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 Agili-C^TM implant (CartiHeal, Inc.) is used for the treatment of painful knees with joint surface lesions. The implant, which is made of aragonite, a form of coral based calcium carbonate, may help to stimulate the growth of healthy cartilage and bone, through infiltration of blood and bone marrow cell. Andreas H. Gomoll, MD, sports medicine surgeon at HSS, who is conducting the trial at the institution, says the technology has shown promising results in preclinical studies as well as human studies previously conducted in Europe.

Damage to knee cartilage, also termed osteoarthritis in its more severe form, is increasingly common in the United States¹.The condition, which involves damage to the joint cartilage and its underlying bone, can be caused by several factors, including traumatic injury, repetitive strain or genetics.

The most common procedures for patients with cartilage damage are microfracture and debridement surgeries. In debridement the surgeon shaves the damaged cartilage, while in microfracture the orthopedic surgeon makes tiny holes in the surface of the joint. The holes allow increased flow of blood to the affected area, promoting the formation of fibro-cartilage.

Although debridement and microfracture surgeries works reasonably well for many people, it’s not universally effective -- prompting the search for alternative treatments. Previous surgical approaches to treating cartilage damage typically involved patients with localized damage and little or no damage to the bone. The Agili-C^TM study on the other hand, is the first trial of a cartilage repair implant that also allows people with more extensive cartilage damage, so-called early osteoarthritis, to be enrolled. Early osteoarthritis is marked by more extensive damage than is traditionally treated with cartilage repair. Patients with end-stage, or bone-on-bone osteoarthritis, however, are not eligible for the trial.

“What is potentially groundbreaking about this, and what this study does that no other surgical study has done before, is go to the realm of early osteoarthritis. It opens a potential population that is significantly larger than that we can currently treat,” he says.

Although no therapy is likely to prevent future joint replacement surgery, Dr. Gomoll says that even delaying the need for surgery by a decade or so could allow some people to avoid revision procedures later in life.

Another potential advantage of the technology, Dr. Gomoll says, is that Agili-C^TM is an “off-the-shelf” product that does not require customization for individual patients or special storage and handling. While prior studies of synthetic plugs made from resorbable plastic were unsuccessful, “this new study is a beautiful way of using nature to heal nature by using coral-based material to treat cartilage damage in patients”, he says.

In this study the patients are randomly assigned to receive either the Agili-C^TM implant or the current standard of care, microfracture or debridement surgeries, in a ratio of 2:1 (for every two patients that receive the Agili-C implant, one patient will receive the current standard of care). The study in not blinded and the patient knows what kind of treatment they received.

The outpatient procedure is performed under general or local anesthesia and takes approximately one hour. Patients can expect to spend roughly one month on crutches after surgery.

Participants in the trial will be followed over the next two years and assessed on several measures, including pain, daily functioning, and their ability to return to physical activities such as work and sports. They also will undergo periodic X-ray and MRI procedures to track physical changes in the joint.

Over 180 patients, out of minimum 250, have been already enrolled into the study in leading centers in Europe and US. The HSS researchers are now enrolling patients as well. To qualify for the study, patients must be aged 21 to 75 years; have visible cartilage defects or mild to moderate knee osteoarthritis (not involving bone-on-bone contact); and have a body mass index less than 35.

For more information, contact Dr. Gomoll at GomollOffice@HSS.edu.

¹https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5584421

Dr. Gomoll writes that joint preserving surgery includes a group of highly specialized procedures that are not performed by a lot of physicians such as cartilage and meniscus transplants.

The best candidate for these procedures is someone in their 20s, 30s or 40s with damaged cartilage or meniscus who is at an activity level or age where joint replacement is not recommended.

"As a big proponent of personalized medicine, I believe it's incredibly important to sit down with a patient to go over their history, previous operations, and figure out exactly what that specific patient needs," writes Dr. Gomoll.

Read the full article at DailyVoice.com.

The multicenter Calypso Study will assess the safety and effectiveness of Moximed’s implantable shock absorber for the knee.  Moximed is a medical device manufacturer based in Fremont, California and is the sponsor of the study.   

The trial will enroll 80 men and women with medial knee OA, a painful, debilitating condition in which the cartilage barrier separating the ends of the femur and tibia deteriorates, allowing the two bones to rub against each other. Medial knee osteoarthritis can result from a variety of factors, including advanced age, the loss of estrogen after menopause for women, wear-and-tear from physical activity or obesity, and previous trauma to the joint, such as a torn ligament or meniscus. According to the CDC, an estimated 1 in 4 Americans suffer from some form of OA, and half are under the age of 65. 

