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Dr Matthew BrickOrthopaedic Surgeon
Anterior CruciateLigament Injuries
A.C.L Function
The cruciate ligaments and thecollateral ligaments provide
stabilityto the joint by holding the bonestogether. Of those
ligaments, theanterior cruciate is important in that itholds the
knee together duringtwisting type activities. Duringeveryday
walking and in straight linerunning, the ACL is hardly used. Assoon
as any twisting is performedhowever, this ligament is
essential.Without it the knee twists further thanit is designed to,
giving a feeling thatthe knee comes out of joint. It is thisfeeling
of coming apart that givesrise to the instability or loss
ofconfidence in the knee that is seenwhen the ACL is torn. As it is
arotatory instability, it occurs whentwisting or sidestepping is
attempted,or when uneven ground isencountered. If major, it may
occurin everyday activities. In somehowever, it occurs only on
thesporting field, where it is hard toconcentrate on protecting the
kneeand where sudden twisting andturning occurs.
Meniscal Cartlilage and Articular(Lining) Cartilage:
Figure 1: The lateral and medialmenisci attach near the centre
ofthe tibia.The menisci function as space fillersto spread the load
between thesurfaces of the femur and tibia. Theends of these bones
are not thesame shape and thus the menisciare needed to make up for
thatincongruity. The end of the femur isround and the top of the
tibia is flat.They primarily function somewhatlike shock absorbers
but they alsohave a secondary role to enhancelubrication and
nutrition of thearticular or lining cartilage. They aremade of
springy cartilage, a little likeyour ears.
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Figure 2: The menisci act likethese chocks to stabilize
andsupport the round load (Femur)ona flat surface (Tibia)
Loss of meniscus (particularly thelateral one) leads to a poor
spread ofweight across the joint surface. Thismeans that loads are
taken oversmaller areas of the joint, and hence,pressures are
higher, causingincreased rates of wear of the liningsurface. It
also follows that the moremeniscus that is lost, the faster
thatwear occurs.
The articular cartilage covers theends of he bones of the knee
jointand allows for its smooth movement.It is a shiny, white, ultra
low frictionmaterial, that acts as a bearingsurface for the joint.
(it is easily seenon the end of uncooked lamb bonesetc). This
articular cartilage is verydifferent from the meniscal
cartilages(or menisci mentioned above) and isthe most delicate and
irreplaceablestructure within the knee. Once thisgets damaged and
wear starts tooccur, the knee can no longer bereturned to its
normal state. Injury to
this lining can be treated bydebridement, a process of
cleaningup: removing loose fragments andsmoothing the remaining
damagedsurface. This removes all thefragments which may potentially
fallinto the knee and in a number ofcases, it also helps to
decrease pain.Despite this however, a permanentdefect remains which
shows almostno attempt to repair itself. Once adefect exists in the
smooth liningsurface, further wear occurs withtime. In essence, it
is this damage tothe bearing surface of the knee thatstarts off the
progressive processknown as ‘osteo arthritis’.
Microfracture is the most commonlyused cartilage-repair
technique. Thebare bone at the base of theulcerated area is cleaned
untilsmooth. A very small awl or pick isthen introduced and 2mm
diameterholes are punched in the underlyingbone. This allows bone
marrow cellsto escape and form a healing cellpopulation. The
intended result is afibrocartilage patch. (fibrous cartilageor scar
tissue cartilage) Althoughthis is not as durable as the cartilagewe
are born with, it is better thanbare bone.
The other factors that affect wearrates are age and usage. The
younghigh demand athlete puts his kneesthrough much more than
theweekend recreational sportsman.For this reason, a
lateralmenisectomy in a sixteen year old, isvirtually guaranteed to
produce wear,that is sufficient to be noticeable onx-ray within ten
years. On the otherhand, a medial meniscectomy in a35 year old, may
show very little
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change on x-ray for 20 years. In theyoung therefore, menisci
should berepaired whenever possible and thisis particularly so in
the case of thelateral meniscus which seems to bemore important
that its medialcounterpart. Family history is alsoimportant as
osteoarthritis has aninherited component. An athletewho has a
strong family history ofosteoarthritis is especially at risk ifhe
or she loses a meniscus.
