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ACL *repair* experiences ("internal brace")

 Poster: A snowHead
Poster: A snowHead
Hi, has anyone on here had the "internal brace" treatment to repair (not replace) an ACL? I've been looking into it and wondered how people are faring a few years after having it. It seems to be relatively new technique and it would be good to get some information on the longer term outlook of the treatment. I believe it was invented by Gordon Mackay who has done a reasonable number of these ops and it's becoming increasingly popular. The idea is that you basically thread a kevlar (?) tape through the ACL and the ACL regrows and rejoins along it though there is uncertainty as to whether the new ACL actually bears any load or if it is actually the tape that performs the load-bearing function of the ACL. I do like the idea of a quicker recovery period and not having to give up some hamstrings as I would in an ACL replacement.

Cheers!
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 Obviously A snowHead isn't a real person
Obviously A snowHead isn't a real person
Hi @aclbroke, welcome to Snowheads - even if not in the best circumstances...

There was some discussion about this a while ago: http://snowheads.com/ski-forum/viewtopic.php?p=2853048

Probably particularly worth reading the comments by Jonathan Bell
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 Well, the person's real but it's just a made up name, see?
Well, the person's real but it's just a made up name, see?
Thanks. Sad

I saw that thread and am hoping Ksenia will get back to me about their progress. It is really a longer term question though i.e. 30+ years.
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@aclbroke, I can't comment on the internal brace, but my experience of a hammy graft has been nothing but positive. Yes, the initial 6-8 weeks are a pain in @rse (and knee), but after that I actually enjoyed the rehab. It got me back down the gym, I lost a bunch of weight I'd been meaning to lose for years and my legs became much stronger. I was skiing 9 months after the op, with a CTi OTS knee brace, and after a nervous couple of runs it was all good. The op leg got tired initially, but that soon goes away. I had a few 121 lessons, giving knee history, and was given lots of exercises, drill and advise based on the specific issue and recovery. As a result I'm a much better skier, and slimmer & fitter (reports that I'm better looking and more amusing are perhaps less reliable).

I'm not suggesting snapping an ACL as a training method, but it doesn't have to be all doom and gloom.
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 Anyway, snowHeads is much more fun if you do.
Anyway, snowHeads is much more fun if you do.
Quote:

I was skiing 9 months after the op, with a CTi OTS knee brace


Hi Dr John, I ruptured my ACL + meniscus tear last September playing football (age forty-something) Sad and could have had the op this month (Feb'17) but have put it back until after my ski trip in April.
Lots of work in the gym several times a week at the moment hoping to be strong enough in the quads and hams to take part at a leisurely pace - my consultant says I'll be ok wearing a brace and no crazy skiing (damn Toofy Grin ).
So I'm on the lookout for brace recommendations, hence why I'm on here. Consultant recommended a Bauerfeind Softec Genu, retailing at £499 - no thanks.

I've seen a Ossur CTi OTS on eBay for half that - so would you recommend?

Been looking at Donjoy braces too (4titude and FullForce). Any other recommendations by anyone?
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You'll need to Register first of course.
@Gilbern74, I have used an Ossur custom for a while. They are custom made so not sure there is any benefit in buying one second hand. What if the seller is a different build to you? You will end up slopping around in it or being uncomfortably tight. They are intended to prevent hyper extension and must have sufficiently good grip on both your thigh and shin to prevent this. Even with the brace I have had a case of tibial plateau bruising from hyper extension so I would say they are not a catch all. But, like all safety equipment I will probably continue to use it as who knows what might have happened if I hadn't?

This is not a thread about external braces. That has been done many times previously, but if you go down the brace route is your knee not worth a few hundred pounds to protect?
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 Then you can post your own questions or snow reports...
Then you can post your own questions or snow reports...
@aclbroke, ksenia did post an update on another thread earlier this year:
http://snowheads.com/ski-forum/viewtopic.php?p=2995121&highlight=#2995121
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 After all it is free Go on u know u want to!
After all it is free Go on u know u want to!
aclbroke wrote:
Hi, has anyone on here had the "internal brace" treatment to repair (not replace) an ACL? I've been looking into it and wondered how people are faring a few years after having it. It seems to be relatively new technique and it would be good to get some information on the longer term outlook of the treatment. I believe it was invented by Gordon Mackay who has done a reasonable number of these ops and it's becoming increasingly popular. The idea is that you basically thread a kevlar (?) tape through the ACL and the ACL regrows and rejoins along it though there is uncertainty as to whether the new ACL actually bears any load or if it is actually the tape that performs the load-bearing function of the ACL. I do like the idea of a quicker recovery period and not having to give up some hamstrings as I would in an ACL replacement.

Cheers!


There are lessons to be learned from history.

