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ACL *repair* experiences ("internal brace")

 Poster: A snowHead
Poster: A snowHead
@@ryancartiers, A lot of stuff to read there!
One day, this has got to be the way to go, surely. The DIS looks interesting too.
I note from your last quoted paper (tbf, the only one which I seriously skim read) that all the interventions were on patients with detachment and avulsion ligament injuries. I saw a reference in another post above about this too. Any reason for this as opposed to mid ligament, latitudinal, non-avulsion tears to ruptures? Are there different outcomes & prognoses, and why?
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 Obviously A snowHead isn't a real person
Obviously A snowHead isn't a real person
@@grizzler Research on repairs going back to the early '90s has found that proximal avulsion (and the rarer distal avulsion) tears have better outcomes for repair than other types. I'm not a doctor, so I cannot explain the exact mechanism (it may not be fully understood...), but the native ACL can heal/scar into the femoral (or distal) footprint when attached sufficiently, while it does not seem able to heal/scar into itself. I also believe that tissue quality may be retained better in extreme proximal and distal tears than in midsubstance and other types of tears. This article has more info/references

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5124221/

I am very happy with my repair at almost 3.5 months post-op, but still waiting for the long-term outcome studies. Also not going to rush back to activity just because everything feels better.
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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?
@EastCoastUS, Interesting. Seems that the "midsubstance" tears are those crying out for some kind of brace, ladder, framework, stitching, etc etc, then.

I wonder if there's ever been any research into those people who have ACL ruptures and 'cope' without surgery. Where are their injuries? I was told by various doctors and physios that my (bilateral, apparently midsubstance) ruptured ligaments may (stress may) have reattached themselves either to themselves or to the PCL or some other internal structures. I have heard this suggestion in others in a similar situation to me. This suggests that a mid-ligament rupture can indeed - and spontaneously and unsupported - heal itself to something; yet surgically it seems not to want to. Puzzled
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@Grizzler,
When my consultants and physio have compared the Lachman test on both my knees, they stated that on my injured leg (which MRI showed a fully ruptured ACL and classed as deficient amongst all the other injuries) there was a very solid end point, and that the amount of movement compared to my good leg, was only slightly more. Telling me verbally that as the end point was so solid, and not what they generally encounter when there is no ACL, that either my good knee was also ACL deficient by comparison or that the ACL on my injured leg had somehow repaired, or re attached to something or somewhere else within my knee.

I did mention to both of them that I would look forward to reading their report, neither of them included that in their reports though, and just noted either a subtle pivot shift - that on test I was not aware of - or that there was no pivot shift problem.

Fingers crossed, 10 month since accident and no instabilities in my knee, and having just had 1st session snowploughing on plastic, which highlighted very tight hips, my knee was fine Smile SO Im going to treat myself as being a person who's ACL is healing, and take it easy and wear some kind of strapped knee support or brace when skiing.
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 Anyway, snowHeads is much more fun if you do.
Anyway, snowHeads is much more fun if you do.
@grizzler,
From what I have heard/read, copers (people with torn or no ACL but stable knees) usually have a ton of muscle strength that provides stability in the absence of the ACL. But muscle strength alone isn't enough, and it just comes down to anatomical differences. I haven't heard anything about the nature of the tears themselves because I think true "copers" are people who's knees are somehow stable while lacking a working ACL, not people who's ACLs still function (though I have read at least one case study about a full ACL tear spontaneously healing). There are copers who have no ACL tissue left at all. At the time of my injury my legs were about as strong as they have ever been, and yet my knee became very unstable and had instability incidents months post-injury just walking across the room despite having full range of motion.

My ACL tissue scarred onto my PCL, which is what enabled me to have a repair 3 months post-injury. Most repairs can only be performed closer to the injury unless the tissue quality is maintained by scarring to the PCL. In terms of surgically repairing midsubstance tears, I think that because the ACL is made up of bundles of long fibers that are constantly "flexing", it is difficult to patch it when it torn across itself, while in extreme proximal and distal tears the bundles are more likely to remain relatively whole.
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Markhandford wrote:
Fingers crossed, 10 month since accident and no instabilities in my knee, and having just had 1st session snowploughing on plastic, which highlighted very tight hips, my knee was fine Smile


A managed return to skiing snowHead snowHead
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 Then you can post your own questions or snow reports...
Then you can post your own questions or snow reports...
@Markhandford, sounds like good news and a good plan Very Happy

Having both ACLs out at the same time, they can never compare good knee with bad for me, but also have reported from the start (once back in UK) that there is not a very obvious laxity in either knee (as much in the MCLs as ACLs, apparently). Not said that there is a firm end point as such, but said it could just be a natural laxity for me, or else an ACL related laxity, but basically only a minimal issue which therefore justifies the non-surgical route. Of course, I could just be clenching on for dear life! Relaxing the muscles is not my strong point...

