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New approach to ACL reconstruction?

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The telegraph Ski and Snowboard magazine has an interesting article this month about a new approach to ACL reconstruction using an 'internal brace' - claiming to significantly improve recovery time.
The original article doesn't seem to be available online, but it appears to be discussing this... http://www.mackayclinic.co.uk/the-internal-brace-at-a-glance/
Fortunately I'm not shopping for one at present, but interesting if tge hype is to be believed (normal caveats with medical 'innovations' apply).
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Interesting - wonder if this would successful with a damaged reconstruction.
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@Tubaski, I had some of the early artificial ligaments put into my right knee when all the soft tissue was damaged in an accident back in 1989. I was back teaching relatively quickly (mine was via open-knee surgery) but the first one snapped when I slipped on spilt food in school, as did the second one. The third reconstruction was also via open-knee surgery but using my own tissue (bone-tendon-bone from my patella tendon). Those less fortunate than me, i.e. those whose artificial fibre ligaments did not snap and get removed, have paid a high price for their high-tech rapid healing solutions - these include amputation in some cases. The artificial fibres broke down in the body and in particles were transported all over the place and have caused all sorts of problems.

I now treat these kinds of miracle solutions with a huge degree of scepticism until it is accepted AND practiced widely by specialists in all areas. There was the Healing Response process a few years back (Bode Miller had this and it enabled him to return to racing in the same season I think. There was a big razzamatazz article about it on the Steadman-Hawkins Clinic web site for ages, but it disappeared as the process was shown to be not quite the miracle solution it was supposed to be. LARS was another "quick fix" that was promoted heavily for a while, but has since been proven not to be quite as good as the marketing. Even doctors and knee specialists who promoted it heavily have published articles withdrawing their endorsements.
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@Samerberg Sue, shame. I was told the next time I damage my knee I would need a complete knee replacement but that I am too young for one. Hoping to hear of some good new break throughs before I wreck it again. Happy
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@Samerberg Sue, thanks. I hope a degree of scepticism was evident in my original post. I certainly intended it as a "I read this and it sounds interesting, discuss" rather than a "hey look - miracle cure!".
I completely agree with you about not wanting to be an early adopter of stuff like that until it is proven and widespread. I would hope that they would be wise to the problems with earlier alternatives, and not make the same mistakes, but given some of the stuff you hear about parts of the healthcare industry that may well be a naive hope.
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Quote:

Those less fortunate than me, i.e. those whose artificial fibre ligaments did not snap and get removed, have paid a high price for their high-tech rapid healing solutions - these include amputation in some cases. The artificial fibres broke down in the body and in particles were transported all over the place and have caused all sorts of problems.


I am still in possession of my carbon fibre recon which took place in 1982 - I am currently waiting for a hip replacement, and have quite severe Osteoarthritis in the other hip, both knees, spine and starting to ache in the shoulders. Wonder if there is a link. The carbon fibre was 24 month recovery for me, bloody painful and only ever got approx 110 degree movement back in the joint
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Tubaski wrote:
The telegraph Ski and Snowboard magazine has an interesting article this month about a new approach to ACL reconstruction using an 'internal brace' - claiming to significantly improve recovery time.
The original article doesn't seem to be available online, but it appears to be discussing this... http://www.mackayclinic.co.uk/the-internal-brace-at-a-glance/
Fortunately I'm not shopping for one at present, but interesting if tge hype is to be believed (normal caveats with medical 'innovations' apply).


I am due to undergo this type of operation next Tuesday....

Can report on the progress if of interest after
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After all it is free Go on u know u want to!
I wont comment directly on this procedure as i'm conflicted in that i advise a regenerative sport/orth company on something similar.
But..
Do bear in mind that historically results of repair have been almost universally poor.
Artificial ligaments have also almost universally had poor results.

Someone may crack the problem one day but how is not clear at present.
We really do need some improvement in techniques for managing ACL rupture.

