The information that follows includes information provided by AAOS. This includes the details of anterior cruciate ligament (ACL) anatomy and the pathophysiology of an ACL tear, treatment options for ACL injuries along with a description of ACL surgical techniques and rehabilitation, potential complications, and outcomes. The information is intended to assist the patient in making the best-informed decision possible regarding the management of ACL injury. More information can be found here.
The bone structure of the knee joint is formed by the femur, the tibia, and the patella. The ACL is one of the four main ligaments within the knee that connect the femur to the tibia.
The knee is essentially a hinged joint that is held together by the medial collateral (MCL), lateral collateral (LCL), anterior cruciate (ACL) and posterior cruciate (PCL) ligaments. The ACL runs diagonally in the middle of the knee, preventing the tibia from sliding out in front of the femur, as well as providing rotational stability to the knee.
The weight-bearing surface of the knee is covered by a layer of articular cartilage. On either side of the joint, between the cartilage surfaces of the femur and tibia, are the medial meniscus and lateral meniscus. The menisci act as shock absorbers and work with the cartilage to reduce the stresses between the tibia and the femur.
The anterior cruciate ligament (ACL) is one of the most commonly injured ligaments of the knee. In general, the incidence of ACL injury is higher in people who participate in high-risk sports, such as basketball, football, skiing, and soccer.
Approximately half of ACL injuries occur in combination with damage to the meniscus, articular cartilage, or other ligaments. Additionally, patients may have bruises of the bone beneath the cartilage surface. These may be seen on a magnetic resonance imaging (MRI) scan and may indicate injury to the overlying articular cartilage.
Cause
It is estimated that the majority of ACL injuries occur through non-contact mechanisms, while a smaller percent result from direct contact with another player or object.
The mechanism of injury is often associated with deceleration coupled with cutting, pivoting or sidestepping maneuvers, awkward landings or “out of control” play.
Several studies have shown that female athletes have a higher incidence of ACL injury than male athletes in certain sports. It has been proposed that this is due to differences in physical conditioning, muscular strength, and neuromuscular control. Other hypothesized causes of this gender-related difference in ACL injury rates include pelvis and lower extremity (leg) alignment, increased ligamentous laxity, and the effects of estrogen on ligament properties.
What happens naturally with an ACL injury without surgical intervention varies from patient to patient and depends on the patient’s activity level, degree of injury and instability symptoms.
The prognosis for a partially torn ACL is often favorable, with the recovery and rehabilitation period usually at least 3 months. However, some patients with partial ACL tears may still have instability symptoms. Close clinical follow-up and a complete course of physical therapy helps identify those patients with unstable knees due to partial ACL tears.
Complete ACL ruptures have a much less favorable outcome without surgical intervention. After a complete ACL tear, some patients are unable to participate in cutting or pivoting-type sports, while others have instability during even normal activities, such as walking. There are some rare individuals who can participate in sports without any symptoms of instability. This variability is related to the severity of the original knee injury, as well as the physical demands of the patient.
About half of ACL injuries occur in combination with damage to the meniscus, articular cartilage or other ligaments. Secondary damage may occur in patients who have repeated episodes of instability due to ACL injury. With chronic instability, a large majority of patients will have meniscus damage when reassessed 10 or more years after the initial injury. Similarly, the prevalence of articular cartilage lesions increases in patients who have a 10-year-old ACL deficiency.
Nonsurgical Treatment
In nonsurgical treatment, progressive physical therapy and rehabilitation can restore the knee to a condition close to its pre-injury state and educate the patient on how to prevent instability. This may be supplemented with the use of a hinged knee brace. However, many people who choose not to have surgery may experience secondary injury to the knee due to repetitive instability episodes.
Surgical treatment is usually advised in dealing with combined injuries (ACL tears in combination with other injuries in the knee). However, deciding against surgery is reasonable for select patients. Nonsurgical management of isolated ACL tears is likely to be successful or may be indicated in patients:
- With partial tears and no instability symptoms
- With complete tears and no symptoms of knee instability during low-demand sports who are willing to give up high-demand sports
- Who do light manual work or live sedentary lifestyles
- Whose growth plates are still open (children)
Surgical Treatment
ACL tears are not usually repaired using suture to sew it back together, because repaired ACLs have generally been shown to fail over time. Therefore, the torn ACL is generally replaced by a substitute graft made of tendon.
- Patellar tendon autograft (autograft comes from the patient)
- Hamstring tendon autograft
- Quadriceps tendon autograft
- Allograft (taken from a cadaver) patellar tendon, Achilles tendon, semitendinosus, gracilis, or posterior tibialis tendon
Patient Considerations
Active adult patients involved in sports or jobs that require pivoting, turning or hard-cutting as well as heavy manual work are encouraged to consider surgical treatment. This includes older patients who have previously been excluded from consideration for ACL surgery. Activity, not age, should determine if surgical intervention should be considered.
In young children or adolescents with ACL tears, early ACL reconstruction creates a possible risk of growth plate injury, leading to bone growth problems. The surgeon can delay ACL surgery until the child is closer to skeletal maturity or the surgeon may modify the ACL surgery technique to decrease the risk of growth plate injury.
A patient with a torn ACL and significant functional instability has a high risk of developing secondary knee damage and should therefore consider ACL reconstruction.
It is common to see ACL injuries combined with damage to the menisci, articular cartilage, collateral ligaments, joint capsule, or a combination of the above. The “unhappy triad,” frequently seen in football players and skiers, consists of injuries to the ACL, the MCL, and the medial meniscus.
In cases of combined injuries, surgical treatment may be warranted and generally produces better outcomes. As many as half of meniscus tears may be repairable and may heal better if the repair is done in combination with the ACL reconstruction.
COnsuting an orthopedic surgeon is highly recommended before deciding on your treatment plan. Your doctor will be bale to tell you the severity of your injury and how to best go about healing it. To make an appointment with Dr. Hinkes or Dr. Fletcher in Boca Raton, FL, call us at 954-979-3255.
