• Common Sporting Injury

The Anterior Cruciate Ligament is commonly ruptured (torn) in football, netball and skiing. In Football the player is running, sidesteps without contact / tackle, the thigh bone rotates on the lower shin bone. The ligament that connects the two - namely the anterior cruciate ligament- tears. The player will fall to the ground in severe pain, need to leave the pitch.

The ACL is a stong ligament and it requies great force to rupture it, hence skiing and the landing from a hight in netball or volleyball. Patients will often feel or hear a snap or crack, and will feel that the knee dislocated for a split second (which the outer half of the knee actually does)

  • The injury

The knee will swell up - this is due to bleeding in the knee from the torn ligament which has a good blood supply. In the UK a typical course of events is attendance to Accident and Emergency, where an ray is taken, the patient is reassured it will settle down, is given crutches and pain killers. Additional injuries such as cartilge tears may have occured at the time of injury.

The knee will setle down as the bleeding stops and is resorbed. Most of the pain has passed by 8-10 days. Motion will recover, and the ability to fully weight bear will return.

At about 6 weeks the knee will feel good - but the ligament is no longer properly attached. Without the ligament patients will typically: be able to run in a straight line, but not run and turn. The leg will feel as if the lower bone is not properly connected to the upper bone, and patients will not be able to trust it.

  • Initial treatment

The goals are to reduce swelling and regain a full range of motion. Therefore ice packs, anti-inflammatory tablets ( such as Ibuprofen or diclofenec - care if have ulceres or asthma), and a compression bandage all help. Crutches will allow the patient to be mobile. Sometimes the knee willl not go fully straight- this can be due the end of the torn ACL getting in the way or a torn cartilage structure getting in the way. This is the role for an MRI scan (magnetic Resonace Image) scan. This will show wether or not there is a cartilage tear. Some tear types benefit from repair and there are advantages in having this done early.

  • Timing of anterior cruciate Ligament Reconstruction

Although it is a dramatic injury, early surgery has problems of arthrofibrosis (ecessive scarring in the joint) and thus surgery should be delayed until the knee has regained a full range of motion- typically 4-6 weeks. The thinking is the knee can recover from one "hit" at a time but not two. Thus an ACL injury followed a few days later can lead to excessive scarring in the joint, whereas an ACL injury followed a settling down period and then surgery at typically 6 weeks does not. This is frustarting for the patient, This time can be used positively in strenghening the Hamstrings, regaining range of motion, preparing mentally for surgery.

  • Types of Anterior Cruciate Ligament Reconstrucion

Hamstring or Bone patella bone.

At present it is not possible to repair the two ends together. The ligament ends are removed and a new ligament is substituted in its place. This new ligament is, in effect, a transplant of other "spare" tissue that we can do without - dont worry there is good evidence that the spare tissue grows back from where it was borrowed. This borrowed tissue is termed a graft. Occassionally ther may be reasons to use tissue from a donor. The advantages of donor material is that it doesnt have to be borrowed from yourself, the principal disadvantage is the risk of infection including HIV, prions.

90% of USA surgeons now use a Hamstring Technique. Hamsting and Bone-Patella_bone give similar results in terms of knee stability

  • Hamstring graft for ACL has the following benefits:

Smaller Scar

Less pain

Quicker revery

Better kneeling ability

Better jumping strength

Better ability to starighen the knee

Much lower long term arthritis risk behind the knee cap- the 15 year risk for bone-patella-bone is 75%

Key hole technique