UTK Special 1/25/22

An ACL Revolution from an Unusual Place

Ronald Acuna Jr. lay face down in the warning track dirt, his knee twisted behind him. He made one attempt to get up, then went back down, waiting for the Athletic Trainer to make the long run from the dugout to right field. That image of one of the top young stars in the game, felled by an unlucky step, resonated and felt like Atlanta’s hope of a deep run was in the same spot.

We know now that the Braves were able to overcome the loss of their superstar, plus more injuries, but Acuna was left heading to surgery. We’re six months out from that now and Acuna is hitting again, hoping to be ready whenever the season starts. ACL surgery was successful, as it often is, but the loss of Acuna could have been devastating for the Braves and for the game, with a loss of nine months to a year to the rehab.

While an ACL (anterior cruciate ligament) sprain and re-construction is less common in baseball than other sports, the surgery is largely the same as it has been for decades. There’s significant evidence that Mickey Mantle had ACL surgery in his early career, making him perhaps the earliest elite athlete to have the surgery.

While there have been modifications to the surgery over the years, most have been evolutionary rather than revolutionary. The damaged ligament is removed and tunnels are drilled where a transplanted tendon, usually from a center-cut of the patient’s own patellar tendon (called an autograft), the tendon is then looped through the holes and anchored in place.

It’s relatively simple as a procedure and largely successful. There are variants on how and where the tunnels are placed, which tendon is used to reconstruct the damaged ligament, and there’s some use of allografts, a donated tendon from another person, usually a cadaver’s Achilles for size and strength.

This common procedure has a common rehab as well and again, this has been more or less in place since the 1980’s with only evolutionary changes. The biggest change has been a quicker weight bearing phase, rather than waiting for the anchors to fully heal, which can take six to eight weeks.

It’s not just elite athletes like Acuna, Andrew McCutchen, or a long list of players like Saquon Barkley in football. ACL injuries are prominent at lower levels of football and rampant in female sports like soccer, volleyball, and basketball. All mean a painful injury, an expensive surgery, and a long rehab with lost time, potentially ending a career or missing that final season of school age competition.

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ACL injuries can happen anywhere, even rural Chesapeake, West Virginia. Sports are big in the Mountain state, from perennial power West Virginia University to Marshall, a well-known Division 1 school, and huge in high school sports as well. It’s this state, these valleys, the twisting roads from place to place, where Dr. Chad Lavender practices and where a new technique might completely change how ACL reconstruction is done and how athletes return from it.

Lavender’s story is common to many orthopaedic surgeons. He was an athlete himself, a long snapper at WVU, who realized his sports career was going no further, but using sports to further his own plans. Lavender stayed at WVU for medical school and came to Marshall for his residency, where he’s built an innovative practice.

“The key to all this is the support I get,” said Dr. Lavender in an talk we had in January 2022. “Marshall Orthopedics and this community has allowed me to do so much. This is where I’m from, so I don’t think I could have done this kind of thing at a Harvard, at a Stanford.”

What Lavender has done is a modification of the surgery itself, again more of an evolution than revolution, but that has taken the return time from this kind of surgery and cut it by half and potentially more.

The surgery is called “Lavender Fertilized ACL” (I’ll call it LFA for ease) and the description is dead on. The surgery itself is done arthroscopically - an “all inside” technique that is common but not ubiquitous in a world where open (large incision) surgery is still commonly done for this procedure. Dr. Lavender also uses an autograft that isn’t common, using the quadriceps tendon rather than the patellar or hamstring tendon.

“It’s a strong tendon for the graft,” Lavender explained, “and anecdotally, people just seem to recover faster, so that’s what I’ve focused on.”

Lavender then supports the transplanted tendon with a piece of Arthrex Suturetape, a new procedure called InternalBrace. (I was the first mainstream writer to discuss this procedure, in this article.) This is becoming more common in all sorts of joint reconstructions, with much of the focus on ankles and elbows. Lavender’s use of the InternalBrace procedure helps guard the healing ligament and makes the overall construct stronger.

