You May Not Need That ACL Operation

Here is another follow up to our current trends in anterior cruciate ligament (ACL) reconstruction management which started a while ago. This one seems to be the best one yet, especially if you're considering whether to do the operation or not.

You may NOT need surgery after all. Please read on to find out more.

An article by Swedish physiotherapist/ researcher and colleagues (Frobell et al, 2010) made headlines when it was published back in 2010. Allow me to give you a little info on Frobell. While working as a physiotherapist back in 2001 rehabilitating ACL injuries and also assisting at ACL surgeries (to better understand the procedure), he was inspired to find out more. In one particular case, a patient's ruptured ACL had partially healed and attached to the posterior cruciate ligament or (PCL) and the knee was stable and did not require surgery. This led him to investigate further which brought about the following study.

The researchers reported that 60% of all ACL reconstructions could be avoided in favour of correct advanced rehabilitation. Their results made waves all over the world and were of course met with healthy skepticism (including yours truly). Many nay sayers said it could not be done. It was even agreed that their results will probably not hold up in the long term.

Surprise surprise, the same researchers have published a 5 year follow-up study that confirms the results from the earlier study. More importantly, the results also show that the risk of osteoarthritis and meniscus injuries (requiring surgery) is not higher than those treated with physiotherapy alone.

The patients also did not experience any difference in function, activity level, quality of life, pain, symptoms etc. The researchers reported that there wasn't any difference in any outcome between patients that were operated soon after injury, operated on later and those who did not have any operation at all.

Take home message from the researchers? Young, active patients with ACL injuries may be better off doing specialized rehabilitation initially rather than getting an ACL reconstruction.

Well, I guess the key here if you want to avoid surgery is specialized rehabilitation with experienced physiotherapists as mentioned by the researchers. Come talk to us if you have any questions, we have much experience with ACL injuries and we do aqua based rehabilitation as well.

The researchers are now starting their third part of the study, Knee ACL Non-operative treatment (KANON) whereby they follow-up on the patients 10 years after their ACL injury. I will be waiting for their results.

References

Frobell RB, Roos HP, Roemer FW et al (2013). Treatment For Acute Anterior Cruciate Ligament Tear: Five Year Outcome Of Randomised Trial. BMJ 346(Jan 24 1) :f232. DOI: 10.1136/bmj.f232.

Frobell RB, Roos EM, Roos HP et al (2010). A Randomised Trial Of Treatment For Acute Anterior Cruciate Ligament Tears. NEJM 363(4): 331-342. DOI:10.1056/NEJMoa0907797.

*Picture from flickr.com

More On LARS For ACL Reconstruction

This eagerly awaited post will discuss the evidence behind the LARS surgical procedure for ACL reconstruction (http://physiosolutions.blogspot.com/2011/01/lars-for-acl-reconstruction.html). This is a follow up to our original current trends in ACL reconstruction management which first started on March 19 2009 (http://physiosolutions.blogspot.com/2009/03/current-trends-in-anterior-cruciate.html).

In all the papers reviewed, knee laxity was objectively measured from injured to non-injured side using the KT-1000. Most of the papers reported that laxity was within normal range but did not give the exact measurements so it is difficult to compare. 

In one of the papers, a significant difference was found in knee stability between the 4-strand hamstring graft group (4SHS) showing 2.4mm difference from side-to-side compared with 1.2mm difference in the LARS group (Liu et al. 2009). However, laxity scores were found to be significantly greater in the LARS group at 6 months compared with the bone-patella tendon bone (BPTB) group and remained greater throughout the follow-up but although it was not statistically significant (Nau et al. 2002). 

At 24 months the BPTB group had 2.38mm laxity and the LARS group 4.86mm (Nau et al. 2002). There was a fair range of measurements shown in each study, although measurements were taken over differing time periods which may account for this. 

It is interesting to note that the BPTB group had greater stability compared to the LARS group, where the 4SHS did not. 

Well, the results of studies have shown that LARS is comparable to the use of autologous surgery (of BPTB & 4SHS) in short-term studies. With similar findings in knee laxity post-surgery and return to functional activities. There also appears to be a low risk of complications including synovitis which was the main concern for the previous use of artificial ligaments. Patient satisfaction appears to be higher which may be due to the possibility of a quicker rehabilitation time period.

