On the Forefront of ACL Reconstruction: 4 Points From Dr. Freddie Fu

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Freddie Fu, MD, is an orthopedic surgeon and the chairman of University of Pittsburgh Medical Center's Department of Orthopaedic Surgery. Dr. Freddie Fu, orthopedic surgeonDr. Fu is known for his pioneering surgical techniques to treat knee and shoulder injuries and for his extensive scientific and clinical research in the biomechanics of joint injuries. He has earned more than 70 professional awards and numerous research grants for sports medicine and orthopedic surgery research.

1. Moving away from traditional non-anatomic reconstruction. About 10 years ago, Dr. Fu began to look more critically at ACL reconstruction as it was performed in the 1980s and early 1990s, which he says was "fast and efficient but got away from the anatomy."

"It was very common to put the ACL graft in the wrong place," he says. "If you put the ACL graft in the wrong place, the forces that are normally directed through the ACL when the joint is loaded, will now be distributed to the surrounding structures such as muscle, collateral ligaments and articular cartilage. As a result, there is more wear and tear on the cartilage in the knees, potentially progressing to the early onset of osteoarthritis. It was a quick fix that you will probably have to fix again later."

One of the problems with this procedure is that it did not take the anatomic and functional properties of the ACL into consideration, as they were not fully understood at that time. As research has progressed, a better understanding of the native "double-bundle" anatomy of the ACL has developed. "Every ACL is made up of two functionally different bundles," he says. "For years we've been replacing them with one non-anatomically placed single bundle, which, at least in the short term, seemed to work."

2. A renewed interest in anatomy. Dr. Fu's individualized anatomic approach aims to place the graft in the exact place of the original ACL with either one or two bundles, depending on the size, shape and orientation of the ligament being replaced. Many other factors can also dictate whether a single- or double-bundle reconstruction is performed, including notch size and associated injuries.

"The double-bundle concept taught me that we should place the ACL in the right place, whether using one or two bundles," he says. "There is variation of size and shape of every ACL. Some are small, some are large. It's unique in every case."

When put in the correct place, the ACL graft may approximate the function of the native ACL and prevent the wear and tear seen with traditional non-anatomic techniques. "We need to eliminate non-anatomical graft placement as a risk factor for osteoarthritis," Dr. Fu says. In fact, the difference between the correct and incorrect positions may only be a millimeter or two, he says. The difference can be so subtle that patients often feel stable after a non-anatomic reconstruction.

However, the physical exam in the doctor’s office is not sensitive enough to register the subtle, subclinical alterations in knee biomechanics associated with misplacement of the graft. Dr. Fu is collaborating with Scott Tashman, MD, at the UPMC Biodynamics Lab, where they use a highly sophisticated machine to measure in vivo kinematics of the knee joint and track its movements down to 0.1 millimeters.

3. Learning through research. Currently, Dr. Fu is leading a team of researchers at UPMC who are conducting numerous studies pertaining to ACL reconstruction and the corresponding anatomy. In this regard, he and his team have published more than 100 papers on the ACL and Dr. Fu has lectured on the anatomy, surgery and outcomes of ACL surgery in more than 15 countries throughout the world.

Recently, Dr. Fu and his team have secured a $2.9 million grant from the National Institutes of Health (NIH) to conduct a randomized controlled clinical trial comparing anatomic single-bundle to anatomic double-bundle reconstruction techniques. The trial will include 160 cases over three years and is one of the largest clinical trials on the ACL ever performed in the United States. So far, he and his team have completed 50 cases.

He described the procedure they are testing as more anatomically correct and individualized than ACL surgeries have been in the past. "We don't want to do a one-size-fits-all surgery. Every patient is different," Dr. Fu says.

4. Overcoming the learning curve. Dr. Fu's clinical trial is in full swing, and clinically it appears that anatomic ACL reconstruction, whether single- or double-bundle, will facilitate good clinical outcomes. It is the more objective outcome measures, however, such as the sensitive in vivo kinematic measurements that may or may not show a difference between the two techniques. The next challenge will be getting surgeons to change and adopt the more anatomical approach.

"You need to change the whole way you approach the injured ACL," he says. "That's hard for somebody who's done hundreds of non-anatomic reconstructions. It's hard to admit you made a mistake."

The learning curve for his new procedure is steep. "It took me 30 years to get to where I am, and we have just recently learned to place the ACL graft in an anatomic position."

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