Anterior cruciate ligament (ACL) injuries are common in adult and child athletes. The ACL is an important soft tissue structure in the knee that connects the femur to the tibia. ACL tears are usually treated through reconstructive surgery, in which the torn ligament is replaced with a tissue graft to mimic the natural ACL. Some 175,000 ACL reconstructions are done each year in the U.S., and the number is increasing.
At HSS, our surgeons perform close to 1,500 ACL repairs per year, nearly tripling in the past ten years. At HSS, specialists take an interdisciplinary approach to treating patients with ACL injury, with physiatrists, surgeons, and imaging and rehabilitation professionals collaborating to find the best treatment option for each patient. Because patients with ACL injury are more likely to develop early-onset osteoarthritis, HSS physicians and scientists are investigating ACL repair with the goal of improving short-term and long-term outcomes for patients. A few of their studies are highlighted below.
While the standard adult method of ACL reconstruction is performed successfully on older teenagers, there are a variety of options available to treat young children with ACL tears. One option developed at HSS by pediatric orthopedic surgeon Daniel W. Green, MD, and orthopedic surgeon Frank A. Cordasco, MD, is called the All-Inside, All-Epiphyseal Reconstruction (AE). A recent study published in The American Journal of Sports Medicine found that the AE allows young athletes to return safely to sport.
Performing ACL reconstruction on children is difficult, because the typical adult-type reconstruction can cause damage to open growth plates, potentially causing uneven limb lengths or deformities. Therefore, in years past, surgeons postponed ACL surgery until children stopped growing, or used surgical techniques that were not anatomically accurate.
“Non-operative treatment means telling a nine-year-old not to play sports for the rest of his or her childhood. That is a poor option for most children and their families,” says Dr. Green.
The AE technique is similar to adult ACL surgery but uses new technology and intraoperative X-rays to place the new ACL graft anatomically in the knee, without the graft crossing the adjacent growth plates. It is performed arthroscopically and results in a near anatomic ACL reconstruction with a very high rate of return to play. It is one of several techniques performed successfully at HSS to repair ACL tears in children.
The investigators compared knee stress and stability between the two surgical techniques, finding that the AE allowed knees to withhold stresses better at a running angle. “This is important because most field and court sports involve knee function close to this position. Also, the AE does not require an open incision, reducing the risk of soft tissue trauma,” says Dr. Cordasco.
Investigators from the Women’s Sports Medicine Center at HSS recently analyzed health records of 506 players who entered the Women’s National Basketball Association (WNBA) combine in 2000-2008 to learn which injuries and surgeries were most common among elite women basketball players. In a study published this year in The American Journal of Sports Medicine they found that the most common surgery was ACL reconstruction, at fourteen percent. They also learned that a history of this surgery did not affect the players’ round drafted or career length, indicating that ACL reconstruction can be highly successful at getting athletes back to elite sports.
“Not enough research exists about women’s sports injuries and response to treatment. Outcomes data are important when treating athletes with ACL injury, which is increasingly common in female athletes” says Jo A. Hannafin, MD, PhD, director of Orthopedic Research at HSS, co-director of the Center and a study author. “It is gratifying that the data show what we suspected: that ACL reconstruction does not keep women from playing basketball,” says Lisa R. Callahan, MD, co-director of the Center and a study author.
At HSS, an interdisciplinary team evaluates each patient with an ACL tear to determine if surgery is necessary. A new study published by HSS surgeons in Knee Surgery, Sports Traumatology, Arthroscopy found that roughly a quarter of recreational skiers who tear their ACL while hitting the slopes can be successfully treated without surgery. “Some patients who injure their ACL while skiing can get away without surgery. In such cases, their ligament heals by itself, they will have stable knees, and they will be able to do whatever they want, including skiing,” says Robert Marx, MD, an orthopedic surgeon who led the study.
The study found that at six to twelve weeks post ACL tear, results from the physical examination of the knee can identify skiers who will recover without surgery. “ACL injuries resulting from recreational skiing can be less traumatic than ACL tears seen in sports that involve pivoting and contact, such as soccer or football,” says Dr. Marx.
Read the full Discovery to Recovery Fall 2013 issue.