Wednesday, June 30, 2010

Failed ACL Repairs: More Common than You May Think

Nick Van Erp, active in soccer since elementary school and lacrosse since junior high, tore the anterior cruciate ligament in his knee during a spring lacrosse game his freshman year of high school. His injury, caused by stepping into a pothole and hyper-extending his knee, required surgical repair, ending his season prematurely and the remainder of his high school sports career.

Three years and two failed surgeries later, he made his way to the University of Michigan Health System in July 2009 to get what he hopes will be his final knee surgeries.

“I haven’t played soccer since freshman year and I’ve tried to play lacrosse, but every time, [my ACL] tears,” says Van Erp, a Grand Rapids resident.

Failed ACL repairs common

This eighteen-year-old’s story is not unique—an estimated 400,000 people suffer an ACL injury each year, requiring primary reconstruction surgery to repair the injury. Unfortunately, 18,000 to 35,000 of those repairs will fail and require revisions, which are additional surgeries for reconstruction. Revisions are more complicated, less successful and require a longer rehabilitation period than the first surgery.

Orthopaedic surgeons at U-M perform 200-300 ACL primary reconstructions each year. In addition to primary reconstructions, U-M surgeons perform about 30 revisions each year to correct failed ACL primary reconstructions performed elsewhere.

“Why those ligaments fail is subject to a lot of debate but probably has something to do with the techniques used the first time, and then the fact that so many [patients] go back to the sports that originally caused the problem,” says Ed Wojtys, M.D., director of the MedSport sports medicine clinic at U-M.

Primary ACL reconstruction surgeries, performed by orthopaedic surgeons, replace the injured ligament with an autograft from the patient’s body, such as a tendon of the kneecap or hamstring.

Most reconstruction surgeries are done by making small incisions in the knee and inserting instruments to perform the repair. After surgery, typically four to six months of rehabilitation therapy is needed for the repair to fully heal. If surgery and rehabilitation is done correctly, the patient typically will have reduced pain, good knee function and stability, and return to normal levels of activity.

“The most common reason for an ACL [repair] to fail is technical error, where the actual graft is placed in a non-anatomic position and the most common wrong position is too vertical—too up and down—which doesn’t allow the graft to restore rotation,” Jon Sekiya, M.D., associate professor of orthopaedics at U-M.

Common reasons for ACL repair failure include:_• inadequate time for rehabilitation, _• physiological factors such as the alignment of the patient’s bones or muscle function, _• additional injuries at the same time as an ACL injury—such as to cartilage in the knee or another knee ligament—which may also require repair to restore stability to the knee, _• reoccurring trauma due to intense physical activity, and _• improper surgical techniques.

Finding an experienced surgeon

An American Board of Orthopedic Surgeries survey found that 85 percent of surgeons who are doing ACL [repairs] do 10 or less per year.

“I definitely don’t think that the exact number of surgeries you do is indicative of necessarily the skill level,” Sekiya says. “However, I do think there are subtleties to this surgery that if encountered during an operation, may not be recognized in a less experienced ACL surgeon and can lead to failure. We do see that.”

To reduce the chance of an ACL repair failure, Sekiya says patients should talk to surgeons and other clinical staff who may be involved in their care about their experience before deciding on where to get the surgery.__“When trying to choose a place to take care of their ACL and their injury, [patients] should make sure the surgical staff and therapists are well versed to take care of all the problems they may encounter,” says Sekiya, who is also Nick Van Erp’s orthopaedic surgeon. “Patients can simply ask their surgeon if they are comfortable doing the procedure – they will likely get an honest answer.

Long road to repair

Nick Van Erp, who was en route to a third ACL repair surgery elsewhere when he was referred to U-M for a second opinion, is now on the road to recovery.

“I think we were headed down a course that was similar to the two episodes that had previously failed,” says Jeff Van Erp, who is Nick’s father and also a practicing physician.

Upon examination, Sekiya found that Van Erp’s problem was more complicated than a failed ACL repair. He and the Van Erps opted for diagnostic arthroscopy, to fully evaluate the knee and prepare it for future surgeries. This took place in August 2009.

The procedure revealed that Van Erp’s meniscus had been removed during a previous surgery, which is a secondary stabilizer to the ACL, and that he had bowed knees, which also contributed to his two previous ACL reconstruction failures. During the procedure, Sekiya also removed previously placed hardware and filled in the tunnels left behind with bone grafts.

In October 2009, Sekiya performed a tibial osteotomy, where he had to break and re-fix Van Erp’s shin bone to realign his knee. And finally, in March 2010, Sekiya transplanted a new meniscus and performed a double-bundle ACL reconstruction to provide stronger reinforcement to the knee.

“[I have] no real pain anymore,” Nick Van Erp says. ”And I know the tibial osteotomy worked because [my knee] feels more stable.”

“We’re obviously very happy that we decided to invest the time and energy into getting an opinion from someone who specializes in essentially catastrophic joint situations like Dr. Sekiya,” says Jeff Van Erp.

Nick Van Erp hopes to play intramural lacrosse at Kalamazoo College next year.

“I’m hoping this is the last knee surgery,” he says. “Hopefully everything will work and I can go to college and not have to worry about this.”

• Nick Van Erp has been undergoing physical therapy and expects to be completed in September 2010.

Surgical repair of knee injuries does not decrease risk of osteoarthritis


Arthroscopic surgical repair of torn anterior cruciate ligaments (ACL) or meniscal cartilage injuries in the knee does not decrease the chances of developing osteoarthritis, according to a new study published in the online edition and August print issue of the journal Radiology.

A decade after the initial injuries were diagnosed using MRI, localized knee osteoarthritis was evident in patients, regardless of whether or not the injuries had been surgically repaired.

"This study proves that meniscal and cruciate ligament lesions increase the risk of developing specific types of knee osteoarthritis," said Kasper Huétink, M.D., the study's lead author and resident radiologist at Leiden University Medical Center in the Netherlands. "Surgical therapy does not decrease that risk."

According to the American Academy of Orthopaedic Surgeons, the ACL, which is one of four ligaments that connect the bones in the knee, is the most commonly injured ligament. Injury typically occurs when the ACL is overstretched or torn.

Approximately half of ACL injuries will cause damage to other areas of the knee, including the meniscus, a wedge-shaped piece of cartilage that acts as a shock absorber for the knee joints. Surgical treatment is usually advised to repair these injuries.

Knee osteoarthritis is a common public health problem affecting more than nine million Americans. It typically develops gradually over several years. Knee osteoarthritis symptoms can include pain, stiffness, swelling and reduction in knee mobility.

For the study, researchers gathered information from the database of a previous multicenter study of 855 patients. The earlier study was conducted from 1996 to 1997 to evaluate the diagnostic value of knee MRI relative to arthroscopy in patients with knee pain.

In the current study, Dr. Huétink and colleagues followed up with 326 of the original 855 patients. All 326 patients had experienced knee pain for four weeks or more prior to the initial MRI and treatment. Initial findings and differences in treatment were compared with current follow-up x-rays and MRI exams.

The results showed that patients with ACL and meniscus tears are at a greater risk for developing osteoarthritis. Meniscectomy, which is the surgical removal of all or part of a torn meniscus, did not reduce that risk.

According to Dr. Huétink, the long-term and short-term clinical benefits of partial meniscectomy vs. meniscal repair procedures need to be further investigated.

"There is a higher risk of developing knee osteoarthritis at specific sites after tearing a meniscus or cruciate ligament," Dr. Huétink said. "We showed a direct relationship between injury and long-term consequences, and showed that surgery has no impact on long-term outcomes."