ACL RECONSTRUCTION

OPTIMAL MANAGEMENT OF ACL INJURY IN 2007 – PART 2

By Mr Andy Williams, FRCS (orth)

MANAGEMENT OF ESTABLISHED ACL RUPTURE The vast majority of patients will benefit from anterior cruciate ligament (ACL) reconstruction surgery. Surgery can be justified on a number of grounds. For the patient's foreseeable future surgery can provide a higher chance of restoration of function with a low risk of complications when undertaken well.

For the longer term the question arises as to whether ACL recon- struction earlier can help prevent later problems. There is now good evidence that early ACL reconstruction carried out earlier protects against meniscal tears. There is no good evidence, however, that ACL reconstruction reduces, or delays, the onset of osteoarthritis. In time, I believe that this will be proven, although at the moment the evidence has not accumulated. There are a number of articles suggesting that ACL reconstruction might actually increase the risk of osteoarthritis. These are more often than not fundamentally flawed in their methodology. For example, often patients who are more likely to stress their joints are selected for ACL surgery and it is perhaps not surprising that the sedentary ones who opt for non- surgical approach get less wear in the joint. Furthermore, these papers are now somewhat historic when the techniques of ACL reconstruction were rather crude.

Currently I offer ACL reconstruction to all professional athletes and, whilst explaining that surgery is not obligatory, also to the majority of my young active patients. I would certainly include

those in their forties in this group. I do not consider there to be an age limit for ACL reconstruction. In those patients with relatively quiet lifestyles in their fifties and above, I would certainly not consider rushing into ACL surgery without, in most cases, a trial of non-surgical treatment first. If patients have symptomatic instabil- ity of their joint- this may simply be a lack of trust, as opposed to frank giving way, I am happy to offer them ACL reconstructive surgery regardless of their age. Older patients do have a greater risk of an unsatisfactory outcome since their bone is softer and the ten- don used for graft is weaker. This is compounded by their age-relat- ed muscle atrophy. Nevertheless, the results are pleasing in most cases.

NON-SURGICAL TREATMENT OF ACL DEFICIENCY For only a very few patients is non-surgical treatment appropriate. The emphasis is on strengthening and enhancement of agility. The process should emphasise strength and the quick-firing of the ham- strings in particular, but in truth all lower limb muscles as well as those of the trunk, need to be strong and co-ordinated.

Figure 1: A middle one-third patellar tendon graft

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Figure 2: A four-strand hamstring graft being constructed

SURGICAL RECONSTRUCTION Historically attempts at suture repair of the ruptured ligament were performed during the sixties and seventies but almost invariably the repair failed. Until recently it was held that repair was not an option for a rupture of this ligament. In the seventies extra-articu- lar techniques were used to 'tighten' the lateral compartment of the joint to prevent the pivot shift phenomenon. The McIntosh lateral tenodesis was a popular option. Whist this certainly was effective in some cases, it tended to stretch out and was a fairly brutal procedure. In the early eighties intra-articular reconstruction procedures were developed and the modern era of ACL surgery dawned. The surgeon aims to place a soft tissue graft in the position of the original ACL. This can be undertaken as open or arthroscopic surgery and there are a number of graft choices. There are some certainties regarding this surgery, but many myths. The various issues are explored below.

sportex medicine 2007:33(Jul):10-15