Injury Mechanism
Injuries to the anterior cruciateligament occur most often in
athleticactivities (especially twisting andturning sports, such as
football andnetball) but may be ruptured in workinjuries and
non-athletic activities.The injury usually occurs withoutcontact
and often is associated witha sudden change in direction (egside
stepping) or a sudden change inspeed (a deceleration injury). It
mayalso occur with the body falling overa fixed leg or with a
hyper-extension(over straightening) injury to theknee.The athlete
often describes theincident “My knee went one way andmy body went
the other.”
Figure 3: The ACL is the greyligament visible in the centre
ofthis 3D knee model.
When the injury occurs, theindividual will often hear a ‘pop’
or‘snap’ or experience the sensation oftearing inside the knee. The
kneethen swells almost immediately,because of bleeding from vessels
inthe torn ligament. Generally theinjured person has to be carried
offthe field and finds that any attempt toweight bear is difficult
because theknee feels extremely unstable. Theimmediate feeling of
instability isdue, not only to the loss of theligament, but also to
a loss of thenerve fibres within that ligament.These nerves provide
a sense ofwhere the joint is in space which iscalled
proprioception. Loss of thatsense causes a loss of the sensationof
how bent the joint is, how fast it isbending and so on. Without
thatknowledge there can be no accuratefeedback to the muscles that
movethe knee or to the muscles thatprotect the knee; and hence,
controlof the joint may be lost, leading to a
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feeling of instability or loss ofconfidence.
With time the feeling ofproprioception improves. This isbecause
the nerve fibres in the otherligaments attempt to make up for
theloss of sensation from the nervefibres in the anterior
cruciateligament. This situation is neverquite as good as the
original but, ifthe demands on the knee are low, itmay be
sufficient to get by.
After the Injury
What happens after injury to theanterior cruciate ligament is
asudden loss of control of the knee,which gradually returns. In
mostpeople, it takes about two months toreach a level where they
can thinkabout playing sport again. Thosewho seem to get back to
sportwithout surgery (about 30%) oftenonly have partial tears of
theligament. Whilst the injured knee inthis group may be looser
thannormal, it is thought that functionmay be satisfactory because
someof the proprioceptive nerve fibresremain intact. These are
thought toprovide enough feedback to themuscles around the knee, to
enablethose muscles to compensatesomewhat for the partial loss of
theligament.
Even for those with a completerupture, the feeling of stability
doesgradually improve over a 2-3 monthperiod. If by that time
however, fullconfidence in the knee has not beenrestored, then that
knee will probablynever be able to perform a twisting,turning sport
again without ACL
reconstruction. If a return to thosesports is made, then a
repeat injuryis likely, due to the ongoinginstability. From then
on, every timethat the knee gives way, moredamage is done. Sooner
or later,that damage will include injury to thearticular lining
cartilage, which isirreparable. This may herald an endto impact
loading type activities andin essence, represents
osteoarthritis,which will progressively worsen withtime. Because of
this risk it is nowconsidered preferable to reconstructthe unstable
knee early on, thushopefully, preventing recurrent injury.Our
studies show that the athletewho undergoes reconstruction in
thefirst 6 months before many instabilityepisodes does better long
term thansomeone who has the operation 2-3years later after
multiple episodes ofgiving way.
In general patients with ACL injuriesmay be put into one of
three roughlyequal size groups:
The first group contains people whodo well and return to their
sportwithout too much trouble. In thisgroup the re-injury rate is
not all thathigh and, as suggested above, themajority in this
group, have partialtears only. Essentially, the re-injuryrate, over
a two year period, isthought to roughly equal thepercentage tear of
the ligament. Itcould be said that a 30% tearprobably has a 30%
chance of goingon to complete rupture within twoyears if normal
sporting activity iscontinued.
