We have been doing ligament reconstruction surgeries for nearly three decades now, and we have been exposed to synthetic ligaments in our decades of experience. When Xiros actually came in contact with us and showed us the benefits of the JewelACL as a standalone ACL reconstruction ligament, we were quite sceptical initially in our understanding, because historically the ligament had not lived up to the expectations of the surgeons, and there have been reports of some rejections and synthetics. 

But when I talked to a couple of surgeons who have been using the JewelACL, especially Professor Kosowski in Poland, I was quite convinced, seeing his series and other series of other surgeons in the UK, that this ligament has stood the test of time. 

I went through all the articles and biomechanical studies, and they were reinforcing the use of this ligament as a solution to a lot of problems which we have while using autografts and allografts in patients with a single or multiple ligament injury.

What I have understood is the design and material, as well as the way it is applied. So all these three things that work together make the JewelACL different from other synthetics. 

The essential design is something which is friendly to the incorporation of the synthetic ligament with the normal host tissue. The way it is fixed is essentially a very simple method and better for any arthroscopic surgeon who is doing ligament reconstruction can easily go ahead and do this. It has also stood the test of time, and I think that is very important for a synthetic to do so. 

We started using synthetics more so in difficult cases, which essentially included obese patients, who had a BMI more than 40, and these are patients who fall down again and again, and they break their autografts. We also use this in complex ligament injuries, which actually had fractures and fracture dislocations, multiple injuries. Also, in revision scenarios, we were able to rehabilitate these patients well. The patients had much less pain postoperatively. Relapse recurrence of these ligament injuries never happened again, and their follow-ups show us that they were actually up and about very quickly.

We got convinced that if these ligaments can work in these difficult circumstances, we can slowly go ahead and replicate the same results by putting in and implanting these ligaments in our normal patients, those who have simple ACL tears or maybe a simple PCL or MCL tear.

So when you do complex cases and find that it is working, when you do a simple case, we think it will work.

The rehab protocol has become enhanced, so now we no longer wait for the graft incorporation to happen; we can actually get the patient going. The tunnel formation implanting the JewelACL synthetics is actually so minimal that we preserve a lot of bone. The patient's postoperative pain is much less because hardly any bone oedema happens. Primarily, synthetics have a day one strength; we allow them to do almost all kinds of activities soon after the surgery, when they are pain-free.

So our rehabilitation protocol has completely changed, and in elite athletes, they love it because they are back into the gym in a couple of days and are doing a good amount of work, so they don't allow their muscles to get into inhibition, and that's the best part of all these ligaments.

Implanting JewelACL needs good surgical precision, unlike autografts or allografts, where 100% accuracy might not be required, but for the incorporation of a synthetic, because it's an isometric graft, your placement of the graft and fixation have to be nearly absolute.

I would actually encourage young surgeons to go back, looking into the anatomy of the ACL, and then do all of these steps very precisely. Once done precisely, the results are excellent, so precision is important, and that is why teaching and training are very important in the implantation of synthetic ligaments. 

Right now, it is being used more for single or double ligament reconstruction. I think in the future, the multi-ligament reconstruction cases are where we should actually be encouraging more use of synthetics. Revision cases are also coming up in large numbers; this could be for many reasons, but these again are cases where synthetics are a solution.

Going ahead, we could incorporate some kind of biology into synthetics.

Every time we go to any other place, usually the first question which comes back to us is the same one; "Synthetics were not working well previously". They are talking about Gore-Tex, carbon fibre, and so many others, which had their own issues. I think we have to convince them by showing our results and the literature about this specific ligament. I think one should not compare apples to oranges; one has to understand how this ligament is different from all other synthetics which are available in the market or which were available historically, and how our surgical technique has made the difference.

I would show them our clinical results, we have been implanting for nearly 1.5-2years. Though our results are limited, there is a world of literature of more than a decade of these ligaments working very well. So when they are convinced by the literature and the results of their peers, the conviction becomes much stronger.