TREATMENTS AND RECOVERY STRATEGIES FOR ACL INJURIES
The ACL is a critical ligament in the knee joint that prevents the tibia from moving too far forward and stabilises rotational movements. ACL injuries, which frequently occur in athletes and those with physically demanding jobs, can lead to instability and functional limitations. With around 175,000 ACL reconstructions performed annually in the US alone and tens of thousands here in Singapore, it’s evident why ACL sprains are a major concern.
The decision to undergo ACL surgery is based on several factors, including the severity of the injury, the presence of other knee injuries, and the overall impact on the patient’s quality of life. Opting for surgery typically involves ACL reconstruction, immediate post-operative care, a focused rehabilitation program, and long-term considerations — all of which are discussed in our latest blog article.
Surgical Reconstruction of the ACL
Surgical Reconstruction of the ACL
A torn ACL cannot heal naturally and as such, surgical reconstruction is standard. Modern ACL reconstruction uses minimally invasive arthroscopic techniques with small incisions, a camera, and specialised instruments.
Arthroscopy, a procedure that entails removing torn ACL tissue and creating tunnels in the femur and tibia to secure the new graft, offers benefits like smaller scars and less tissue disruption.
A critical decision in the surgical treatment of damaged or diseased bone is the selection of the graft material, primarily autografts and allografts. The choice depends on various factors, including the size and location of the bone defect, the patient’s overall health, and the surgeon’s experience and preference.
Autograft Options
Autograft Options
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- Patellar Tendon Graft uses the middle third of the patellar tendon (connecting the kneecap to the shinbone), often with bone blocks. It offers strong initial support and potentially better long-term results, especially for female patients, with a lower chance of the graft failing. However, it may cause pain at the front of the knee, discomfort when kneeling, and requires a larger cut. There’s also a risk of issues with the patellar tendon itself. It might not be ideal for adolescents due to its proximity to growth plates. Despite this, it has a good track record, particularly in high-level athletes.
- Hamstring Tendon Graft uses two of the hamstring tendons (muscles at the back of the thigh). Its benefits include a smaller cut, less pain after surgery, and a reduced risk of pain around the kneecap or patellar tendon rupture. The initial support might be weaker, and some patients may experience lasting hamstring weakness. Some research indicates higher re-tear rates in active female athletes. However, it causes fewer problems at the donor site, which is appealing to those worried about pain at the front of the knee.
- Quadriceps Tendon Graft uses the middle third of the quadriceps tendon (muscles at the front of the thigh), sometimes with a piece of bone from the patella (kneecap). It’s known for its strength and a lower chance of pain and numbness at the front of the knee. It has shown lower failure rates in young athletes (aged 10-18) and can be used in growing individuals. It is often considered for demanding cases due to its strength and protection of growth plates, avoiding hamstring weakness.
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Allograft Options
Allografts use tissue from a deceased donor (patellar tendon, hamstring tendon, or Achilles tendon). They are readily available in various sizes and shapes; there is no need for a second surgical site.
While allografts present benefits like a smaller incision, shorter surgical procedure, and reduced post-operative pain, avoiding donor site issues, they also come with a potentially increased risk of re-injury and graft failure, particularly for younger, active patients. There is also a minimal risk of disease transmission to consider.
Generally, allografts aren’t recommended for young patients due to the higher re-injury risk. They may be suitable for casual athletes, those over 40, patients needing revision surgery, and those who prefer a less invasive procedure. While they can work for non-competitive athletes, they are generally not as strong as autografts.
ACL Reconstruction Potential Complications
ACL reconstruction surgery success rates exceed 80% but complications can occur, as with all types of surgery. Common risks include infection or bleeding, nerve and blood vessel damage, and knee stiffness.
Arthrofibrosis, severe scarring causing stiffness, is more likely if surgery is too early before regaining motion. Conversely, delaying surgery over three months can increase the risks of cartilage or meniscus damage.
