Post-Gazette: To their knees – An emerging approach to ACL reconstruction shows promising outcomes
Heading into her junior year of high school, Audrey Biggs was on the verge of a breakthrough summer.
Just as the 16-year-old executed her signature head-fake move at the 2022 Under Armour Basketball Tournament in Indianapolis, however, her knee gave out with a “pop” that echoed through the gym.
Tearing her anterior cruciate ligament, or ACL, meant Biggs would sit on the sidelines for six months, so she didn’t think it was possible to return midway through her junior year campaign.
But she did.
In fact, Biggs made a dominant comeback, averaging 12.0 points and 4.9 rebounds over 13 games for Boyd County High School in Catlettsburg, Ky.
This successful return led to her commitment to play basketball at Pitt this fall, which she credits to a relatively new technique known as fertilized ACL reconstruction developed by an orthopedic surgeon at W.V.’s Marshall University. The method — an add-on to the traditional ACL repair — significantly reduces recovery time and re-injury rates, according to recent research.
While the procedure shows promising outcomes, it remains an emerging option still undergoing clinical trials. With the nearest surgical site about 100 miles from Pittsburgh, local surgeons are interested in the technique’s possibilities, including its recovery timeline.
From paper to practice
A long snapper at West Virginia University in the early 2000s, Chad Lavender remembers his teammates getting injured. With that memory intact, he developed the fertilized ACL technique in 2018 as a surgeon at Marshall Orthopaedics in Huntington, W.V.
Results of a four-year clinical trial, published in 2023 in the Marshall Journal of Medicine, showed that 80% of participants in the fertilized ACL group returned to normal function in three months, versus 35% who underwent a traditional ACL reconstruction, with a typical recovery taking six to nine months.
A newer study released last month by Lavender’s team in the journal Arthroscopy found that those who received the fertilized ACL procedure had improved knee movement, better limb symmetry, enhanced bone tunnel healing and higher quality-of-life ratings.
In with the new
As the fertilized ACL procedure remains an emerging technique among most orthopedic surgeons, many standard ACL reconstruction methods have evolved as well, also leading to quicker recoveries.
From immobilization following surgery to femoral nerve blocks, many practices in ACL reconstruction surgery now are largely accepted as “old school.”
Aman Dhawan, an orthopedic surgeon at Penn State Health, is open to using the biological components of the fertilized technique to enhance graft incorporation, but is concerned about the long-term outcomes of internal braces. His caution is related to the Lars graft, a synthetic ligament introduced in 1992 that showed high failure rates years after implantation.
“The jury is still out on any technique that uses a synthetic graft, including the fertilized method,” said Dhawan. “There are certainly others that have also incorporated some of these synthetics to their ACL techniques, but until we get data four or five years out, and we see what these do, I think we have to take everything with a little bit of a grain of salt.”
Shaka Walker, an orthopedic surgeon at St. Clair Hospital, has not performed the fertilized ACL technique but often uses internal braces with cadaver grafts for added support and stability. He too believes more data is needed to assess the long-term benefits of the fertilized technique.
Previously, the standard procedure involved a femoral nerve block that immobilized the quadriceps muscle and used a large drill for the tunnels that went entirely through the bone.
Now, Lavender, Varacallo and Walker use different types of nerve blocks that effectively control pain while preserving muscle function. They also use a smaller drill that only partially penetrates the bone, removing as little bone as needed to secure the graft in place.
Dhawan and Walker, despite performing standard ACL reconstructions, have discontinued femoral nerve blocks, saying that they may slow down recovery, especially in the quadriceps muscle.
“I’d be very interested to see what the five-year data looks like from Dr. Lavender, and I certainly wouldn’t dismiss the work he’s done, because I think it’s very interesting,” said Walker. “I suspect from the preliminary information that I read, [the fertilized technique] probably will work, but the question is, will it work better than what we’re currently doing?”
