2015 ISAKOS Biennial Congress ePoster #1222

Primary Repair Using a Healing Response Technique Versus Conservative Treatment in Acute Proximal Tears of the ACL: A Case Controlled Prospective and MRI Based Study

Katja Tecklenburg, MD, Priv.-Doz., Aldrans, Tirol AUSTRIA
Manfred Lener, MD, Imst AUSTRIA
Gerhard Ruedl, PhD, Innsbruck AUSTRIA
Alois Schranz, MD, Imst AUSTRIA
Medalp Sportclinic, Imst, Tirol, AUSTRIA

FDA Status Cleared

Summary: A healing response procedure within 48 hours after injury can restore stability and knee function in proximal ACL tears, with proper patient selection and defensive rehabilitation protocol.

Abstract:

Background

There is a trend towards a more biologic approach after ACL injury due to findings that imply a healing potential after ACL injury. Healing of the ACL and clinical outcome after operative treatment of high grade proximal ACL ruptures using the healing response technique described by Steadman JR et al. were examined. The results were compared to a conservative control group. We hypothesized that the operative approach will result in a better healing rate than conservative treatment with complete remodelling of the ACL on MRI, provided that patients were properly selected.

Methods

35 Patients who were diagosed (clinical examination and MRI) with a proximal ACL rupture within 24 hours after injury were prospectively assigned to 2 groups. 20 patients in group A underwent immediate arthroscopy using healing response technique with microfracturing around the femoral attachment site on the medial wall of the lateral femoral condyle. 15 patients in group B were treated conservatively. Patients with additional ligament injuries greater than grade II or with history of a previous knee injury or DJD were excluded from the study. Both groups followed a strict and detailed rehabilitation protocol with 6 weeks of bracing and decelerated physiotherapy for 3 months.
A clnical FU examination including a control MRI was performed in all cases at 10-24 months after injury. Main focus was on clinical outcome measures: overall knee stability and patient satisfaction, clinical and subjective IKDC, Tegner score.
All MR images were screened for signs of ACL remodelling and healing. The results were classified as either „no healing“, „partial remodelling“, or „complete healing with intact ACL“.

Results

Mean patient age: 36,7 (range 19-47) in group A and 35,8 (range 19-58) In group B.
Revision rate: 4/20 patients in group A (20%) and 3/15 patients in group B (20%) had undergone ACL reconstruction due to recurrent anterior knee instability within the FU period. These patients were excluded from further FU.
Clinical outcome group A: IKDC clnical: 11 x A (69%), 5 x B, 0 x C or D (69%); IKDC subjective: 94,9 +/- 4,8
MRI group A: intact ACL at FU - 10 patients, partial remodelling - 5 patients, no healing - 1 patient. 4 patients refused to undergo MRI
Clnical outcome group B: IKDC clinical: 3 x A (25%) , 6 x B, 3 x C; IKDC subjective: 90,4 +/- 9,1
MRI group B: intact ACL at FU - 4 patients, partial remodelling - 5 patients, no healing - 3 patients.

Discussion

A treatment algorithm with arthroscopic ACL healing response technique provides better results regarding stability, patient satisfaction and remodelling of the previously injured ACL than conservative treatment, although both groups had an identtical revision rate with subsequent ACL reconstruction of 20%. Given the fact that a biologic approach with healing of a high grade ACL tear may not only preserve a better knee proprioception but also accelerates the overall recovery time to 3 months until return to pre-injury activity levels, this treatment option should be given more attention to in future ACL research.