What is the evidence that a repair is better than reconstruction?
If you’ve torn your anterior cruciate ligament (ACL), the traditional road to recovery would involve a reconstruction. But recently we’ve seen a relatively new technique gain traction (and quite a lot of publicity) because it promises to restore 100% of ligament strength, reduce residual instability and improve recovery times. Yet data may suggest that ACL repair isn’t the future of ligament repair after all.
Repairing vs reconstructing
Until the last couple of years, ACL repair has had a pretty poor track record of success. The problem lay in the nature of the ligament. Ligaments don’t tear in a nice, clean line. They often explode, and there’s little blood supply to help ligaments regrow. Try stitching one back together and it simply won’t last – and that’s if there’s much ligament left to stitch.
So repairing the ligament became an also-ran to reconstruction. ACL reconstruction involves using tissue from elsewhere in the body and ‘asking’ it to become a ligament. The graft effectively provides the scaffold around which new tissue can grow and form a solid and permanent new ligament. It is tested, safe and effective. It isn’t fool proof, but as this study noted, “primary ACL reconstruction has satisfactory outcome rates as high as 97%.”
But a relatively new technique does away with the graft and speeds up the healing process. With ACL repair, the knee surgeon stitches the ligament back together and uses a strong, thin bracing tape to protect the ligament whilst it heals.
It sounds good. It sounds so good that it is being marketed at athletes and children as the ACL treatment of choice to get them back to their sport in record time.
Except the data doesn’t quite support the claims.
ACL repair failure rates
It’s important to note at this point that data on ACL repair is scant. There’s a small amount of data published (generally by the proponents of the technique) which is positive. And there’s a similarly small amount of data which isn’t.
But the findings of the negative data are worrying.
“The cumulative incidence of graft failure in the first 3 years after surgery was 48.8% … in the [ACL repair] group, as opposed to 4.7% … in the [ACL reconstruction] group” this study found, under the headline ‘ACL Repair With Suture Ligament Augmentation Is Associated With a High Failure Rate Among Adolescent Patients’.
Another report in The Orthopaedic Journal of Sports Medicine found “Failure-free survival in the repair group was less than 50% at two years.”
We’ve been here before with new techniques. Sometimes the idea behind them is so good and so noble that people forget to look at the actual data. But the problem right now is that a procedure which appears at the very least to require more research is being marketed pretty forcefully in some quarters as a viable solution for children.
This is a real worry, because in addition to raising what appear to be false hopes in a significant number of cases, you’re increasing the risk for the child who now needs a second procedure – and setting their recovery back 6-9 months.
So if you or your child suffers an ACL tear and you’re offered an ACL repair over a reconstruction, question the claims, search the evidence for yourself, and make sure you make any decision with your eyes open.
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