A quick bit of glossary of terms that may be confusing:

i) Repair means to try and save the ligament and stitch it back in place.
ii) Augmentation is to bolster the repair with another cord of material like gortex or some other polymer.
iii) Reconstruction is to remove the ruptured ligament and substitute it either with a graft ( a bit of tendon) or an artificial cord of polymer.

The operation of internal brace is an augmented repair using an artificial ligament.

Right here goes:

Repair of the anterior cruciate ligament (ACL) used to be carried out frequently.

It was abandoned because the results were consistently poor with continued instability.

This has been shown in many long term follow up studies.

There were some studies in 80's and 90's that suggested that repair of the ACL plus augmentation with an artificial ligament could get good results.

The results were mixed and it was abandoned.

At the time alot of artificial ligaments were placed into the knee to deal with ACL rupture.

I've taken out many and when they shred they leave lots of unpleasant debris in the knee which doesn't look good ground into the surface of the articular cartilage..

Recently there has been an attempt to revisit total replacement of the ruptured ligament with an artificial ligament. The results have

been disastrous for many of the patients who were subject to this surgery.

Since that latest round of bad results there has been alot of interest in whether we can, once again, repair the ligament ( Augmenting it with a cord of artificial material) rather than replace it.

You'll notice that this approach is sounding familiar!

Here is a bit more history to consider along side the current approach that is being championed by the "designer" of the internal brace procedure.

One thing is clear and that is that not all ACL ruptures are the same, in particular the site of injury and the extent to which it involves both bundles of the ligament.

One author some time ago looked at a series of repairs and concluded that a clean detachment off the femur was the pattern that does best with repair.

This pattern of tear accounted for 22% of all the injuries. So how do you identify which will do well, it looks almost certain that it will be very few?

MRI doesn't help because it isn't that reliable in identifying the injury let alone detailing the site and extent of damage.

In other words it will be extremely difficult, if not impossible to identify which ligaments may be worth repairing, but it should be a small minority.

One of the suggestions why repair didn't work in other patterns of tear was that the damaged ligament

ends up quite frayed at the ruptured end and that when attempting to reattach it it is a bit too short thus resulting in a gap. The BEAR technique

( currently being developed in Boston) attempts to deal with this by filling the gap. We wait to see if it works, so far there is no proof you can bridge the gap.

Rob La Prade shares this view http://drrobertlaprademd.com/dr-laprade-comments-dr-murray-new-bear-acl-repair-technique/.



Do remember there are no published results ( other than anecdotal report) demonstrating the success of this operation nor that the recovery is any quicker.

We may learn who could benefit from this operation and whether it works as more results get published but that is not clear at the moment.

Finally the claims that recovery will be quicker are unsubstantiated.

Recovery from ACL surgery is limited initially by swelling in the knee then by the steady recovery of neuromuscular function. If anything the current thinking is that we

have been trying to get patients back too soon and are not completing a full neuromuscular recovery program. Its for that reason i started the Return to ski program that few SH have been on.

I also now now have my own physio in every follow up appointment to help me judge recovery and i've found that i have slowed recover programs down to accommodate the time need to regain strength etc.

Finally don't forget that not everyone should have an ACL reconstruction as it may be required.

Jonathan Bell
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You'll get to see more forums and be part of the best ski club on the net.
@Gilbern74, I'd recommend it because it worked for me, haven't tried any other. I had mine fitted by a physio (on strong recommendation from surgeon) who also advised on best use. Weaned myself off it after 2-3 years (about 7 weeks skiing), & now don't even think about it, apart from a slight ache in the afternoons, which is easily dealt with by slope-side self-medication.
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Ski the Net with snowHeads
Please could we try to keep this on topic. I am not talking about any external brace that you strap over your leg. I am talking about a relatively new surgical procedure.

Thanks @Dr John, for the encouragement. The more positivity I get, the better on this. It's good to hear that the future is not bleak. It's just the decision making is quite hard on which procedure to get.

I value your input greatly @Jonathan Bell. I've been doing a lot of reading (too much?!) and the failed carbon fibre ligaments of the 80s are certainly at the back of my mind. There has been a 1 year study where the success rate of the internal brace is similar to the ACL replacement. This is a link to the recent report on it which makes interesting reading:
http://www.mackayclinic.co.uk/wp-content/uploads/2016/12/ACL-repair-revisiteduse.pdf

The BEAR link is interesting and the more innovation on this the better.

Obviously I'm in this for a lot more than 1 year so I'm trying to weigh things up. Biggest concern is, what are the long term chances of the reinforcing tape failing and if it does fail can the healed ACL bear the load all by itself? Also, would the tape failure create a problem in the body akin to the carbon fibre failed ligaments and would you be able to detect the failure of the tape? If I can reconcile these things in my head I would be happy to try the new technique.

(Edited to fix a mix up with doctors' name)
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snowHeads are a friendly bunch.
One year isn't enough
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 And love to help out and answer questions and of course, read each other's snow reports.
And love to help out and answer questions and of course, read each other's snow reports.
My son, who is 20, had ACL and ALL repair last Tuesday (6 days ago) using the internal brace technique.

