Sports Medicine Research: In the Lab & In the Field: An Individualized Approach to ACL Reconstructions (Sports Med Res)
Wednesday, November 30, 2011

An Individualized Approach to ACL Reconstructions

Prospective randomized clinical evaluation of conventional single-bundle, anatomic single-bundle, and anatomic double-bundle anterior cruciate ligament reconstruction: 281 cases with 3- to 5-year follow-up

Hussein M, van Eck CF, Cretnik A, Dinevski D, & Fu FH. American Journal of Sports Medicine. 2011 November 15. [Epub ahead of print] doi: 10.1177/036546511426416
http://www.ncbi.nlm.nih.gov/pubmed/22085729

Rupture of the anterior cruciate ligament (ACL) can result in decreased function, knee stability, and an increased likelihood of meniscal and cartilage damage. ACL reconstruction is often performed to restore stability/function, and includes various surgical techniques focused on restoring pre-injury joint kinematics. The purpose of this prospective randomized study was to compare the results of 3 unique ACL reconstruction techniques (i.e., conventional single bundle-graft focused to limiting anterior translation of tibia, anatomic single bundle-graft placed closer to anatomic position of the original ACL, and anatomic double bundle-two separate and distinct graft bundles to replicate the anatomic position and composition of the original ACL) among 281 patients. The analyses included 72 patients that were assigned to the conventional single bundle, 78 patients to the anatomical single bundle, and 131 patients to the anatomic double bundle group. There were no pre-operative differences between the 3 groups in all subjective and objective measures (i.e., Lachman, pivot shift, anterior drawer, KT-1000, International Knee Documentation Committee [IKDC] form). Average post-surgery follow up was 51 months (range 39 to 63 months). Anatomic single bundle reconstructions resulted in better anteroposterior and rotational stability than the conventional single bundle technique, despite having similar patient outcomes (Lysholm & IKDC). Anatomic double bundle technique resulted in better anteroposterior and rotational stability than the anatomic single bundle technique with no differences in patient outcomes as well.

This study is the first to take a look at the graft placement in addition to the surgical technique performed. Restoration of joint kinematics to pre-injury function seems to be dependent on replicating the original ACL as closely as possible. The results of this study reinforce the concept that graft placement may be one of the most critical components of an ACL reconstruction. Even though the anatomic double bundle was found to be statistically superior to the anatomic single bundle technique for stability outcomes, the clinical relevance remains unclear, as there were no differences found in patient outcomes among any of the surgical techniques. This may indicate that patient outcomes are not solely dependent upon restoration of joint kinematics. While it is evident that physicians and clinicians need to be concerned with correct anatomic graft placement, we also need to figure out what else is influencing patient reported outcomes. It may be that we need to focus on other aspects (e.g., psychological) throughout the rehabilitation process as well. It is important to remember to treat the whole patient, as opposed to just the injury. In regard to patient centered approaches, the authors also introduced the notion of future studies investigating an individualized approach to patient ACL reconstruction based on their anatomic architecture. This is an interesting concept, and I wonder what features would determine anatomic single bundle versus double bundle surgical techniques. Does anyone have any opinions on what else may influence patient outcomes post-ACL reconstruction?

Written by: Nicole Cattano
Reviewed by: Jeffrey Driban

Related Posts:
Is More Better? Double-Bundle Versus Single-Bundle ACL Reconstructions

Hussein M, van Eck CF, Cretnik A, Dinevski D, & Fu FH (2011). Prospective Randomized Clinical Evaluation of Conventional Single-Bundle, Anatomic Single-Bundle, and Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction: 281 Cases With 3- to 5-Year Follow-up. The American Journal of Sports Medicine PMID: 22085729

6 comments:

Mark A. Rice said...

I think that there is a multitude of items that influence outcomes regardless of the procedure performed.

1. The number of visits alotted to the patient through their private insurance is a huge factor. Patients burn through their visits in the early post-op phase while focusing on inflammation control and ROM restoration. When the time comes to get into more agressive rehab,
they have utilized many of their visits and the return is not as great as it could be if they A) had more visits or B) begun structured rehab
a bit later after the initial management phase.

2. "Straight cash, homie" With the cost of co-pays what they are today(upwards of $40-$50), some patients flat out can't afford to follow
through with their recovery.