"Healing response" disappeared because, whilst it was the latest breakthrough a few years ago, it didn't work (which wasn't very surprising)

Jonathan Bell
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@Jonathan Bell, LARS has also more or less disappeared in terms of being a viable alternative graft option despite the massive marketing campaign it used to promote all the advantages of the scaffold. The high profile Australian surgeons who promoted it have since rescinded their endorsements and published articles against its use. I know some youngsters (under 16 years old at the time of the operation) who did have LARS reconstructions and they have successfully returned to quite high level sports and one actually managed to get a basketball scholarship to a top US university a couple of years or so later. But he and his father really worked hard with physios and other therapists to ensure he did not overdo things too quickly.

I think Bode Miller's need for a full ACL reconstruction a short while after his "triumphant" return to racing was the first coffin nail in the Healing Response saga, although I was surprised to see the story still promoting it as a "miracle cure" on the Steadman-Hawkins site for a couple of seasons after the event!
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@Jonathan Bell, Thank you Jonathan, As you say, "Someone may crack the problem one day but how is not clear at present.
We really do need some improvement in techniques for managing ACL rupture." The only way for improvements to happen is to be opened minded and give it a go. Perhaps I will regret it in the future, but at least I will know, that I have tried. I had my best friend undergoing ACL reconstruction which ended up in 3 different operations with 3 different doctors and he was out of action for 3 years even though he followed rehab protocol. One other friend has never been able to walk properly after operation and now does not do any sport at all.... So in my opinion, the risk is out there regardless which operation you go for.
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ksenia wrote:
@Jonathan Bell, So in my opinion, the risk is out there regardless which operation you go for.


That's very true.
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And love to help out and answer questions and of course, read each other's snow reports.
@Samerberg Sue,

The resurgence of artificial ligaments a few years ago was a classic case of failing to learn the lessons of history..and a very large marketing budget.
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Hi Ksenia, how is your knee doing since last year? I ask as I may choose to have this treatment. I started a related thread here:

http://snowheads.com/ski-forum/viewtopic.php?p=3022951

Thanks very much.
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@aclbroke, Sorry to hear about your injury.

At the date of the operation it has been decided by Dr Wilson that I do not have enough left of my ACL to undergo repair surgery and had my ACL reconstructed with hamstring draft. It has been a very long year, but I now back snowboarding so can't complain to much. Good luck to you with your knee and speedy recovery!
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Otherwise you'll just go on seeing the one name:
@aclbroke, Sorry to hear about your injury.

At the date of the operation it has been decided by Dr Wilson that I do not have enough left of my ACL to undergo repair surgery and had my ACL reconstructed with hamstring draft. It has been a very long year, but I now back snowboarding so can't complain to much. Good luck to you with your knee and speedy recovery!
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Thanks @ksenia replying. Hope you have a long and successful snowboarding career. Physio is already hard work pre-op. Feels like my knee will snap or something every time I bend it but I'm assured it won't!

Something I haven't mentioned is that another reason I'm thinking about ACL repair is that maybe it will delay the onset of osteoarthritis more than ACL replacement. I keep reading articles about how 15 years after the op you get bad arthritis. Sad Maybe I should just stop reading and accept my fate. :-/
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internal brace is NOT an artificial ligament, it's a procedure that facilitates the ACL regrowing afterward. Removal & reconstruction stats show osteoarthritis to be highly predictive. Not sure why you think an ACL that regrows to its previous state would experience this.
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@ryancartiers wrote:
internal brace is NOT an artificial ligament, it's a procedure that facilitates the ACL regrowing afterward. Removal & reconstruction stats show osteoarthritis to be highly predictive. Not sure why you think an ACL that regrows to its previous state would experience this.


Perhaps i can clarify.

I was invited to open a meeting last week with a lecture on the Journey of ACL repair past , present and future.
The inventor of internal brace was at the meeting.
We discussed and debated the current state of play and scientific literature available.

