“Young athletes gain enormous health benefits from participation in team sports, and as sports medicine physicians, we strongly encourage athletic activity. However, we have seen a concerning increase in knee injuries involving the anterior cruciate ligament, commonly called the ACL. Adolescents playing team sports that require cutting maneuvers or a sudden change of direction, such as soccer, basketball, football and lacrosse, are most vulnerable. Research suggests that the risk of non-contact ACL injury can be dramatically reduced through neuromuscular training — the adoption of various exercise and conditioning strategies that improve movement and allow athletes to change speed and direction with greater strength and body control," explained Dr. Fealy. 

The article appeared in the print issue on August 21, 2024.

A new retrospective study from Hospital for Special Surgery (HSS) evaluated 72 patients who underwent arthroscopic SCR with dermal allograft to treat symptomatic irreparable rotator cuff tears. All patients were operated on at HSS between 2012 and 2017. Nearly 42% of the patients had a history of failed rotator cuff repair.

After surgery, the overwhelming majority of patients demonstrated significant improvements in forward elevation, abduction and external rotation through their pre- and post-operative active range of motion. At follow-up appointments, patients completed various patient-reported outcome surveys including Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons (ASES), and University of California at Los Angeles (UCLA). Patient scores were high, averaging 80%, 78% and 85%, respectively.

Five patients required a second operation – no other complications were recorded.

“This technique has proven to be effective for patients with irreparable tears,” said Joshua S. Dines, MD, HSS sports medicine surgeon and senior study author. “As we continue to do more outcomes research, we become more precise at predicting the best candidates for each technique. While not for everyone, this has emerged as a great option for patients who may not be right for a reverse shoulder replacement.”

The authors look to perform future research evaluating the long-term outcomes and results.

This study is available online as part of the AAOS 2020 Virtual Education Experience.

Abstract Title: Clinical Outcomes following Arthroscopic Shoulder Superior Capsular Reconstruction

Authors: Daniel Hurwit, MD, Justin Chan, Michael Fu, MD, John Apostolakos, MD, Stephen Fealy, MD, Frank Cordasco, MD, David Dines, MD, Lawrence Gulotta, MD, Joshua Dines, MD.

Reconstruction is the current standard of care surgical treatment for tears of the anterior cruciate ligament (ACL). This procedure typically uses a graft, or a piece of tissue, placed in the knee minimally invasively, using small incisions. About 300,000 ACL reconstructions are performed annually in the United States with well documented rates of success.

ACL repair is an older technique that involved suturing (sewing) torn ACL tissue, not rebuilding it with a graft. ACL repair was performed in the 1970s at select institutions, including Hospital for Special Surgery, but was abandoned due to unacceptably high failure rates of up to 50%.

Today, ACL repair has been modernized and can be performed through a minimally invasive approach. Proponents suggest that modern ACL repair techniques may be performed safely and may lead to a quicker recovery than ACL reconstruction. However, the limited studies to date raise questions that must be discussed in detail with your surgeon.

1. It is critically important to get ACL surgery right the first time.

When ACL surgery fails, surgeons must do a revision procedure to correct or revise the problems that were not fully addressed the first time. Revision requires reconstructive ACL surgery with a graft. (ACL repairs cannot be done as revisions.) Redoing ACL surgery may result in higher rates of failure, lower rates of return to sports, and increased risk of osteoarthritis.

The importance of successful initial ACL surgery holds true for people of all ages, but it is particularly critical for young athletes, for whom a failed surgery can have devastating consequences, including years lost from sport in the short term as well as chronic pain and loss of function in the long term.

2. Failure rates for ACL repair appear to be significantly higher than those for ACL reconstruction in people of all ages.

Current studies suggest that modern ACL repair techniques have a failure rate that may be five to ten times higher than that of ACL reconstruction^1,2,3. One major recent study in a prominent sports medicine journal found that arthroscopic ACL repair has unacceptable outcomes in young athletes, with short-term failure rates of close to 50%².

It has been suggested that ACL repair may be appropriate for older adults who have a type of ACL tear called a proximal avulsion and who do not participate in “cutting and pivoting” sports such as basketball, volleyball, and soccer. For these patients, failure rates in the short term appear to be much higher than ACL reconstruction in this age group^1,2,3.

