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We invented the ACL knee stem cell injection procedure like we invented many of the same day orthopedic injection procedures being offered today. What prompts this blog post is an e-mail from a patient who reported her results and recovery. Like many of our patients, she avoided an ACL surgery recovery through the Perc-ACLR procedure. Hence I’ll spend a bit of time going over ACL surgery recovery and then compare and contrast that to what she experienced.

The Knee ACL Ligament

The knee anterior cruciate ligament or ACL is a major internal stabilizer of the knee joint. It controls the forward and rotational movement of the bottom leg bone (tibia) on the upper thigh bone (femur). It can be injured by trauma and often if the patient continues to have pain, they are offered an ACL reconstruction surgery (1).

Knee ACL Surgery Recovery

If you have a knee ACL reconstruction surgery, holes are drilled in the femur and tibia and a tendon from the patient or a cadaver ligament is strung between the two spots. The new ligament is not really like the original equipment, in that it’s inserted at a very different angle and it doesn’t have any position sense (called proprioception) (2). In addition, a natural ligament has two bands that help control rotation, but the vast majority of ACL reconstruction surgeries only install one tendon, so this original architecture is not replicated in the surgery (3).

Because of all of this, ACL surgery recovery takes about a year. For example, In one recent research study, it took professional football players about a year to return to play after ACL reconstruction surgery (4). A different study examined an accelerated return to play protocol with the goal of getting athletes back to sports faster by 6 months and discovered that only a measly 19% could get back that fast (5). In addition, at least one group of researchers has shown that the evidence supports that athletes should wait two years before returning to sports (11). Hence, despite what some orthopedic surgeons claim, it’s highly unlikely that you will return to sports any sooner than 9-12 months if you have surgery!

Is ACL Surgery a Major Surgery?

As discussed, the procedure involves drilling holes in bones and then usually harvesting a tendon by cutting a piece out of one of your tendons (usually patellar tendon or hamstrings). Recent research has surprisingly shown that based on markers of cartilage injury, the surgery is actually a second insult to the joint cartilage (6). Complications include blood clots, pulmonary embolism, infection, nerve damage, ACL graft failure and other problems (7). Hence, no matter how you cut it, this surgery is a major procedure.

What Can I Expect after ACL Surgery?

Expect significant pain that requires narcotics for a few days to a few weeks (on average 9 days) (12). Most surgeons won’t want you walking without a brace and crutches for the first few weeks as the tendon or ligament graft has to adhere to bone. Average time to get rid of crutches spanned from 2-3 weeks (13) and return to driving about two weeks. However, be cautious, as several studies have discussed that reaction time to brake with the right leg being operated can be delayed for 3-6 weeks (14, 15) Hence, physical therapy is begun with simple range of motion exercises and then touch down weight bearing that advances by to place more weight on the knee without crutches. Return to work takes two weeks to 3 months, less if you’re in a white-collar job and slightly more in occupations that use the knee or legs to lift (8). Simple straight-line exercises can be performed by 3-months at that time including light running with a brace and most patients advance to light cutting and pivoting by 6 months (16). Improving strength is key during this time.

Can You Avoid ACL Surgery?

At Centeno-Schultz, we developed an ACL injection procedure that involves the injection of high dose bone marrow concentrate taken from the same patient as a way to treat about 2/3rds of the ACL tears that normally require surgery without that invasive procedure. This is called the Perc-ACLR procedure (Percutaneous ACL Reconstruction) and it involves very precisely injecting the stem cell containing bone marrow cells into the ACL tear using C-arm fluoroscopy. This is a very technically demanding procedure to perform through a needle that takes months to years of specialized training to master. To get a sense of what that procedure looks like, check out my video below:

Stem Cell Therapy maxresdefault - ACL Surgery Recovery vs Perc-ACLR

We’ve published two studies so far showing quicker return to sports than ACL reconstruction surgery as well as good evidence of healing on post-injection MRIs (9,10). We are completing a randomized controlled trial which will be submitted for publication soon and these results continue to show excellent outcomes.

How Quick is Perc-ACLR Recovery?

First, there is no time on crutches.  Patients are placed in a brace and walk out of the office. Narcotics are used for 1-2 days. Since there are no crutches, most office patients return to work immediately or take 1-2 days off. While only 19% of ACL surgery patients get back by 6 months, the vast majority of our patients are back playing by 6 months. Why? Less trauma to perform the procedure means a much quicker recovery.

One Patient’s ACL Recovery Journey with the Perc-ACLR Procedure

It’s always great to hear how your patients are doing many years after a procedure. Renatta had the Perc-ACLR procedure three and a half years ago instead of ACL surgery and here is her e-mail that she just sent Dr. Markle:

“Hello Dr. Markle, I hope you are doing well…It’s been 4 years since I tore my ACL and it will be 4 years this coming March since the 1st Regenexx ACL procedure with you…I have no complaints and I’m fully functional with some minor limitations…I have been spreading the word about the Regenexx procedure. In fact, one of my co-workers recently flew to Colorado and saw you. …Take care and thanks again for what you & the Regenexx team has done in healing my knee! :-)”

The upshot? ACL surgery recovery can be tough, but about 2/3rds of patients who now get surgery can be treated using the Perc-ACLR procedure and enjoy a much quicker recovery. Find out if you’re a candidate for this groundbreaking new technology developed at CSC!