The second group contains peoplewith a complete ACL tear who
seem
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to do well until they play ademanding sport. They may evendo
well at training but, on taking tothe field, a re-injury soon
occurs.This group otherwise copes well inday to day life and thus,
onlyrequires surgery if a return to twistingtype sports is desired.
Sports suchas netball and football demand goodACL function and for
people wantingto play these sports, even at lowlevels,
reconstruction of a completelytorn ligament is recommended.
The third group contains peoplewhose knees feel frankly unstable
ineveryday life. This group all requiresurgery to give their knee a
feeling ofstability. That stability then protectsagainst further
injury and furtherdamage to the knee.
Who Warrants Surgery?
Overall, it may be seen that a largenumber of people who injure
theiranterior cruciate ligament mighteventually benefit from
surgery. Theexact number is uncertain butcurrently it is thought
that some 50%or more would be helped. As withmeniscal injury, this
is somewhatage dependent and the requirementfor surgery does
decrease with age.This is not only because thedemands placed on the
kneedecrease with advancing age butalso because the number of
partialtears increase with age and theability to cope with
proprioceptiveloss improves with age. Theopposite situation occurs
in theyoung age group (under 18) wherealmost all tears are complete
and themajority tend to be verysymptomatic. In this group
therefore, almost all patients willdevelop enough instability to
warrantsurgery.
Those who sustain injuries to otherligaments of the knee, in
addition toa tear of the anterior cruciateligament are more likely
to fall intothe third group. Virtually all of thesepeople are
better off consideringsurgery.
Those with suspected meniscaltears, which may be repairable,
mayalso be better off consideringsurgery. It is not possible to
knowwhether a meniscal tear will berepairable or not until the knee
islooked into but nevertheless if theinjury seems major and
suggests thispossibility, then surgery may be abetter long term
alternative.
It is possible to repair a meniscusand leave a torn ACL alone,
but thebreakdown rate of meniscal repairsin an unstable knee is
more thandouble the failure rate in stableknees. For this reason,
isolatedmeniscal repair without ACLreconstruction is rarely
performed. Ifa meniscal tear is symptomatic andrequires treatment
and, for reasonsof time or employment, areconstruction cannot be
performed,then partial menisectomy isundertaken. This situation
isregarded as a compromise to hastenreturn to work and is not a
substitutefor reconstructive surgery. Twisting,turning sports then
need to beavoided, until such time as the kneeis made stable.
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Conservative Treatment
Treatment for injuries of the anteriorcruciate ligament cannot
bestandardized because of individualdifferences in injury patterns
andbecause of different expectations ofpatients in regard to return
tosporting activities. In the patient whosees sport purely as
recreation andwho would consider giving it up if itmeant that an
operation could beavoided, a hamstring re-educationand
rehabilitation programme mayprovide a satisfactory knee foreveryday
use. This type of exerciseprogramme however, is not asubstitute for
ACL reconstructionbecause the ligament itself neverheals. What it
achieves is bettercontrol over the knee, by improvingstrength and
by improving thefeedback from the other ligaments(proprioceptive
training). This type ofprogramme is supervised by
yourphysiotherapist and involves hardwork that can only be done by
you.Given adequate provocation,however, the knee will still give
wayand further injury may occur.
Patients with an old anterior cruciateligament rupture need to
avoidrecurrent giving way and buckling. Ifthese episodes are
associated withpain and swelling and are frequent,the knee will
develop progressivewear and tear arthritis (osteoarthritis).
Patients in this situationneed to either consider the option
ofsurgical reconstruction or change thedemands that they are
placing ontheir knee.
For those patients who are athleticand who do not wish to
considergiving up sporting activities, it maybe that a surgical
procedure toreconstruct the ligament will providethe best chance of
returning to areasonable level of performance.
