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ANTERIOR CRUCIATE LIGAMENT/ACL INJURIES
ANATOMY
The anterior cruciate ligament (ACL) connects the tibia (shin bone) to the femur (thigh bone). Its main functions are:
- to prevent these two bones moving too much in relation to each other
- to provide rotational stability within the knee
The ACL is particularly prone to injury during sporting activities that involve significant amounts of twisting and turning, such as skiing. Whilst there is also a posterior cruciate ligament (PCL), this is damaged far less often and I will focus only on the ACL in this section.
Like all ligaments, the ACL acts as a firm soft tissue stabiliser of the joint. There are a number of nerves within the ACL which act as sensors that provide the brain with information about joint position sense (proprioception). When, for example, the ACL is stretched this information forms part of a “feedback mechanism” to activate certain protective muscle actions.
Occasionally, during rigorous sporting activity, the ligament can become over-stretched or completely torn. When the ACL is damaged as part of a twisting injury the patient may hear or feel a “popping” sensation. As the ligament has a blood supply, when torn the knee fills with blood becoming swollen quite quickly. It is almost impossible to continue sporting activity after ACL rupture and urgent medical review is required.
SYMPTOMS AND IMPACT OF ACL INJURY/DAMAGE
When the ACL is damaged, the knee can feel acutely unstable and, occasionally, will cause the knee to give way/collapse.
Patients without an intact ACL can find it very difficult to return to any sports that require twisting and turning, such as, rugby, football, squash and skiing. However, other “in line” sports such as running, cycling or cross training are often possible, despite ACL deficiency.
DIAGNOSIS OF INJURY TO THE ACL
As with all surgical conditions, diagnosis of damage to the anterior cruciate ligament is made by a combination of:
- listening to the patient’s history
- examination findings
- use of modern imaging techniques e.g. MRI scan
Once a definitive diagnosis has been made, the patient and surgeon can discuss the best way to proceed.
TREATMENT OF ANTERIOR CRUCIATE LIGAMENT (ACL) INJURIES
First and foremost, it is vital to stress that, even in the presence of complete rupture of the ACL, the need for surgery is by no means inevitable.
As mentioned previously, it is perfectly possible to pursue many sports without a functioning cruciate ligament. However, more rigorous, high-demand sports that involve a lot of “cutting”, twisting and pivoting are much more dependent on an intact, functioning ACL.
For most patients, the initial treatment centres on reducing the swelling within the knee whilst strengthening the muscles around the knee to act as secondary supports for stability. Physiotherapists will also work on balance and “proprioceptive feedback” which aims to minimise the chance of the knee giving way during day-to-day activity.
In addition to any natural stability thus achieved, a specialised ACL stabilisation brace can offer substantial support during sports such as skiing and tennis. This brace is very different from the standard “hinge-type” braces often prescribed in the early stages of injury. The use of a specialised ‘ACL’ brace such as the CTi Edge Brace (http://www.ossur.co.uk/Pages/10070) can provide additional temporary stability for an injured knee with or without ligament reconstructive surgery.
ACL RECONSTRUCTION SURGERY
Surgical reconstruction of the anterior cruciate ligament has become an increasingly popular operation over the last decade.
Due to advances in surgical techniques, this has turned what was a major open operation to one that is now minimally invasive (via arthroscopic portals).
Like most surgical procedures, there are many ways of achieving ACL reconstruction. Most surgeons across the world use a similar technique to restore a ‘new’ ACL, but the choice of graft material varies widely. Each surgeon or surgical unit will have their own rationale for their technique/graft choice.
During subsequent consultations with the patient, I will discuss the surgical options available in terms of reconstruction and what I feel is the best technique to be employed in each individual case.
We will consider the following:
- The type of graft that can be used, such as
- patient’s own tissue - hamstrings or patella tendon graft , or
- Allograft (donor tissue from a cadaveric )
- The type of reconstruction (single bundle or double bundle)
- The fixation methods for the graft
As indicated, there are a variety of different techniques available, but surgeons have their own preferences based on their own experience and results.
For example, in the United States of America, there is a general preference for using Allograft (whilst In the UK, this option is less popular and less available. A ‘hamstring’ graft is most commonly used in the UK.
ACL reconstruction involves undergoing a general anaesthetic and an in-patient stay of one or two nights. The operation itself lasts for just over an hour and a tourniquet is applied to the leg during the procedure.
The operation is carried out under direct vision of the arthroscope (camera) inserted within the knee. A bony tunnel is drilled within the shin bone (tibia) and the thigh bone (femur) to allow the graft to be pulled across and held in place securely. This graft is, in effect, creating a ‘scaffold’ on which a new ligament can grow.
In the majority of cases, I use the hamstring technique (semitendinosus and gracilis) with an “Endobutton” (Smith & Nephew) to hold the graft in the femur with a “Bioabsorbable RCI” screw in the tibia.
After surgery
In the immediate post-operative period, the priority is:
* to reduce the swelling in and around the knee
* to regain the range of motion
The post-operative programme is as follows:
- Crutches and a brace are provided for a two-week period, but you will be able to stand unsupported
- Physiotherapy begins the day after surgery
- The sutures are removed from the wounds after two weeks
- You should be able to easily bend the knee to a right angle at two weeks, when the
brace and crutches can be discontinued
The mainstay of the recovery after the operation is dependent on good quality outpatient physiotherapy. I encourage patients to see a physiotherapist close to their home or work so they can easily arrange regular sessions. As the wounds settle, the priority changes from the range of motion to muscle-strengthening and proprioceptive/balance work.
You will be very closely monitored after surgery by both myself and the physiotherapist to make sure that they are recovering well. The physiotherapist plays a very important role in the recovery process and we stay in close contact during this time to ensure the expected progress is being achieved.
Naturally, every patient recovers at a slightly different rate and there is no “normal” with respect to returning to sporting activity post-surgery.
I would, however, expect you to be able to cycle within the early months following surgery. Only after five to six months, will he/she be able to run.
The speed of recovery from this operation is limited by the ability of the body to integrate the graft material into the bony tunnels and to become fixed. This integration takes a minimum of ten weeks, but the graft itself is not “mature”/strong enough for participating in contact sports for at least six to nine months.
Only once the body has created a “neoligament” from the hamstring “scaffold” is the knee strong enough to tolerate the twisting/pivoting forces of more rigorous sporting activity.
Frequently Asked Questions
How long will I be in hospital for?
Approximately 2 days.
Should I change my dressing?
No, this dressing should be left alone until the stitches are removed. However, if you have any fresh oozing or bleeding from the wound, please contact the Knee Unit straight away.
Can I shower whilst wearing the dressing/bandages?
Yes, the dressing is waterproof.
When can I drive?
Approximately 2 - 4 weeks after surgery, please ask Mr Sweetnam’s advice.
How long do I need off work?
Usually 2 weeks, but in some cases patients where patients have manual jobs they need to take a further week off work.
Will I require physiotherapy following my op?
You will be given an exercise sheet by the physiotherapists on the ward, you will then need to see a physiotherapist at least once a week for the first few weeks. If you don’t have a physiotherapist, please call Mr Sweetnam’s secretary on 0207 483 5449 who will recommend one in your area.
Seek solutions where surgery is the last resort