Shorter Path Back

January 11, 2019

When football players undergo anterior cruciate ligament (ACL) replacement surgery, they generally expect to be sidelined for six to nine months. At Louisiana State University, however, players routinely return to play in five months.

So what’s the story behind LSU’s success? According to an article in The Advocate, it’s the material used to replace the ACL. 

Instead of using a part of the patellar tendon to replace the damaged ACL as most surgeons do, LSU Team Physician Brent Bankston, MD, an orthopedic surgeon at Baton Rouge Orthopaedic Clinic, uses hamstring tendons. This eliminates the need to cut pieces of bone at either end of the patellar tendon, which connects the kneecap to the tibia. While including small pieces of bone with the patellar tendon helps it heal faster when it takes the ACL’s place between the femur and tibia, it can also create pain for the athlete. Dr. Bankston said studies have shown that up to 30 percent of athletes experience some chronic pain in the area the bone was cut from, and some cases can result in fracture of the kneecap.

“I’ll give you many, many cases of athletes who have taken (the patellar tendon) from their good knee and it still aches today,” LSU’s Athletic Training Director Jack Marucci, MS, ATC, said. “(It) becomes the bad knee. That tells you alone, we’ve created a problem here. We know that creates a problem. So why do we keep doing that?”

LSU began using hamstring tissue instead of the patellar tendon to replace the ACL back in 2002 at the suggestion of then Head Football Coach Nick Saban, who had had a player use it during his previous coaching stint at Michigan State University.

“Saban pushed to go the other way,” said Dr. Bankston, who had used hamstring tendons before when doing the surgery with basketball players. “We said, ‘It’s a recognized surgery; it’s a good surgery; and we’ll see how it goes.’”

So if LSU is having this much success in getting players back on the field so quickly after ACL replacement, why isn’t everyone using the hamstring? One reason is that physicians have been concerned that the hamstring tissue wouldn’t hold up as well in football players compared to the patellar tendon, which is stiffer. However, LSU has seen only one re-tear in 39 replacements, which is about the same rate expected from more standard methods.

Steve Jordan, MD, an orthopedic surgeon at the Andrews Institute in Gulf Breeze, Fla., and Team Physician at Florida State University from 1991 to 2015, told the paper the hamstring surgery is also seen by many as unreliable because of early failures that resulted from ineffective techniques that have since improved. The article states:

“The earliest hamstring surgeries in the ’80s and ’90s, Bankston said, replaced the ACL with a strand from one hamstring tendon: the semitendinosus, which is not as stiff as the patellar tendon. Studies showed, Jordan said, that this method had a re-tear rate that was 1½ times higher than the patella surgery.

But over time, physicians started combining the semitendinosus with another tendon near the hamstring—the gracilis—and that made the graft just as sturdy as the patella tendon surgery.”

Dr. Jordan noted that a 2016 study published in The American Journal of Sports Medicine found that only “minor and mostly insignificant differences were found” between the two methods.

Marucci and his colleagues hope they can help change the perception of using hamstring tissue in ACL repair. They plan on publishing a paper detailing their success with the hamstring method in the next few months.

“They’ll always come back, ‘Where’s the hard evidence?’” said Derek Calvert, MS, ATC, an Associate Athletic Trainer at LSU. “Now we can say, ‘We have that paper that shows 17 years of a Division I college and what they’re doing.”

“Everyone is afraid to go against the establishment,” expanded Marucci. “That’s why we’re going to publish … this is a big deal.”

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