #surgery … between Sept 2011 and Sept 2014”

“Only patients who had completed one year of follow-up were included … max time from injury to surgery was increased to 3 months”

*I’m within this time frame, & receiving a diagnosis that will not facilitate a successful outcome*

“Beyond this time the ACL remnant begins to remodel and retract, and the tissue is no longer able to be placed back at its original attachment point”

“Loss of proprioception is important as it may lead to overloading of the ACL graft ... It is estimated that less than 50% of patients return to sport after reconstruction, and those that do often find that they cannot perform at the same level as pre-injury/pre-surgery”

“The majority of studies assessing gait and knee kinematics post-ACL reconstruction show an improvement in gait pattern compared to pre-surgery, but compensatory mechanisms of muscle use persist in the majority of patients indicating sub-optimal performance of the reconstructed graft. Graft donor site morbidity from tissue loss and scarring is well documented with hamstring weakness and anterior knee pain problematic after hamstring and patellar tendon harvesting respectively”

“modifications introduced to the ACL reconstruction technique to try to improve outcomes include: changes in graft tunnel position, double bundle rather than single bundle grafts, retention of the ACL remnant and variations in graft fixation techniques.

NONE of these modifications have been shown to make a significant difference to patient reported outcomes.”

*Earlier return to function could result in less hospitalisation and healthcare usage post-operatively, with an earlier return to work and sport. This could potentially have benefits not only to the patient but to the health service and society as a whole.

the time to surgery in patients undergoing acute ACL repair with IBLA is likely to be shorter than those undergoing ACL removals, the majority of whom will have failed a period of conservative care.

https://www.omicsonline.org/open-access/anterior-cruciate-ligament-repair-revisited-preliminary-results-of-primary-repair-with-internal-brace-ligament-augmentation-a-case-series-2161-0533-1000188.php?aid=52900

A Review of Ligament Augmentation with the InternalBrace

Despite the timeline passing for DIS eligibility, the fact a repair option regrowing ACL’s has existed for so long spurred me to keep looking.

I came across article A Review of Ligament Augmentation with the InternalBrace

https://www.researchgate.net/publication/288006378_A_review_of_ligament_augmentation_with_the_InternalBrace_The_surgical_principle_is_described_for_the_lateral_ankle_ligament_and_ACL_repair_in_particular_and_a_comprehensive_review_of_other_surgical_ap

Halfway through the 18 pages I find some application to the ACL, how it reduces harvest site morbidity & cost.

Based on the US stat 1 – 10 per 1000 people = 100k – 400k ACL reconstruction s occur annually; Canada would have 32,000+ reconstructions, which involves removing or bypassing the remaining ACL, despite in the majority of cases sufficient tissue remains for a repair to be considered, particularly within 3 months.

It explained grafts do not produce a normal feeling knee; there’s a loss of proprioception, which when present is important as this prevents overloading of the ACL graft; and estimates less than 50% of patients return to sport, and those that do often find they cannot perform at the same level.

“Graft harvest is associated with a degree of morbidity from tissue loss; muscle weakness with hamstring grafts & anterior knee pain are common with patellar tendon grafts.”

“there is a decrease in knee power and work performed postoperatively by the muscles around the injured knee”

“compensatory mechanisms of muscle use persist in the majority of patients, indicating sub optimal performance of the reconstructed graft”

There was also a study cited confirming “significant increase in osteoarthritic changes as early as a year post op” and stats on reconstruction failures.

“The clinical benefits of a well prepared and healed ACL are likely to be greater for patients than those offered by a traditional ACL reconstruction”

“Sufficient ACL tissue can remain for up to 3 months following ACL injury to allow a repair; procedure is time dependent as the ACL remnants are not suitable for direct repair after the tissue retracts and atrophies”

• Perhaps this is an option I am still within the timeline for.  I have just under 5 weeks left if it is.

The Internal Brace is a 2mm high molecular weight polyethylene that protects a repair by being a check rein if the ligament is stretched beyond its physiological range.  Should failure occur reconstruction remains possible without compromise to the knee joint.

Earliest patients are from Sept. 2011

If found suitable, the ability to repair a torn ACL can be confirmed at the time of #surgery.

“Early phase rehabilitation was consistently accelerated.  Limited pain and selling facilitated early range of movement, muscle control and restoration of function.”

“…avoidance of donor site morbidity & minimal surgical trauma.”

“better outcomes were achieved for ACL repair at the majority of time points”

“Pain…was less in patients”

“4 cases had arthroscopically confirmed ACL healing”

“…eliminate the shortcoming of current reconstruction techniques”

“…change in orthopaedic practice relegating ligament reconstruction appropriately as a salvage procedure; only if the tissues fail to heal adequately after augmentation & repair.”

The article is from back in 2015, so I start searching the authors of the published medical journal studies and references to find other research they’ve done.

info on ALL (Anterolateral Ligament)

May 13, 2018

53 days since injury.

