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ACL Injury: Does it require surgery?

What is an ACL tear?

An ACL tear is a relatively common sporting injury affecting the knee and is characterized by tearing of the Anterior Cruciate Ligament of the knee (ACL).

A ligament is a strong band of connective tissue which attaches bone to bone. The ACL is situated within the knee joint and is responsible for joining the back of the femur (thigh bone) to the front of the tibia (shin bone).

The ACL is one of the most important ligaments of the knee, giving it stability. The ACL achieves this role by preventing excessive twisting, straightening of the knee (hyperextension) and forward movement of the tibia on the femur. When these movements are excessive and beyond what the ACL can withstand, tearing to the ACL occurs. This condition is known as an ACL tear and may range from a small partial tear resulting in minimal pain, to a complete rupture of the ACL resulting in significant pain and disability, and, potentially requiring surgery. An ACL tear can be graded as follows:

  • Grade 1 tear: a small number of fibres are torn resulting in some pain but allowing full function
  • Grade 2 tear: a significant number of fibres are torn with moderate loss of function.
  • Grade 3 tear: all fibres are ruptured resulting in knee instability and major loss of function. Often other structures are also injured such as the menisci or collateral ligaments. Surgery is often required.
Iliotibial Band Syndrome

Iliotibial Band Syndrome

Causes of an ACL tear

ACL tears typically occur during activities placing excessive strain on the ACL. This generally occurs suddenly due to a specific incident, however, occasionally may occur due to repetitive strain. There are three main movements that place stress on the ACL, these include:

  • twisting of the knee
  • hyperextension of the knee
  • forward movement of the tibia on the femur

When any of these movements (or combinations of these movements) are excessive and beyond what the ACL can withstand, tearing of the ACL may occur. Of these movements, twisting is the most common cause of an ACL tear.

ACL tears are frequently seen in contact sports or sports requiring rapid changes in direction. These may include: football, netball, basketball and downhill skiing. The usual mechanism of injury for an ACL tear is a twisting movement when weight-bearing (especially when landing from a jump) or due to a collision forcing the knee to bend in the wrong direction (such as another player falling across the outside of the knee). Occasionally an ACL injury may occur during a sudden deceleration when running.

Signs and Symptoms of an ACL tear

Patients with an ACL tear may notice an audible snap or tearing sound at the time of injury. In minor cases of an ACL tear, patients may be able to continue activity only to experience an increase in pain, swelling and stiffness in the knee after activity with rest (particularly first thing in the morning). Often the pain associated with this condition is felt deep within the knee and is poorly localized.

In cases of a complete rupture of the ACL, pain is usually severe at the time of injury, however, may sometimes quickly subside. Patients may also experience a feeling of the knee going out and then going back in as well as a rapid onset of considerable swelling (within the first few hours following injury). Patients with a complete rupture of the ACL generally can not continue activity as the knee may feel unstable, or may collapse during certain movements (particularly twisting). Occasionally, the patient may be unable to weight bear at the time of injury due to pain and may develop bruising and knee stiffness over the coming days (especially an inability to fully straighten the knee). Patients with a complete rupture of the ACL may also experience recurrent episodes of the knee giving way following the injury.

Diagnosis of an ACL tear

A thorough subjective and objective examination from a physiotherapist is usually sufficient to diagnose an ACL tear. Investigations such as an X-ray, MRI scan or CT scan may be required to confirm diagnosis and determine the extent of damage or involvement of other structures within the knee.

Treatment for an ACL tear

Most patients with a minor to moderate ACL tear  heal well with appropriate physiotherapy. The success rate of treatment is largely dictated by patient compliance. A vital aspect of treatment is that the patient rests sufficiently from any activity that increases their pain. Activities placing large amounts of stress on the ACL should also be minimized, particularly twisting and hyperextension of the knee. Resting from aggravating activities ensures the body can begin the healing process in the absence of further damage. Once the patient can perform these activities pain free a gradual return to these activities is indicated provided there is no increase in symptoms.

