Surgery a gold standard: Gives those with ACL injuries a leg up on managing knee pain
Published on: Tuesday, August 08, 2023
By: Dr Dharmalingam Muthiah
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Women have four to eight times the risk of ACL tear due to hormonal cycle, joint hyper laxity and anatomical variation. Men with narrow intercondylar notch are at risk of bilateral ACL tear.
In fact, Anterior Cruciate Ligament (ACL) tear is one of the most common Orthopaedic surgeries worldwide.
The incidence of ACL tear is 40-50 per 100,000 people.
Well known superstars like Virgil Van Dijik, Brazilian Ronaldo (pic), Zlatan Ibrahimovic and Tiger Woods (pic) have all been sidelined for a substantial period of time due to this injury.
This article will discuss the role of ACL in the stability of the knee and the current state of the art treatment of this potentially career ending injury.
Anatomy, function of Cruciates
The human knee is stabilised in the Anterior Posterior plane (front to back) by two important ligaments that form a cruciate when seen in the frontal plane.
These ligaments are called Anterior and Posterior Cruciate Ligaments respectively. The ACL is on average 38mm in length and 10mm in width and is made of two functional bundles (AM and PL) that are slightly rotated.
The ligament is innervated by a small sensory nerve that gives input to the brain regarding joint position. ACL is made of Type I (90 per cent) and Type II (10 per cent) Collagen.
ACL is the prime stabiliser of anterior translation of Tibia on Femur and provides rotatory stability. The stability is further enhanced by dynamic stabilisers ie muscles. The maximum tensile strength of ACL is 1725N.
Injury mechanism, risk factors
Acute deceleration, pivoting, hyperextension during landing and acute blows to knee (from the sides) are the main mechanisms involved.
ACL injuries occur both in contact and non-contact sports that require jumping and pivoting on a planted foot.
High risk sports are football, netball, American football, basketball, rugby and Aussie Rules.
Women have four to eight times the risk of ACL tear due to hormonal cycle, joint hyper laxity and anatomical variation. Men with narrow intercondylar notch are at risk of bilateral ACL tear.
ACL tear symptoms
An acute sensation of snapping is usually felt followed by an excruciating pain and immediate gross swelling due to bleeding into the joint.
The athlete will often have to be carried out and will limp for a week or two.
The swelling and pain will subside with time but the knee will be unstable – sensation of giving way – that are often followed by recurrent pain and swelling.
This can even occur during non-sporting activities. As a result, the athlete will lose confidence and be unable to return to pre-injury level.
ACL tear diagnosis
Typical history and a good clinical examination by an experienced Orthopaedic surgeon will clinch the diagnosis.
MRI is imaging of choice and will reveal associated injuries to the menisci, cartilage, bones and other ligaments.
MRI will also help in planning surgery. Plain X ray is of help in suspected fractures or bony avulsion of ACL. CT scan and Ultrasound are rarely of use in ACL injuries.
Treatment of ACL injuries
Non-surgical treatment is reserved for non-active middle-aged patients and the elderly. Treatment includes physiotherapy to enhance muscle strength and lifestyle modification.
Surgical treatment, on the other hand, is the gold standard in the management of ACL injuries in young active adults.
A torn ACL will never repair/ heal itself or can be repaired directly (lacks the capacity due to intra-articular nature of the injury), thus, needs to be reconstructed with donor tissues, almost always with tendons.
Ideal patients are young and active. Failure to stabilise the knee will result in accelerated wear and tear of the articular cartilage (Osteoarthritis) and late meniscal tears.
The risk of Osteoarthritis is 10-fold and there is a 1 per cent increase in cartilage breakdown with every month of delay. A good ACL reconstruction will slow the progression of Osteoarthritis. The ideal time of reconstruction is 3 weeks post injury.
Surgical technique has evolved from open surgery in the past to an all-endoscopic injury currently practiced worldwide. The principles of ACL reconstruction are:
1. Patient selection – all young adults and active middle aged.
2. Timing of surgery – ideally 3 weeks post injury.
3. All endoscopic technique – fast recovery and very low complication.
4. Choice of grafts:
l Autograft(own tendons) – cheap and readily available, minimal adverse effect from harvesting.
l Bone – Patella Tendon – Bone, Hamstring, Quadiceps tendons.
l Allograft (donated) – (a.) expensive and small risk of disease transmission.
(b.) Shorter operating time and no adverse effect of graft harvesting.
l Synthetic grafts – for low demand patients.
5. Graft fixation – (a.) plethora of techniques (endo-buttons, interference screws, bone staple, post etc).
(b.) Choice depends on surgeons’ preference and cost.
(c.) All aim for rigid fixation.
6. Management of concomitant injuries (staged or can be performed at the time of ACL reconstruction)
(a.) Meniscal repair or trimming.
(b.) Cartilage grafting and fracture fixation.
7. Pre and Post – (a.) Operative rehabilitation.
(b.) Very important component of overall care.
(c.) Failure to adhere to a structured rehabilitation will result in a poor outcome.
(d.) Poor compliance will result in graft laxity or rupture.
(e.) Rehabilitation focuses on regaining full knee motion, muscle strength, proprioception and confidence. The programme will balance accelerated functional recovery and graft protection during remodelling and maturation.
8. Return to sports – (a.) ideally six to nine months.
(b.) Delay if confidence, proprioception and muscle strength is not achieved.
Current complications resulting from surgery remain very low. The most dreaded complication is infection (< 1 per cent) and Deep Vein Thrombosis.
Other possible complications are post-operative knee stiffness, graft laxity or rupture.
The overall results of ACL reconstruction are very satisfactory. 90 per cent of athletes can return to pre-injury level of activity.
The risk of Osteoarthritis is ever present even in the well stabilised knee. The management of ACL knee injuries is ever evolving and we haven’t heard the last of it yet.
This article was contributed by Dr Dharmalingam Muthiah who is a Consultant Orthopaedic, Arthroscopic Sports and Joint Reconstructive Surgeon at Gleneagles Hospital Kota Kinabalu.
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