Anterior Cruciate LigamentReconstruction
Reconstruction of the anteriorcruciate ligament is a
complexsurgical procedure and there aremany different ways to go
about it.The preferred method is to use aportion of tendon from
elsewhere asa graft. In most case this meansusing two of the
hamstring tendons(semi-tendinosis and gracilis) butother tendons
can be used. Anothergraft is the middle one third of thepatellar
tendon.
Choice of Graft
The two most common graft choicesare the hamstring graft and
thepatellar tendon graft. Each hasadvantages and disadvantages
andeach has excellent long term results.
Twenty years ago the patellar tendonwas the most commonly used
graft.Today around 85% of sports kneespecialists will use the
hamstringtendons as their first choice. This isbecause using the
hamstringscauses fewer problems. Themajority of the tendons grow
backand strength deficits in the harvestedleg vary between 3 and
15% oneyear after surgery. The major loss is“terminal flexion
torque”. This is thehamstring power in the last fewdegrees of
flexion. This range is
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infrequently used by most athletes. Iwould hesitate to use a
hamstringgraft in a track sprinter as even a tinyloss of top end
speed could makethe athlete uncompetitive. (I wouldsuggest delaying
surgery until thetrack career is over.) Nonethelesshamstring ACL
grafts have returnedAll Blacks and Silver Ferns to theirformer
level.
Patellar tendon grafts also havebeen successfully used for
athletesat the highest level for many years.The main problems that
concern usis many patients complain of kneecap pain, the inability
to kneel andthe loss of the last 3-5 degrees ofextension. (I can’t
quite straightenmy knee doc!) Follow up also showsa worrying
incidence of early arthritisof the knee cap within 7 years or
so.
The technique for reconstructing theanterior cruciate ligament
hasimproved significantly in recent yearsand can now be done in
anarthroscopically aided manner. Thisdoes not mean that there are
noincisions, however, because the graftstill has to be taken in a
standardopen type manner. The incisionscan be kept to around 3cm
thoughby using the scope. The knee jointitself is usually not
opened as all thework in the joint can be done via thearthroscope.
This causes less painand a shorter hospital stay andallows for an
earlier and better rangeof knee motion. It also means lesswasting
of the muscles postoperatively and an earlier return tonormal knee
function.
Surgical Technique
My primary graft choice is almostalways the hamstring tendons. I
usea double bundle reconstruction.The normal ACL has two distinct
andseparate bundles each with adifferent function. Traditionally
ACLreconstruction has been a singlebundle approximation
somewherebetween the two original bundles.Surgical techniques
usually try andrecreate the pre-injury anatomy butthere have been
many technicalproblems with making both bundles.The operation is
more difficult, takesmore time and has more
potentialcomplications.
The two normal ACL bundles
Testing in the lab has shown the twobundle reconstruction to be
more likethe natural state and is more stable.We do not yet have
the long termproof in the clinical setting to showsuperior function
and return to sport.
My own reasons for developing thistechnique are:
1. The loss of the ACL alters thebiomechanics of the knee,
placingmore load on the medial (inside)aspect of the knee. Single
bundlereconstruction does NOT restorethis. This may explain why
single
Postero-lateral
Antero-medial
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bundle reconstruction makes nodifference to the long-term
arthritisrate suffered by patients who rupturetheir ACL. Fully 50%
eventuallydevelop arthritis whether or notthey have their
ACLreconstructed. It is my hope that bymaking biomechanics (forces
acrossthe knee) more normal (and doublebundle reconstruction does)
this latearthritis rate might be reduced.
2. Few patients with a single bundlereconstruction will describe
theirknee as “normal”. Yes, it is goodenough to return to sport but
not fullynormal. More patients with a wellperformed double bundle
ACL willdescribe their knee as normal. Myown patients with a
previous singlebundle in one side and a doublebundle in the other
side prefer theirdouble bundle knee every time so farwith no
prompting. It is my hope toget a better functional result asnature
almost always does knowbest!
3. I have dealt with the commontechnical problems of double
bundlereconstruction. The operation takesa very acceptable 68
minutes or soand complications have beenminimized. I perform the
operationat least 70 times per year so getplenty of practice!
