My son Erik, then 23, was playing basketball when an opponent stepped on his foot and the anterior cruciate ligament in his right knee ruptured with an audible pop. This critically important ligament, best known as the A.C.L., is a ropelike structure that connects the femur (thigh bone) to the tibia (shin bone), stabilizing the knee joint.
A torn A.C.L. is an all-too-common injury that typically results in complex surgery and prolonged rehabilitation. It can spell the demise of a promising athletic career and limit an amateur’s ability or willingness to participate in sports like tennis, basketball, soccer, football, skiing and gymnastics that involve quick twists and turns or pounding stress on the knee.
But Erik was lucky. His A.C.L. tore about a quarter of the way down the ligament, and the orthopedic surgeon he consulted immediately after the injury was a maverick decades ahead of his time. Ignoring longstanding professional practice that still calls for removing and reconstructing the torn ligament with a tendon from elsewhere in the leg, Erik’s surgeon simply stapled the longer piece of the torn A.C.L. to his femur.
Twenty-seven years and countless hours of tennis and basketball later, Erik’s repaired knee is still intact, stable and pain-free. He recently learned that, despite continuing orthopedic orthodoxy that insists on reconstruction, many others with a torn A.C.L. — perhaps as many as 40 percent with this injury — could benefit from a modern version of the simplified procedure and more rapid recovery Erik experienced.
One of the pioneers in modernizing simpler A.C.L. surgery is Dr. Gregory S. DiFelice, who has done A.C.L. repairs, instead of reconstructions, on about 250 patients during the last decade at the Hospital for Special Surgery in New York. Dr. DiFelice maintains that repair rather that reconstruction is especially helpful for children 18 and younger who are more likely than older patients to reinjure a reconstructed A.C.L. Over all, he said in an interview, the risk of reinjury with the repair method has been no greater than that following reconstruction.
Reconstruction involves removing the torn ligament and replacing it with a graft — a tendon surgically removed from the patient’s hamstring, quadriceps or kneecap, or sometimes taken from a cadaver — and attaching it with screws or buttons through tunnels drilled into the femur and tibia. As it heals, the grafted tendon develops scar tissue that results in a firm, reliable knee joint with an overall failure rate of about 5 or 10 percent.
But Dr. DiFelice said that when the damaged A.C.L. is removed, the patient loses the nerve endings within it that send signals to the brain about what the knee is doing. Also, range of motion may be compromised, and during the lengthy recovery that can take six to eight months or longer for the graft to be strong, thigh muscles atrophy and must be rebuilt before the patient can safely return to demanding activity.
Thus, Dr. DiFelice said he wants to encourage other practitioners and their patients to pursue the lesser surgery and shorter rehab whenever circumstances permit, especially when the full length of the A.C.L. tears directly off the bone. However, he explained that even when the torn ligament is not quite long enough to reach the bone, he’s developed an augmentation procedure to add a small strut to make it reach. Using this method, he said, he now has to resort to the standard reconstruction surgery for less than a third of the patients he sees.
There are at least two important caveats to this story:
1) Unlike the introduction of new prescription drugs, new surgical procedures are not subject to government approval and typically are not tested in controlled clinical trials, at least not until they have been used for years. So patients must rely on what surgeons tell them about the effectiveness of their procedures, supplemented perhaps by reports from patients.
2) Training and practice are required before a surgeon attempts what Dr. DiFelice does, and thus far there are not many already adept at the technique. Changes in medical practice can sometimes proceed at a glacial pace, and it may be up to patients to pressure doctors to depart from accepted procedures. Also, it may require pressure on medical insurers to cover the costs of a new operation.
Another surgeon in the New York area now doing A.C.L. repairs in lieu of reconstruction is Dr. Howard J. Luks, at Westchester Medical Center. He reports that the loss of nerve connections to the brain following A.C.L. reconstruction may explain why such knees sometimes feel unstable.
However, Dr. Luks emphasized that “current repair techniques only allow us to consider tears which occur high in the A.C.L. near the femur insertion” and that “the tear cannot be too old. If the tear is old, then the ligament will degenerate, and it may not be able to be brought back to the part of the bone it needs to be repaired to.”
Keep in mind, too, that there are risks associated with any surgery, including infection, stiffness, pain, blood clots and with the A.C.L., ligament failure. For children who are still growing, there is a risk of damaging growth plates during the surgery.
Those with an A.C.L. injury should also know that surgery is not their only option. My brother, in his 50s when he tore his A.C.L. while skiing, opted not to have surgery. Instead he did extensive physical therapy, and by wearing a leg brace for added support, was able to ski and play tennis despite his damaged ligament.
The American Academy of Orthopaedic Surgeons suggests that nonsurgical management may be appropriate for those with partial tears and no symptoms of instability; those with complete tears without instability during low-demand sports who are willing to give up high-demand sports; people who do only light manual work or are sedentary; and children whose growth plates are still open.
The academy says that a person’s activity level, not older age, should be a considered when deciding on surgery. “Active adult patients involved in sports or jobs that require pivoting, turning or hard-cutting as well as heavy manual work are encouraged to consider surgical treatment,” including older patients once excluded from surgical consideration, the academy wrote.
Whether repair or reconstruction is done, postoperative physical therapy starting right after the operation is vital to a successful outcome. The academy cautions that patients should return to sports only after pain and swelling are gone and full range of motion, muscle strength, endurance and leg function are fully restored.