Andy Williams – ACL Reconstruction in Professional Athletes – A Surgeon’s Perspective – Injury Rehab Network Event
The second Injury Rehab Network event of 2023 featured Mr Andy Williams, knee surgeon at and founder of Fortius Clinic.
Andy’s presentation discussed a surgeon’s perspective on ACL reconstruction in professional athletes. Over 300 sports rehabilitation professionals from the U.K. and around the world joined live on 8th February 2023 for the presentation, which provided insight into Andy’s 24 years of working in professional sports, including research and experience at the cutting edge of knee surgery in professional sports.
The recording of Andy’s presentation is available to watch here
Andy Williams MB, BS; FRCS (Orth.), FFSEM(UK) – Fortius Clinic
Andy is a Knee surgeon at, and founder of Fortius Clinic, London; Reader at Imperial College, London; and Honorary Senior Research Fellow at the University of Oxford.
He completed a fellowship in Brisbane, Australia, with Peters Myers / McMeniman. Andy was a Senior Lecturer / Honorary Consultant at The Royal National Orthopaedic Hospital, Stanmore, from 1997 – 2000 and then spent 15 years as a consultant at The Chelsea and Westminster Hospital.
Andy focuses exclusively on ‘sports knee’ surgery. 80% of patients are professional athletes.
He has published over 125 peer-reviewed articles. His study of knee motion employing weight-bearing, ‘dynamic’ MRI was awarded The Hunterian Professorship by The Royal College of Surgeons of England for 2005-2006. The current focus of Andy’s work is on the MCL after a fruitful period of work on the anterolateral soft tissues and surgery relevant to ACL injury.
He was a lead editor of the 39th Edition of Gray’s Anatomy. He was the executive of the British Association for Surgery of The Knee. He sits on the Editorial Board of The American Journal of Sports Medicine and previously of The Bone and Joint Journal. He was awarded the ABC Travelling Fellowship (2002). The Times newspaper named him in the U.K.’s Top 100 Doctors in 2011. He is the first U.K. member of The Herodicus Society, a U.S. sports surgery organisation.
ACL reconstruction in professional athletes – A surgeon’s perspective
Andy’s presentation, “ACL reconstruction in professional athletes – A surgeon’s perspective, ” introduced his work with professional athletes and learning from ACL surgery. He discussed ACL ruptures, the consultation, expectations when working with professional athletes, graft choices, the operation, rehab, experience, methods and return to play in football.
Mr Andy Williams, Knee Surgeon
Mr Williams has worked with professional athletes for 24 years. Andy described his practice in which 80% of patients are athletes, accounting for over 50% of his ACL reconstructions. His patients are from 75% of EPL teams, previously peaking at 52 football teams. In rugby, Andy works with 9 Premiership rugby teams.
Andy considered how working with professional athletes has made him better through high expectations and the necessity to get it right first time (GIRFT). He discussed how athletes do extraordinary things and may suffer rare or exaggerated common lesions. Andy’s professional work has helped advance medicine and care, with athletes often open to contributing to clinical research.
ACL Ruptures in Professional Athletes
Andy discussed ACL ruptures and described how they might be linked to the ‘make-up’ of individuals who can be predisposed to this injury. ACL ruptures are commonly caused by a change in direction that ‘goes wrong’ with early symptoms, including rapid swelling in the knee, which is caused by bleeding in the joint.
Andy stated that ACL ruptures are rare, with one every two years in first team football. However, ACL ruptures can be more common in kids. Two-thirds of ACL ruptures are non-contact with valgus and external rotation load. The typical history includes a pop, lateral pain, and swelling. The classic exam techniques include anterior drawer, Lachman and pivot shift.
Mr Williams discussed surgery for ACL ruptures where ‘most young active patients do best to have a good ACL reconstruction.’ Andy described how non-operative treatment is not appropriate in athletes and that reconstruction has reliable good results in good hands. ACL repair is too unreliable for professional athletes, with little published evidence available.
Andy described how the consultation with professional athletes must be different, with it being essential to understand the pressures on the player. Players’ concerns may include fear of losing their place in the team, a need and desire to play their sport and critical timescales or deadlines related to contract issues or competition.
Andy discussed the need to build trust and faith and to empathise with the player. This may take time, and it’s essential to consider history and do a complete examination thoroughly. Communication is critical, and Andy stated the importance of involving the whole medical team.
It’s important to investigate the injury thoroughly, and Andy described how repeat scans might be required. Andy’s advice is never to hide bad news but to be positive.
The Service Demanded
Andy discussed how expectations are exceptionally high with 24/7 phone contact, and office systems in place to respond immediately with players often seen in the clinic within 24 hours. He described how professional sport is a results-based industry with these high standards also applicable to surgeons who have just one chance to get a result and are only as good as their last case.
‘ACL Reconstruction is Easy’!
Through experience and research, Andy has developed a simple 7-step process for ACL reconstruction:
- Choose the right patient, e.g., an athlete
- Operate at the right time, e.g. have full extension
- Choose the best graft for that person
- Put the graft in the correct place
- Fix the graft properly
- De-stress the graft, e.g., fix peripheral lesions and use lateral extra-articular tenodesis (LET).
- Organise the correct rehab
Athletes are special but, in fact, human!
Andy described that whilst athletes do extraordinary things, they are human. He gave a reminder that you cannot speed up nature and athletes may still suffer complications such as synovitis. Even athletes’ joints need a rest!
Andy described the different options for graft choices as follows:
- B-PT-B (bone-patellar tendon-bone): the best for football
- Hamstrings: good for rugby and netball
- Quadriceps tendon: used for dance in Andy’s view
- Peroneus longus: not fully evaluated as yet
- Allograft: Re-rupture rate is high, so in reality, Andy rarely uses allograft, but it has a place in elite ‘in-line’ power athletes, e.g., sprinters.