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References:

(1) Filbay SR, Grindem H. Evidence-based recommendations for the management of anterior cruciate ligament (ACL) rupture. Best Pract Res Clin Rheumatol. 2019;33(1):33–47. doi:10.1016/j.berh.2019.01.018

(2) San Martín-Mohr C, Cristi-Sánchez I, Pincheira PA, Reyes A, Berral FJ, Oyarzo C. Knee sensorimotor control following anterior cruciate ligament reconstruction: A comparison between reconstruction techniques. PLoS One. 2018;13(11):e0205658. Published 2018 Nov 15. doi:10.1371/journal.pone.0205658

(3) Desai N, Björnsson H, Musahl V, Bhandari M, Petzold M, Fu FH, Samuelsson K. Anatomic single- versus double-bundle ACL reconstruction: a meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2014;22:1009–1023. https://doi.org/10.1007/s00167-013-2811-6

(4) Okoroha KR, Fidai MS, Tramer JS, Elmenini J, Makhni EC, Verma NN, Bach BR, Moutzouros V. Length of Time Between Anterior Cruciate Ligament Reconstruction and Return to Sport Does Not Predict Need for Revision Surgery in National Football League Players. Arthroscopy. 2019 Jan;35(1):158-162. doi: 10.1016/j.arthro.2018.08.007. DOI: 10.1016/j.arthro.2018.08.007

(5) Raoul T, Klouche S, Guerrier B, El-Hariri B, Herman S, Gerometta A, Lefevre N, Bohu Y. Are athletes able to resume sport at six-month mean follow-up after anterior cruciate ligament reconstruction? Prospective functional and psychological assessment from the French Anterior Cruciate Ligament Study (FAST) cohort. Knee. 2019 Jan;26(1):155-164. doi: 10.1016/j.knee.2018.11.006.

(6) Larsson S, Struglics A, Lohmander LS, Frobell R. Surgical reconstruction of ruptured anterior cruciate ligament prolongs trauma-induced increase of inflammatory cytokines in synovial fluid: an exploratory analysis in the KANON trial. Osteoarthritis Cartilage. 2017 Sep;25(9):1443-1451. doi: 10.1016/j.joca.2017.05.009.

(7) Rousseau R, Labruyere C, Kajetanek C, Deschamps O, Makridis KG, Djian P. Complications After Anterior Cruciate Ligament Reconstruction and Their Relation to the Type of Graft: A Prospective Study of 958 Cases.  2019 Sep;47(11):2543-2549. doi: 10.1177/0363546519867913

(8) Groot JA, Jonkers FJ, Kievit AJ, Kuijer PP, Hoozemans MJ. Beneficial and limiting factors for return to work following anterior cruciate ligament reconstruction: a retrospective cohort study. Arch Orthop Trauma Surg. 2017;137(2):155–166. doi:10.1007/s00402-016-2594-6https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5250649/

(9) Centeno CJ, Pitts J, Al-Sayegh H, Freeman MD. Anterior cruciate ligament tears treated with percutaneous injection of autologous bone marrow nucleated cells: a case series. J Pain Res. 2015;8:437–447. https://www.ncbi.nlm.nih.gov/pubmed/26261424

(10) Centeno C, Markle J, Dodson E, et al. Symptomatic anterior cruciate ligament tears treated with percutaneous injection of autologous bone marrow concentrate and platelet products: a non-controlled registry study. J Transl Med. 2018;16(1):246. https://www.ncbi.nlm.nih.gov/pubmed/30176875

(11) Nagelli CV, Hewett TE. Should Return to Sport be Delayed Until 2 Years After Anterior Cruciate Ligament Reconstruction? Biological and Functional Considerations. Sports Med. 2017;47(2):221–232. doi:10.1007/s40279-016-0584-z

(12) Obermeier MC, Sikka RS, Tompkins M, et al. Examination of Early Functional Recovery After ACL Reconstruction: Functional Milestone Achievement and Self-Reported Function. Sports Health. 2018;10(4):345–354. doi:10.1177/1941738118779762

(13) The Videoinsight® method: improving rehabilitation following anterior cruciate ligament reconstruction–a preliminary study.
Zaffagnini S, Russo RL, Marcheggiani Muccioli GM, Marcacci M
Knee Surg Sports Traumatol Arthrosc. 2013 Apr; 21(4):851-8. https://www.ncbi.nlm.nih.gov/pubmed/23361651/

(14) DiSilvestro KJ, Santoro AJ, Tjoumakaris FP, Levicoff EA, Freedman KB. When Can I Drive After Orthopaedic Surgery? A Systematic Review. Clin Orthop Relat Res. 2016;474(12):2557–2570. doi:10.1007/s11999-016-5007-9

(15) Gotlin RS, Sherman AL, Sierra N, Kelly M, Scott WN. Measurement of brake response time after right anterior cruciate ligament reconstruction. Arthroscopy. 2000 Mar;16(2):151-5. https://www.ncbi.nlm.nih.gov/pubmed/10705325/

(16) Harris JD, Abrams GD, Bach BR, Williams D, Heidloff D, Bush-Joseph CA, Verma NN, Forsythe B, Cole BJ. Orthopedics. 2014 Feb;37(2):e103-8. doi: 10.3928/01477447-20140124-10.