Graft failure, though rare, is another risk higher with allografts, especially in younger patients. Implant failure and the need for further surgery are a possibility. In growing children, there’s a risk of growth-related issues.
For failed primary reconstructions, revision surgery is needed to address the cause of failure and potentially require bone grafting or other ligament reconstruction.
In terms of the risk of osteoarthritis, people who have had an ACL injury, even after having reconstructive surgery, have a much higher chance of developing osteoarthritis of the knee. About 50% might experience early OA symptoms within 10-15 years after the operation, and this could rise to 75% within 15-20 years. Further injuries, like tears to the meniscus (cartilage in the knee), increase this risk even more. While reconstruction helps stabilise the knee and might reduce further damage, it doesn’t remove the risk of OA altogether.
Long-Term Outlook & Maintaining Knee Health
The typical return-to-sports timeframe is six months to over a year. Hamstring grafts potentially require slightly prolonged initial healing.
The most crucial factor is the individual’s rehabilitation progress, which is evaluated based on strict criteria, including the absence of significant pain and swelling; achieving full range of motion comparable to the uninjured leg; and restoring quadriceps and hamstring strength to at least 80-90% symmetry.
Athletes must be able to execute sport-specific movements with precise technique and control. Additionally, 85-90% symmetry is crucial and must be demonstrated in hop tests. A safe and supervised phased approach is recommended, starting with non-contact drills and gradually increasing in intensity as patients regain confidence and mental preparedness.
Keeping a healthy weight helps reduce stress on the knee. Regular, gentle exercise, like swimming, cycling, or tai chi, can maintain muscle strength and joint health without putting too much strain on the knee.
A/Professor Andrew Quoc Dutton, a Harvard Fellowship-trained orthopaedic surgeon, brings over 20 years of specialised experience to the management of complex knee injuries, including ACL injury, ACL rupture, and sprained ACL.
Dr Andrew Dutton is also recognised as a pioneer in Singapore for the Single Tunnel Double Bundle Intrafix ACL reconstruction, a technique designed to closely replicate the knee’s natural anatomy, enhancing stability and function.
If knee pain is limiting your life or preventing you from enjoying your favourite activities, take the first step towards recovery. Please book an appointment with our clinic today at (+65) 6836 8000.
References:
- Knee ligament surgery – NHS
- ACL Injury Treatment Program > Departments > Yale Medicine
- ACL Reconstruction Surgery: Procedure and Recovery | HSS
- Anterior Cruciate Ligament Graft Choices – PMC
- Initial Postoperative Instructions ACL Reconstruction + Meniscus Repair – UW Orthopaedic Surgery and Sports Medicine – University of Washington
- Department of Rehabilitation Services Physical Therapy Anterior Cruciate Ligament Reconstruction: Post-Operative Protocol – Brigham and Women’s Hospital
- A TEN TASK-BASED PROGRESSION IN REHABILITATION AFTER ACL RECONSTRUCTION: FROM POST-SURGERY TO RETURN TO PLAY – A CLINICAL COMMENTARY
- Anterior Cruciate Ligament Rehabilitation and Return to Sport: How Fast Is Too Fast? – PMC
- ACL Rehabilitation Phases 4-5 Exercises
- Osteoarthritis and ACL Reconstruction—Myths and Risks – PMC – PubMed Central
- Knee Osteoarthritis Following Anterior Cruciate Ligament Reconstruction: Frequency, Contributory Elements, and Recent Interventions to Modify the Route of Degeneration – PubMed Central
- The Role of ACL Injury in the Development of Posttraumatic Knee Osteoarthritis – PMC
A/Professor Andrew Quoc Dutton Orthopaedic & Sports Clinic Insurance
The A/Professor Andrew Quoc Dutton Orthopaedic & Sports Clinic offers minimally invasive and surgical treatments for sports-related injuries and orthopaedic conditions.
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