Medscape.com interviewed Anil S. Ranawat, MD, sports medicine surgeon at HSS, who discussed the past, present, and future of anterior cruciate ligament (ACL) repair.

Dr. Ranawat noted prior to arthroscopy, surgeons performed an arthrotomy (opening up the knee) to repair the ACL. This approach was a laborious operation and the overall patient success wasn't great. ACL surgery gradually evolved to replacing the ACL instead of repairing it. As more arthroscopic techniques were developed, surgeons began to change the way they performed the procedure. In the past, two large incisions were made and surgeons placed a graft in the right place. However, as surgeons have moved to less invasive arthroscopic surgery, they started putting the graft in the wrong place. Inaccurate positioning of the graft is a consequence of performing more minimally invasive techniques.

Dr. Ranawat underscored the critical need to understand that ACL replacement involves a compilation of factors, including the type of patient you have, the type of graft being used, placement of the graft, and how the graft is fixed and with what tensioning device. Dr. Ranawat added individualized surgery is the future of the ACL restoration. In the 1990s, surgeons performed the same procedure in the very same way on all patients without consideration of these factors.

For surgeons are treating patients with “riskier” knees (i.e., an excessive posterior tibial slope, a patient that is loose-jointed, etc.), it is important to understand the risk factors, and to consider where patients are on that risk curve by reviewing their history, conducting a proper physical examination, and thoroughly analyzing their imaging. Assessing whether a patient has a mild, moderate, or high risk for failure should be done before surgery, not after they re-tear their graft.

Dr. Ranawat concluded with commentary on the future of ACL repair, noting ACL surgery is going back in time - reverting to traditional concepts and procedures; deciding whether ACL repair surgery is appropriate and for which patients; and understanding that the concept of individualized surgery.

Read the full article at Medscape.com.