To date double bundlereconstruction is commonlyperformed in
various centres in theUS and Europe but not elsewhere inNew
Zealand.
Diagram representing towBundles of the ACL
The Post-op Period
Reconstruction of the anteriorcruciate ligament is now an
everydayprocedure, thanks to the very majoradvances in instruments
andtechniques that have occurred in thelast few years. Patients are
inhospital as a daystay or overnightstay and generally no brace
isrequired. Crutches are necessaryfor 1-2 weeks and by 6 weeks
mostpeople can walk with only a minimallimp. Between week 2 and
week 6the patient can swim with a pull-buoyto avoid kicking. Biking
can becommenced at week 4 and runningon even surfaces at week
12provided there is sufficient thighmuscle bulk.
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When first put into the knee, the graftitself is dead. Over a
period of time,however, it gains a new bloodsupply, comes back to
life andstrengthens. Whilst this processprobably takes some two
years tofully complete, it is thought that bythree months some
running can becommenced, and by six monthstraining for sport can be
started.Actually getting back to full sportdepends on individual
progress atthat stage, including the regaining ofproprioception in
the knee. Thismeans a return of the ability to runaround corners
and to twist and turnon the knee. Exercises to promotethis ability
are essential to decreasethe risk of re-injury and areencouraged
when running is wellprogressed. You will work closelywith your
physiotherapist who willassess your progress. A return tosport can
be undertaken anywherefrom six to nine months post-op.
Return to sport is not determined byhow much time has passed but
bywhen you have completed a seriesof tests. The “Return to
Sport”protocol is a four stage programmewhere progress to the next
level isallowed when specific goals havebeen met. Passing the level
fourtests is the signal that sport can becommenced. Your
physiotherapistor trainer will determine when youhave passed these
tests. Aprofessional athlete will almostalways achieve this in six
monthsfrom operation. With work andfamily commitments most
patientstake 7-9 months.
Because recovery is now muchquicker and easier than previously
a
home exercise program is themainstay of post operative
treatment.At your one week check you will beprovided with a post
operativeprogram. After discharge thatexercise program is
continuedwithout change for six weeks. At thesix week mark, most
people arehelped by a visit to a sportsphysiotherapist. At that
stage anupgraded program can be organizedand, if necessary,
supervised. Ifextra therapy is specifically needed,it is easily
arranged, and therapistswith particular expertise in this areaof
surgery can be recommended.
Another time that most people findtherapy helpful is at the four
to sixmonth mark, when they are juststarting to jog or run on the
knee. Arehabilitation program here can bemost helpful, particularly
to regainproprioception, which is essential fora safe return to
sport.
Patients who may benefit from earlytherapy are those who have
tightknees and who are having moretrouble than usual getting
motionback. This includes the patient withrepairs of other
ligaments and thepatient with a meniscal repair whoseknee is tight
due to the stitches in thecapsule around the joint.
Time off work
Students can generally return at 7-10days provided that the
amount oftime spent on their feet is limited.They may also wish to
use theircrutches for a longer period of time.
People in a sit down job can usuallyreturn in two weeks. If the
job
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involves prolonged standing, thenfour weeks may be more
realistic.A job requiring plenty of walking anddriving such as a
sales personusually requires six weeks off.
If there is any heavy work to be donethen two months is probably
theearliest that a return can be madewith light duties. Jobs
requiringprolonged squatting and bendingmay also take at least this
long.Heavy manual labour may take fourto five months. Jobs
requiring theability to run are the most demandingand these may
require six or moremonths for adequate recovery toensue.
Problems of surgery
Overall the number of people whohave problems following
ACLreconstruction is small.Nevertheless problems do occur andthese
need some consideration.
