Improving outcomes for young athletes needing ACL reconstruction

An anterior cruciate ligament (ACL) tear can be devastating to a young athlete. The ACL helps control rotation of the knee and is most commonly torn in sports involving sudden stops and changes in direction like soccer and basketball. Recovery can take, on average, nine months to one year.

While the ACL can be reconstructed through surgery, there is a high risk of re-injury – up to 20 per cent – in patients under the age of 25. To make matters worse, a second surgery (called a revision surgery) is never as successful as the original.

ACL reconstruction surgery uses a graft to rebuild the torn ligament. Grafts are pieces of tissue commonly created from a part of the patient’s body, such as one of the hamstring tendons or the tendon of the kneecap (patellar tendon). 

In an effort to improve patient outcomes, Dr. Alan Getgood, Scientist at Lawson Health Research Institute, explored the benefits of performing an additional surgical procedure in young athletes undergoing ACL reconstruction surgery. Called lateral extra-articular tenodesis (LET), the additional procedure involves creating a new ligament-like structure outside of the knee to provide additional support. 

In the largest randomized clinical trial of its kind, Dr. Getgood and a team of researchers have shown that performing LET may reduce the risk of ACL re-injury in young athletes.

“Although the LET procedure has shown potential in improving patient outcomes, a randomized clinical trial was needed to assess whether or not it reduces the risk of re-injury,” explains Dr. Alan Getgood, who is also an Orthopaedic Knee Surgeon at the Fowler Kennedy Sport Medicine Clinic, which is a collaborative partnership between London Health Sciences Centre (LHSC) and Western University, and Assistant Professor at Western’s Schulich School of Medicine & Dentistry.

Dr. Getgood led the STABILITY trial which included 624 research participants from nine centres across Canada and Europe, including 196 patients from the Fowler Kennedy Sport Medicine Clinic who were treated at University Hospital, LHSC. Participants were under the age of 25, undergoing ACL reconstruction using a hamstring graft and at high risk for re-injury.

Half the participants were randomized to receive standard of care, consisting of ACL reconstruction without LET, and the other half received ACL reconstruction with the additional LET procedure. Re-injury occurred in 11 per cent of patients receiving the standard of care compared to only four per cent of patients who received ACL reconstruction with LET.

“Adding the LET procedure resulted in a 65 per cent relative risk reduction for graft failure,” says Dr. Getgood. “Our results suggest patients under the age of 25 should consider the LET procedure when they have decided on ACL reconstruction using a hamstring graft.”

The research team studied a number of other outcomes including pain, athletic function, muscle strength and return to sports. Although the LET procedure resulted in slightly higher levels of post-operative pain and slightly decreased muscle strength in the three months following surgery, these complications did not persist. There were no differences in outcomes one and two years after surgery. 

The STABILITY trial was funded by the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS). Results were shared last week at the ISAKOS Biennial Congress where the research group was awarded the Jan I. Gillquist Scientific Research Award for best scientific paper presented at the meeting. Dr. Getgood and the STABILITIY team are also being recognized by the American Orthopaedic Society for Sports Medicine (AOSSM) with the O’Donoghue Award for best clinical-based research paper. The award will be presented at the AOSSM Annual Meeting in July.

Dr. Getgood recently received funding from the Canadian Institutes of Health Research (CIHR) to conduct a follow-up study called the STABILITY 2 trial. The study will compare ACL reconstruction with and without LET using two other types of grafts - patellar tendon grafts and quadriceps tendon grafts.

“Our goal is to determine whether the choice of graft affects patient outcomes and whether or not LET should be used with either choice,” says Dr. Getgood. “Ultimately, we hope to enable patients in getting back to the activities they love most.”

For more on the STABILITY trial and how it helped young field hockey player, Payten Lang, check out this article from inside LHSC, a London Health Sciences Centre (LHSC) publication.  

Dr. Alan Getgood (above) led the STABILITY trial, showing that performing LET in addition to ACL reconstruction may reduce the risk of ACL re-injury in young athletes.