Knee replacement surgery is an option for patients with medial knee osteoarthritis, but the procedure is relatively invasive and requires protracted recovery and rehabilitation. As a result, many patients opt for conservative care, which can entail the use of analgesics for pain, physical therapy and special insoles for shoes to help rebalance the affected joint—none of which prevent arthritis from progressing. 

"Many patients were injured when they were young, for example with anterior cruciate ligament (ACL) and meniscal tears, and these unfortunately lead to osteoarthritis in approximately 50% of them by 10 years after injury," said Andreas Gomoll, MD, sports medicine surgeon at HSS. "Since the original injury happens when patients are in their teens or 20s, they might have established osteoarthritis in their 30s and 40s, when knee replacement is not a great option since it has a high likelihood of wearing out during their lifetime and will have to be revised. Not surprisingly, doing a revision replacement is not as good as a primary replacement, and therefore we are looking for ways to delay these types of more invasive procedures for as long as possible. For some, conservative care helps, but not for everyone. That's where a device like the Calypso could fit in. If patients can buy years of improved pain and function, then knee replacement surgery can start later, requiring fewer possible revisions in the patient's lifetime. This device design is all about preserving options, since it can be removed with little-to-no permanent changes to the knee joint structure. Therefore, patients remain candidates for any other potential treatments that might be developed in the future."

The Calypso Study investigational device consists of a cylindrical shock absorber that is implanted along the side of the knee and reduces the amount of weight supported by the knee. 

"Nobody can wear a brace all the time for any length of time, and that's the advantage of an implantable device like Calypso," Dr. Gomoll said. "There is no other device like it and it offers a new approach for these patients."

"We are constantly pushing the biological envelope to preserve joints as long as we can," said Anil Ranawat, MD, sports medicine and knee joint preservation surgeon at HSS. "When a patient is young and has OA, it’s hard to know what the best procedure is. Injection therapy can relieve pain, but treatment benefit is only short term. More invasive surgical procedures, though effective in treating osteoarthritis, can inhibit treatment options down the road for young, active patients. The Calypso implant’s unique design maintains the anatomical structure of the knee while also treating the primary pain generator of OA. Our ultimate goal is to preserve motion and function in our patients."

The implantation surgery takes approximately one hour and can be performed on an outpatient basis, meaning patients can go home the same day. Rehabilitation is easier than for other knee surgeries, Dr. Gomoll noted.

The study will measure improvement over 24 months in pain and function based on a validated measure called the Western Ontario and McMasters University Osteoarthritis Index (WOMAC). The researchers also will track device safety and monitor the integrity of the implant over time using x-ray imaging. 

To participate in the study, patients must be between the ages of 25 and 65 and have had osteoarthritis pain on the inner side of the knee that has persisted for at least six months after trying non-surgical treatments. 

Patients are not eligible for the study if they have osteoarthritis in both sides of the same knee; if they have problems with the ligaments in their affected joint; if they have known allergies to certain metals; if they have been diagnosed with conditions that afflict the skeleton, such as rheumatoid arthritis and Paget’s disease; among other considerations.   

Two sports medicine surgeons at HSS are participating in the study: Andreas Gomoll, MD, and Anil Ranawat, MD.  

"There are not that many stem cells in the bone marrow, which can compromise the quality of the repair tissue. While microfracture surgery has satisfactory results in the short term, they tend to worsen over time, especially in larger defects," said Dr. Gomoll in a release.

Read the full article at beckersspine.com.

In the new study, "Evaluation of the ReNu Amniotic Suspension Allograft after Marrow Stimulation in the Treatment of Osteochondral Defects", Dr. Gomoll and his colleagues will be injecting ReNu into the knees of eight men and women with chondral and osteochondral defects. Osteochondral defects of the knee simultaneously affect both the bone (osteo) and cartilage (chondral) in the joint, while chondral defects only affect the cartilage. These defects can result from an acute sports injury, chronic wear caused by excessive pressure on the joint or other factors such as a genetic predisposition. Over time, these defects can lead to diffuse cartilage damage in the joint, also known as osteoarthritis, a painful, debilitating condition with few effective non-surgical treatment options.

Patients in the pilot study will receive intra-articular injections of ReNu two and four weeks after standard of care arthroscopic surgery to stimulate healing of the defect. During this procedure, surgeons drill tiny holes into the bone at the bottom of the defect to allow blood cells to seep in from the bone marrow below and clot, with the hope that stem cells from the marrow will help produce a new layer of healthy cartilage.

"There are not that many stem cells in the bone marrow, which can compromise the quality of the repair tissue. While microfracture surgery has satisfactory results in the short term, they tend to worsen over time, especially in larger defects," Dr. Gomoll says.

