LIGAMENT INJURIES AND
ACL RECONSTRUCTION

The best expertise in Orthopaedic & Arthritis care

ANTERIOR CRUCIATE LIGAMENT INJURY

I HAVE TORN MY ACL. WHAT DOES THIS MEAN?

The Anterior Cruciate Ligament is one of the four major ligaments of the knee. Ligaments are band-like (or belt-like) structures that connect to bones and impart stability to the joint. Injury to the ACL causes antero-lateral rotatory instability at the knee. Instability causes abnormal movements in the knee which increases the stress on the meniscus (cushion) and the articular cartilage. Repeated episodes of instability cause progressive damage to the menisci and the articular surface and results in degenerative arthritis of the knee.

HOW DO I KNOW IF MY KNEE IS UNSTABLE? WHAT ARE THE SYMPTOMS OF INSTABILITY?
  • Loss of confidence on the leg
  • Loss of balance while walking on uneven surfaces
  • Fear of knee giving way while playing or performing pivoting activities like dancing
  • Buckling or giving a way of the knee (with or without falling)
  • Sudden catching in the knee, usually associated with pain; this may be followed by swelling
  • Inability to straighten the knee – locked knee – happens when there is an associated meniscal tear or loose piece of cartilage
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WHAT WILL HAPPEN IF INSTABILITY IS LEFT UNTREATED?
  • Instability causes abnormal movements in the knee which increases the stress on the meniscii (cushions) and the articular cartilage
  • Meniscal tears occur with twisting motion due to instability
  • Articular cartilage gets damaged as a result of increased stress on the cartilage and dysfunction of the meniscii
  • The end result is degenerative arthritis in the knee – with pain, swelling, limitation of movements and deformity
HOW DOES THE SURGEON ASSESS INSTABILITY?

Noting the history of injury; and severity and frequency of symptoms mentioned above

Physical examination to assess the various ligaments; dynamic testing of the knee

Assessment for associated meniscal tears

Weight bearing and stress X-rays

MRI scan: this is a very sensitive investigation to assess the ligaments (and capsular and accessory reinforcing structures), meniscal injury and damage to the articular cartilage

CAN YOU TREAT LIGAMENT INJURY WITHOUT SURGERY?

Minor injuries of the cruciate ligaments, which do not exhibit symptoms and signs of instability, can be treated without surgery. In addition, there should be no damage to the meniscii or articular cartilage. However, these cases need to be carefully monitored – as instability can develop at a later date.

In growing children, surgery is postponed till the child attains skeletal maturity (i.e., stops growing after puberty). Elderly patients with a sedentary lifestyle are also advised non-operative treatment. However, if the instability is severe, surgery may be necessary for these groups.

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WHEN IS SURGERY NECESSARY?

The main indication for surgery is instability at the knee. In addition, any damage to the meniscii or cartilage due to instability requires surgical treatment.

WHAT IS ACL RECONSTRUCTION? HOW IS IT DONE?

ACL Reconstruction is done by arthroscopic technique (key-hole surgery). A new ligament is fashioned out of tendons of the thigh. Most commonly, the hamstring tendons are used (the semitendinosus with or without the gracilis). If these tendons are thin, the patellar tendon or the quadriceps tendon is harvested. Harvesting the hamstring tendons causes minimal disability. Patellar tendon harvest is sometimes associated with pain on kneeling and delay in quadriceps recovery. Now-a-days, cadaveric grafts are available in some centers. They avoid the morbidity of graft harvest. However, there is a slightly increased risk of infection and graft failure.

The surgery is usually done under epidural anaesthesia. It can also be done under general anaesthesia or regional block. The knee is assessed once again under anaesthesia. The leg is cleaned with an antiseptic solution and draped, and the equipment is set up. The arthroscope is introduced into the knee and a thorough inspection of the knee is carried out. Any meniscal tears are treated by appropriate techniques. The tendon(s) are then harvested. An assistant surgeon fashions the tendons into the desired size and shape on a side table. A quadrupled hamstring graft is the most commonly used construct. Sometimes, the graft is augmented by additional fibre-wire suture tape. The stump of the torn ACL and any adhesions are trimmed. Using appropriate landmarks, a tunnel is made in the femoral and the tibial bones. The diameter and depth of the tunnels are determined by the size of the graft and the fixation method. The graft is fixed at either end with a fixation device. Typically, at the femoral end, a polyester loop with a metal toggle (endobutton or similar device) is used. At the tibial end, an absorbable polymer screw is used. Other types of fixation devices are also used (metal screws, transfixation pins, suture buttons, staples, spiked washers, fixation around a post, etc.). These devices secure the graft till the new ligament gains attachment to the bones. Different manufacturers have different designs of these devices. The choice of the fixation device depends upon the surgeon’s preference and cost considerations.