Bruising in the immediate postoperative period is the
commonestproblem. Obviously everybody hassome bruising, but
occasionally, it issuch that the knee becomes swollenand sore and
the normal milddiscoloration that extends to the footbecomes very
obvious. This givesdiscomfort particularly when standingup and may
last two weeks. To adegree this can be avoided by notwalking around
too much when firstallowed home from hospital. Somepeople however,
do bruise moreeasily than others.
D.V.T’s (deep vein thromboses)also occur but are uncommon
(lessthan 5%). These represent clots in
the deep veins of the leg, usually thecalf. They probably occur
at the timeof surgery and then get slowly biggerover several days.
Because of thisthey may not be felt in the first fewdays. If
noticeable, it is usually asan ache in the calf at the back of
theleg. If this is thought to be occurring,then a Doppler
(ultrasound) scan canbe used to detect it and appropriatetreatment
organized.
If a patient is at risk for thiscomplication (eg those on a
highdoes of oestrogen supplement orhigh dose ‘pill’) then
someprophylactic thinning of the bloodcan be performed. This
doesincrease bruising and bleedinghowever, and thus, is not
regardedas routine treatment.
The concern of having clots in thevein is always that they may
spreadto the lungs (pulmonary embolismor PE). This is a rare event
but doesrepresent the one major and seriouscomplication of this and
other lowerlimb surgery. In the majority ofcases, like DVT’s
themselves, it istreatable by thinning of the blood.This prevents
new clot from formingand allows the body to slowlydissolve the clot
that is present.
Deep infection is uncommon andoccurs in about 1 in every
200cases. Almost all such infectionscan be treated without loss or
failureof the graft. Nevertheless, the graftis threatened by this
problem whichrequires prompt treatment, includingarthroscopic
washout of the kneeand antibiotics. Early diagnosis isvery
important to avoid damage tothe rest of the knee joint.
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Loss of full extension of the kneeis the most common medium to
longterm problem encountered. Some10% of people who undergo
ACLreconstruction have a scarring andtightening reaction to that
surgery.The reason for this is unknown, but itdoes lead to a
general tightening ofthe knee as a whole. This meansslower initial
progress, the kneebeing stiffer and more painful. At theend of the
day, however, theligament in this group remains tightand strong,
and, as the motion isregained, excellent stability can
beexpected.
In almost all cases some loss ofextension is common at
threemonths following surgery. Most thengo on to regain that motion
and atone year less than 5% have anyresidual loss. For that group,
thereare procedures that can beundertaken to help this problem
andif necessary, these can beperformed. With the newertechniques of
reconstruction,however, this type of secondarysurgery is becoming
less and lessnecessary. Los of extension is morecommon with the
patellar tendongraft than with the hamstring graft.
Graft loosening and failure mayalso occur. Just as there is a
10%group at the tight extreme, so thereis a 10% group who seem
toprogressively loosen with time. Thisgroup regains motion early
andeasily and as a consequence, theirknees are not particularly
sore.Accordingly, they tend to return toactivity early and tend not
to protectthe knee as much as perhaps is
ideal. In some instances this cancause early failure of the
graft.
A cause of late failure (6-12 months)is where the graft fails to
get a newblood supply and thus fails to comeback to life. It is not
understood howthis process works, why it works, andwhy, in some
instances it does notwork. If the graft remains dead,however, it
does not have thecapacity to heal and hence everydaystresses will
eventually lead toprogressive rupture of the fibres.Revision
reconstruction may then benecessary and is usually successful.
Graft re-rupture can and doesoccur. No graft is as strong as
anormal ligament and hence a bigenough injury can cause damage
toit. As it turns out however, rupture ofthe ACL in the other leg
is morecommon than rupture of the graft.This is not because a graft
isstronger than a normal ACL butrather that a large percentage
ofpeople who rupture this ligament,have a weaker than normal
ligamentin the first place. This may also beseen in some families
where severalgenerations all rupture their ACLs.
Patello-femoral pain or ache underthe kneecap (patella) is
commononce activity has begun. This ismostly due to the muscles
beingwasted and weak and thereforeresponds well to
exercise,particularly of the VMO muscle.Physiotherapy at this stage
can bevery helpful to reeducate this muscleand to improve
patello-femoral jointfunction. This is more common infemale
patients who usually haveless thigh muscle to begin with.
