Micheal D'Alessandro

Orthopedic Truths #4 The ACL: The ACL is important for some people to remain active. Others tolerate its loss very well. ACL tears are too common in sports. ACL tear prevention programs exist... they work, yet community/ school sports don't utilize them. ACL tears are more common in athletes participating in the same sport year-round. ACL surgery, despite years of research and practice, remains an imperfect solution to a complex problem. Do all ACL tears require surgery? No But yours might. Your child should probably have it. It's the secondary injuries we worry about. What about adults? Many do fine without ACL surgery. Some don't. But it often pays to wait and see. Everyone's knee feels unstable initially. Very often, that stability improves with time and physical therapy. Therefore, for adults, you might want to wait before booking that surgery date. Why is the surgery an imperfect solution? Because the native ACL isn't a straight, single-diameter structure, but our reconstruction is. Secondary injuries can include meniscus tears and cartilage injuries. Those will increase the risk of developing arthritis. The history of reconstruction is wild... and somewhat circular. Back in the 80's and 90's we argued about which graft worked well. We still have those arguments. Now, we added the quad tendon graft to the argument. Would I take hamstrings from a sprinting athlete... no, not really. Am I a quad enthusiast? Not yet. When the MOON group announces their data, then I might. But it took 20 years for that to come out for hamstrings vs BTB. BTB remains the gold standard... and will for a while. But we tried Goretex. We tried other things, too. Those didn't end well. Oh. We have this scope thing. Let’s keep reconstruction via one tunnel. Evolution be damned. The ACL has had the same femoral footprint (attachment) for millions of years. But heck. Let’s put that tunnel here. It worked for some... but many failed. We tried to repair them, but they failed. We developed tools to place the ACL where nature intended it. But going too distal seemed to increase the risk of re-rupture, too. Now we cheat a little back up the wall on the lateral condyle. We tried reconstructing both bundles—certainly, that would work better. I tried them, too, but that didn't work. Fixation... we need screws. The metal screw worked very well. It was predictable and easy to remove. Oh.. I hate seeing screws on the x-ray. Let’s use these awesome bioscrews. Wow…, I haven’t seen a cyst that big before 😩 Sadly... those screws dissolved the bone around the graft, too. Then, we devised some wild, stupid ways to secure the graft that make revision surgery challenging. Thankfully, most of those are gone now. Along the way, we thought we would save our patient's tissue by using cadaveric tissue or allograft. There were disease-spreading issues early on. But that got better. Oops... they fail very often in kids. We don't use them in kids anymore. We can use them in adults. (But your own tissue is better.) Hey... It's been 30 years, so let's repair them again. That still didn't work. Hey... let's put this little sponge in the repair. Okay... That might work... the jury is still out on this. "ACL tears never heal without surgery." But it appears that they do! Enter the cross-brace protocol. It's annoying for the patient. It doesn't pay the surgeon as well. But it appears to work. For some. The jury is still out. More research is needed. But... ACL tears can heal. Rehab. “I let my patients return to sports in 6 mos”. 🙄. Just don't! Don’t mess with the biology of healing. Kids should wait 12-24 mos to return to sports. I don't think that most parents understand the recurrent tear rate. Most kids I see out there are not properly/fully rehabilitated after surgery. It's hard when our lovely insurance companies approve 8 PT visits for an ACL patient. Multinational/well-researched protocols exist for the rehab of an ACL athlete. But they're not used often. Ah... this messy little ligament has generated reams of "research" over the years. Much of it is nonsense, but some solid data exists. The controversies around how to manage these athletes persist. I would have thought we would have been further along, but here we are. Stay tuned... I imagine we are still having the same conversations in 20 years. Ask your school to implement ACL tear prevention programs.