3-month return after ACL reconstruction – Will it stand the test?

Two posts of note about Australian footballer, Nick Malceski and ACL reconstruction from The Australian:

Nick Malceski

Malceski returns at a bionic pace

SYDNEY’s bionic man, Nick Malceski, is expected to line up with the Swans’ reserves next weekend, exactly three months after he tore the anterior cruciate ligament in his right knee.

It will be a timely boost for the Swans – who have missed Malceski’s sublime ball skills and hard-running from defence during the past few weeks – and an extraordinary ray of hope for athletes who suffer serious knee injuries.

Yesterday, exactly 11 weeks since he had a revolutionary knee operation that repaired his damaged ligament with a super-strong synthetic fibre, Malceski took part in a training session that went for nearly two hours.

If he had opted for a traditional knee reconstruction, using tendon taken from another part of his body to repair the ligament, he would not have started running yet and he would not be playing until next year.

But there he was at the Lakeside Oval next to the SCG, sprinting, chasing, kicking the ball long and moving freely alongside his team-mates.

“He is fully fit, but he has also got mental confidence,” said Sydney physiotherapist, Matt Cameron.

“If he looked tentative, we might hold him back, but he isn’t at all.”

Cameron and fitness head Rob Spurrs designed Malceski’s unique program, which condenses the usual 12 months rehabilitation into three months.

“Nick did a 1km time trial last Monday and did the same time (just over 3min10sec) he did in late January. He is back to the fitness levels he was at just before he got injured,” Cameron said.

Malceski only stood aside yesterday during a full contact tackling drill. While he has done some body-on-body training since re-joining team practice a week ago, he will be put to the sword with rigorous full contact training on Monday.

He ruptured his ACL in a pre-season NAB Cup game on February 17, and had the surgery, known as LARS (Ligament Augmentation and Reconstruction System), five days later.

Malceski walked out of the hospital unaided and club doctor Nathan Gibbs says he has been “great from day one”.

“Everything about Nick’s operation has gone as well as you could expect and we just hope it continues.

“You would not normally run for three to four months and he was running at one month, sprinting at two months and should be playing next week at three months,” Gibbs said.

Coach Paul Roos said it looked as if Malceski had not missed a beat.

“He still has to get through a couple of training sessions next week, but at this stage Nick is on track to play with the reserves next Sunday,” Roos said of Malceski, who was second in the Swans’ best and fairest award last year.

“We will get more of a gauge over the next week or so as to how close towards senior selection he is.”

Despite the optimism, there will be a good deal of finger-crossing and touching wood at the Swans during the next week and beyond as Malceski returns to the seniors.

The club came in for criticism from the medical profession when it was first revealed Malceski had opted for the radical procedure which is not commonly performed in Australia.

Gibbs and Cameron became familiar with it during visits over to European sporting clubs such as soccer giant AC Milan, and decided there was enough positive evidence to try it.

Gibbs knows the club will be under the spotlight as the sports’ medical profession watches to see if Malceski’s operation is successful.

“His accelerated rehab has gone very well … the risk is that he re-ruptures it,” Gibbs said.

“But people who have done the operation overseas say the risk is no different to a traditional ACL operation, which is that one in four or five rupture again.

“It is a calculated risk that we took for good reasons.”

But Gibbs won’t judge it successful just yet.

“I am ecstatic that the rehab has gone so well and ecstatic that he is on schedule to play at 12 weeks, but we are still very mindful that he is not out of the woods,” Gibbs said.

“There is a long way to go before we say it has worked.”

And when would that be? “When Nick finishes the year playing at a high level, does not re-injure it and wins the Norm Smith medal – though Geelong and Hawthorn might have something to say about that.”

Australian Football BJSM550


Miracle op to melt down surgeons’ phones

– James Fardoulys, May 10, 2008

IF Nick Malceski survives his first game back from injury next weekend, the phone lines of every knee surgeon in the country will run hot on Monday morning with patients asking for “the Malceski operation”.

Why?

Because Malceski injured his knee on February 17. That makes it a mere 12 weeks since his surgery on February 22, a lightning-fast recovery period compared to the traditional 12-month lay-off.