Going in strong
For a successful outcome, Varacallo said that perfect surgery alone isn’t enough — the key is rehabilitation, which starts well before surgery.
Pre-habilitation, once contraindicated before ACL reconstruction, is now the standard for all ACL treatments. In a 2022 study, researchers found that four to six weeks of pre-habilitation improves strength, range of motion and the chances of returning to sports.
Samantha Morgan, ACL Orthopedic Navigator at Penn Highlands DuBois, starts with postural and mobility assessments to identify functional weaknesses and create personalized plans. While Biggs underwent four weeks of pre-habilitation at Marshall University before surgery, the timeline varies for each athlete.
“The pre-op sometimes can take a month,” Varacallo said. “But if a patient is not swollen, has good knee movement, and can lift their leg strongly, they’re ready for surgery.”
Walker said immediately after undergoing an ACL reconstruction — whether traditional or fertilized — patients need to start physical therapy.
“We teach them how to be masters of the first sets of exercises that they’re going to do after surgery,” said Morgan. “We’re going to fix some mechanics, some things like that that maybe put them at a predisposition to injury.”
Proper rehabilitation after surgery is crucial for many procedures, from knee replacements to open-heart surgeries. After physical therapy, Varacallo said athletes must undergo functional testing before returning to sports.
‘It’s going to be worth it in the end’
One hundred days.
That’s how long it took for Marina Hanes, 17 and a rising senior at DuBois Central Catholic High School, to be fully cleared for sports after tearing her ACL and undergoing fertilized reconstruction surgery by Varacallo in January.
Thirty-eight days following her return, Hanes had the hit that secured the PIAA Class A Softball State Championship win for DuBois Central Catholic in a 2-0 victory over Carmichaels.
And yes, the crowd went wild.
“I was bringing the ball up the court, and I crossed over, and my foot planted, my knee went the other way and then I just collapsed on the floor,” she said, referring to the moment when she tore her ACL in a January basketball game. “At that point, I knew I was done for the season.”
Sarah Geishauser, 18 and a 2024 graduate of Bishop Guilfoyle Catholic High School in Altoona, Blair County, also had a PIAA state championship appearance. The Lady Marauders took down Mountain View, 35-17, to claim the 2024 1A state basketball championship on March 22.
In November, Geishauser tore her ACL during a PIAA state semifinal soccer game, after which she also had the procedure.
“I actually didn’t know [I tore my ACL], because I tried to run after, and then I was out for the rest of the game, and then we actually thought it was my hamstring for two weeks,” she said.
Both athletes credit the team effort and support system at Penn Highlands DuBois for helping them return to play in their respective PIAA championships.
“It’s all behind me now,” Geishauser said. “I would still be recovering, but I’m already healed.”
Bringing innovation home
From the Steelers to the Penguins and Pirates, Pittsburgh is a sports hub. Steel City, however, also graces headlines as a hub for medical innovations.
With more research, Dhawan and Walker believe that the fertilized technique may make its way into the hands of ambitious surgeons in the city.
Besides Varacallo, neither Dhawan nor Walker have heard of any other physicians in the state using the fertilized ACL reconstruction technique due to the newness of the procedure. However, they believe the more data Lavender and Varacallo put out, the more surgeons may be willing to implement the technique.
“In anything we do in medicine, the best way to determine whether or not the treatment is effective is to run one technique against another technique and compare the results,” said Walker.
For Biggs, now an incoming freshman at Pitt, she would like the fertilized ACL technique to make its way to health care systems in Pittsburgh. She believes by doing so, it will help other athletes on their ACL recovery journeys.
“I think that having the [fertilized ACL] surgery here would be great because of the city of Pittsburgh and its reputation of what we have here [medically],” Biggs said.
“This specific surgery has helped so many athletes get back faster, stronger and better than before, so I think having it in Pittsburgh would be great.”
First Published August 11, 2024, 5:30 a.m.