In this Orthopedic Today Interview, Dr. Mandelbaum shares his perspective in the changing face of ACL treamtment.
Repair is not ready
ACL injuries in athletes are a common and potentially debilitating problem. The incidence of these injuries follows a pattern of clustering in different cycles. At the moment, there is significant cluster, especially in female athletes, with respect to noncontact injuries. In recent years, the surgical approaches, with respect to autograft reconstruction, have been successful when returning high-level athletes to competitive sport in the short-term. That said, the potential of OA in the long-term remains.
In recent years the concept of ACL repair has been developed and studied by Martha Murray, MD, and others with respect to the BEAR procedure, a biologic enhancement of an ACL repair. Although this technique has gained popularity, the published rate of re-rupture at 14% in relationship to 6% for ACL reconstruction is too high and unacceptable, in my view, in an athletic population. Furthermore, Gregory S. DiFelice, MD, has presented and published a 37% re-rupture rate in the re-rupture rate in athleteic patients younger than 22 years. In addition, Riley J. Williams III, MD, and colleagues have published a 33% reoperation rate for ACL repair in Arthroscopy.
As sports physicians, our goal should be prevention of ACL injury, prevention of subsequent ACL re-rupture and OA. The concepts and utilization of ACL repair has been shown to be inferior to autograft reconstructive options with respect to re-rupture rate. In the future, in a stepwise fashion, there may be further refinements and additional adjunctive interventions that may facilitate ACL repair. These may include concomitant anterolateral ligament reconstruction or hybrid techniques that utilize autograft or allograft to facilitate repair. At this moment, based on current evidence-based studies, ACL repair techniques are not ready for use in the athlete, but can and should be utilized in low-level recreational and older populations in which risk rates and consequences are lower.