Malceski underwent a new type of anterior cruciate ligament repair, known as the Ligament Augmentation and Reconstruction System (LARS). Like most “new” technology, the history of this type of surgery goes back a couple of decades.

ACL surgery has been around since the 1950s, but became common from the 1980s.

In the past, attempts to directly repair the ligament have failed because it is difficult to suture and the knee difficult to adequately immobilise, which risks loosening the repair.

Surgeons then started using tendons from other sites as substitutes, or grafts, to make a new ACL. These were structurally stronger than the shredded ACL.

The downside was that new blood vessels and nerves had to grow into the graft, and structural changes occurred within the fibres of the graft, before it resembled the original ACL.

This “remodelling” process takes about a year, which is why traditional ACL graft patients are off sport for that length of time.

In the mid-1980s surgeons tried shortening this time off by removing the damaged ACL and replacing it with grafts made of artificial materials such as Dacron or Gortex. The new graft was at maximum strength from day one. There were additional benefits in avoiding problems such as pain, weakness, scarring or infection at the donor graft site, known as “donor site morbidity”.

Unfortunately the initial good results produced by artificial grafts were short-lived.

A knee moves backwards and forwards through about two million cycles per year. No artificial material lasts forever, and within a year most of these grafts have disintegrated.

Worse still, the ground-up debris often causes severe reactions within the knee joint. Typically these players, such as Footscray’s Rod MacPherson and Zeno Tzatsakis, returned for a handful of games, but didn’t play again after the artificial graft failed. The notable exception was Doug Hawkins, who took a year off, then played on for another decade.

In Canada a group tried a slightly different approach. They used an artificial graft stitched inside a hamstring (biological) graft. This was known as the Kennedy Ligament Augmentation Device (LAD).

“Augmentation” means to support a ligament rather than replace it. The idea was for the synthetic device to give short-term support to the hamstring graft until it became strong enough to carry the stresses and strains.

The key difference in this process is that the synthetic graft isn’t being relied upon to carry the long-term load.

The process worked for the Canadians surgeons. It didn’t seem to have the problems of the artificial ligaments used alone, but the biologic graft still took a year to remodel. With no great advantage, most surgeons simply ignored it and stuck to the standard biologic graft techniques.

Enter the LARS. With this technique the surgeon preserves and repairs the original ACL (which is removed with most of the other operations) and augments it with an artificial polyester graft.

It is closer in concept to the Kennedy LAD than the Gortex and Dacron devices. The LARS ligament is buried within the repaired ACL, supporting it while it heals. Because the preserved ACL already has its blood and nerve supply it heals more quickly than a graft — in about three to four months instead of 12.

French surgeon JP Laboureau, who developed the LARS, also looked at some of the other issues in the construction of artificial ligaments to make them friendlier to human biology.

Several thousand LARS devices have been inserted in Europe, so why is this new to us in Australia?

The answer is geography. The LARS was developed in Europe and most of the published data is in non-English journals.

The Europeans have traditionally been prepared to think outside the box and try new ideas, more so than the litigation-conscious English-speaking countries.

Some of their concepts are now widely used. The French decided to put the ball and socket of shoulder replacements the wrong way around in severe rotator cuff deficiencies — it works brilliantly.

The Germans and Swiss invented ways of fixing fractures which are now standard textbook stuff.

On the other hand, Europe is also home to so much voodoo, quackery, and snake-oil remedies, that English-speaking doctors are always cautious about seemingly wondrous claims, and like to test the merits of new techniques for themselves.

On the surface of it Laboureau seems to have done his homework. He has done extensive basic science work on his ligament design and manufacture, and on his operation technique.

In normal medical practice the patient will discuss with their surgeon the pros and cons of all their options. In the case of the LARS ACL reconstruction, do they want a tried and tested biological graft, for which they need one year off sport? Or do they want a LARS ligament repair, where they may be part of the surgeon’s learning curve, but the recovery is significantly shorter?

What about donor site morbidity versus foreign material? The last 20, or 50, or 200 cases the surgeon performed will influence the discussion. This is how medical decisions are normally made.