3. Recovery time. Returning to play at 9 months for a HS football player doesn't seem to make a whole lot of sense to me, especially when an NFLer will return at the same mark on the calendar. That kid hasn't had the same resources available to him as that professional athlete and I believe to return people in the general population back to their sport at the same time frame as a pro athlete, that for all intents and purposes is getting paid to rehab, is possibly a recipe for re-injury. How many people out there could return to what they are doing at a high level after a devastating injury like Willis McGahee suffered? Jobs, family and life are day-to-day obstacles that the everyday patient has to overcome. Throw added rehab time on top of all of that and there just aren't enough hours in the day for you and me to get to 100%. The recovery window for post-op ACL patients in the general population has to be increased.

4. Understanding. After all is said and done and PT visits are exhausted, many patients either don't know or don't understand that
their rehab is incomplete. In order to fully recover, there is more work that needs to be done and much of it from a neuromuscular standpoint.

I do believe certain patients like players need to be reached differently, but I wonder how much outcomes would improve if these
factors were addressed...

Nicole Cattano said...

Mark-You bring up a very valid point about money being the root of it all. The managed care aspect of the injury rehabilitation process surely can affect outcomes. I am fortunate in my setting where we do all of our post-surgery management "in-house" and I couldn't imagine outsourcing any ACL rehab to a PT clinic. We are doing rehab 4-6 days a week, at no cost to the athletes' insurance companies.

Mark-another interesting point you brought up is the notion of returning HS and NFL football players on the same timelines. I agree that there is a push at the lower levels of competition based on what is seen at the professional level. For example, "if Terrell Owens can return in 2 months from this type of an injury, why can't I?" I think surgeons and clinicians need to be more up front with athletes and their respective time-frames for return to play. Research done by Bennyon, et al has shown that biochemical markers are still at abnormally high levels at one year post ACL reconstruction, regardless of the type of rehabilitation and return to play. Even though NFLers are doing it, it still doesn't make it the best thing for anyone to do long-term. I can recall a television special covering retired NFL players and the fact that the average player had 3 knee surgeries after retiring and had extreme difficulties with ADL's. I know that there is a lot of pressure to play at the NFL level, but regardless of the money, long-term sacrifice of a way of life doesn't seem right.

Mark A. Rice said...

Truth be told, the majority of the injuries that Drs see will get farmed out to PT clinics. That's not a knock on the PT clinics, it's more of a state of the union. When dealing with collegiate athletes, I think that it's easy to get trapped in that little world and forget that all of the other patients have to FIND
somebody to take care of them, and then pay for it, too.

You also hit on another topic. The ammount of one-on-one time that you and I are able to give our athletes is drastically greater than what most clinics are able to provide on a day to day basis. This a result from dealing with a fairly reasonable and consistent patient load everyday (when compared to the 30+ patients that a PT or ATC might see in a day at their clinic) and not having to worry about reimbusements and other financial considerations. That's not to say that ATC's don't get swamped, because Lord knows we do!, but we do have the added luxury of multiple treatment sessions per day as well a the student-athlete having day-to-day flexibility based upon their class schedule.

The patients/athletes that come from the college setting have a much better opportunity to have a successful outcome, when compared to the
average patient due to having sports medicine specialists on hand and having minimal to no insurance cost incurred for their rehab. Often times I wonder if they even know how good they have it...

Great post, Nicole.

Nicole Cattano said...

Great points Mark I agree that the athletes that we work with have it good with access to care without insurance concerns. Poorer outcomes coupled with high costs for continued quality care would lead me to question why so many people choose to have their ACL surgically reconstructed. Especially when looking at long term outcomes of osteoarthritis being relatively equivalent in surgical and non-surgical patients who have suffered ACL tears.

Jay Clark ATC said...

Mark, I also want to emphasize your point regarded the number of visits available alongside participation level. When a NFL athlete undergoes ACL rupture, they have daily treatments during all stages of rehab, while patients going to PT go through 3 visits a week maximum with a reliance on HEP programs that are not always followed. This extra attention may also coincide with faster recovery times (along with other theories like more modality options). I think that the state of the union is relatively useful for the general population to get patients to a functional setting, but this plan may not be as effective for athletic individuals.

Nicole Cattano said...

Jay and Mark, I couldn't agree more. Its ashame that some athletes do not have the access to care and must rely on HEP in efforts to successfullyl return to competition levels. In reference to the "extra attention" given - there certainly is a physical benefit, but what about any psychological benefit?

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