Anterior Cruciate Ligament (ACL) Injury
What is anterior cruciate ligament Injury?
Anterior cruciate ligament is an important ligament inside the knee joint for providing stability of the knee. It can get injured in sport or as a consequence of an accident. In sport it us usually due to a non-contact rotational injury at the knee and player is unable to continue the game.
How is it managed immediately?
There is usually likely to be immediate swelling and pain. This should be managed by RICE (Rest, Ice, Compression and Elevation). It is important to consult an appropriate doctor as soon as possible. After a detailed history, the patient would have to be investigated with x-rays to rule out any bony injuries. If a soft-tissue injury is suspected (like ACL injury) an MRI may be necessary, to confirm the diagnosis and also to rule out other associated injuries like a meniscal injury or an injury to one of the other ligaments like PCL or Postero-lateral corner ligament complex.
What are the problems due to ACL injury?
The problems are due to the lack of restraint to the anterior and the rotatory forces on the knee. Normally the ligament acts as a check rein to these forces. But, when it is ruptured, it leads to repeated giving way. This may lead to further secondary damage to the other structures like the meniscii (shock-absorbers). Loss of meniscii, in turn, may lead to early onset OA. The giving episodes themselves may prove to be a nuisance and affect one's lifestyle like being unable to get back to sport, unable to do certain types of occupation, difficulty with stairs etc.
When is surgery indicated?
The whole point of doing an ACL reconstruction would be to a) stop symptoms of instability b) to prevent early OA-osteoarthritis. As for point b) this not been proven convincingly so far, as there is literature to indicate either way. But there is indirect evidence that this might happen.
If he had a concurrent peripheral tear of meniscus, that has to be repaired (sooner rather than later) and protected with an ACL reconstruction.. It has been proven that loss of meniscus leads to early OA.
If he had recurrent symptoms of instability, like his knee giving way, I would offer him an ACL reconstruction. As he is likely to damage his meniscii, which might predispose him to early arthritis.
Also, there is a question of what sort of sport, he wants to get back to. Sometimes people are able to get back to predominantly straight line activities like running, jogging (level 3 sport) etc., without having had an ACL reconstruction. But they find it difficult to play activities that involving jumping and pivoting at the knee like football, squash, basketball, skiing (level 1 and 2 sport) etc.
How is ACL (Anterior Cruciate Ligament) done?
A graft is harvested, the remnants of the native ACL are taken down, tunnels are drilled in the appropriate places and the graft is secured with various fixation devices like interference screws, transfixing pins, endobuttons or fixation posts. Some of these are bio-absorbable (absorbed within the body, after a course of time) as well.
It used to be done as an open procedure, but nowadays it can all be done arthroscopically, with a small fine camera and portals (skin incisions less than 1 cm in size). This helps with early rehabilitation.
What are the graft options?
As for the grafts, three commonly used options are
1. Hamstring Autograft - minimal donor site morbidity which resolves with time
2. Patellar tendon Autograft - slightly higher donor site morbidity - but equally good results as that of the hamstring graft
3. Cadaveric Allograft - Obviously no donor site morbidity. But a very very low theoretical risk (1 in 600,000 ) of viral transmission, as in any allograft.
In the UK, we used to use options 1 and 2. And option 3, when we used to run out of autografts for multi-ligament reconstructions.
But in the US, option 3 seems to be in wide use, at least from what I have seen.
Timing of the operation?
As for the timing of the operation, it is important that he gets his knee straight with physiotherapy and rehabilitation before proceeding with surgery. Also the rehab after the operation is intensive and can take up to 9 months.
If he decides not to go ahead with the operation, he should still have active rehabilitation for his injured ACL.
If he is undecided, go ahead with rehabilitation for now and review his symptoms in a few weeks/months, and then make the decision. But there is some evidence to show that increased time from injury to surgery is associated with inferior outcomes.
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