Should Most ACL Surgeries Be Cancelled?
What if I told you that most ACL surgeries that are performed today are like using a stick of dynamite to kill a mosquito? That a precise injection can replace two-thirds of these surgeries. If I was right, who would be the winners and losers? How would this change orthopedic care?
Welcome to Interventional Orthobiologics
If you’re new to this blog, you may not fully understand that the world of orthopedic care is rapidly changing. That because of interventional orthopedics (aka interventional orthobiologics) a chunk of care that is only surgical today will soon be replaced by precise injections that can help tissue and help patients avoid surgery. To learn more about that, see my video below:
An Introduction to the Stick of Dynamite: ACL Reconstruction Surgery
What if I told you that I would stick a scope in your knee, remove a damaged ligament, drill some big holes, use carpentry tools to anchor a tendon, and hope for the best? Also that the tendon I would use to replace your damaged ligament would never really be like the original equipment I removed.
What if I also told you that this surgery wouldn’t prevent arthritis and would do so much damage that it takes about a year to get back to full sports activity. Also, recent research shows that all of this knee carpentry is causing so much inflammation in the joint that it’s killing cartilage (1). Would you want this surgery? Welcome to ACL reconstruction.
What If You Could Heal the Damaged ACL?
Way back in 2010, we asked a simple question. Could a precise injection of stem cells into a torn ACL heal the damaged ligament? If so, how would you go about doing this? There were no textbooks to show how to place cells into this or any other knee ligament. Hence, we began a long learning process that culminated in the Regenexx Perc-ACLR procedure (Percutaneous-ACL Repair). This is what that procedure looks like:
Along the way, we published several research papers and have also conducted a randomized controlled trial (2,3). The final data in that trial is being collected now after having recruiting all patients. Interim analyses show continued excellent results. We’ve also been collecting MRI results from before and after the procedure showing evidence of healing of the damaged ligament. To see those images, see my video below:
Who Will Lose and Who Will Win Because of These New Technologies?
Every disruptive technology like Perc-ACLR creates winners and losers as the change transforms an industry. The orthopedic surgery sector has been stagnant for many years, really just making small changes to technology first introduced in the 1970s and 80s. That technology was the arthroscope or a way to perform surgery without large incisions. However, besides new techniques and some new equipment, the basics behind arthroscopic surgery remain unchanged. Hence orthopedic surgery is ripe for serious disruption.
Interventional orthobiologics will disrupt orthopedic surgery. To see how that will play out, let’s use the Perc-ACLR procedure as an example.
Who Will Win and Who Will Lose?
There are currently between 100-200,000 ACL surgeries per year in the US alone. If we take the middle number of 150,000, 60% of these would be candidates for Perc-ACLR. The average cost of these procedures is $12,600 without the cost of bracing, revision, complications, and rehab. That’s about 2 billion a year. If we take 60% of that away, that takes more than a billion out of the US orthopedic surgery market. That’s just one procedure of many that will be replaced by interventional orthobiologics.
Given that the cost of ACL surgery when you add in all of the parts and pieces exceeds 20K, even if Perc-ACLR costs 8K, that’s about a 60% savings. So the first winner is the employer. Since there is less downtime, a quicker recovery, and fewer complications and the patient gets to keep his or her original equipment, the second winner is the patient.
Orthopedic surgeons could either be winners or losers here. If they embrace Perc-ACLR and have non-surgical specialists who understand how to perform the procedure, they could offset some of their loss generated by losing surgical volume. If they put their heads in the sand, they stand to lose 60% of the surgical revenue on this one procedure.
Hospitals could be massive losers here, as the Perc-ACLR procedure can easily be performed in a physician’s office, without the need for a surgery center or hospital. Similarly, device manufacturers who serve the ACL surgery space would also be similarly impacted.
Does this Work Long-Term?
Our oldest Perc-ACLR patients are now getting towards 10 years. However, given that we didn’t really ramp up performing the perfected procedure until 2013 and 2014, there are a significant number of patients out 6 and 7 years. How are those patients faring? Based on our registry data very well. Expect a long-term follow-up publication in the next 1-2 years.
Will There Be Regenerative Surgical ACL Options?
Yes, there is already a BEAR (Bridge Enhanced ACL Repair) procedure where the surgeon sews in a scaffold to try to get the ACL to regenerate (4). Early results look good. However, given the cost and invasiveness differential, it’s likely that Perc-ACLR procedure will predominate for the right candidates, but BEAR would be a great alternative for those patients who are not Perc-ACLR candidates because the ACL is too damaged.
The upshot? If you’re new to this blog, welcome to the biggest game-changer in orthopedic care since the arthroscope: Interventional Orthopedics (aka Interventional Orthobiologics). As I hope I’ve shown, given what we’ve witnessed is possible over the past decade, most ACL surgeries should be canceled!
(1) Hunt ER, Conley CE, Jacobs CA, Ireland ML, Johnson DL, Lattermann C. Anterior Cruciate Ligament Reconstruction Reinitiates an Inflammatory and Chondrodegenerative Process in the Knee Joint [published online ahead of print, 2020 Jun 19]. J Orthop Res. 2020;10.1002/jor.24783. doi:10.1002/jor.24783
(2) Centeno CJ, Pitts J, Al-Sayegh H, Freeman MD. Anterior cruciate ligament tears treated with percutaneous injection of autologous bone marrow nucleated cells: a case series. J Pain Res. 2015;8:437–447. https://www.ncbi.nlm.nih.gov/pubmed/26261424
(3) Centeno C, Markle J, Dodson E, et al. Symptomatic anterior cruciate ligament tears treated with percutaneous injection of autologous bone marrow concentrate and platelet products: a non-controlled registry study. J Transl Med. 2018;16(1):246. https://www.ncbi.nlm.nih.gov/pubmed/30176875
(4) Murray MM, Kalish LA, Fleming BC, et al. Bridge-Enhanced Anterior Cruciate Ligament Repair: Two-Year Results of a First-in-Human Study. Orthop J Sports Med. 2019;7(3):2325967118824356. Published 2019 Mar 22. doi:10.1177/2325967118824356