Ignoring symptoms or adopting a ‘no pain, no gain’ attitude is likely to lead to the problem becoming chronic. Immediate, appropriate treatment in patients with this condition is essential to ensure a speedy recovery. Once the condition is chronic, healing slows significantly resulting in markedly increased recovery times and an increased likelihood of future recurrence or ACL surgery.

Patients with an ACL tear should follow the R.I.C.E. Regime in the initial phase of injury. The R.I.C.E regime is beneficial in the first 72 hours following injury or when inflammatory signs are present (i.e. morning pain or pain with rest). The R.I.C.E. regime involves resting from aggravating activities (this may include the use of crutches), regular icing, the use of a compression bandage and keeping the leg elevated. Anti-inflammatory medication may also significantly hasten the healing process in patients with an ACL tear by reducing the pain and swelling associated with inflammation.

Patients with an ACL tear should also perform pain-free flexibility and strengthening exercises as part of their rehabilitation to ensure an optimal outcome. One of the key components of ACL rehabilitation is pain-free strengthening of the quadriceps, hamstring and gluteal muscles to improve the control of the knee joint with weight-bearing activities. The treating physiotherapist can advise which exercises are most appropriate for the patient and when they should be commenced.

Surgery for an ACL tear

Surgical reconstruction of the ACL is often required in patients who have a complete rupture of the ACL and are seeking the highest level of function. The procedure is known as an ACL reconstruction and generally comprises of arthroscopic surgery to reconstruct or repair the ACL with other tissue from your body. The hamstring tendon or patella tendon are most frequently used in this process.

Following ACL reconstruction surgery a lengthy period of rehabilitation of 6 – 12 months or longer is required to gain an optimal outcome and return the patient to full activity or sport. Surgery for an ACL tear should be particularly considered in patients who have a complete rupture and:

  • are < 40 years of age
  • need a high level of knee function for recreational, work or sporting activity
  • have associated damage to their menisci or collateral ligaments of the knee
  • are able to comply and commit to intensive rehabilitation
  • have ongoing knee pain, swelling or recurrent episodes of the knee giving way despite appropriate rehabilitation

Following a complete ACL tear, patients who choose not to have surgery may suffer from ongoing knee instability and recurrent episodes of the knee collapsing or giving way with certain movements (particularly twisting). Patients with a complete ACL tear may also have an increased likelihood of developing knee osteoarthritis due to excessive movement and subsequent wear and tear of the knee.

In those patients who undergo surgical intervention, rehabilitation should commence from the time of injury, not from the time of surgery. This is essential to minimize swelling, improve range of movement and strength and ensure an optimal outcome following surgery.

Prognosis of an ACL tear

With appropriate management, most patients with a minor to moderate ACL tear (grades 1 and 2) can return to sport or normal activity within 2 – 8 weeks. Patients with a complete rupture of the ACL will frequently require surgical reconstruction followed by a lengthy rehabilitation period of 6 – 12 months or longer to gain optimum function. Patients who also have damage to other structures of the knee such as the meniscus or collateral ligaments are likely to have an extended rehabilitation period.

Physiotherapy for an ACL tear

Physiotherapy for patients with this condition is vital to hasten the healing process, ensure an optimal outcome and reduce the likelihood of future recurrence. Treatment may comprise:

  • soft tissue massage
  • joint mobilization
  • taping
  • bracing
  • ice or heat treatment
  • electrotherapy (e.g. ultrasound)
  • anti-inflammatory advice
  • exercises to improve flexibility, strength and balance
  • hydrotherapy
  • education
  • activity modification advice
  • crutches prescription
  • biomechanical correction
  • a gradual return to activity program

Other intervention for an ACL tear

Despite appropriate physiotherapy management, a small percentage of patients with a minor to moderate ACL tear and most patients with a complete ACL tear do not improve adequately. When this occurs the treating physiotherapist or doctor can advise on the best course of management. This may involve further investigation such as an X-ray, CT scan or MRI, or a review by a specialist who can advise on any procedures that may be appropriate to improve the condition. Surgical reconstruction of the ACL is frequently required in cases of a complete ACL rupture particularly when conservative measures fail.