It’s the next part where Lavender’s procedure is radically different. For years, doctors have used biologic agents to help strengthen or heal areas. Common examples include platelet rich plasma therapy, where the patients blood is drawn, spun down to get to a more concentrated mixture, and injected back into the injured site, and more complex things like Orthokine. Lavender uses aspirated stem cells, or as Dr. Lavender says, stromal cells.

“We use a special demineralized bone matrix. You can work with it and put it up in those tunnels, in both the femur and the tibia,” Lavender explained. “It has some staying power. Then a couple years ago, I realized that while I was drilling those tunnels, I could use that bone, the [patient’s own] bone, and mix it in with the demineralized bone matrix.” The bone shaving, which was normally discarded, is instead spun in a small centrifuge to get the stromal cells at a higher concentration. The bone shaving, which was normally discarded, is mixed with the stem cells and demineralized bone matrix into a putty, it is then used to fill the tunnels once the tendon is anchored into place.

Biologic agents like Lavender’s 'putty’ are common and legal. Standard Suturetape comes with a collagen solution on the surface, but studies on its use show very little change in terms of efficacy. “It’s like what you do with a potted plant,” Lavender says. “That’s why I call it a fertilized ACL. We’re fertilizing that socket, waiting for the seeds to grow.”

The combination of all these techniques makes up the complete procedure and they all contribute to the results. It’s those results that really stand out.

In the most basic sense, the LFA procedure allows for the possibility of quicker healing, protects the graft more, and allows for a return to work or play in about half the time as the current standard procedure and rehab, though Dr. Lavender is careful never to emphasize that.

The rehab itself is not significantly different than normal ACLs, and have been handled by many physical therapists. “I get calls from them. The therapists continued to call me patient after patient, asking ‘How am I supposed to react with patient X? He's already at the 12 week timeframe, he's running at six weeks, what do you want me to do? Do you want me to hold him back?’”, Lavender said. “I started to be very free with our PT protocol and basically started allowing them to return at their tolerance. I really didn't give them a lot of limitations other than no pivoting or cutting sports.

Lavender continued. “[The patients] routinely would would run at six to eight weeks, they routinely at 12 weeks would pass their testing to return to play! Still today, I hold athletes until the whole six month period. I don't let them return to full activity, except for very isolated scenarios, where the benefit outweighed the risk for them to return early. That's where we are now. The research that I have shows at 12 weeks the operative knees are performing at 80 percent of the non-operative knees, which may correlate with earlier return to play at, say, four and a half months.”

While Lavender holds to the six month limit for return to sport, I had to ask about those limited situations. My guess was that he would be a bit freer for someone in their senior season. “You're exactly right,” he said. “Basically, the timing has to work out to be four and a half months. It has to be a low risk position, or someone that their livelihood depends on it, or a scholarship depends on it. Very few instances. The misconception is that we're out here returning kids to play at six weeks and that's not true. They are running and doing things [in therapy] at that point, but we haven't returned somebody that early, nor do we expect it. Now the four and a half month mark, I think is reasonable in the future based on the data.”

Lavender isn’t keeping his procedure a secret either. He’s been teaching doctors around the country and some are doing the procedure themselves, though he’s yet to see large numbers of doctors adopting the procedure. Overall, Lavender thinks the procedure has been done over 500 times, between himself, other surgeons at Marshall, and other doctors who have learned the technique.

Lavender explains that he doesn’t think there’s a problem with any other techniques. “I've always tried to make a point that this is more about research than it is to sit here and say, well, we've found the holy grail of ACL surgery,” he says. “What we're saying is we're continuing to research this and we're really pleased with our early term results. We have a randomized trial that we've already finished enrollment in and some of that data is already finalized. We're really excited about the future of this technique.”

Lavender continues, saying, “I think it's all how you frame things. You would never hear me say this is the only way to do it. That's not what I say. When I go out and talk to surgeons, I'm not telling them to stop going patellar tendons or stop doing hamstrings. They should use what they think is best.”