Early days but he can currently extend the knee fully and bend it more than 90 degrees. He is using crutches but can put some weight on it without pain. Since yesterday he has not needed to take any painkillers.

Hospital physio told him that because he doesn't need to protect his hamstrings (since no graft required) his rehab should be easier. He starts rehab physio this week.

Surgeon was Prof. Adrian Wilson of Hampshire Knee. He will only use this technique where he deems it appropriate. The plan, in my sons case, was to use hamstring grafts, but having got into the knee, he decided that he was a perfect candidate for IB repair (this was previously explained and discussed).

I will update with his progress if there's interest here.
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So if you're just off somewhere snowy come back and post a snow report of your own and we'll all love you very much
Thanks @Tiredoldskibum. I hope it goes well for your son. I think there is certainly interest in how things go though the ideal would be to meet people who had the repair op 20 years ago but clearly that won't happen with a new treatment.
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 You know it makes sense.
You know it makes sense.
@aclbroke,

My understanding is that, when ACL reconstruction/repair was first tried (30 odd years ago in the US), the pioneering surgeon first tried repairing the ligaments rather than rebuilding them. He found that two out of three subsequently failed so he turned his attention to using grafts instead which has become the standard procedure.

Four or five years ago Dr Mackay looked at the process again and started trying repairs. The current procedure, is different to one tried 30 or so years ago in that rather than just stitching the ligament back together, a reinforcing artificial brace is constructed (using FiberTape) around which ligament tissue can eventually regenerate (note, I am in no way medically qualified so I stand to be corrected here).

The same materials and similar techniques are used in other reconstructive orthopaedic surgeries

Much more info here

https://www.arthrex.com/knee/fibertape-and-tigertape


As an aside, I recently spoke with a man who underwent ACL reconstruction using grafts, over 20 years ago and has had to have multiple (I think he said 14) surgeries since. He opted to have the knee joint replaced two years ago and is delighted with the outcome. But he is only in his early 50s now so that artificial joint has to last him a long time. There are no guarantees of anything, all you can do is look at what's on offer, weigh up the advice and choose what you think is best for you.


Last edited by You know it makes sense. on Mon 27-02-17 14:44; edited 4 times in total
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 Otherwise you'll just go on seeing the one name:
Otherwise you'll just go on seeing the one name:
Thanks for the link, I too read this recently. I feel like I've researched this to death now! It is great that the ACL can actually mend with the internal brace + tape.

My main concern is basically about how long the tape lasts and if it fails, is that failure detectable and does it have effects that cause problems in the body, and can the healed ACL take the strain all by itself? Also, the tape is incredibly strong and (as far as I can tell - can't find a datasheet) inelastic unlike the ligaments of the body which have an element of elasticity. Does this difference in behaviour cause a problem long term? ACL research does seem to be going far too slowly so it's good to see new techniques being tried all the same. So many people get this injury. :-/
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 Poster: A snowHead
Poster: A snowHead
Again, my understanding is that the tape stays put forever, but that the regenerated (for want of a better word) ligament provides most of the stability.

As you quite rightly say, there are no long term statistics available for this procedure, but that is true of anything newish. If we resisted all change on that basis we'd still be hunter-gatherers Very Happy

Best of luck to you in whatever you decide to do
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 Obviously A snowHead isn't a real person
Obviously A snowHead isn't a real person
@aclbroke, why not contact Gordon himself to ask those questions? He is pretty approachable.

I didn't have my ACL repaired by him, but I did have the lateral and medial menisci cleaned up in a follow up operation and he was really good with those. (past personal experience is no guarantee of etc etc....)
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 Well, the person's real but it's just a made up name, see?
Well, the person's real but it's just a made up name, see?
aclbroke wrote:

I value your input greatly @Jonathan Bell. I've been doing a lot of reading (too much?!) and the failed carbon fibre ligaments of the 80s are certainly at the back of my mind. There has been a 1 year study where the success rate of the internal brace is similar to the ACL replacement. This is a link to the recent report on it which makes interesting reading:
http://www.mackayclinic.co.uk/wp-content/uploads/2016/12/ACL-repair-revisiteduse.pdf

The BEAR link is interesting and the more innovation on this the better.

Obviously I'm in this for a lot more than 1 year so I'm trying to weigh things up. Biggest concern is, what are the long term chances of the reinforcing tape failing and if it does fail can the healed ACL bear the load all by itself? Also, would the tape failure create a problem in the body akin to the carbon fibre failed ligaments and would you be able to detect the failure of the tape? If I can reconcile these things in my head I would be happy to try the new technique.

(Edited to fix a mix up with doctors' name)

I had my Carbon Fibre implant more than a year after the original study. As the ever kind Mr Bell says - One year is not enough. I could not recommend being a ginuea pig rolling eyes
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