Editorial Comment: Improving Care for Patients with ACL Injuries: A Team Approach
An ACL rupture is a serious event in the life of any athlete, whether recreational or pro, and the study and treatment of these injuries involves a host of important considerations. Restoring our patients’ long-term knee function—and studying these injuries effectively—requires a multidisciplinary team approach, as these injuries and the science behind them is complex. The days of the “independent” biomedical- or clinician-scientist working in a solitary laboratory are over. Open image in new window Open image in new window
As Alberts and colleagues recently pointed out: “The long-held but erroneous assumption of never-ending rapid growth in biomedical science has created an unsustainable hypercompetitive system that is discouraging even the most outstanding prospective students from entering our profession—and making it difficult for seasoned investigators to produce their best work. This is a recipe for long-term decline, and the problems cannot be solved with simplistic approaches. Instead, it is time to confront the dangers at hand and rethink some fundamental features of the US biomedical research ecosystem” .
Team-based science is necessary in the current “hypercompetitive” environment . We define team-based science as a multidisciplinary, multicenter exploratory investigation with clear vision, strong leadership, and well-defined aims or testable hypotheses that result in unequivocal answers to high-impact questions. The components of a strong multicenter, multidisciplinary research team include clinician scientists and scientists working collaboratively, strong leadership, supportive environments, unparalleled and unique research infrastructure, multiple combined funding sources, creativity in thought and action, abandonment of the individual investigator ethos, and validated outcomes tools.
The current symposium focuses on four main areas: (1) Mechanisms of ACL injuries, (2) screening for ACL injury risk, (3) prevention of ACL injuries, and (4) outcomes of ACL Injury. The embrace of improved outcome measures—patient-reported scores, objective pivot shift measurements, and sophisticated return to sport quantification like performance metrics—makes it clear that the results of ACL reconstruction are not as good as once thought. Our challenge is to define what success really means to our patients.
Previously, ACL injury outcomes focused on graft integrity and anterior tibial translation measurements. Researchers surmised that performance of a more “anatomic” ACL reconstruction would solve all deficiencies. However, we still fall short of “success”—some athletes live with instability or do not return to their sports, while others develop arthritis due to altered joint mechanics. As a consequence, research teams have fittingly changed their focus, concentrating on novel investigations. For example, the last several years have seen a widespread acknowledgement that the extra-articular lateral-sided knee structures are important in controlling tibial rotation [2, 3, 4]. This realization has sparked both ingenuity and debate, which are leading to advances in knowledge in a relatively short amount of time on the anterolateral ligament and lateral complex.
Despite these innovations, no single graft choice or surgical technique can guarantee the perfect outcome. In order to truly advance our field, we must draw on our collective expertise and unique approaches to the ACL-injured knee. The surgeon must realize that even if the perfect ACL reconstruction is performed, that graft will share the same fate as the torn native ACL if the biodynamics of the athlete are not corrected. When researchers and clinicians across disciplines collaborate, we improve all facets of athlete care in synchrony—injury recognition, surgical indication, preoperative rehabilitation, surgical technique, and postoperative rehabilitation.
Not only do we need a team approach for our athletes once they are injured, but we must keep the same zealous approach to prevent these injuries. Coaches, parents, and young athletes must “buy in” to the concept of injury prevention, and it is our obligation to ensure we are properly educating our local athletic communities. Working collaboratively with sports medicine physicians, teams of physical therapists, strength and conditioning coaches, head coaches, and athletic trainers can implement ACL injury prevention programs to reduce the incidence of noncontact ACL injuries among athletes. It is only when we finally reach this culmination of innovation, cooperation, and prevention that we have a chance at real long-term success in treatment of ACL injuries.
- 2.Lording T, Corbo G, Bryant D, Burkhart TA, Getgood A. Rotational laxity control by the anterolateral ligament and the lateral meniscus is dependent on knee flexion angle: A cadaveric biomechanical study. Clin Orthop Relat Res. [Published online ahead of print May 23, 2017]. DOI: 10.1007/s11999-017-5364-z.
- 3.Nitri M, Rasmussen MT, Williams BT, Moulton SG, Cruz RS, Dornan GJ, Goldsmith MT, LaPrade RF. An in vitro robotic assessment of the anterolateral ligament, part 2: Anterolateral ligament reconstruction combined with anterior cruciate ligament reconstruction. Am J Sports Med. 2016;44:593–601.CrossRefPubMedGoogle Scholar
- 4.Rasmussen MT, Nitri M, Williams BT, Moulton SG, Cruz RS, Dornan GJ, Goldsmith MT, LaPrade RF. An in vitro robotic assessment of the anterolateral ligament part 1: Secondary role of the anterolateral ligament in the setting of an anterior cruciate ligament injury. Am J Sports Med. 2016;44:585–592.CrossRefPubMedGoogle Scholar