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ACL Reconstruction: Still the Gold Standard?

For more than 50 years, surgical reconstruction has been the gold standard of care for ACL injuries, which are increasingly common among young athletes in sports from soccer to basketball. As many as 200,000 ACL ruptures are reported each year.

Reconstruction has a 95% success rate and can be very successful, but it can also lead to challenges such as decreased hamstring strength and loss of proprioception. Reconstruction also does not delay future post-traumatic osteoarthritis (PTOA). In one meta-analysis of more than 4,000 patients) the risk of PTOA after ACL injury was 20% at 10 years and more than 50% at 20 years.

PTOA risk has led to a resurgence of interest in ACL repair, an older technique that has been transformed by modern technology. Decades ago, ACL repair involved using sutures to sew tissue back together. It also required prolonged immobilization 1n a cast and had a high failure rate.

However, current literature demonstrates that ACL repair should only be used under specific circumstances. Despite its promises of faster return and new ligament-preserving techniques, ACL repair should continue to be used with caution, says Joseph Liu, MD, an orthopaedic surgeon with USC Orthopaedic Surgery, a part of Keck Medicine of USC, and USC Athletics team physician.

An evolving technique
The indications for ACL repair are still evolving (i.e. proximal tears for select patients). In those cases, ACL repair may allow for quicker recovery than reconstruction. It may also lead to decreased surgical morbidity) faster return of range of motion, and less awareness of the knee, helping to make it feel more “normal.”

With advances in preserving and repairing native tissues, ACL repair may also eliminate the need for an autograft from the hamstrings or patella tendon for select athletes. Not having an autograft could theoretically improve biomechanics and reduce the risk of complications, such as loss of hamstring strength or anterior knee pain.

Athletes who undergo ACL repairs may return to sports faster with accelerated rehabilitation. One study showed an overall 85% return to any sport, 70% return to knee-strenuous sport, and 60% return to preinjury levels among patients who underwent ACL repairs, says Dr. Liu. And, if repair fails, reconstruction remains an option.

Determining who benefits
Improvements in imaging studies such as MRI means that specialists can precisely locate tear locations and identify patients most likely to benefit from primary ACL repair.

Other promising developments in ACL care include mechanical supplementation to provide knee joint stability during recovery. Devices include Internal Brace Ligament Augmentation (IBLA) and Dynamic lntraligamentary Stabilization (DIS) techniques. In addition, researchers are looking at biologically enhancing knee repairs with hydrogels, stem cells, or platelets and platelet-rich plasma (PRP).

Once patients are diagnosed with an ACL tear, they can ask their physician about the most appropriate route — repair or reconstruction — to get them “back in the game” again. For most, reconstruction will be the recommended route.

“ACL reconstruction remains the gold standard for ACL tears; however, select patients may benefit from repair,” says Dr. Liu. “Ultimately, a shared decision between the patient and surgeon is key to optimal success following surgery.”


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