Some facts:

IN ACL repair with Internal brace the repaired ligament is supported by a suture tape to allow the ligament to heal by the formation of scar tissue - it does not regrow or regenerate.
It is generally accepted that the best evidence that we have for it is that in some studies that looked at, largely failed, outcomes from ACL repair a small subset have been identified that seemed to do better than the majority. 10 to 20% of those with recent ACL repair who have an injury at the end of the ligament closest to the femur bone seem to do better than most.
It is these that anyone carrying out repair should be trying to heal - with encouragement of scarring.

There is no evidence at all that repair, by any method, will prevent osteoarthritis- non what so ever.

There are no high quality studies that confirm that ACL repair is better than reconstruction. There are no high quality studies confirming that it is better to repair than non operative treatment. That should be made very clear by any surgeon who offers it.

Osteoarthritis after ACL rupture and reconstruction is a disappointingly stubborn problem.
This is because of old techniques, and additional problems with stiffness, joint surface damage and loss of meniscus.
If the joint is extensively damaged reconstruction does not prevent osteoarthritis but nor does repair.
There are some some good studies that have identified that rate of osteoarthritis is low under the following circumstances.

ACL reconstruction using 'modern ' techniques.
Intact or successful repair of both meniscii.
Healthy, undamaged joint surfaces.
post operatively full range of movement , especially full extension.
Much of this is determined by the state of the knee when reconstructed.
Many have torn meniscii when they present for advice.
That is a reflection of the injury - or neglect to get it treated rather than the surgery regardless of whether the ligament is repaired or reconstructed.

There is a little evidence that retaining the stump of the ruptured ligament and passing the new graft up the middle of it may reduce rerupture.
It is thought this is because the ligament has important nerve endings in it. These are obviously retained if the ligament is repaired but to date no one has demonstrated lower re rupture rates in repair.

Jonatha Bell
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Correct - it heals by the formation of a clot - by growing through the lattice work of the internal brace material - which is why it is called regenerative medicine - not sure how you missed that during your conversation - it is also explained in several of the published medical journals reporting 1, 2, + year results - I'm quite busy but will post these at some point or you can easily look them up online.

All studies I've seen for the 3 different techniques, Internal Brace, BEAR and the other show better results than amputation & reconstruction - which is probably why they have been allowed to proceed. BEAR is starting trial 3.

You are correct that the location of tear is a factor, also outlined in at least one of the studies.

The first person to receive internal brace from the inventor you spoke with has had it for 7 years; no indications of osteoarthritis yet. Given that it is seen about 10 - 20 years after reconstruction and this technology is only reaching that stage you are correct that we don't have stats yet. Please detail the factors of reconstruction that accelerate osteoarthritis you seen quite knowledgeable on it.

It is quite clear that non-operative treatment - referred to as 'conservative' - means patients will be limited in what they can do and must be aware of this so they don't re-injure; leading a conservative life a.k.a skiing is unlikely an option for most. Surgeons make it very clear what a patient will not be able to return to certain previous activities if they don't repair or reconstruct the injury. Really, you can't find any studies comparing the differences between conservative treatment and reconstruction?

You can't make the claim "If the joint is extensively damaged reconstruction does not prevent osteoarthritis but nor does repair." after pointing out "there are no high quality studies"
- what's your statement based on then?

I'll let you know how it turns out first hand; posted my 1st diagnosis @ryancartiers
also hit 102 degrees bend last week up from 85 previously.
heading for another round on the bike now...
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Quote:
There are no high quality studies that confirm that ACL repair is better than reconstruction. - Jonatha Bell


I am interested in your opinion whether this is a 'high quality' study and how you evaluate:
Early knee osteoarthritis is evident one year following anterior cruciate ligament reconstruction: a magnetic resonance imaging evaluation.
[url=https://www.ncbi.nlm.nih.gov/pubmed/25692959][/url]
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@@ryancartiers, out of interest...are you a medic and where are you based?
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@ryancartiers wrote:
It is quite clear that non-operative treatment - referred to as 'conservative' - means patients will be limited in what they can do and must be aware of this so they don't re-injure; leading a conservative life a.k.a skiing is unlikely an option for most. Surgeons make it very clear what a patient will not be able to return to certain previous activities if they don't repair or reconstruct the injury.

