Is ACL Repair Viable as a Method of Treating ACL Injury?

ACL repair surgery offers promising alternatives to traditional reconstruction, with potential benefits including faster recovery and lower surgical morbidity. Patient selection is crucial, as not all ACL injuries are suitable for repair. Recent findings suggesting spontaneous healing of ACL tears have sparked renewed interest in native ACL preservation. However, more comprehensive studies are needed to compare the outcomes of ACL repair versus reconstruction. Patients with ACL injuries are encouraged to seek consultation with an orthopedic surgeon to exaplore the most appropriate treatment options tailored to their specific needs.

ACL primary repair with internal brace (A) vs. ACL reconstruction with a tendon graft (B)
Source: BostonJointPreservation.com

What are Anterior Cruciate Ligament (ACL) injuries?

Anterior Cruciate Ligament (ACL) tears are significant injuries affecting knee stability and function. Left untreated, they can lead to further complications and potential career-ending consequences for athletes. Traditional treatment involves ACL reconstruction, replacing the torn ligament with a substitute graft. However, the concept of ACL repair, initially explored in the 1970s and 1980s, has re-emerged with advancements in surgical techniques and biologics.

Advantages of ACL Repair Surgery

Recent experiences from surgeons in the USA and Europe highlight the benefits of ACL repair, including faster restoration of range of motion and potentially improved proprioception. Compared to reconstruction, ACL repair is less invasive, resulting in lower surgical morbidity. Additionally, in cases of failure, revision surgery following primary repair is expected to be less complicated than revision reconstruction.

Disadvantages and Controversies for ACL Repair Surgery

Not all ACL injuries are suitable for primary repair, as success depends on various factors such as tear location, tissue quality, patient age, and activity level. Some studies suggest that only certain types of ACL injuries are amenable to repair, particularly acute or recent injuries. Delayed treatment may result in higher failure rates due to shortening or scarring of the ACL stump. Furthermore, young patients may have higher re-rupture rates following repair, leading to cautious recommendations for patient selection.

Recent Findings Regarding ACL Tear Treatment Options

Recent studies have challenged conventional wisdom by suggesting that ACL tears may heal spontaneously, particularly in proximal tear patterns. While this notion contradicts established beliefs, it encourages a re-evaluation of native ACL preservation and repair as a treatment option. However, the long-term outcomes and comparative effectiveness of ACL repair versus reconstruction remain subjects of ongoing research and debate. We may have to wait a little longer before we can have a definitive answer if ACL repair is suitable as an accepted method to treat selected ACL injuries.

Conclusion

If you have recently suffered an ACL injury or are experiencing knee instability, do visit your orthopaedic surgeon and have an in-depth discussion on the available ACL treatments that could help you speed up your recovery.  Your doctor can assess your individual case and help you determine the best course of treatment for your specific needs and goals. Remember, the road to recovery may be challenging, but with the right treatment and support, you can overcome your injury and return to the sports you love stronger than ever.

Book a consultation with Dr Sean Leo at Orthokinetics if you have any concerns or questions about ACL injury and treatment options.

Tips for recovering from an ACL Surgery

This article first appeared in Orthokinetics Blog. Adapted with permission.

Acute Cruciate Ligament (ACL) surgery can be a complex and challenging recovery process. From pre-surgery planning to incorporating physical activities and maintaining a healthy diet, these tips aim to ease the journey of patients toward successful knee surgery recovery.

Undergoing any type of surgery can be a daunting experience, and surgery related to bones, muscles, or the heart can pose significant challenges that you must manage for the rest of your life. Knee surgery, in particular, requires a great deal of attention and care. Acute Cruciate Ligament (ACL) surgery, in particular, presents a unique set of challenges that require you to follow your physician's advice and get creative with your recovery plan to ensure a speedy and successful recovery.

In this post, we offer practical tips to help ease your journey as you undergo ACL surgery.

1. Pre-Surgery Planning

Before the surgery, you must plan ahead to ensure that you have the necessary support and equipment post-surgery. Depending on the extent of the surgery, you may require the use of crutches or a brace, and you may need assistance with daily tasks such as driving or mowing the lawn. It's crucial that you are informed about when to seek help and that you have a support system in place to assist you during this period.

2. Do Some Homework

Living with crutches can be challenging, particularly for athletes who don't want to compromise their performance. However, you can take steps to make things easier:

• For bathing, use a detachable shower chair and showerhead

• Use a backpack to carry necessary things

• To avoid hits and strikes, better to move things from the way for crutches

• Use a wheeled chair to move around the home

• Get rid of all exposed cords and throw rugs to avoid any accidents after knee surgery

3. Add Some Physical Activities to Your Lifestyle

Maintaining a good workout routine is one of the best ways to ensure a successful recovery after knee surgery. You can work with your physical therapist to develop a post-surgery plan that focuses on strengthening the knee to prevent the risk of re-injury.