The researchers will follow the patients periodically for the next two years, making assessments of joint pain and function. The primary outcome of the study is any change after one year of treatment in two validated measures that provide researchers with ratings of mobility, pain, ability to perform activities of daily life and other important aspects of joint function.

Secondary outcomes of the trial are changes in knee pain and function both at the one-year mark and after two years of treatment.

Patients in the trial will be between 18 to 55 years old. The study is open to both men and women; however, because the safety of many medications, including ReNu, on developing fetuses is unclear, participating women must not be pregnant; must be using birth control; be postmenopausal; have been surgically sterilized; or be sexually abstinent.  

Ideally, Dr. Gomoll says, the factors contained in ReNu will help stimulate the patients’ own stem cells. And because stem cells have anti-inflammatory properties, they will help create a more hospitable environment for healing.

"The goal is to improve the quality of the new tissue by calming the knee down and giving the patient’s own stem cells from the bone marrow a boost," he says.

In addition, Dr. Gomoll and Dr. Sabrina Strickland (sports medicine surgeon at HSS) just concluded a randomized controlled trial of ReNu for the treatment of knee arthritis.

"Interim 6 month data showed that treatment with Renu resulted in clinically relevant and statistically significant improvements in pain, symptoms and activities of daily living scores as compared to hyaluronic acid and saline," Dr. Gomoll said. At the six-month mark, significantly more patients who received injections of ReNu reported benefit than did those who received either sham injections or conventional care with viscosupplementation injections. If the approach succeeds over time, "it will be one more treatment option we have, especially for patients who are not great candidates for knee replacement"—such as the old and infirm, but even more importantly young, healthy people who worry that they will lose mobility with the artificial joint.

Organogenesis, based in Canton, Mass., provided funding for both studies.

Dr. Gomoll, who co-founded the society, discussed trends in orthopedic cartilage repair.

"There is increased interest in regenerative medicine approaches, such as platelet-rich plasma and stem cells, for osteoarthritis and cartilage defects. However, data in this emerging field remains limited, and the clinical introduction has frequently outpaced research," said Dr. Gomoll.

"We need to form a more collaborative network among cartilage repair specialists to collect outcomes," he added.

Read the full article at beckersspine.com.

Read the full article at beckersspine.com.

"Research shows that certain exercise programs can benefit people with knee arthritis. However, not all patients obtain sufficient pain relief through exercise," explains Sabrina Strickland, MD, an orthopedic surgeon and lead investigator at HSS. "The new study, which will take place at hospitals around the country including HSS, is designed to enroll a relatively young, active population of people with knee osteoarthritis. It will be interesting to see the results, as hyaluronic acid injections are typically used for an older patient population."

Study participants will be divided into two groups. One group will receive two hyaluronic acid injections combined with a physical exercise program of at least eight weeks. The other group will be provided with an exercise program alone, also to last eight weeks. All patients will receive a diary to record their activity and progress. They will see the physician for follow-up visits three months and six months after enrollment.

The initial doctor exam, x-rays, hyaluronic acid injections, exercise program, and follow-up visits will all be provided free of charge to study participants. Patients who have failed to obtain sufficient pain relief from the exercise program alone at the three-month follow-up will have the option of receiving the hyaluronic acid injections.

Dr. Andreas Gomoll, an orthopedic surgeon at HSS, is also involved in the study, which is open to individuals from 21 to 55 years of age. To qualify, patients must have experienced persistent knee pain lasting at least three months prior to the initial screening; lead an active lifestyle (play a sport or train at least two to three times per week); receive a diagnosis of knee osteoarthritis confirmed by an x-ray; and meet a number of additional requirements.

Anyone interested in learning more about the study is invited to send an email to StricklandOffice@hss.edu or Digirolamod@hss.edu. You can also call 212-606-1725 or 212-774-2673.

HSS sports medicine surgeon Andreas H. Gomoll, MD, who did not treat Wentz, explained the recovery time for both injuries.

"If just the ACL is damaged, recovery for an elite athlete who can focus on recovering (rather than having to go to work and rehab in the evenings) can be as short as six months. If other ligaments are damaged enough to require repair, such as the lateral collateral ligament (LCL), then recovery will be longer - closer to nine to 12 months," Dr. Gomoll said.

Dr. Gomoll also noted that Wentz's meniscus damage does not raise any red flags.

"Meniscus injury, while increasing the risk of arthritis later in life, doesn't add much to the recovery, since most meniscus tears in these elite athletes are cleaned up, rather than stitched back together," he added.

Read the full article at 973espn.com.

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