Really, you can't find any studies comparing the differences between conservative treatment and reconstruction?


From fairly extensive enforced efforts last year, my experience is that there are few studies available which can give a definitive answer, to a scientifically-acceptable standard, of the benefits, downsides or outcomes of surgical vs conservative interventions. Too many human and personal factors also come into play, never mind precise type, location and cause of injury (including sport engaged in at the time, if applicable) and comorbid injuries, joint and tissue damage and inflammatory reactions. However, there are several reasonably recent studies which support conservative treatment, including in sportspeople, including skiers at non-professional, non-competitive levels. It is still an evolving field and clinical attitudes change accordingly. This has been discussed on this and associated threads.

I must, respectfully, challenge your statement that conservative treatment will limit the activities of those with ACL injuries, that they must henceforth lead a "conservative life" and that skiing is not an option for them any longer. It is certainly not "clear" that this is the case, from research or anecdotally, and surgeons do not make it clear that without surgery their patients will be doomed to limited lifestyles. They have no evidence to say this in every case, and as professionals must weigh the patient and their activities and wishes/needs up along with their clinical presentation. Sometimes they will strongly recommend a non-surgical response to the injury, even when it initially appears severe.
The whole position is, in fact, anything but clear and a matter of some hot debate, as these fora discussions demonstrate. My understanding is that about a third of ACL injured people will need surgery, a third will be fine doing anything and a third may have to change or limit activity in some way. This is very generalised, of course: and who knows what future outcomes will or might be in any case as none of us have a parallel control self against which to compare. Then you can add in the question of bracing and how that might assist people to carry on at their chosen, or a reasonable, level; or how it could hinder...
I have seen it noted that, whether treated conservatively or surgically, the return rate to where a person was before, especially at high levels of sports, is very far from 100%. Is that psychological or injury related? I don't know, maybe a mixture: and it's probably the same in amateur recreational sportspersons (and mountaineers, dancers, etc etc) too.
My own personal view is that ACL and knee injuries are very individual things and cannot be generalised over, in the short or long term. I feel from what I have read that outcomes are always more negative than had the person never injured or lost a rather vital piece of string that holds their knee together: not really surprising. But some people never have an ACL, a apparently. Others never know they've damaged or lost it. So who knows?
Note also that a lot of studies do not look at skiers (at least 1 does, however, and gives them better outcomes) but sports with more twisting forces, jumps & landings, like basketball, rugby, tennis, football, netball...
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@ryancartiers wrote:
Quote:
There are no high quality studies that confirm that ACL repair is better than reconstruction. - Jonatha Bell


I am interested in your opinion whether this is a 'high quality' study and how you evaluate:
Early knee osteoarthritis is evident one year following anterior cruciate ligament reconstruction: a magnetic resonance imaging evaluation.
[url=https://www.ncbi.nlm.nih.gov/pubmed/25692959][/url]


Thank you for suggesting that i look at home page of Pubmed, a site that archives all published medical papers.
I'm fairly familiar with it.

Jonathan Bell FRCS (Orth)
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@@ryancartiers, i was going to post this before Jonathan set out his credentials...but you might be interested on this UK site where surgeons are reviewed (I see from Facebook you are based in Canada). I would say that Jonathan's patients are pretty satisfied wirh his approach to knees

https://www.iwantgreatcare.org/doctors/mr-jonathan-bell

Anyway, I hope you get the outcome you are hoping for
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Jonathan Bell wrote:
Perhaps i can clarify.
That's as welcome as ever, although I hope my interest in this topic remains purely academic.
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