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Anterior Cruciate Ligament (ACL) Reconstruction

An ACL reconstruction involves replacing the anterior cruciate ligament in the knee. It’s done to improve the stability and the function of the knee, often after an injury.

Your care will be adapted to meet your individual needs and may differ from what is described here. So it’s important that you follow your surgeon’s advice.

The anterior cruciate ligament (ACL) is a strong ligament that runs through the centre of the knee. It controls the stability and the movement of the knee. It’s usually damaged by twisting or overextending the knee, often combined with slowing down very quickly, especially during sports. The common causes are football and skiing.

ACL reconstruction involves replacing the anterior cruciate ligament of the knee with a graft. The graft is usually a section of tendon taken from another part of your knee, but sometimes it’s a donor graft (allograft). At the moment, synthetic grafts are not recommended. Your surgeon will discuss the different graft options with you.

The operation is normally performed using a narrow, tube-like telescopic camera called an arthroscope. This means that the surgeon will only make several small cuts to examine the inside of the knee and to replace your torn ACL. Getting the donor graft will also need one or two additional small cuts in the skin.

Preparing for your operation

Your surgeon will explain how to prepare for your operation. For example, if you smoke, you will be asked to stop as smoking increases your risk of getting a chest and wound infection, which can slow your recovery.

ACL reconstruction can be done under general anaesthesia, which means that you will be asleep during the procedure, with an overnight stay. The operation can also be done under local or regional anaesthesia as a day case. This completely blocks feeling from the knee and the leg, and you will stay awake during the operation. You may be offered sedation with a regional anaesthetic to help you relax during the operation.

If you’re having a general anaesthetic, you will be asked to follow fasting instructions. Typically you must not eat or drink for about six hours before a general anaesthetic. However, some anaesthetists allow occasional sips of water until two hours beforehand.

At the hospital your nurse may check your heart rate and blood pressure, and test your urine.

Your surgeon will ask you to sign a consent form. This confirms that you understand the risks, benefits and possible alternatives to the procedure and have given your permission for it to go ahead.

About the operation

A number of small incisions (usually less than 10mm long) are made in the skin over the knee that is being treated. Your surgeon will insert the arthroscope and other surgical instruments into the knee through these cuts. Sterile fluid is put into the joint to help extend the joint and get a clearer picture of the inside of the joint. Your surgeon will then trim the torn ligament and prepare the knee for the replacement graft.

A graft will usually be taken from your patella tendon, which connects your knee cap and shin bone, or from part of your hamstring tendon. Your surgeon will then drill a tunnel up through your upper shin bone (tibia) and lower thigh bone (femur), diagonally from the inside of your knee to the outside, above your knee.

The graft will be inserted in the tunnel, attached to the bones and fixed in place, usually with screws. The incisions are closed with stitches or adhesive strips. The operation usually lasts one to two hours.

What to expect afterwards

You will need to rest until the effects of the anaesthetic have passed. General anaesthesia temporarily affects your coordination and reasoning skills, so you must not drive, drink alcohol, operate machinery or sign legal documents for 48 hours afterwards. If you’re in any doubt about driving, contact your motor insurer so that you’re aware of their recommendations, and always follow your surgeon’s advice.

After a regional anaesthetic it may take several hours before the feeling comes back into the treated knee. Take special care not to bump or knock the area.

When you feel ready, you can begin to drink and eat, starting with clear fluids. Dressings will cover the small wounds and a bandage will support your knee and help to control swelling. You will be encouraged to move your knee soon after surgery to stop the joint becoming stiff.

You will need to arrange for someone to drive you home. You should try to have a friend or relative stay with you for the first 24 hours.

Your nurse will give you some advice about caring for your healing wounds before you go home. You may be given a date for a follow-up appointment.

You will also see a physiotherapist who will give you some exercises to do while you recover. The amount of physiotherapy you need varies, so follow the advice of your physiotherapist and surgeon.

Recovering from ACL Reconstruction

It can take between six and 12 months for you to recover your knee function after an ACL reconstruction. However, this depends on the individual so you should follow your surgeon’s advice on returning to your usual physical activities and sports. You must also follow your surgeon’s advice about driving and returning to work. You shouldn’t drive until you’re confident that you could perform an emergency stop without discomfort.

