Yet another example of ACL regrowth.
A procedure that’s been producing results for 10 years, yet public healthcare systems - including Canada’s - does not offer it.
How is it we are a decade behind in current orthopedic practices, and what is being done to prevent falling further behind?
One of the names I noticed on a few publications was Dr. Mackay at The Mackay Clinic, who it turns out pioneered the InternalBrace, and found the following:
“2 International Netball players have regained pre-injury levels of function 12 weeks after their ACL rupture has been treated with the internal brace.
“with the healing of their ACL confirmed by MRI. These exceptional outcomes are partly explained by the procedure’s preservation of nerve and blood supply and the avoidance of donor site problems thanks to the IB fixation, although the duration of recovery is also determined by the individual and the unique nature of their injury. The Internal Brace is quickly becoming a standard procedure in skiing and impact sports, especially in the USA,”
https://www.mackayclinic.co.uk/the-internal-brace-at-a-glance
I started looking up everything I could find on this, so I could talk about having it done here during my next appointment this week at AKIC with my sports medicine doctor at University of Calgary.
Side note related to stairs - I also recall a meeting to explore a possible Operations Manager position with a fast growing startup May 2nd. They had stairs and I hoped they didn't ask me to walk up them to where the offices are – stairs were very difficult at this point – luckily we had it in the main area which was a nice change. Still tried to make it less obvious.
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
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.
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.
I continued doing research on BEAR trial, including articles from ResearchGate, BEAR Trial 2 at Boston Childrens
Apparently an ACL tear is one of the most common types of knee injury, accounts for around 40% of all Sports Injuries.
Treatment can be surgical or conservative (which is reserved for sedentary patients). Physically active patients seek surgical treatment to restore functional strength to the ligament. The current standard surgery uses a graft made by stripping perfectly fine tendon tissue or ligament from elsewhere (hamstring, patella, etc.). In addition to removing good tendon and having to recover from this in addition to the knee injury, I’m concerned from the high risk of early onset osteoarthritis in the injured knee from the standard surgery.
Rehabilitation from this takes 9 months to a year to regain the loss of quadricep strength and knee flexibility caused by having a portion of tendon removed.
From what I understand BEAR uses stitches and a bridging scaffold (a sponge injected with the patient’s blood) to stimulate healing of the torn ACL. This maintains a clot that facilitates ACL regrowth by providing barrier from synovial fluid effects.
Another way of saying it:
a suture repair to bridge the gap between torn ligament tends & incorporates a bioactive scaffold to promote self-repair. The sponge is inserted into the area where the torn ACL once was, soaked in the patient's own blood and then attached to both torn ends of the damaged ACL. Over time, the sponge acts as a "bridge" and allows the ACL to reattach itself, thus re-growing a fully intact ligament.
The bovine scaffold acts as a bridge that lasts in the joint long enough to allow the ACL ends to heal back together.
Patients then wear a restrictive hip-to-ankle post operative brace for 6 weeks, at which point they switch to another sports brace.
Recipients so far demonstrated faster recovery time than graft recipients, & hamstring strength at 3 months was significantly better in BEAR patients.
After first finding an ACL healed itself, the 2nd thing I found were the BEAR trials run Boston Childrens in these two articles from 2016:
A safety study had been done on 10 patients, all reported “doing well, with knees working as well as knees treated with ACL reconstruction.” The 1st patient surgery was Feb. 2015 (> 3 yrs ago), for Corey Peak, who also tore it skiing. He concluded that it was a better option to treat a torn ACL; within 3 months post-surgery, his MRI showed that his ACL had started to naturally knit together; he was jogging on a treadmill. Soon after, cycling to work.
Bridge Enhanced ACL Repair - How it works:
When viewed under a microscope, ACLs still have active cells and blood vessels after injury. The ligament itself works hard to heal, however the synovial fluid — the lubricating substance that exists inside of all joints —washes away the blood clot that serves as the initial connection between torn tissue ends in other parts of the body.
Conventional treatment for an ACL tear involves removing the torn ends of the ligament that’s trying to heal itself, & fabricating another from a tendon graft, usually done by stripping away good tissue (hamstring or patella). Patients who had 1 injury then have to recover from 2 separate injuries—the torn ligament + the uninjured area where the graft was taken out.
Whereas a traditional reconstructions involves removing good tissue for a graft from another part of the body to fabricate an ACL, BEAR allows patients to re-grow their own ACL. This resulted in both quicker #recovery and fewer long-term complications than the traditional ACL amputation & reconstruction.
An estimated 150,000 ACL tears still occur every year in the USA. “ACL re-tear rate can be as high as 20% for teens. Up to 80% of patients develop arthritis 15-20 years after surgery.”
Given the eligibility criteria timeline, I need to figure this out fast, as I was at 38 days, and I didn’t want unnecessary ligament removal.
I started doing my own research on knee injuries to understand what was going on better, and due to the poor response times and lacking diagnosis Alberta Health Services, I had to start looking into other options for service.
For a previous problem my then running coach Glenroy Gilbert recommended at I travel from Ottawa to Toronto to sports medicine Dr Anthony Galea who was very helpful.
(who's clients have included golfer Tiger Woods, Olympic medalists Dara Torres, Mark McCoy medalist (hurdles), Donovan Bailey; NFL players Jamal Lewis, Javon Walker , Santana Moss; Chris Simms, and figure skater Patrick Chan).
Major League Baseball players Alex Rodriguez, Huston Street and John Patterson have also received treatment from Galea (correct me for any wrong handles).
Looked him up again and saw a few years after that, he introduced PRP (Platelet Rich Plasma) therapy as a way to treat his patient injuries.
What I like about Dr. Galea is he does not let limitations of conventional medicine establishment prevent him from the practice of advancing medicine (see his TED talk).
PRP therapy is the process of treating an injury with a patient's own blood, concentrating & reinjecting your natural growth factors with the intent of promoting soft tissue growth in ligaments & tendons. It is legal and widely used now, often paired with stemcell injections.
For ACL repair PRP alone did not appear to be a solution; at best it may have be an accelerator in the right situation.
Stem cells have potential, yet do not ensure the physical tissue's position is achieved (may not resolve leg lock) and sometimes result in tumors and defects - stem cell technology for ACL is too early from what I see, and there was not strong research backing this for ACL repair either.
So I continue to do as much research as I can late evenings & weekends.
*in US this would be 4 weeks post op