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Gregory S. DiFelice, MD, of the Hospital for Special Surgery, New York, NY, talks about primary ACL repair
Q: What is the latest news with primary ACL repair?
A: Well, it seems that the ice is starting to break as more and more surgeons are warming up to the idea that there may be a middle ground with regards to the treatment of ACL injuries. In other words, repairing appropriately selected tear patterns could be an effective treatment option to complement the current binary approach that includes nonoperative treatment and reconstruction as the only options. Thanks to an incredibly productive two years of research led by my research fellow, Dr Jelle van der List, we have a lot more to talk about with regards to all facets of the discussion surrounding ACL repair. After struggling to get our research even accepted to meetings, it seems as if the worldwide orthopaedic community is realising that “less may be more,” since we now have had posters, presentations, and scientific exhibits at nearly every major meeting and have published over 20 papers and book chapters.
Q: At Arthrex, we can certainly confirm that there are many surgeons who have started to perform ACL repairs for well-selected patients. How have your results been?
A: So far, so good. The last thing in the world that I want to do for my patients is a surgery that will not be successful for them, and thus I have been tracking my results very closely. Importantly, the first cohort of 11 patients that we reported on in Arthroscopy in November 2015,[1] has passed the important five-year mark. In our first paper, 10 out of 11 patients were doing great at a minimum of two years’ follow-up and I am happy to report that at a minimum of five years’ follow-up, they continue to do so. All 10 patients that were doing well at the first follow-up continued to do even better at the five-year follow-up without significant reinjuries. The paper was recently published in Arthroscopy.[2]
This data is critical because the research detailing the outcomes of the original cohorts of patients who underwent open ACL repair back in the day showed significant deterioration between the two- and five-year follow-ups.[3] We realized that the numbers are small, but also understand that you have to start somewhere. We are now amassing the data on a much larger cohort. We recently presented the results of my first 56 patients at both ESSKA and AOSSM, showing 90 per cent successful outcomes at an average follow-up of three years.[4] This paper has been accepted and published online.[5] Currently, I have performed more than 200 arthroscopic ACL primary repairs and to date have had 14 patients reinjure their ACL that I am aware of. I say reinjure because, aside from the patient that was reported in the first 11 patients who failed his repair at three months post-op without a significant trauma, the other patients all reinjured their repaired ACL between nine months and two years post-repair when they experienced another significant injury, usually while playing sports.
Q: Speaking in rough numbers, some may say that the failure rate is likely the same or possibly even higher than with ACL reconstruction. Why would a surgeon want to learn a new technique to repair the ligament rather than