In practice this is what will happen:

Nick Malceski will run onto the paddock.

If he goes down in the first five minutes clutching his knee, the LARS ligament people might as well pack up and go on holidays for the next six months, because things are going to go very quiet for them.

If he gets through the game, and especially if he kicks a goal, they can cancel all their plans for the immediate future because they will be busier than the proverbial one-legged fireman stamping out bushfires.

That’s how sports people make decisions. Such is the fickle world of sports medicine.

James Fardoulys is a Brisbane orthopedic surgeon specialising in sports injuries

SYDNEY’s bionic man, Nick Malceski, is expected to line up with the Swans’ reserves next weekend, exactly three months after he tore the anterior cruciate ligament in his right knee.

It will be a timely boost for the Swans – who have missed Malceski’s sublime ball skills and hard-running from defence during the past few weeks – and an extraordinary ray of hope for athletes who suffer serious knee injuries.

Yesterday, exactly 11 weeks since he had a revolutionary knee operation that repaired his damaged ligament with a super-strong synthetic fibre, Malceski took part in a training session that went for nearly two hours.

If he had opted for a traditional knee reconstruction, using tendon taken from another part of his body to repair the ligament, he would not have started running yet and he would not be playing until next year.

But there he was at the Lakeside Oval next to the SCG, sprinting, chasing, kicking the ball long and moving freely alongside his team-mates.

“He is fully fit, but he has also got mental confidence,” said Sydney physiotherapist, Matt Cameron.

“If he looked tentative, we might hold him back, but he isn’t at all.”

Cameron and fitness head Rob Spurrs designed Malceski’s unique program, which condenses the usual 12 months rehabilitation into three months.

“Nick did a 1km time trial last Monday and did the same time (just over 3min10sec) he did in late January. He is back to the fitness levels he was at just before he got injured,” Cameron said.

Malceski only stood aside yesterday during a full contact tackling drill. While he has done some body-on-body training since re-joining team practice a week ago, he will be put to the sword with rigorous full contact training on Monday.

He ruptured his ACL in a pre-season NAB Cup game on February 17, and had the surgery, known as LARS (Ligament Augmentation and Reconstruction System), five days later.

Malceski walked out of the hospital unaided and club doctor Nathan Gibbs says he has been “great from day one”.

“Everything about Nick’s operation has gone as well as you could expect and we just hope it continues.

“You would not normally run for three to four months and he was running at one month, sprinting at two months and should be playing next week at three months,” Gibbs said.

Coach Paul Roos said it looked as if Malceski had not missed a beat.

“He still has to get through a couple of training sessions next week, but at this stage Nick is on track to play with the reserves next Sunday,” Roos said of Malceski, who was second in the Swans’ best and fairest award last year.

“We will get more of a gauge over the next week or so as to how close towards senior selection he is.”

Despite the optimism, there will be a good deal of finger-crossing and touching wood at the Swans during the next week and beyond as Malceski returns to the seniors.

The club came in for criticism from the medical profession when it was first revealed Malceski had opted for the radical procedure which is not commonly performed in Australia.

Gibbs and Cameron became familiar with it during visits over to European sporting clubs such as soccer giant AC Milan, and decided there was enough positive evidence to try it.

Gibbs knows the club will be under the spotlight as the sports’ medical profession watches to see if Malceski’s operation is successful.

“His accelerated rehab has gone very well … the risk is that he re-ruptures it,” Gibbs said.

“But people who have done the operation overseas say the risk is no different to a traditional ACL operation, which is that one in four or five rupture again.

“It is a calculated risk that we took for good reasons.”

But Gibbs won’t judge it successful just yet.

“I am ecstatic that the rehab has gone so well and ecstatic that he is on schedule to play at 12 weeks, but we are still very mindful that he is not out of the woods,” Gibbs said.

“There is a long way to go before we say it has worked.”

And when would that be? “When Nick finishes the year playing at a high level, does not re-injure it and wins the Norm Smith medal – though Geelong and Hawthorn might have something to say about that.”

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