4. Fuel Up with a Healthy Diet

Considering the severity of knee pain and the recovery period, it's important to fill up the kitchen with healthy meals that are easy to prepare and rich in nutrients.

In addition, incorporating high-fiber foods can help to support the digestive system and keep it things moving smoothly. Constipation may be common after knee surgery due to reduced mobility and the use of pain medication post-surgery. One can add berries, bran, peas, and apples to boost the fiber intake. You should avoid alcohol and caffeine, as they may interfere with your medications.

5. Have Adequate Rest

You should avoid performing intense physical activities right after ACL surgery, as it can be risky. Focus on engaging in sedentary activities that keep the brain active, but not the knee. You can involve yourself in mind work or activities that do not require physical exertion. Give their knee enough time to recover with adequate rest and appropriate physiotherapy.

6. Keep a Close Eye on the Knee

After a successful ACL surgery, it's important to keep a close eye on the recovery process to ensure that there are no complications. If you experience moderate pain, excessive swelling, or fever for a few days, you should visit an orthopaedic surgeon. The sooner a problem is detected, the better the chances of a successful recovery.

7. Be Patient

The recovery process takes time, and the duration varies depending on the extent of the ACL surgery. Some patients may recover in a few weeks, while others may require a month or more. You must be patient and follow your sports doctor's recommendations to ensure a successful recovery. It's important not to put too much pressure on your knee joints, which are still weak after surgery.

In conclusion, ACL surgery recovery can be a complex and challenging process, but with the right planning, support, and care, you can achieve a successful recovery. These practical tips can help you ease your journey toward a successful knee surgery recovery.

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How to Identify an MCL Tear?

When it comes to understanding the types of knee injuries, ligament turns out to be a potential problem as it leads to severe knee pain and discomfort. The ligament is basically a tough fibrous connective tissue in a short band that is made up of stringy, long collagen molecules. They are responsible for keeping bones connected with other bones, particularly in the joints. Their task is to ensure proper mobility of the joint and prevent discomforting or those movements that may cause problems later on.

Causes of Knee Ligament

Knee ligament injuries are common in athletes or people who are involved in physical efforts on regular basis. Being sporty, you might face ligament injuries due to rapid change in direction, wrong landing from a jump or a blunt hit to the knees like in football tackle. The incident usually happens as the result of high speed that leads to muscle in-coordination or weakness to ligament tears or sprain.

Severity and Symptoms of Knee Ligament Injuries

When it comes to finding out the severity of the knee ligament, a professional orthopedic surgeon used to explain that it depends upon the tearing or stretching of the ligament.

Here is what you should always consider:

·       When suffering from a mild grade I sprain, there is no tearing but stretching. Even though the joint does not swell or hurt but, it increases the risk of having more injuries in the future.

·       In a moderate grade II sprain, there is partial tearing in the ligament. Bruising and swelling are quite common health issues but, really difficult and painful at the same time.

·       In case of a severe grade III sprain, the ligament tears completely and causes swelling or bleeding in the skin. The joint loses its stability and strength to hold weight. The considerable part is that there is no pain in grade 3 tear because all pain fibers are torn during the injury.

Types of Knee Ligament Injuries

Based on the severity and need for knee surgery, it’s important to look at the following two types:

1.     Medical Collateral Ligament (MCL)

2.     Anterior Cruciate Ligament (ACL)

So now, let’s have a brief discussion on both and know how to identify these ligament injuries.

Medical Collateral Ligament

Medical Collateral Ligament- MCL

It is a thick, wide band that starts from the inner knee part from the femur (thighbone) up to the shinbone that is about four to six inches from the knee. Its major responsibility is not to allow the leg from extending too far while keeping it stable and moving in its position.

Causes of Tears in MCL

In order to save your sports performance, your responsibility should be to know how to avoid MCL injuries, especially to keep it safe from hitting directly from outside. When the knee gets pressure on its ligaments, chances are high that your knee area would tear too far then it should do.

Yes, it’s quite common to see athletes facing ACL and MCL tears at the same time. Even, the ligaments get damaged by repeated stress, thus causing the part to lose its elasticity and normal stretch.

Click here to read more on how to identify if an ACL tear.

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About the Author
Dr Sean Leo is a former SAF Medical Scholarship recipient and served as CO of the Medical Classification Centre at CMPB. After retiring from active military service in 2012, Dr Leo joined Changi General Hospital where he was the Director of Hip and Knee Service.  He subsequently went into private practice at Mt Elizabeth Novena Hospital. As an orthopaedic surgeon, Dr Leo is specialized in knee and lower limb surgery with a focus on sport injuries, rehabilitation and performance. 

