Nearly all knee professionals believed that a torn ACL was irreparable and that surgical reconstruction was usually required to maintain knee function. But this new study, which focused on 80 injured knees, found that many torn ACLs could apparently re-knit and heal on their own, reducing the need for expensive and often painful surgery. It turned out to be.
A new study published this month found that British Journal of Sports Medicine90 percent of the 80 torn ACLs studied showed signs of healing and repair at scans after approximately 3 months. Patients followed a newly developed brace and physiotherapy protocol.
Lyle J. Mitchelli, professor of orthopedic surgery at Harvard Medical School and chair emeritus of the sports medicine division at Boston Children’s Hospital, said the new study was “interesting.” He is treating and researching his injured knee, but has not participated in any new research. “Spontaneous healing was simply assumed to be impossible in most cases after ACL injuries in adults.”
The discovery has sparked heated debate among sports medicine physicians, researchers, therapists, and especially orthopedic surgeons, who perform thousands of ACL surgeries each year. The finding that in many cases such surgery may not be necessary may redefine future treatments for ACL injuries, showing that knees are more resilient than previously thought. suggesting.
Why ACL tears are so common
“I was 18 years old and I had just torn my anterior cruciate ligament while playing soccer,” said Stephanie Philvey, a senior researcher at the University of Melbourne who led the study. “I still remember the surgeon saying, ‘Do you ever want to play sports again?’ If so, her ligaments would need to be reconstructed.” She underwent surgery. .
In 2018, Reported by the Centers for Disease Control and Prevention Between 2002 and 2014, 283,810 ACL surgeries were performed, a 22% increase during that period. The total is almost certainly much higher than it is now. Each of these surgeries cost an average of $24,707, according to 2019 survey at arthroscopy.
The ACL connects the femur (thighbone) and tibia (shinbone) diagonally on the inside of the knee joint. It is one of the knee’s most important and vulnerable supporting tissues and is prone to overstretching. Hitting the knee from the side, making a sudden change of direction, or jumping and landing can cause the anterior cruciate ligament to pop out, often tearing it in the middle or tearing it out of the bone.
Athletes aren’t the only ones who get injured. As my friend found out, some people tear their anterior cruciate ligament from tripping over a curb, getting stuck on a puppy, or sneezing too hard.
Tips That ACL Can Be Healed
For decades, ACL tears were thought to never heal due to lack of blood flow. Standard treatment, especially for active people, is to remove the torn ACL and replace it with cobbled ligaments from tissue taken from elsewhere in the body or from cadavers.
Subsequent recovery is slow and reinjury is frequent. Muscle strength and balance in the affected leg are often lost due to prolonged muscle atrophy and nerve severance during surgery. Often the injured knee becomes arthritic within his decade.
However, there are also suggestions that ACLs may improve against medical orthodoxy. anatomical study The 1990s showed that There was blood in the ligament. Other times, when the surgeon opened or examined the knee, an unexpected spontaneous healing was observed.
“We know from the clinic that healing sometimes happens,” said Richard Fröbel, associate professor of orthopedic surgery at Lund University in Sweden, who has conducted a large European study of ACLs.
“But I didn’t know how often it was.”
Braces and physical therapy to repair a torn ACL
A few years ago, Stephanie Philbay began to question the need for ACL surgery, as her reconstructed knee was not exactly the same.So she thought she and her co-workers were the first Re-analysis results It was derived from a Fröbel-directed study of 120 ACL ruptures, some of which were surgically repaired, but some of which were not.
MRI scans two years after injury suggested that about 30 percent of ACLs in people who skipped surgery had healed.
Hoping to improve those odds, Philbay and her collaborators, notably orthopedic surgeon Marvin Cross and his physician son Tom Cross, keep the injured knee immobilized at a 90-degree angle for a month. developed a special new fixation protocol designed to , so I was able to bring the battered ends of the ligaments closer together to speed up healing.
