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acl tear

ANTERIOR CRUCIATE LIGAMENT TEAR

Description

An anterior cruciate ligament (ACL) tear is a sprain (tear) of a ligament that helps maintain the normal relationship of the femur (thigh bone) and the tibia (leg bone). This ligament is most important in sports that require pivoting, cutting, jumping, and landing. This ligament does not heal when it is completely torn. (grade III)  About half the people who tear their ACL also have a torn meniscus cartilage. The ACL does not heal on its own but many people can function in their normal lives with little or no difficulty after the initial swelling subside. However, it is common for such individuals to have episodes of instability and re-injury to the knee with extensive cartilage damage and a greater risk of arthritis. Especially when playing sports that require cutting, jumping, or pivoting.

Signs and Symptoms

  • Pop heard or felt at the time of injury

  • An inability to continue playing

  • large amount of swelling

  • Inability to straighten knee

  • Knee instability described as giving way or buckling, particularly when trying to pivot or cut

Risks

  • Sports with pivoting, jumping, cutting, or changing direction (basketball, soccer, volleyball)

  • Contact sports (football, rugby)

  • Poor physical conditioning (strength and flexibility)

  • Female gender > risk than male gender

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Treatment

Initial treatment consists of relative rest, medications, elevation, and ice to relieve pain and reduce the swelling. Crutches are often recommended with partial weight bearing until able to bear weight with little or no pain. Once the initial swelling has subsided, range-of-motion, stretching, and strengthening exercises are started. Occasionally a physician may recommend a knee brace. Patients who do not participate in ports that require pivoting, cutting, and jumping, surgery may not required and rehabilitation alone may be sufficient treatment.  However, these individuals often require a brace during exercise and individuals who participate in sports that require contact, pivoting, cutting, and jumping; and individuals who have persistent instability during normal activities usually require surgery. 

Nonsteroidal anti-inflammatory medications (such as aspirin and ibuprofen) or other minor pain relievers (such as acetaminophen) are often recommended. Take medication only as directed by your physician. Contact your physician if any bleeding, stomach upset, black tarry stools, or signs of an allergic reaction occur. Pain relievers may be prescribed as necessary by your physician. Use only as directed. Cold is used to relieve pain and reduce inflammation for acute and chronic cases. Cold should be applied for 20 minutes 4 times daily.

Indications for Surgery

Surgery usually is not recommended until the injured knee has full range of motion and muscle control of the thigh (usually 3 or more weeks following injury). In surgical repair of an ACL tear, the torn ligament is replaced because the ligament, when torn, usually cannot be repaired (sewn together). Results after repair of the ligament are not as good as after reconstruction (replacement) of the ligament.
The goal of the operation is to restore the function of the torn ligament—that is, to allow a return to sports that require pivoting, cutting, change of direction, and jumping and landing. ACL grafts undergo a degeneration process (the graft is usually at its weakest 6 weeks after the surgery) followed by a regeneration process, which may take up to 1½ years.
 

The goal of the operation is to restore the function of the torn ligament—that is, to allow a return to sports that require pivoting, cutting, change of direction, and jumping and landing. ACL grafts undergo a degeneration process (the graft is usually at its weakest 6 weeks after the surgery) followed by a regeneration process, which may take up to 1½ years.

Contraindications to Surgery

 

Risks and Complications of Surgery

 

Infection; bleeding; injury to nerves (numbness, weakness, paralysis) of the knee, leg, or foot (it is not uncommon to have some numbness, temporary or permanent, on the outer part of the upper leg) Rupture or stretching of the reconstructed ligament, causing recurrent instability Knee stiffness (loss of knee motion) Rupture of the patellar tendon or patellar fracture (both uncommon) Pain from screw used to hold the graft (rare) Clot in the veins of the calf or thigh (deep venous thrombosis, phlebitis) that may break off in the bloodstream and go to the lungs (pulmonary embolus) or brain (causing a stroke)

 

Technique (What Is Done)

Surgery is usually performed with the assistance of an arthroscope; it may be done on an outpatient basis (you go home the same day), or you may stay in the hospital overnight. The torn ACL is replaced by a graft. Grafts most commonly used include (1) the central third of the patellar tendon, from the same or opposite knee; (2) hamstring tendon; (3) quadriceps tendon; and (4) allograft (transplant from a cadaver) patellar tendon or Achilles tendon. Each graft has its benefits and risks, and the type used for your graft is determined based on a discussion between you and your surgeon. When the torn ACL is removed, some bone in the knee is shaved to help the surgeon see where the graft goes and to help reduce pressure on the graft. Other structures in the knee are examined at the time of reconstruction, including the meniscus and articular cartilage. Bone tunnels are drilled in the leg bone and the thigh bone to place the ligament in almost the exact same position as the torn ACL was. The graft is held in position with screws, heavy sutures (stitches), spiked washers, or posts. The devices used to hold the graft in place usually do not need to be removed.

This surgery is therapy dependent.  Goals for rehabilitation of ACL reconstruction include reducing knee swelling, regaining knee range of motion, and regaining strength in the leg and thigh muscles. Often a graduated program is specified. You may return to sports when there is no pain and when full knee range of motion, muscle strength and endurance, and functional use has been restored. This usually requires 4 to 6 months following ACL reconstruction.