@EastCoastUS, ton of muscle strength definitely isn't me Laughing Anatomical difference may be. I guess I don't care as long as they keep on holding together and don't hurt or ache too much.
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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!
I can highly recommend@AndAnotherThing.., as someone to trust with your journey back to skiing after a knee injury, he has been through the hamstring graft ACL repair and recovery, and as a qualified alpine ski instructor he can ease you back in to the sliding game! Sorry mate, didn't think that a shout out in the acl internal brace repair thread was good practice, but what the heck Smile

I had the all clear from my physio, who simply stated that "although my quads are 'massively weak' on the injured leg, my functional strength is good, and that it's clear I have worked hard on developing hamstring and glute strength, with a bit of imbalance, but to go and ski on plastic or indoors as I will be pleasantly surprised".

(I have skiid with @AndAnotherThing.. variable conditions off-piste in North Wales a few times, socially rather than a coaching role, we are both mountain professionals, him as a ski instructor and me as a winter mountaineering instructor, he seemed to put up with my blunt humour, and we have been comparing acl injury for most of the year)

I left it for another 4 weeks of gym work before stepping back in to a pair of bindings.
So after some warm ups and some very gentle drills, including an unplanned emergency right hand turn, injured knee taking the lead role, all was good and as was mentioned to me a few times; "we are all standing upright at the end of the night!" which is always good.
I see my physic next week and will get input on hip mobility/range of movement and come up with a plan for the next progression step.

I love it when a plan comes together, it makes all the diversions and set backs turn in to stages of learning about how to manage my recovery, as all of us should now know the mantra 'everyones knee recovery journey is different" Smile
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You'll get to see more forums and be part of the best ski club on the net.
@Markhandford, Cheers Mark, really good to see you back on ski's and a pleasure to help snowHead snowHead
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Ski the Net with snowHeads
EastCoastUS wrote:
@@grizzler
Also not going to rush back to activity just because everything feels better.


Smart. I'm proceeding in the same manner.
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snowHeads are a friendly bunch.
EastCoastUS wrote:
@grizzler,
(though I have read at least one case study about a full ACL tear spontaneously healing). There are copers who have no ACL tissue left at all. At the time of my injury my legs were about as strong as they have ever been, and yet my knee became very unstable and had instability incidents months post-injury just walking across the room despite having full range of motion.


I posted 2 links to case studies on full ACL tears spontaneously healing.
Also met a guy a few months ago who seemed to be operating fine and said he had no ACL anymore.
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And love to help out and answer questions and of course, read each other's snow reports.
Grizzler wrote:
@@ryancartiers,
I note from your last quoted paper (tbf, the only one which I seriously skim read) that all the interventions were on patients with detachment and avulsion ligament injuries. I saw a reference in another post above about this too. Any reason for this as opposed to mid ligament, latitudinal, non-avulsion tears to ruptures? Are there different outcomes & prognoses, and why?


The research (see Difelice articles I posted) says that the original research back in the day showed overall success for ACL repair was not good - however they did not look at the type of tears. Reviewing the stats again shows certain types of tears had excellent success, other not - so the type of tear determines one eligibility for ACL repair.
There's other research that repeats this, although I haven't looked at the stats.
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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
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
Markhandford wrote:
@Grizzler,

I did mention to both of them that I would look forward to reading their report, neither of them included that in their reports though, and just noted either a subtle pivot shift - that on test I was not aware of - or that there was no pivot shift problem.



My physio said there's something called an Arthrometer to test ligament laxity - I plan on finding someone who has one to test me in a bit - maybe something that could help you assess also
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 You know it makes sense.
You know it makes sense.
Grizzler wrote:
@Markhandford,

Having both ACLs out at the same time,


wow, dude how did you injure yourself - only ACL's or other sprains?
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 Otherwise you'll just go on seeing the one name:
Otherwise you'll just go on seeing the one name:
I posted more info on #internalbrace primary repair #surgical technique @ryancartiers today, here's the link:
https://www.arthrex.com/what-surgeons-are-talking-about/131FD01B-7B44-491D-B5F7-015A9474A65E

Lot's of info, looks like they've added a bit since May.
Prof. Mackay's website has also been updated.