While Dr. Lavender does defer some to other approaches, that doesn’t mean that he lacks confidence in what he’s doing. “I feel like in five to ten years, every surgery will have some type of orthobiologic medium, following after what we're doing and kind of showing that thought process. It may not be my actual consistency, right or the the the composite graft that I use, but I think they'll have InternalBraces and I think there'll be some aspect of biology in those high level athletes. I really believe that.”

The easy thing to do to promote this surgery would be chase a big name athlete. They’ve called, Lavender told me, but elite athletes seldom want to be first, especially with a change from a successful, predictable procedure. Teams have enquired too, but Lavender hasn’t sought out a big name to promote his procedure.

“For example, a new study that came out a couple months ago, specifically looking at young female soccer players,” Dr. Lavender explained. “They have about a 30 to 40 percent chance of another ACL injury under the age of 20. When you're faced with those type of issues and we talked about the return to play rates as low as 60 percent, that's what's given me so much passion towards the knee, the ACL, because there's so much we can improve on right. Standard rotator cuff, 90 to 95 percent of those patients do very well. That's one of the reasons that I focus so much on the ACL and on young athletes in West Virginia. That’s my passion.”

The other problem is that even cutting the return time in half isn’t the cure-all for the ACL that many would hope for. Ronald Acuna Jr. had his knee injury on July 9th and had the surgery about a week later. Even at the most aggressive, Acuna would not have come back from his injury in time to play in the World Series three months later. He would, however, have had a much shorter rehab time, allowing him to be more ready for the 2022 season.

We saw another example of why LFA could be game changing with Saquon Barkley in 2021. Barkley, the star running back for the New York Giants, sprained his knee in the first week of the 2020 NFL season. He missed the entire season, but wasn’t back to 100 percent by the start of the next season, a full year after his injury and subsequent surgery.

Barkley had the best of care and rehab, yet still struggled to come back. His 2021 season was a disappointment, and many pointed to a recent study done by Dr. Tim Hewett, a professor and researcher at the Mayo Clinic. Hewett’s study is summarized in this quote from the paper, originally published in the Journal of Sports Medicine:

“[W]e present evidence in the literature that athletes achieve baseline joint health and function approximately 2 years after ACLR. We postulate that delay in returning to sports for nearly 2 years will significantly reduce the incidence of second ACL injuries.”

However, even Hewett seems intrigued by the LFA. “I spoke with Dr. Lavender at length at [a convention] and the technique sounds potentially promising,” Hewett told me via email. “I’d say ‘proceed with caution’ given the biological considerations and cautions in our two year paper.”

Dr. Lavender agrees. “Dr. Hewett is absolutely correct and his research clearly shows there is evidence that if we wait longer we will have fewer re-ruptures,” he said after hearing Dr. Hewett’s quote. “However the question is where is the risk benefit ratio balance for return to play appropriate and also it is important to continue to study different novel techniques and subgroups that could return safely at earlier timepoints. Many surgeons certainly feel biologics and the InternalBrace could be the answer to that, but further study will be needed.”

There’s a question about whether people will need an accelerated return, whether for competitive or lifestyle reasons. If this surgery continues to prove effective, it will give people the option, something that doesn’t exist today and could be extremely valuable. Everyone seems to agree with that, at least.

While most people focus on return to play, whether for elite or youth athletes, usually measured as a function of time, Dr. Lavender points to a more technical test as a better judge of why LFA is a better technique for many. That’s what’s simply called the hop test and it is a standard technique for measuring progress after any knee injury, requiring each patient to perform several types of single leg hops.

With a recent blind study, a group of patients were divided into two groups and tested by physical therapists that didn’t know which group was which and tested them at twelve weeks. The group that had undergone LFA consistently showed significantly higher scores at that point in time in their rehab.

I showed these results to Brittany Dowling, a well-respected biomechanist currently working at Midwest Orthopaedics at Rush in Chicago, and she agreed that these early results showed good potential. “This is a great first step but there are other tests I’d like to see - tuck jumps, drop jump, cutting using motion capture and force plates, even strength measures- but there’s a lot of room for further research from here.”

