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.
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