3. There is still much we don’t know about ACL repair.

There has been no scientific evidence that shows a difference in postoperative pain between ACL repair and reconstruction. Rehabilitation and return-to-play protocols for ACL repair have not yet been established. Proper guidelines for rehabilitation and return to sports are essential to keep people safe from re-injury.
 

Andrew D. Pearle, MD

Chief, HSS Sports Medicine Institute

Bryan T. Kelly, MD

HSS Surgeon-in-Chief and Medical Director

Answorth A. Allen, MD

David W. Altchek, MD

Struan H. Coleman, MD, PhD

Frank A. Cordasco, MD, MS

David M. Dines, MD

Joshua S. Dines, MD

Stephen Fealy, MD

Andreas H. Gomoll, MD

Lawrence V. Gulotta, MD

Jo A. Hannafin, MD, PhD

Anne M. Kelly, MD

John D. MacGillivray, MD

Robert G. Marx, MD, MSc, FRCSC

Michael J. Maynard, MD

Moira M. McCarthy, MD

Danyal H. Nawabi, MD, FRCS

Stephen J. O’Brien, MD, MBA

Anil S. Ranawat, MD

Scott A. Rodeo, MD

Howard Anthony Rose, MD

Beth E. Shubin Stein, MD

Sabrina M. Strickland, MD

Karen M. Sutton, MD

Samuel A. Taylor, MD

Russell F. Warren, MD

Thomas L. Wickiewicz, MD

Riley J. Williams III, MD

References

1. Jonkergouw A, van der List J, DiFelice G. Arthroscopic primary repair of proximal ACL tears: outcomes of the first 56 consecutive patients and the role of additional internal bracing. Knee Surg Sports Traumatol Arthrosc. 2019 Jan;27(1):21-28.

2. Gagliardi AG, Carry PM, Parikh HB, Traver JL, Howell DR, Albright JC. ACL repair with suture ligament augmentation is associated with a high failure rate among adolescent patients. Am J Sports Med. 2019 Mar;47(3):560-566.

3. Wright RW et al. Risk of tearing the intact ACL in the contralateral knee and rupturing the ACL graft during the first 2 years after ACLR: A prospective MOON cohort study. Am J Sports Med. 2007 Jul;35(7):1131-4.

For more information visit https://www.hss.edu/condition-list_torn-acl.asp.

The findings of a recent study showed athletes ages 15-19 accounted for 56.8 percent of all ulnar collateral ligament (UCL) reconstruction procedures. 

CBS Local Sports spoke to Stephen Fealy, MD, sports medicine surgeon at HSS, who cited "The numbers for youths, and it’s almost impossible to keep true track of it on a national level, but anecdotally the numbers of youth injuries has seemed to continue to increase."

"The other thing that we really think is happening is, I’m here in New York and I grew up here, and essentially we would only pitch and throw during warm weather seasons in the spring, summer and fall," said Dr. Fealy. "But, what is happening is that baseball has become a year-round sport. More and more kids are throwing all year long. There really is no true downtime."

He added that not all UCL injuries in young athletes require surgery for treatment. Some may be eligible for PRP therapy, or can be treated non-surgically with rest and physical therapy.

Read the full article at CBSLocal.com. 

"Take one positive thing away from every meeting. Everyone's got something to contribute and collectively, that will be a whole lot more than you can accomplish on your own," said Dr. Fealy.

Additionally, Dr. Fealy explained that listening is a vital skill in learning information about a person and providing the best medical care. "In my practice, I do my best to say 'tell me your story' and sit back," he noted.

"Getting people better is fun. Taking care of smart, active people is a privilege," he added.

Listen to the full interview at spearcenter.com

The article reported that Stephen Fealy, MD, sports medicine surgeon at HSS, regularly visits Goldman Sachs Group Inc. and provides orthopedic care to their staff.

Dr. Fealy noted that "these people work incredibly hard, they come in with back pain, hip pain".

While his patients report different musculoskeletal issues, Dr. Fealy said he typically treats cases of "investment-banker neck," a type of arthritis that afflicts those who spend a good portion of their time looking at monitors.

From primary care physicians to specialists, Lagnado reported that Goldman Sachs employees have the convenience of seeing a variety of experts quickly and efficiently without having to venture far from the office.

One managing director said it was a big plus to see Dr. Fealy for a number of ailments.

Read the full article at wsj.com [subscription required].