The implications for patients (and that means you) include the need for a faster rehabilitation program and the need to adapt exercises for a shorter recovery period. There appears to be a lack of current protocol for therapy following the LARS surgery as evidenced by the differing time periods to weight-bear and return to previous levels of activity. 

The evidence found is positive for the future that the LARS may be used for elite athletes or manual labourers who need to return to previous injury levels quickly. However, further comparative research is required to draw a more accurate conclusion. Longer term studies are also required to look at any further potential complications. 

Looking at all the evidence, the biggest "positive" is not harvesting a patient's patella or hamstring and thereby causing pain/ weakness potentially in that area. If the LARS ruptures again though,  it would end up much more complicated and it will have to be redone in 2 different procedures. 

References

Gao K, Chen S et al (2010)Anterior Cruciate Ligament Reconstruction with LARS Artificial Ligament: A Multicenter Study With 3 – 5 Year Follow-up. Arthroscopy: The Journal of Arthroscopic and Related Surgery, vol. 26(4), pp. 515-523. 

Legani C et al (2010). Anterior cruciate ligament reconstruction with synthetics grafts. A Review of Literature.’International Orthopaedics (SICOT), vol. 34, pp. 465-471.

Liu Z, Zhang X, Jiang Y et al (2009). Four-strand hamstring tendon autograft versus LARS artificial ligament for anterior cruciate ligament reconstruction. International Orthopaedics (SICOT), pp. 1-5.

Nau T, Duval, N et al (2002). A new generation of artificial ligaments in reconstruction of the anterior cruciate ligament: Two-year follow-up of a randomised controlled trial. JBJS vol. 84, pp. 356-360. 

*Picture from Herald Sun.

LARS For ACL Reconstruction

This may be the best piece of news if you have just torn your anterior cruciate ligament (ACL) and want to return to sports quickly. Please read on for our follow up posting for our current trends in anterior cruciate ligament (ACL) reconstruction management which first started on Mar 19 2009 (http://physiosolutions.blogspot.com/2009/03/current-trends-in-anterior-cruciate.html). This may  revolutionize surgical treatment after serious sports injuries.

Ligament Augmentation and Reconstructive System (LARS) surgery is currently the quickest available technique to return to sports after tearing your ACL. The surgery involves using a ligament created from industrial-strength polyester fibres (PETP or polyethylene terephtalate) to replace the torn ACL.  This procedure has cut the recovery time by a third. The ends of the ruptured ACL are sutured together and the synthetic ligament is passed through the middle of the ACL.

I first read about this technique way back in 2008, but wasn't convinced then. Aussie Rules football player (whom our Australian patients/ readers will be familiar with) Nick Malceski of  the Sydney Swans underwent the procedure after tearing his ACL and was back playing in 12 weeks!

Typical recovery time to return to sport for an ACL tear is 9-12 months. Just ask soccer players like Alan Shearer, Michael Owen, Brazil's Ronaldo (who has torn both ACL's) and Singapore football players like Indra Sahdan and  Mohamed Nor Rahman. They were sidelined 9-12 months after tearing their ACL's. Tiger Woods made his comeback after almost a year off after tearing his.

Currently, elite athletes who have undergone the LARS procedure include AFL star Port Adelaide midfielder David Rodan, Carlton's Brad Fisher, Brisbane Lion's Josh Drummond and NRL Cronulla winger Luke Covell who returned to Rugby League action just 11 weeks after rupturing his ACL.

Records show that there were 10 LARS knee reconstructions in Australia in 2006 and the number surged to 750 in 2009 (including ankle, shoulder and knee surgeries).

Before you go banging on your surgeon's doors for LARS, bear in mind that that are pros as well as cons. While this technique is popular in Europe and Canada, this procedure is not approved by USA medical authorities as there are fears that the synthetic implant may have adverse effects 5-10 years down the track. Plus no surgeon in Singapore can do the procedure yet.

Stay tuned as we discuss the pros and cons of the LARS procedure and the current published evidence so far in our next post.

* Picture of LARS graft from Dericks, G 1995, ‘Ligament Advanced Reinforcement System Anterior Cruciate Ligament Reconstruction.’ Operative Techniques in Sports Medicine, vol. 3(3), pp. 187-205.