For an appointment, email appointment@orthokinetics.sg.

Is Your ACL Injury Suitable for Repair Rather Than A Replacement?

An ACL tear has always been a dreaded injury for athletes. For complete tears of the ACL, the mainstay of treatment for athletes who wish to return back to their sports had always been to undergo reconstruction surgery. Unfortunately, such therapy results in a prolonged period of rehabilitation that might see an athlete being out of the game for almost 9 months.

A rapid rehabilitation and return to play after an ACL surgery have always been a desired outcome for many athletes. Unfortunately, the traditional treatment of ACL tears remedies the problem by replacing a torn ACL with a graft. The time required to return to play after the surgery is often dependent on how rapidly the graft incorporates and how quickly the surrounding muscle rehabilitates after the surgery. This can take any time between 6 to 9 months and effectively results in the athlete missing the playing season.

"...to return to play after the surgery is often dependent on how rapidly the graft incorporates and how quickly the surrounding muscle rehabilitates after the surgery."

In recent years, doctors have been developing new techniques of treating ACL injuries. These techniques involve the repair of the torn ACL rather than a replacement of the ACL by a graft. This is a paradigm shift in the way that ACL tears are treated. The ACL ligament unlike some other ligaments in the body does not heal itself after its ruptures. The anatomical position of the ACL within the knee subjects it to constant forces as the knee is moving. Additionally, the ruptured ends of the ligament are constantly surrounded by synovial fluid which makes clot formation that is essential for scar tissue formation virtually impossible. However, in recent years, a greater understanding of the biology of healing may have led doctors to discover new ways to circumvent these problems. 

"In recent years, doctors have been developing new techniques of treating ACL injuries."

Repair of the ACL offers several advantages. By repairing the ligament instead of replacing it with a graft, the patient is spared donor site morbidity that comes with graft harvest. Additionally, repair of the original ligament may also preserve some of the nerve fibers present in the original ligament that will help in proprioception (perception of position) of the knee.

"By repairing the ligament instead of replacing it with a graft, the patient is spared donor site morbidity that comes with graft harvest.

There are 3 areas that doctors aim to address with their new techniques.

Repairing of the Ligament Back to Bone

Not every ACL tear occurs in the midsubstance of the ligament. There are a proportion of tears that occur from the femoral attachment of the ACL. This means that the ligament itself is largely intact but it’s attachment to the upper bone has been interrupted.

"It may be possible to repair the original ligament back to the bony point and reinforce the repair with an internal brace."

When this injury pattern is observed on the MRI and confirmed intraoperatively, it may be possible to repair the original ligament back to the bony point and reinforce the repair with an internal brace (synthetic and inert suture ribbon). The reinforcement with a synthetic ribbon, shields the repair from the deforming forces of the knee that the ACL ligament would otherwise be subjected to. This allows the ligament time to heal back to its original position and serve its function once it has done so.

Promote Rapid Healing

The healing environment within the knee is usually poor because of the constant movement of the knee and synovial fluid that surrounds the ligament ends. However, new technology utilizing growth factor concentrations (eg. Platelet Rich Protein Gels) are now available to enhance the healing potential of the injured site. Doctors and researchers have opined that increasing the growth factors locally at the repair site would enhance the speed and the quality of healing.

Rapid Rehabilitation

As the patient is spared from a tendon harvest to replace the torn ACL, the repair surgery is essentially less damaging to the surrounding tissues. This means that the patient can potentially recover from the pain and swelling, faster post-surgery and have a higher chance to rehabilitate their muscles back to pre-injury conditions earlier. All this translates to a more rapid recovery process for the patient.

Controversy and Contraindications

While these advantages are certainly desirable, ACL repair is relatively new as a concept of treatment. Currently, there isn’t a widely adopted way to repair the ligament. Furthermore, certain configurations of injury seem to be more amenable to repairs. As a result, this form of treatment has not been universally accepted by surgeons yet. Nevertheless, there are currently research and clinical trials that are being conducted and we should expect a clearer consensus in the near future.

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About the Author
Dr Sean Leo is a former SAF Medical Scholarship recipient and served as CO of the Medical Classification Centre at CMPB. After retiring from active military service in 2012, Dr Leo joined Changi General Hospital where he was the Director of Hip and Knee Service.  He subsequently went into private practice at Mt Elizabeth Novena Hospital. As an orthopaedic surgeon, Dr Leo is specialized in knee and lower limb surgery with a focus on sport injuries, rehabilitation and performance. 

For an appointment, email appointment@orthokinetics.sg.