If you need pain relief, you can take over-the-counter painkillers such as paracetamol or ibuprofen. Always read the patient information that comes with your medicine and if you have any questions, ask your pharmacist for advice.

You can also apply ice packs (eg frozen peas wrapped in a towel) to your knee to help reduce any pain and swelling. Don’t apply ice directly to your skin as it can damage your skin.

What are the Risks?

Anterior cruciate ligament reconstruction is commonly performed and generally safe. However, in order to make an informed decision and give your consent, you need to be aware of the possible side-effects and the risk of complications of this procedure.

Side-effects

These are the unwanted but mostly temporary effects you may get after having the procedure.

You should expect some pain, stiffness, swelling and bruising around your treated knee. This is likely to last for some weeks and will gradually improve as the knee heals and as you get back to your normal day-to-day activities.

Complications

Complications are problems that occur during or after the operation. Most people aren’t affected. The possible complications of any operation include an unexpected reaction to the anaesthetic, infection, excessive bleeding or developing a blood clot, usually in a vein in the leg (deep vein thrombosis).

Complications specific to ACL reconstruction include the following.

  • Infection of the wound or joint. Antibiotics are given during surgery to help prevent this. Joint infections are rare following an ACL reconstruction, but if this happens you may need arthroscopic wash-out of the knee joint and a long course of antibiotics.
  • A small risk of damage to nearby nerves or blood vessels. Nerve damage could result in altered sensation or loss of feeling in the skin over the knee.
  • Over time, the graft may tear or stretch, or scar tissue may form around it. The screws that fix the graft in place may also come loose. If this happens, you may need further surgery.
  • If the replacement tendon graft is taken from your patella or quadriceps tendon, there is a possibility that the tendon may become tender or painful (patella or quadriceps tendinosis) or that the kneecap may be more susceptible to cartilage damage or fracture in the future.
  • For some people knee pain and function doesn’t improve and further surgery may be needed.
  • Limited straightening and bending of your knee usually improves with physiotherapy and exercising, but may occasionally need further surgery.
  • Severe pain, stiffness and gradual loss of function of the knee (CRPS or Complex Regional Pain Syndrome): this is a rare condition and the cause is unknown. If this happens, it may take months or years for your knee to get better.

The exact risks are specific to you and differ for every person, so we have not included statistics here. Ask your surgeon to explain how these risks apply to you.

Should my child have ACL Surgery?

ACL Tears in Children

ACL reconstruction surgery is the standard treatment for young, active people who sustain an ACL tear. But what happens when that person is a child? Should ACL surgery be delayed until the child is older, or should ACL reconstruction be performed before skeletal maturity?
Answer: Traditionally, when a child injured his anterior cruciate ligament (ACL), a connection within the knee important for joint stability, surgeons were reluctant to operate and reconstruct the ligament right away for fear of damaging the growth plate. The concern was that before a child has reached skeletal maturity (about 12-13 years old in girls or 14-15 years old in boys) this type of surgery presented a risk of injuring the growth plate. Growth plate problems resulting from ACL surgery could lead to unequal leg lengths or angular deformity. However, recent research shows that the risk of growth plate problems is much less then the risk of permanent knee damage if the ACL is not fixed.

ACL Injury

Growth Plates in Children

The growth plates are the part of the bone that grows in length. Most bone growth occurs near to the ends of long bones in these areas called growth plates. Two of the most active growth plates in the body are just above and just below the knee joint. These growth plates contribute to the length of both the thigh bone (femur) and shin bone (tibia).Traditional ACL reconstructive surgery involves making a tunnel in the bone directly in the location of these growth plates. At the time of skeletal maturity, the growth plate closes. Once the growth plate is closed (or nearly closed) the risk of causing a growth disturbance is gone. However, by drilling a hole through an open growth plate, the body may close the growth plate early. This could lead to complete growth plate closure, causing leg length inequality, or partial growth plate closure, causing angular deformity. Angular deformity could in turn lead to knock knees (genu valgus) and bow legs (genu varus), These conditions progressively worsen with further growth and could lead to problems such as joint damage and arthritis.

