The case against ACL repair
Prof. Nick London has concerns about those marketing ACL repair as a viable option for children and young people.
Earlier this year, my Yorkshire Knee Clinic colleague Jim Newman published a post which looked at the worrying survival rates of ACL repairs (as opposed to ACL reconstructions). I’m not going to repeat Jim’s points (although they’re well worth reading here), but it’s worth a very quick recap on the difference between repair and reconstruction.
ACL reconstruction is the accepted way to resolve a torn ACL. It uses a graft from elsewhere in the body (a hamstring, for example) which acts as a scaffold around which new tissue can grow. ACL reconstruction success rates are good – about 97%.
ACL repair is different. Here, the ligament is stitched back together using a brace to support the healing process. Success rates are considerably less impressive. As Jim noted, The Orthopaedic Journal of Sports Medicine found “Failure-free survival in the repair group was less than 50% at two years.”
Making the vulnerable more vulnerable
My concern – and it’s a major concern – is that ACL repair is a treatment being specifically marketed at children and young people – our most vulnerable patients. Faced with a lengthy spell out of the sport they love, who wouldn’t opt for a procedure that can effectively halve the time they spend on the sidelines? And who wouldn’t be swayed by slick marketing that trumpets ACL repair as the treatment of the future?
Yet the increased failure rate of the procedure isn’t the only worrying element here.
High volume = higher success
There is a bit of a vogue for paediatric surgeons to take on this sort of surgery, but paediatric orthopaedic surgeons don’t specialise in the knee. They could be managing any number of musculoskeletal procedures and may well carry out only very small numbers of ACL reconstructions.
I believe that ACL reconstruction in children and adults should be performed by experienced knee specialists. By that, I mean knee ligament surgeons who carry out high numbers of such procedures every year – because it is only through carrying out high volumes that a surgeon becomes adept at dealing with the unusual and unexpected.
And if that’s the case with ACL reconstruction, then it’s surely doubly so for still largely experimental techniques such as ACL repair.
We need to be careful not to eliminate ACL repair as a potentially viable treatment for the future. It is possible that the technique could prove useful in selected patients in the future. The evidence to date may be that too many of these new techniques fail, but that could conceivably change.
And even with that worryingly high failure rate, you could perhaps make the argument for accepting a higher risk if the benefits of success were high, and failure didn’t prevent traditional ACL reconstruction from being the fallback option.
But we don’t have the evidence that this is a benign operation. So my concern is that in opting for ACL repair, you have an operation which may muddy the waters for successful reconstructive surgery further down the line.
We can’t accept that.
That’s why, in my opinion, ACL repair should only be carried out as part of carefully controlled clinical trials. It should certainly not be marketed as the technique of the future. And it absolutely must not be targeted at – and prey on the sporting hopes of – children, young people and athletes – and we know that is happening in some quarters.
We already have tried and tested techniques for ACL reconstruction performed by high volume knee specialists. Our most vulnerable patients deserve nothing less.