I'm 6 months post op on Christmas day.
(and I plan to do my rehab exercises that day like every other)

Still working on trying to post a photo here...
[img]https://www.facebook.com/RyanCartiers/photos/pcb.2209118539416014/2209118099416058/?type=3&theater[/img]
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 Poster: A snowHead
Poster: A snowHead
@ryancartiers wrote:
Grizzler wrote:
@Markhandford,

Having both ACLs out at the same time,


wow, dude how did you injure yourself - only ACL's or other sprains?


If that's addressed to me, it's a Dudette NehNeh but, hey, no matter.

Took out both ACLs as complete mid ruptures, I'm told, plus both MCLs as bad but not complete tears. Lots of swelling, haemarthrosis, etc. Feels to me that there was lateral involvement and bone bruising too, also possible mild meniscus/cartilage, particularly on 1 knee, but nothing else ever formally diagnosed.
Got hit at speed from diagonal rear and landed an apparent aerial 720 on my splayed legs and chest rolling eyes Don't do things the easy way, me...
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 Obviously A snowHead isn't a real person
Obviously A snowHead isn't a real person
In case it helps anyone, I came across an article explaining what a grade 3 sprain is. May help someone else trying to decipher this - helped me reread my MRI (in Oct 6 & 7 posts) & understand it:

"About ½ of all injuries to the anterior cruciate ligament occur along with damage to other structures in the knee, such as articular cartilage, meniscus, or other ligaments.
Injured ligaments are considered “sprains” and are graded on a severity scale.

Grade 1 Sprains
The ligament is mildly damaged in a Grade 1 Sprain. It has been slightly stretched, but is still able to help keep the knee joint stable.

Grade 2 Sprains
Stretches the ligament to the point where it becomes loose. This is often referred to as a partial tear of the ligament.

Grade 3 Sprains
This type of sprain is most commonly referred to as a complete tear of the ligament. The ligament has been split in 2 pieces, and the knee joint is unstable.

Partial tears of the ACL are rare;
More ACL injuries are complete or near complete tears."
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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?
Anyone looked into Dr. Stone work in San Fran? He uses piggies for parts.
I have a complete messed up knee & was shown his work about a decade ago when I was diagnosed with a meniscus bucket tear to go along with all the other knee issues I have!
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Here is recent article about it (albeit from the same group of authors representing the company that makes the suture tape): https://www.ncbi.nlm.nih.gov/pubmed/30612165
At mean 3.2 year follow-up, the failure rate for primary repair without internal brace was 13.8% versus 7.4% with internal brace in an overall sample of 56 patients with proximal tears and good tissue quality. The failure rate still seems pretty high to me, and the mean follow-up for internal brace was only 2.4 years, so that hardly qualifies as long-term. But, while the sample size is small, a 7.4% failure rate would be comparable or better than reconstruction. But the 5-year follow-up data will be a lot more meaningful than what we have so far.

Here's a scarier article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6083779/
It was written by a bunch of research assistants, rather than an orthopedic surgeon. The reported failure rate for internal brace within 2 years was 52.6%. However, this was defined as revision surgery or internal brace failure, and I am not sure that internal brace failure necessarily indicates failure of the ACL repair because the internal brace is intended as a secondary support during healing of the native ACL, not as a permanent aid to the native ACL. They do not differentiate between the need for revision surgery and internal brace failure (which may not require revision surgery). They also say that laxity is greater for repair with internal brace versus a quadriceps reconstruction, but the mean laxity for repair with internal brace was only 2.5mm, which is lower than most given clinical thresholds for laxity (3mm or 5mm). My healthy knee is more lax than my repaired knee, so laxity itself is not meaningful if it's sub-clinical level. The study was also conducted on an adolescent cohort (mean age 14.1 years), and it does not discuss patient selection (which is absolutely critical in studying ACL repair). We do not know if the participants had midsubstance tears, secondary injuries, or other contraindicated factors that would rule them out as viable candidates for ACL repair with internal brace. The results in this study are certainly anxiety-provoking for someone like myself who is 5 months out from having this surgery, but they are not conclusive. It looks like a bunch of new findings are starting to come out about this procedure, but it will be another couple of years before longer-term data are released.
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Anyway, snowHeads is much more fun if you do.
A paper published on october 2018 also by prof mackay shows good results after 2 years follow up.
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