ACL Tears in Children

Knees that are unstable as a result of ACL tears have a high chance of meniscus tears and cartilage injury. Many surgeons have recommended that ACL surgery in children be delayed until the child has reached skeletal maturity. The hope being that by delaying surgery, you could avoid the potential complications of growth plate injury as a result of ACL surgery.Two factors have lead to more surgeons recommending early ACL surgery, even in children. First, more recent research has evaluated the risk of growth plate injury in comparison to the downside of delaying surgical treatment of the torn ACL. The risk of meniscus tears and cartilage injury was found in a recent study to be higher than the risk of growth disturbances. Second, there are modifications to traditional ACL surgery that allow the growth plate to be minimally affected in children. Furthermore, your doctor may recommend a specific type of graft to help minimize the chance of growth plate injury if surgical treatment is pursued. Therefore, more surgeons are recommending early ACL surgery, even in children.

The bottom line is that the risks of waiting (joint instability, meniscus tears, and cartilage injury) appear to be greater than the risk of growth plate injury for early ACL reconstruction with current surgical approaches. As a result surgeons today are more likely to recommend early ACL reconstruction.

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Anterior Cruciate Ligament (ACL) injury

Injured your Knee ACL? Suspect your ACL Torn? Get professional opinion about your Knee Injury. Call us +65 6471 2744 or email to: info@boneclinic.com.sg for appointment

Definition of Anterior Cruciate Ligament (ACL) Injury

The anterior cruciate ligament, or ACL, is one of four major knee ligaments. The ACL is critical to knee stability, and people who injure their ACL often complain of symptoms of their knee giving-out from under them. Therefore, many patients who sustain an ACL tear opt to have surgical treatment of this injury.

What is the ACL (Anterior Cruciate Ligament)?

The anterior cruciate ligament, also called the ACL, is one of the four major ligaments of the knee. The ACL prevents excessive motion of the knee joint–patients who sustain an injury to their ACL may complain of symptoms of the knee “giving out.”

Sign of an ACL Tear:

The diagnosis of an ACL tear is made by several methods. Patients who have an ACL tear often have sustained an injury to the knee. The injury is often sports-related. They may have felt a “pop” in their knee, and the knee usually gives-out from under them.

ACL tears cause knee swelling and pain. On examination, your doctor can look for signs of instability of the knee. These special tests place stress on the ACL, and can detect a torn ligament.

An MRI may also be used to determine if the ligament is torn, and also to look for signs of any associated injuries in the knee.

Is ACL surgery necessary?

ACL tears do not necessarily require surgery. There are several important factors to consider before undergoing ACL surgery. First, do you regularly perform activities that normally require a functional ACL? Second, do you experience knee instability? If you don’t do sports that require an ACL, and you don’t have an unstable knee, then you may not need ACL surgery.

There is also a debate about how to treat a partial ACL tear. If the ACL is not completely torn, then ACL reconstruction surgery may not be necessary.

Many patients with an ACL tear start to feel better within a few weeks of the injury. These individuals may feel as though their knee is normal again, but the problems with instability may persist.

Surgery of an ACL tear:

The usual surgery for an ACL tear is called an ACL reconstruction. A repair of the ligament is rarely a possibility, and thus the ligament is reconstructed using another tendon or ligament to substitute for the torn ligament.

There are several options for how to perform ACL surgery. The most significant choice is the type of graft used to reconstruct the torn ACL. There are also variations in the procedure, such as the new ‘double-bundle’ ACL reconstruction.

Risks of ACL surgery include infection, persistent instability and pain, stiffness, and difficulty returning to your previous level of activity. The good news is that better than 90% of patients have no complications with ACL surgery.

Read more about Anterior Cruciate Ligament (ACL) Reconstuction

Read more about Should My Child Have ACL Surgery

Read more about Getting Back to Sports after ACL Injuries

Read more about Other Ligament Injuries

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