Recently, double bundle technique – in which two graft constructs are placed to re-create the complex anatomy of the native ACL – have been advocated. The normal ACL has two bundles. The antero-medial bundle provides antero-posterior stability and the postero-lateral bundle provides rotational stability. Double bundle ACL reconstruction is meant to reproduce this natural configuration. The disadvantages with these techniques are: lack of adequate graft tissue (many double bundle proponents use cadaveric allografts), increased complexity of the procedure and increase in the cost of the fixation devices. In addition, this is technically difficult in normal or small-sized knees (where the ACL footprint is less than 18 millimeters). More than 90 percent of ACL reconstructions done is single bundle constructs.

Sometimes ACL injury is associated with postero-lateral corner injury. These cases need reconstruction of the postero-lateral corner in addition to ACL reconstruction. If this is not done, the reconstructed ACL may fail with time.

Recently, double bundle technique – in which two graft constructs are placed to re-create the complex anatomy of the native ACL – have been advocated. The normal ACL has two bundles. The antero-medial bundle provides antero-posterior stability and the postero-lateral bundle provides rotational stability. Double bundle ACL reconstruction is meant to reproduce this natural configuration. The disadvantages with these techniques are: lack of adequate graft tissue (many double bundle proponents use cadaveric allografts), increased complexity of the procedure and increase in the cost of the fixation devices. In addition, this is technically difficult in normal or small-sized knees (where the ACL footprint is less than 18 millimeters). More than 90 percent of ACL reconstructions done is single bundle constructs.

Sometimes ACL injury is associated with postero-lateral corner injury. These cases need reconstruction of the postero-lateral corner in addition to ACL reconstruction. If this is not done, the reconstructed ACL may fail with time.

POST-OPERATIVE REGIME

Post-operatively, the knee is supported in a bulky dressing or a brace. Painkillers and antibiotics are administered. The patient is mobilized the next day. Exercises are started for knee bending and muscle strengthening. Weight-bearing is allowed as tolerated. Ice packs are applied to reduce the swelling. The patient can be discharged the day after the operation. Physiotherapy is continued in the patient’s home or as an out-patient. The sutures are removed between 10 and 14 days. Periodic follow-up in the clinic is done.

REHABILITATION AND FOLLOW-UP

Usually, an accelerated rehabilitation regime is followed. In the first 6-8 weeks, recovery of movements and preservation of muscle strength is emphasized but without placing undue stress on the reconstructed ligament. Between 2-6 months, progressive strengthening exercises are advised. Balance training and pivoting exercises are generally avoided in the first 6-9 months (or more) for normal patients. This regime may be shortened for professional sportsmen. In addition, they receive an extra programme for sports-specific training.

POSTERIOR CRUCIATE LIGAMENT AND MULTI-LIGAMENT INJURIES

The Posterior Cruciate Ligament (PCL) is the strongest ligament of the knee. Injury to this ligament causes posterior instability. The PCL is rarely injured alone. PCL tears are commonly associated with injury to the postero-medial corner or postero-lateral corner of the knee. Sometimes the ACL and PCL are injured together. Most often, the PCL is torn in its mid-substance. Sometimes, it may be avulsed from the tibial attachment.

Avulsion injuries with Grade I laxity (0-5 mm laxity) may be treated non-operatively. Grade II laxity (5-10 mm) with a bony fragment which is 8 mm or more needs fixation of the bony attachment. Grade III (10-15 mm) laxity needs fixation. Fixation of the avulsed bony attachment can be done by open or arthroscopic or minimally invasive techniques.

Mid-substance tears with Grade I laxity can be treated non-operatively. Grade II and III tears require surgical treatment in the form of PCL reconstruction.

Multi-ligament injuries require reconstruction of the PCL along with repair or reconstruction of Postero-Lateral Corner or Postero-Medial Corner or ACL. In the acute setting this can be done after 4-5 days (to allow the swelling to subside). Sometimes the repairs are done in two stages (two operations). The surgical techniques are similar to ACL reconstruction.

When multiple ligaments need reconstruction, obtaining enough graft can be a challenge. Sometimes, the tendons from the other leg are harvested or cadaveric ligament (allograft) may be needed. The knee may require protection in a brace for 3-4 months after PCL or multiple ligament reconstruction. Rehabilitation after such surgery may take longer than ACL reconstruction.

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