Vincent Chassaing - MD
Treatment of an ACL tear is geared towards obtaining a stable knee which allows the patient to return to his or her activities and sports.
Treatment options. :
The approach to ACL tears has greatly evolved over the last few years :
- Stitching together the torn portions of the ACL has now been abandoned. The results were too unsatisfactory.
- Prosthetic replacement of the ACL (synthetic graft) has also been abandoned for now. Grafts tried to date have nearly uniformly caused pain and swelling in the knee and have been subject to early failure.
Thus, currently the choice is between :
- a non-operative treatment consisting of vigorous physical therapy or
- surgical reconstruction with "an autograft", i.e. a graft taken from the patient’s own body. The choice of autografts includes:
* the patellar tendon (known in France as the operation of MacIntosh and of Kenneth Jones). This is now considered the classic operation for an ACL tear and in this operation, as described by Kenneth Jones, 1/3 of the patellar tendon is harvested along with a piece of bone from the tip of the patella (knee cap) and from the tibial tuberosity (where the tendon inserts). These bone segments at the end of the tendon are buried in tunnels within the tibia and femur, and this provides for a very stable construct. However, this form of fixation increases the risks of persistent pain at the area of the harvested tendon and/or about the patella. Such pain is minimized with the use of the following grafts:
* The fascia lata. This is a tough, thin and wide band of tissue just below the outer aspect of the thigh. A strip can be harvested and used to replace the ACL.
* The tendons of the "pes anserinus": this is otherwise known as a hamstring graft. It utilizes the tendon of the gracilis and of the semitendinosus. The harvesting of the these tendons does not appear at this point to have a detrimental affect on the clinical function of the knee. Each graft is long enough to be folded in half, thus providing a graft with four strands. Due to the easier recovery, this is currently our preferred technique.
Use of an arthroscopic technique allows for smaller incisions and allows the surgeon to address other intra-articular pathology, such as torn menisci.
In addition to the graft technique described above, the surgeon may choose to add yet another graft on the outer aspect of the knee. This is the extra-articular reconstruction of Lemaire, whereby the above mentioned fascia lata is used as a graft connecting the outer aspect of the tibia and of the femur. This is done when the instability is chronic and of greater than average magnitude.
Operative and non-operative treatments work hand in hand. The knee needs to undergo rehabilitation prior to any surgical reconstruction and needs further rehabilitation following surgery.
Generally speaking, it is preferable to allow two months to elapse between the time of the injury and the time of surgery. This allows for the knee to have recovered as much as possible from the accident. The knee is better able to withstand surgery, and the recovery is made easier. In high level athletes, this time table can be sped up.
In any case, this is never an emergency procedure. The patient can decide at which rate he or she chooses to rehabilitate the knee prior to surgery. As such, the patient chooses his or her own surgical date. There is no harm in waiting, as long as the patient does not perform any jumping or twisting activities and limits his or her sports to swimming biking or simple jogging.
ACL treatment: decision making
1. Age. The younger the patient the greater the need for surgical reconstruction. Nevertheless, the knee can be reconstructed at any age. One is only as old as one feels!
2. The specifics of anticipated sport.
The twenty-year-old handball athlete is a much better candidate for an ACL reconstruction than a fifty-year-old weekend bicyclist. Sports involving jumping, twisting and pivoting require a knee with intact ACL. It is strongly contraindicated to resume such sports without an ACL even if you feel no instability. Without the protection of the ACL, you’re at risk for eventually damaging other structures within your knee and you may hasten the onset of arthritis.
3. The degree of initial laxity.
The tests described above allow us to determine quantitatively the amount of instability present in a given patient with an ACL tear. There appears to be a correlation between the instability that we detect on our test and the instability that the athlete will note him or herself.
4. The build of the athlete.
Different people have different tolerances to an ACL tear. In a muscular subject whose leg is slightly bowed (varus) and who is not loose-jointed), an ACL tear may be well tolerated. On the other hand, in a young woman with considerable joint laxity and genu valgum (knock knee’d) a tear of the ACL can lead to instability even in the absence of specific athletic activities.
5. The pre-injury status of the knee.
The more damaged the knee prior to the injury, the greater the chance that the ACL tear will be symptomatic and harmful.
In a subject who is young, loose jointed, athletic and well motivated, it is reasonable to propose an ACL reconstruction. This will prevent a hasty deterioration of athletic skills and may prevent further damage to the knee. Having said this, this is never an emergency procedure, and the recovery is quicker and more straightforward when the knee has been optimally rehabilitated. In marginal cases it may be desirable to evaluate the patient functionally prior to deciding on any surgery. Surgery may be recommended if it is obvious that the athlete is having episodes of giving way in everyday life or during sports. While unnecessary surgery is to be condemned, it would be a shame in this day and age not to avail one self to an operation which can reliably stabilize the knee following an ACL injury.