People bring clothing to the tailor to avoid the “one size fits all” experience. They are looking to receive a custom fit – some of the tailor’s best work – of a suit or dress so that it fits his or her body perfectly.
The standard approach to ACL injury across the world is to perform a reconstruction of the ligament using a variety of techniques and grafts. This procedure removes all of the remnants of the torn ligament, and replaces them with a graft, that is supposed to act as scaffolding for the body to create a new ligament out of scar tissue. I consider this technique to be the “one size fits all” approach.
As an orthopedic surgeon at Hospital for Special Surgery with a primary focus on ligament repair, “one size fits all” is not a term commonly used when describing my approach to ACL injuries. I prefer to think of my approach to treating ACL injuries as a customized approach. Using a variety of techniques that I have developed and refined over the past 5-7 years, I strive to save as much of the native ligament tissue and native biology, as possible. I only use reconstruction as a last resort when there is little native tissue to work with.
Saving the native ACL tissue allows me to minimize the surgical insult to the patient, while maximizing the native biology, blood supply and nerve endings. This allows these patients to recover more quickly, and have a knee that feels more “normal.” Currently, I am able to save most or the entire native ligament in close to 50% of my ACL injured patients.
This customized approach depends on the patient profile, and is also critically dependent on the type of tear that the ligament has suffered. A rough breakdown of the treatment possibilities is as follows:
No surgery required: I generally do not perform ACL surgery for elderly patients and/or for patients whose activity profile does not warrant intervention.
Repairing the ‘perfect tear’ or Primary ACL Repair: When a patient tears his or her ACL right off the bone, I am able to reattach it back in place. When this ‘perfect tear’ occurs, it is called a ‘proximal avulsion’ type tear. An MRI can help to determine if an ACL can be repaired using my technique, however, only about 10-20% of patients qualify for this approach. This injury pattern tends to be more common in those whom have experienced a ski injury. To date, the youngest patient to undergo this procedure was six years old, and the oldest was 57 years old. I refer to this surgical option as the ‘small’ ACL surgery, because the recovery time for these patients is significantly faster than if they had undergone a full ACL reconstruction. These patients definitely get back in the game sooner! Furthermore, if the knee is reinjured at a later date, a straightforward reconstruction can be performed to address the new injury. In other words, no surgical bridges are burned by performing the repair first for the appropriate tears. It is also a perfect approach for children with growing bones. It should be noted that these tears are best treated within the first 1-3 weeks after injury. There are exceptions, but time should not be wasted before being evaluated!
Repairing the ‘almost perfect tear’ or ACL Preservation: After a few years of doing ACL Primary Repairs, my patients were doing so well and recovering so much quicker than normal ACL reconstructions, that I became frustrated when I thought the patient had the ‘perfect tear,’ when in reality it was an ‘almost perfect tear.’ When a patient experiences a tear that is ‘almost perfect’ but doesn’t quite reach back to the bone, I change my technique slightly. I still preserve as much of the native ACL as I can by repairing it, but then I add a small graft that is placed in the center of the old ligament to preserve the ACL and simply bridge the gap between the remnant and the bone. Because I save the majority of the native ligament, I don’t need to use a large graft like in a reconstruction. Close to 30% of my ACL patients qualify for this procedure. I refer to this surgical option as the ‘medium’ ACL surgery and these patients also get back in the game sooner! Again, if the knee is reinjured at a later date, a straightforward reconstruction can be performed to address the new injury because of this conservative approach. Time is also of the essence here, and patients should try and be evaluated as soon as possible after their injury. Being conservative, this approach is also great for children with growing bones.
Dealing with the ‘no so perfect’ ACL tear or ACL Reconstruction: This is one of the final, straight forward, options in my surgical bag of tricks and I try to use it as a last resort. I refer to this surgical option as the ‘large’ ACL surgery, and recovery times are generally longer. However, remember this is the first and only resort for the absolute majority of other ACL surgeons worldwide! I use this option when the ACL tear is right in the middle and the tissue is too destroyed to try and preserve it. In this case, ACL reconstruction, using a large graft, either autograft (from the patient) or allograft (from a cadaver), is necessary. If the knee is reinjured at a later date, revision surgery can be quite complicated due to the more invasive nature of the initial surgery. These patients definitely get back in the game; it just takes a bit longer. Approximately 50% of my patients need to have a reconstruction to address their ACL injury.
I developed this unique, customized approach to ACL surgery over my first fifteen years in practice because I wasn’t happy with the standard ‘one size fits all’ approach of reconstruction for everyone, and all injury types. Reconstruction sacrifices all of the native tissues, is ‘big’ surgery, and, in my opinion, is not necessary for close to half of my patients. By addressing the unique needs and injury patterns of my patients on a case-by-case basis with personalized surgery, I guess I am like a custom tailor for their knees.
To hear more from Dr. DiFelice about his procedure, please check out this exclusive HSS video:
Dr. Gregory DiFelice is an orthopedic surgeon specializing in Sports Traumatology and Joint Reconstruction Surgery at Hospital for Special Surgery. He has particular interests in ligament reconstruction of the knee with extensive experience in multi-ligament reconstructions, cartilage and meniscal repair of the knee, arthroscopic shoulder surgery including labral and rotator cuff repairs, and arthroplasty of the knee, shoulder and hip.
