ACL RECONSTRUCTION

The anterior cruciate ligament (ACL) is a band of dense connective tissue which courses from the femur to the tibia. The ACL is a key structure in the knee joint, as it resists anterior tibial translation and rotational loads.It is one of four major ligaments around the knee offering stability and guidance to knee motion. There are two components of the ACL, the anteromedial bundle (AMB) and the posterolateral bundle (PLB).

The anterior cruciate ligament is one of the most commonly injured ligaments of the knee. The incidence of ACL injury is higher in people who participate in higher risk sports, such as basketball, football, soccer, volley ball, skiing and any kind of contact sports. The mechanism of injury is often deceleration coupled with cutting, pivoting or sidestepping maneuvers, awkward landings or “out of control” play.

At the time of injury, most athletes relate a “pop” in the knee, often heard by other players. There is usually immediate swelling and inability to continue playing. The knee often feels unstable.

Treatment of ACL tears can be non-surgical for partial tears, but is often surgical, especially if the player wishes to return to the previous level of play. Partial tears can be treated conservatively for 2-3 months through physical therapy and athletic retraining to enable return to sports. If there is continued symptom of instability or feelings of giving way, the partial tear may need surgical reconstruction.

For surgical intervention, there are several key factors that must 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. Activity level, significant functional instability, and presence of combined injuries (meniscal, additional ligamentous, or cartilage damage) are all further indications for surgical intervention.

The current “gold-standard” for reconstruction of the ACL is to use the patellar tendon graft or Hamstring graft. The patellar tendon graft involves using the central 1/3 of the same knee’s patellar tendon and bone chips on each end to reconstruct the ACL. Tunnels are drilled into the bone above and below the knee to place the ACL graft. The benefits of the bone-tendon-bone graft are that the bone chips heal well to the bony tunnels in the leg bones, lower risk of graft failure, and improved stability.Pitfalls associated with patellar tendon grafts include anterior knee pain, patellar (kneecap) pain, weakness of the quadriceps muscle (front of the thigh), and a low risk of patellar (kneecap) fracture.

The hamstring tendon used for grafting the ACL. is generally done through a smaller incision, has little pain associated with the front of the knee, and generally has faster return of quadriceps strength. Fixation of the hamstring graft has been shown to be equal to or greater than the bone-tendon-bone fixation. The cons with hamstring grafting are weakness of hamstring and inner thigh muscle groups and possible elongation of the graft itself.

After surgery, physical therapy is a crucial part of successful ACL reconstruction, with exercises beginning immediately after the surgery. Much of the success of ACL reconstructive surgery depends on the patient’s dedication to rigorous physical therapy. With new surgical techniques and stronger graft fixation, current physical therapy uses an accelerated course of rehabilitation.The patient’s sense of balance and control of the leg must also be restored through exercises to improve neuromuscular control. This usually takes 4 to 6 months.

For return to sports, it is recommended that the athlete participates in sport specific training to mimic sporting activities in a controlled environment before returning to competitive play. This is recommended to prevent re-injury, as well as to maximize the athlete’s ability to play well, without fear or anxiety regarding the injured knee.

PREVENTION OF INJURIES

Unfortunately, no single exercise can prevent injury to the ACL. The good news is that you can give yourself some protection by developing and Maintaining strength and endurance in your lower extremities. To promote stability in the knee, perform closed-chain exercises (e.g., leg presses, squats, lunges) as part of your strength-training program. Also, do some cross training in your cardiovascular workout with the stairclimber, stationary bike, elliptical cross trainer and the ski machine.

You can also avoid an ACL injury by preparing for your favorite sport in the preseason. Plan for at least four weeks of endurance training before your basketball, tennis, or racquetball league begins. Also: Have fun, but be sensible when playing your sport. Whenever you find that you must stay away from your regular routine for two or three weeks due to travel or illness, ease up for several workouts to give your body time to recondition. Preconditioning work out is of atmost importance.