Do You Need ACL Repair?
ACL ruptures are the most common injury of the knee joint. The infamous popping sound when the ligament tears is now synonymous with pain and months of recovery. ACL repair and rehabilitation are almost always necessary to restore range of motion. But which approach is the best? Today, most surgeons depend on knee arthroscopy, which is considered the best way to repair an ACL tear.
Understanding your ACL
ACL stands for anterior cruciate ligament, a fibrous piece of tissue that connects the shin and thigh bones. The ACL is one of 4 vital ligaments in the knee that help with stability. ACLs prevent the knee from going too far forward and also help with a change of direction. These qualities make the ligament prone to tears, especially in sports like basketball, football, skiing, and soccer. Women are several times more likely to get an ACL tear than men due to smaller, more elastic ligaments.
Tears and treatment
ACL injuries cause swelling, stiffness, pain, and a loss of motion. The knee feels unstable and gives way when bearing weight. These symptoms all depend on the degree of the ACL tear, measured in 3 grades. Grade 1 injuries are sprains, reducing the elasticity of the ligament. Grade 2 injuries are partial tears but can still require surgery. Grade 3 tears are full-thickness tears. The ligament fully detaches from the bone and needs immediate surgical attention. For ACL surgery, there are different routes the surgeon can take to get the best results.
Repair vs reconstruction
ACL repair is often confused with reconstruction. An ACL repair works well for a partially torn ligament. The doctor cleans up the tissue and bone, then reattaches the ruptured tissue back to the bone. ACL repairs can restore some motion, but the technique may not be as effective. Ligaments tend to tear at the midway point, reducing stability. On the other hand, reconstruction removes all damaged tissue and replaces the ACL with a new ligament. In almost all cases, reconstruction is the best surgical method.
Open vs knee arthroscopy
Before reaching the operating table, both parties will discuss the type of ACL surgery. The doctor will perform either open surgery or knee arthroscopy. Minimally invasive surgeries like knee arthroscopy have been leading the way in ligament repair. However, that does not mean open surgeries are obsolete. A knee arthroscopy uses a small device with a camera attached through a small incision to perform the surgery. This means faster healing, faster surgeries, and more minor scars. Open surgeries use an incision several inches long to access the knee fully. For severely damaged knees, this gives the surgeon a larger scope to operate.
Single bundle vs double-bundle surgery
The ACL consists of 2 bundles of strong fibers. The anteromedial bundle helps with stability, and the posterolateral bundle helps with flexibility. Sometimes, a surgeon will decide on either a single-bundle or double-bundle surgery. Most surgeries use a single-bundle approach. The surgeon places one solid tendon graft in the space of the anteromedial bundle, using one tunnel through each bone. Double-bundle surgery uses 2 smaller grafts to substitute for each bundle, with 2 tunnels instead. This surgery is complex, taking added time and expertise. A study showed that while both procedures were equally effective, double-bundle surgery had improved overall performance. Double-bundle surgeries also had a lower failure rate over time.
Autograft vs allograft
Regardless of the type of surgery or technique performed, reconstruction requires a tendon graft. Grafts can come in 1 of 2 ways. The surgeon can take an autograft, a tendon sample from the patient’s quadriceps, hamstring, or patellar tendon. An allograft is a donor tendon, usually from the donor’s Achilles tendon or patellar tendon. Allografts are particularly expensive but remove the risk of morbidity around the autograft site. Donor’s tendons mean the surgical procedure is flexible as well. Autografts, on the other hand, reduce the chances of infection and tend to incorporate easily. Over time, studies have shown autografts have a slight advantage.
What’s the best route?
The surgical techniques will depend on several factors. These include the degree of damage, cost, surgeon expertise, and much more. Knee arthroscopy has a significant advantage, particularly when combined with an autograft. Some surgeons may be able to perform double-bundle procedures. However, this technique is still at the infancy stage. Don’t be afraid to get a second opinion on the injury. Weigh out all options and choose the right surgeon and technique available.