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Patello-femoral pain can also occurfrom damage to the articular
lining ofthe patella itself. This happens inabout 10% of ACL
injuries andunfortunately, it can prove relativelydifficult to
treat. Nevertheless thisproblem is generally minor andusually does
not interfere withsporting activities to any greatextent.
Patella tendonitis or ache from theremaining patella tendon, is
notuncommon at some stage duringrecovery when using a
patellartendon graft. Fortunately, this tendsto be transient and
tends to settleover a 1-2 month period. In mostpeople this occurs
when running iscommenced and it represents stresson the remaining
smaller patellatendon. This stress then stimulatesthe tendon to get
bigger and stronger(hypertrophy) until it is able to cope.As such
therefore, with time thetendon usually settles down andstops aching
when used. On the fewoccasions when this does nothappen, steroid
ionto-phoresis canhelp. This is where cortisone (astrong
anti-inflammatory agent) isdriven across the skin and into
thetendon electrically (without having toinject it).
Ultimately most knees settle downover a 12 to 15 month period
oftime and by that stage most peopleare no longer conscious of
theirknee. Ache from the fixation screwis not all that uncommon,
butfortunately is rarely bad enough torequire treatment. If the
screw isprominent enough to interfere with
kneeling, however, then removalmay well be warranted.
Graft Malposition is a surgical errorwhen the new graft is not
placedexactly where the original ACL wassited. The graft only needs
to be afew millimeters away from thecorrect site to cause problems
likepersistent instability and loss ofmotion. I urge patients to
make suretheir surgeon performs this operationfrequently as
“practice makesperfect”. I believe ACLreconstruction is not an
easyoperation that can be performedaccurately by the occasional
surgeon
Summary
The anterior cruciate ligament is amajor and important ligament
in theknee which is commonly injured.Treatment depends on the age
of thepatient, the exact nature of the injury,the nature of any
associated injuries,the lifestyle of the patient and theirfuture
sporting aspirations. In thosepatients who are willing to alter
theirlifestyle a rehabilitation programmemay be adequate but for
the keenathlete who is wanting to return totwisting and turnings
sports, areconstruction may be the betteralternative. With the
advent of betteroperative procedures to reconstructthis ligament,
such as have beendeveloped in the last few years, theproblems that
use to be associatedwith this form of surgery are lesscommon and
the functional resultsare better. In general 90% of thoseundergoing
reconstruction will beable to return to their previous sport
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and more than 70% will be able tocompete at their previous
level.
Nowadays, an ability to return tosport at the pre-injury level
is rarelydue to loss of the anterior cruciateligament:
reconstruction of thatligament being generally successful.Rather,
it is more usually due toirrepairable damage that has beencaused to
other parts of the knee atthe time of the initial injury or
insubsequent injuries. (CollateralDamage) It is known that
earlyreconstruction with intact menisciand articular cartilage has
a betterlong-term outcome than latereconstruction, when
repeatedepisodes of instability have damagedthese structures.
What do I do now?
The decision to proceed with surgeryis one that can only be made
by you.You should not feel pushed in anyone direction. I see my
role asanswering all of the questions youcan think of and helping
you makethe decision you believe is best foryour future.
There is no rush to make a decision.If the notes above have
raisedquestions for you, you are welcometo email me at
[email protected]
If you wish to proceed with surgeryyou need to let my office
know sothat I can make an application toACC for funding for your
surgery.This process is supposed to take nomore than 21 days but
unfortunatelydelays are common. As soon asACC writes to you with an
approval
for surgery you can get in touch withRose or Bridget at my
office to plan atime for surgery that suits you. Mylists are
usually booked up for about6 weeks and your ACC approvalremains
valid for 6 months. (It canusually be renewed if necessary.)
Rose and Bridgetphone 09 477
2080email:[email protected]