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KNEE INJURIES

“In general the higher the demands on the knee the more likely the need for ligament reconstruction”

Arthroscopy

Sometimes full assessment can only be carried out by examination under anaesthesia and arthroscopy. Only with the muscles fully relaxed is it possible to obtain a true picture of the damage and the joint laxity.

Fate of the torn ACL There is an old adage:

One third have no instability One third alter sporting participation, use braces etc., and live with the instability One third have ACL reconstruction

However the improvements in techniques and therefore results and the wider availability of surgery have meant more people undergoing reconstruction. Not all ACL injuries give instability and certain types of injury such as the low speed injury in skiing are less likely to require reconstruction.

It is not clear if an ACL deficient knee is more liable to arthritis in later life but neither can it be said that ACL reconstruction will lessen these risks. If the knee is continuously giving way damaging the chondral surfaces then correction of the laxity is likely to be of benefit.

Much research is currently directed at the kinematics of the normal, ACL deficient and ACL reconstructed knee and this information will help to answer these questions.

Indications for ACL reconstruction

The main indication must be functional instability. Cruciate ligament reconstruction aims to regain stability, not to reduce pain, effusion or lessen subsequent arthritis. Pain nearly always comes from associated injuries and the symptom of the cruciate deficient knee is sudden “pain-less” collapse.

Age is not a contraindication. It is not usual to perform definitive reconstruction until close to skeletal maturity, but equally it is never too late for the surgery as long as the indications are correct. In the older age group the method of reconstruction, eg. using a synthetic ligament, may change and caution must be used when there is pre-existing arthritis as the altered kinematics may make the arthritic symptoms worse.

One group that can present a difficult dilemma is the injured professional sports person with no obvious major instability soon after the injury. In general the higher the demands on the knee the more likely the need for ligament reconstruction. It is usual for high quality sports people to undergo reconstruction of the damaged ligament.

Methods of reconstruction The most common methods involve using:

Central third patella tendon with adjacent bone blocks

Four strand hamstrings (semitendonosis and gracilis doubled over)

Synthetic material Extra articular tissue Allograft (donor)

The most common tissues used for reconstruction are those of the patient’s (autograft). The patella tendon and hamstrings are used equally frequently depending on the surgeon’s preference. If the patients have a kneeling occupation, pre-existing knee cap pain or cosmetic appearance is important, the hamstrings may be preferred. Many surgeons who treat professional players prefer the patella tendon.

Synthetic ligaments are more popular and successful now than a decade ago due to improvements in techniques and materials. Synthetic ligaments would seem to be suited to the over-45 age group when the patient’s own tissues are starting to lose strength.

Extra articular repairs are done rarely in the UK and in general terms arthroscopically-assisted graft placement has superceded traditional open techniques.

The average time in hospital is two to three days and crutches are usually required for at least the first week. It is now unusual to use any form of external immobilisation and patients are usually safe to drive within three weeks. The return to work time varies between three weeks in sedentary jobs and six weeks in manual occupations.

Rehabilitation

It used to be said that “you can’t reconstruct the cruciate ligament – all you can do is get rid of the symptoms of instability”. With the research into joint mechanics and particularly with motion analysis techniques it may be possible to remodel the cruciate graft into something resembling the old ligament. Rehabilitation techniques change according to science and also to fashion.

Close kinetic chain exercises where the foot of the affected leg never loses contact with the ground or a plate was thought to be more safe and functional than open chain exercises, however the latter are now becoming fashionable again in America.

The full scope of prevention of ACL injury is the subject of another article but there remains no doubt that the scientific appraisal of sports injury can lead to some degree of injury prevention.

Mr David Rees is a consultant orthopaedic surgeon at the National Centre for Sports Injury Surgery at The Robert Jones and Agnes Hunt Orthopaedic and District Hospital NHS Trust, Oswestry. He specialises in sports injury surgery and has particular interests in arthroscopic knee surgery, the sports spine (spondylolsis) and cartilage cell regeneration. He performed the first autologous chondrocyte cartilage cell implantation in the UK.

32 SportEX

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