While wearing the brace, patients completed extensive physiotherapy exercises, including repeated tightening of the thigh muscles to reduce atrophy.
The therapist loosened the brace every few weeks and removed it after 12 weeks. Injured knees were scanned at the beginning and end of 3 months.
Philbay and her colleagues, who reviewed scans from the first 80 patients for the new study, found that 90 percent of the knee healed (defined as an MRI signal showing tissue bridging the torn edge). I noticed
None were completely healed according to a standard 4-point scale of ACL health, which scores total tissue tear as zero. However, 50% now qualify as grade 1 injuries, with torn end entanglements, 40% reach grade 2, and 10% reach grade 3, representing nearly intact ACLs. ing.
Higher scores indicate greater satisfaction with knee function and stability.
Meike van Heringen, a Danish medical student living in Melbourne, said he was “13 months out from injury” from a torn ACL. He tore both anterior cruciate ligaments playing field hockey and is currently part of a research team investigating the healing of the anterior cruciate ligament.
In 2018, surgeons reconstructed her right knee, but just recently her left knee was treated with a new fixation protocol.
“At this point, I can do anything I want with both feet,” she said, including playing elite field hockey again. But her right leg, with a surgically-formed ACL, “feels like it’s about 90 to 95 percent better” five years later, compared to the left leg, where the ACL appears to be healing. The leg is “already 95-100 percent healthy,” he said. 13 months. “
Skepticism from the Surgical Community
But some experts scoff. Timothy Hewett, professor of orthopedic surgery at the University of Marshall’s Joan C. Edwards School of Medicine, said it was “unlikely to believe” that ACLs healed on their own, and he wrote many of the papers on ACL injuries. He has co-authored hundreds of peer-reviewed papers, including
An MRI scan that shows the raw ends of a torn ACL rejoined is probably scarred or possibly misread, Hewett said. “Authors should not use the word ‘healing’ in this context,” he said.
At a recent international conference of surgeons and knee researchers in Boston, attendees discussed the new study and it was to some extent dismissed, Hewett continued. “You could easily hear a world-renowned researcher say, ‘That’s BS,'” he says.
But other scientists are keen. “This is a groundbreaking study,” said researcher Daniel Bellavi of the Gesundheit University (University of Health Sciences) in Bochum, Germany. He is a co-author of a 2022 review of outcomes after ACL reconstruction or physical therapy. He was not involved in new research.
People’s knee scans and functional improvement show “ACL”. can Shedding tears heals,” he said.
The research and controversy mirror what happened with “meniscal injuries in the knee,” Micheli said. “Early on, the trend was to trim or repair meniscal tears. Subsequent research Many of these cases have been suggested to have curative potential, and surgery may be unnecessary or counterproductive.
But this new research and the possibility of ACL healing is questioning whether a repaired ACL is as robust as an uninjured ligament, and whether Philbay’s study showed signs of spontaneous repair in some knees. Many questions remain, including why it was not.
Philbay hopes to start a large randomized controlled trial soon to compare results after fixation protocols with those after ACL surgery or no treatment. She also discusses with researchers and therapists internationally, including in the United States, the use of correctional protocols in practice and the provision of data on outcomes.
In the meantime, she’s tracking outcomes for an additional 280 ACL patients who have completed the brace. So far, their knees have shown comparable improvement to their first 80-year-old, she said. Some patients have reported that many years after the injury, their unreconstructed ACL feels like new.
On the other hand, some people choose reconstructive surgery because the knee becomes unstable or painful for a long period of time.
“It’s always an option,” Philbay said. “There is no statute of limitations on surgery.
That possibility could help make the new research’s impact on ACL treatment immediate and substantial, Bellaby said. “If it was a friend or a loved one who had just torn the anterior cruciate ligament, I would say to them, ‘Hey, personally, I’ll see what happens and I’ll consider this brace, but if I were you. I wouldn’t,'” he said. “Hurry up and go to surgery.”
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