Another issue that is raised about the LFA is that while the procedure has shown good early results, there is very little published data. That kind of data takes years and while Lavender and others are starting to publish this, more research will be necessary.

Part of this is in the graft itself, where all the work on the tunnels and the protection by the InternalBrace doesn’t make the transplanted tendon become a functional, living ligament any faster. Yes, the tendon actually changes at a cellular level, but those changes come in a four to five year period and nothing that is done in this or any surgery is known to accelerate that process.

Again, Dr. Lavender understands this line of thinking and agrees. “I would again say this is why we are studying this and in no way would we make a comment we certainly can bypass previous knowledge and return to play at three or four months at this point,” he answered.“Our goal at this point is to study whether patients can return safely sooner than six months, but also understanding our technique only can add to the previous standard reconstructions because it is safe and doesn’t add any complications.”

While Dr. Lavender has focused on the knee and specifically the ACL with his procedure, I asked him if this could be used for other techniques. InternalBrace has been used extensively with ankles and elbows. Lavender wouldn’t speculate on that possibility, given his focus both on knees as a specialty and on his practice in West Virginia. “We just see more knees,” he explained.

Stories like the one above are anecdotal, but show both the potential and the risks of judging procedures like this. Davis made it back and started his football career at WVU, only to be felled by an autoimmune disease, causing him to get to dangerous blood counts. This obviously has nothing to do with his knee, but Davis’ inability to continue with football could be considered a ‘failure’ in some studies.

To be clear, this is very early days for LFA in terms of validation studies. Lavender acknowledges this and is excited that he’s getting some of his first three-year studies done to go with some of the exciting early results. “A new procedure isn’t going to have five and ten year studies,” Lavender explained, “and people want that. I get it. The profession moves slowly for reasons, but what we’ve seen is promising. What really means the most to me is seeing these kids back on the field, doing what they love and getting a chance maybe they wouldn’t have had.

As those studies come out - and a major one for the LFA is upcoming in spring 2022 with the first look at that three year data - it will be interesting to see how quickly the surgery is integrated. There are other innovative techniques, from the InternalBrace ACL to the late Dr. Freddie Fu’s “anatomic reconstruction” that he developed over years and has been widely adopted in European soccer.

Then again, who knows when something could go viral in the modern world? “We had a patient who put out a video on TikTok,” Lavender said with a laugh. “And we got a lot of calls. People quickly learned where Scott Depot, West Virginia was! We haven’t marketed this. I’ve waited two, two and a half years to really get out and talk about this. I wanted the scientific process to take hold.”

If it hasn’t been clear throughout, the LFA is a promising technique that bears further research. That said, this surgery exists and it has been performed hundreds of times. Men, women, and young people have suffered a grievous injury, one of the most feared in sports, and have come back, sometimes in significantly less time than the standard surgery. That should be big news and a basis to push forward.

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When Jameson Williams went down, grabbing his knee near the logo of the 2022 National Football Championship Game in Indianapolis, the certain first-rounder could have seen millions of dollars fade away. Because ACL surgery is so successful, Williams will still be drafted, likely still in the first round. However, dropping from the tenth pick (and he could have been drafted even higher) to the 30th pick, where he was picked in an NFL.com mock draft recently, would cost him nearly $10 million dollars.

The potential of a Lavender Fertilized ACL is that someone like Williams could be on the field for the first day of training camp, six months after his injury. A team wouldn’t be wondering how much he could play, or if he’d miss camp. The same goes for Ronald Acuna, who could have a more normal off-season if not quite make it back for the World Series.

However, the real value of LFA or something like it that pushes the science of sports medicine forward isn’t for Acuna or Williams. It’s in the possibility that a high school soccer player might not miss their senior season. It’s in a college player not missing a year of their sports career, one they can never get back. Dr. Lavender and his procedure aren’t just for pros. In fact, the strength of the procedure is in the very fact that it could work for anyone, anywhere.