I come across some info on ALL (Anterolateral Ligament) and find:

‘Despite technologic advances in the surgical technique for ACL reconstruction, some patients continue to have rotational instability post operatively, decreasing the return to sport rate. Failures can occur because of improper tunnel positioning, problems with patient rehabilitation, or non-optimal incorporation of the graft used for reconstruction’

and

‘recent biomechanical studies have shown it is an important stabilizer against anterolateral tibial rotation’

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5263705           

Then found in Dr DiFelice NY’s article

Ground Breaking ACL Repair Approach Could Help 80,000 in US Alone

“Skier Veronika Velez Zuzulova competed 20 weeks after suffering a torn right ACL: an injury that according to traditional thinking should have required ACL Reconstruction Surgery and an 8 - 12 month #recovery.

Foregoing the traditional, Zuzulova opted for ground breaking ACL repair surgery instead of ACL removal & graft reconstruction – that had her training just 6 weeks after surgery with enough time to enable her to be ready for the Pyeong Chang Olympic Games.”

“more than 150 Repairs and has published both two-year and five-year post-surgery data on his initial cohort to validate the procedure’s success”

“published more than 15 professional, peer-reviewed articles on the subject”

“unwarranted bias which limited ACL Repair as an option” 

“failing to recognize that ACL Repair success was much higher when treating specific types of tears, the data lead to the erroneous conclusion that ACL Repair was not a reliable course of action.”

Can “repair greater than 50% of the athletes who present to him with ACL tear”

“up to 80,000 of the 300,000 patients suffering ACL tears in the US alone may be helped”

French surgeon Dr. Bertrand Sonnery Cottet performed Zuzulova’s surgery, and again the article mentioned Scotland's Dr. Gordon MacKay at The Mackay Clinic.

Despite the mounting cases and supporting publications suggesting that, for the appropriate tear type, ACL Repair is the preferred treatment method, the shift away from unnecessary reconstructions —widely ascribed to by orthopaedic surgeons—has been slow. 

"To keep all options open, athletes, parents and healthcare professionals need to take a closer look at ACL Repair," says Dr. Gregory S. DiFelice. This is especially important for younger athletes who have been shown to have high rates of re-injury and can develop significant arthritic changes as early as 10 years post-reconstruction. 

"success rate with ACL Repair is approximately 95% in all comers from recreational up to professional athletes. In the few patients that have suffered re-injury, Reconstruction was performed without undue difficulties. It is interesting to note that Dr DiFelice uses the standard Reconstruction procedure only as the last resort whereas the majority of #surgeons use it as their only option."

https://www.gregorysdifelicemd.com/olympic-skier-miracle-comeback.html

Analysis of the older data reveals certain subgroups, especially proximal tears with good tissue quality, had better outcomes.   

Again, the acuteness of the tear was a significant factor in repair – it is quite clear the direction I was being in given in Canada was wrong, and reducing the likelihood of a positive outcome.

I email Dr Difelice to find out what I can ask at my appointment this week, and am prepared to go to the US again.

Also email DIS again.  Ensuring I exhaust all potential options.

ACL Regeneration in 8 year old link

Prior to the brace I noticed people look at me more; seems the limp was really noticeable.  They still look at me with the brace too.

May 5, 2018

Also found another article on ACL Regeneration, this time in an 8 year old with mid-substance rupture, where "conservative treatment with a brace led to a stable knee with regeneration of the ACL on both the physical examination and MRI after 5 years."

https://www.rpajanssen.nl/images/user/files/JKSR%20ACL%20healing.pdf

I email my doctor one of the articles, asking for information on the % of ACL tear, and confirmation whether clot retention is needed to facilitate ligament healing, and if the bending exercises they prescribed will work against the bodies natural healing mechanism.  I stop doing the exercises pending response.

May 6, 2018

Bent my leg while I was sleeping, pain returns.

No reply from email yesterday.

Torn ACL - wait time for diagnosis

noticed more painful to walk in running shoes than ski boots

Sunday March 18

- drove back to Calgary

Will be interesting navigating healthcare as a patient with my background implementing lean at 3 hospitals.  Alberta is behind all the western Canadian provinces in their adoption of Lean Healthcare to improve patient outcomes.

BC started a few years before they moved me there,  Saskatchewan is at the point they're using 3P, and Alberta sandwiched in between by my measure has not even started.

Going to pay particular attention to wait times.

Monday March 19

went to see my doctor who sent me for xray & ultrasound on knee - went same day - report in photo.  I still think everything is ok and may be able to hit May long Sunshine village. Didn't go for the meds or crutches.

so far

88% wait time (10.75 hours) for

12% value add/service (1.5 hours).

Tuesday March 20

morning - walking is tough, actually considering crutches MRI & Acute Knee Injury Clinic appointments requested.

Wed. Mar 21

24 hours later AKIC responds to request, no appt yet.

Nothing from MRI. 

*If I were in the US I would have had it yesterday and would be reviewing the results.

let's see how long it takes Alberta Health Services

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