Do as small an operation as possible
Mr Williams discussed the case of an athlete who suffered a traumatic knee injury in 2007. Andy operated on the patient with injuries including multiple lesions, lateral femoral impaction fracture and lateral and medial meniscus tears. The initial operation included surgery to the fracture, meniscus, and posterolateral corner (PLC) repairs. The knee was then braced for 6 weeks, allowing PCL and MCL injuries to heal, before isolated ACL reconstruction was completed with an allograft at eight weeks.
Andy aims to undertake as small an operation as possible to promote good and fast recovery. The athlete, a sprinter, was able to continue competing and went on to be successful in elite competitions, including the 2012, 2016 and 2020 Olympic Games.
MDT and Rehab
Andy described how he works closely with multi-disciplinary teams for the rehabilitation of ACL injuries. He commented, “The physios are the people who make me look good…or sometimes look bad!”.
He discussed the importance of respecting the medical/ physio team and to engage with them with good communication, to learn about rehabilitation, and work together to develop a plan.
Andy’s advice for rehab is to go long on timelines so as to not raise expectations.
He described some of the considerations, methods and options for ACL rehab, including:
- Weight-bearing status
- Range of motion
- Bracing or not
- Electric stimulation
- Blood flow restriction
- Trunk/ pelvis – core
- ‘closed chain’ vs ‘open chain’ quads
- Agonist vs antagonist to ligament
- Balance/ coordination
- Aerobic fitness
- Active rest
Get it right first time
Andy reiterated that the service demanded and expectations in professional sports are exceptionally high. He described how excellent performance comes from attention to detail with the following advice for practitioners:
- Think long and hard and plan a lot
- Accept observers in the operating room
- Have good/ extra help- don’t do an ACL solo!
- Encourage a long hospital stay and keep control of the early stages of recovery and rehab
Experience of ACR in football
Andy discussed data from his research into ACL reconstruction based on the following:
- Retrospective single-surgeon consecutive series 2005 – 2018
- All isolated ligament injury, e.g., no MCL surgery
- Cases with meniscal/ chondral lesions included
- Minimum two years follow up
The research outcomes were described by Andy as follows:
- Patient Reported Outcome Measures (PROMs) are impossible due to a lack of compliance with research.
- Almost 100% follow-up for:
- Return to play (RTP) time, level, rate
- Re-rupture rate
- Tegner score (activity level/ ability)
ACL Reconstruction Methods
Andy discussed different options and methods for operative techniques, including:
- AMB (anteromedial bundle) or central femoral tunnel position for the ACL graft
- 4-strand hamstring or patellar tendon graft
- LET for those at higher risk of graft re-rupture
- Always central tibial position
Andy shared findings from research based on ACL surgery completed with 232 patients.
Results: return to play rates
Of the 232 patients:
- 222 (96.1% returned to professional football
- 209 (90.1%) returned to the same or higher Tegner level
Andy discussed how three factors independently affected the RTP rate:
- Players under the age of 25 had a higher rate of RTP
- With a subsequent operation prior to RTP, this reduced the RTP rate
- Undergoing meniscal surgery at ACLR decreased the RTP rate
Andy stated that there was no effect from graft choice, femoral tunnel position, nor LET.
Results: return to play times
Andy described how the mean time to RTP from surgery was 10.5 months, with three factors found to independently increase RTP time:
- Age under twenty-five
- Recurrent effusions
- Medial meniscal repair at ACLR
Again, there was no effect from graft choice, femoral tunnel position, nor LET.
Andy summarised his presentation with the following conclusions and advice for practitioners:
- Never-ending study improves results
- High RTP rates are possible after ACR in elite athletes
- RTP can be delayed by synovitis, additional surgery, young age
- Graft re-rupture varied according to surgical technique
Andy acknowledged the research paper that he worked on together with a team of sports medicine professionals:
Andy kindly answered questions put forward by the practitioners who attended the session.
Q1. What is your advice for the use of corticosteroids following ACR?
A1. Be cautious as steroids may have a direct toxic effect on articular cartilage but, most importantly, allow athletes to overload softened vulnerable joint surfaces speeding their breakdown. For the right purpose and patient, steroids can support physio.
Q2. Is there a lower age limit for ACR surgery?
A2. There is no lower age cut-off, and surgery can be a higher priority for children as it helps to stabilize the joint and may prevent long-term problems.
Q3. Is non-operative management of ACL injuries becoming more normal?
A3. It has its place but needs careful monitoring. Non-operative management can cause greater damage due to recurrent knee joint instability, e.g. osteoarthritis. For surgery, it’s important to choose a good surgeon carefully, as the worst thing is bad surgery! Good ACL reconstruction is a reliable procedure.
Q4. Have you worked with patients with ACL injuries in combat sports?
A4. In Judo ACR, we use the hamstring tendon as this is better suited to the demands of the sport and the time athletes spend on their knees and the floor. Quad tendon could also be used for ACL reconstruction in judo athletes. In taekwondo, the patellar tendon is preferred together with a LET to protect the graft as the sport is so explosive.
Q5. What is the optimal timeframe for ACL reconstruction?
A5. It is often preferable to wait for surgery, and this is particularly true for the normal population, where the demands and expectations may not be so high. It is best to wait to operate on a ‘quiet’ knee with little swelling and the ability to extend rather than operate on an angry injured knee.
The recording of Andy’s presentation is available to watch here
Follow Mr Andy Williams and Fortius Clinic
- Website – https://www.fortiusclinic.com/
- Twitter – @FortiusClinicUK https://twitter.com/FortiusClinicUK
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