ACL reconstruction the long road to recovery
It happened in Moncton in 2017 during the first minute of the game. Julian Boyd had the ball and as he slipped through the “screen” he felt his foot stuck to the floor.
“I felt the shift in my knee, I know that feeling, it’s happened three times before,” says Boyd, a power forward for the London Lightning, National Basketball League of Canada champions.
“At least we won the game. Because it happened in Moncton, we weren’t scheduled to leave until the next day. I kept the knee iced in the hotel and then when we returned to London I headed to the Fowler Kennedy Sport Medicine Clinic to confirm that I had torn my ACL,” says Boyd.
The ACL is stiff and rigid, and one of the key ligaments that help stabilize the knee joint. The ACL connects the thighbone to the shinbone, and is most commonly torn during sports that involve sudden stops and changes in direction such as basketball and soccer.
Dr. Robert Litchfield, LHSC orthopaedic surgeon and medical director of the Fowler Kennedy Sport Medicine Clinic, performed Boyd’s surgery.
The surgery involves reconstructing the ACL using a graft - a piece of living tissue that is implanted surgically - to replace the ligament.
For Boyd, the surgery included an additional procedure - a Lateral Extra-articular Tenodesis (LET) - which creates a new ligament-like structure on the outside of the knee.
“Studies have shown that the addition of the LET procedure helps keep about 40 per cent of the stress to the ACL graft off the knee of athletes who return to pivoting contact sports such as basketball,” says Dr. Litchfield.
Since this was Boyd’s fourth ACL repair - his first in London - the surgery was more difficult.
“Technically the surgery is more challenging because you’re working around the old hardware and bone tunnels of the previous surgeries, so the revisions can be difficult,” says Dr. Litchfield.
Despite the complexity of the surgery, patients go home the same day. In fact, LHSC has been treating ACL surgeries primarily on an outpatient basis since the mid-1980s.
“We want patients back using the knee right away – using crutches the first two weeks, using a stationary bike, and then following the Fowler Kennedy rehabilitation protocol,” says Dr. Litchfield.
It’s a long rehabilitation period and that’s the hard part. Boyd’s first two re-injuries happened a few months into rehab.
“I went to the gym to shoot some hoops with a teammate. I felt pretty good so we ended up playing a little one-on-one. I jumped, I landed, and right away I knew I had injured it again,” says Boyd.
That is one of the challenges for a professional athlete who trains hard. While Boyd’s physical fitness and athleticism allowed him to recover the muscles and joints around the surgery, the biology of healing and growing the ACL graft takes time.
“Julian is a great lesson on how easily you can be injured again. He was very active early on in his recovery after the first and second surgeries,” says Dr. Litchfield. “Despite being a great athlete, there’s no fast track to healing an ACL injury. These take nine months to a year to heal.”
Knowing what he had to do and for how long wasn’t easy for Boyd, but he was determined to stay positive.
“Knowing that if I do this, I can play again, it keeps you going. It’s hard to see that from nine months out and you have to be strong-minded. There’s nothing I’d rather be doing than playing basketball at this point in my life, and there’s no slacking off,” says Boyd.
The nine months following surgery were dedicated to intense rehab at Fowler Kennedy and on January 28, 2018 Boyd stepped back on the court with the London Lightning. That night he played 20 minutes and scored nine points. The following game he was back up to speed posting 18 points in 19 minutes.
A few months later, Boyd was a key member of the Lightning to lead the team to its fourth national championship.
“Now my knee feels normal, super healthy and steady,” says Boyd. “I was very happy to have been in London and at LHSC with Dr. Litchfield for the surgery. I was very lucky.”
Happy is also how Payten Lang describes her experience with surgery and recovery following a torn ACL in 2016 while she was still in high school.
“I was playing volleyball, jumped up and when I came down and landed I could feel my ACL tear,” says Lang. “It was very painful.”
Like Boyd, Lang received ACL reconstruction with LET. And like Boyd, she spent many months healing and getting back into shape with physiotherapy and working out.
“My balance was off. I lost so much muscle mass, I could see the difference in my legs,” she says.
Lang is also a participant in a multi-centre randomized clinical trial comparing ACL reconstruction with and without the LET procedure in individuals who are at high risk of graft failure.
Dr. Alan Getgood, LHSC orthopaedic surgeon and Lawson Health Research Institute researcher, is the principle investigator of the trial which encompasses nine centres – seven in Canada and two in Europe – and with 624 participants, it is the largest randomized trial of this type world-wide.
Dr. Getgood is also Lang’s surgeon and she is one of 196 patients at LHSC to participate in the trial.
“I thought it was very interesting to take part. I participate in a number of athletics and I am going into kinesiology, so I thought it would be a great opportunity,” says Lang, who was named Rookie of the Year for the 2017 - 2018 season as a member of the Western varsity field hockey team.
For her part in the study, Lang has periodic appointments with Dr. Getgood and the research team. During the appointments she answers a series of questionnaires and participates in range of motion testing. At the six-month, one-year and two-year appointments, she participates in strength and jumping tasks.
While the study data will be ready in April 2019, Dr. Getgood is encouraged by the results so far.
“ACL surgery is the bread and butter of sports medicine surgery, and while the surgical outcomes are good, they’re not perfect. There are some areas where we have little influence, but there are areas where we can try and improve the outcomes for the patients,” says Dr. Getgood.
In addition to surgical options, Dr. Getgood sees more focus in the future on injury prevention and prevention of re-injury through better-devised warm-up techniques.
Lang now does a warm up – a light run and stretching – before she goes on to a practice or game.
“There is nothing more satisfying than to see a young patient back to the level of activity they had prior to injury,” says Dr. Getgood.
That is certainly the case for Lang, who is back in top condition, playing a number of sports.
“I was a little scared at the thought of tearing the ACL for a second time. When I started playing indoor soccer again, at first I was not engaging as much in scrimmages,” says Lang. “Now I trust myself and my knee feels really good.”