Treatment of Anterior Cruciate Ligament (ACL) Tears
Mr Deepu Sethi is an expert orthopaedic knee surgeon specialising in the treatment of ACL tears, in London. He uses cutting-edge techniques to for ACL repair or ACL reconstruction surgery, to restore stability, allowing faster recovery and return to sport. Mr Sethi is one of the highest volume ACL surgeons in the UK.
What is the treatment for an ACL tear?
Many factors need to be considered when deciding the best treatment for someone who has torn their ACL. Factors include, associated injuries (for example an associated meniscus tear), age of the patient, level of activity of the patient and the future sporting ambitions for the patient.
Many people can be treated successfully with physiotherapy and it is important to appreciate that not everybody who tears their ACL requires surgery.
Do I need surgery if I have a torn ACL?
Younger patients and those who wish to return to a sporting activity (especially twisting and pivoting sports) may decide to proceed with surgery. The aim of surgery is to regain stability of the knee and reduce the risk of future injuries.
Complete tear of Anterior Cruciate Ligament (ACL)
Treatment options for Anterior Cruciate Ligament (ACL) Tears
Anterior Cruciate Ligament (ACL) Reconstruction
What does ACL surgery involve?
ACL surgery is normally performed as daycase (go home the same day as surgery) under general anaesthetic. Graft tissue is taken from the same leg and is then implanted into the knee to create a "new ACL". Surgery is performed via 3-4 key hole incisions, with a further incision (approximately 3cm long) used to take the graft.
Where is graft taken from for my ACL reconstruction?
There are two broad options when choosing which graft to use for an ACL reconstruction. The preferred option for most is using tissue from your own leg and this is called autograft. The other option is to use donor tissu, which is called allograft. In general autograft is the "gold standard" with a lower failure rate, though there may be circumstances when allograft / donor tissue may be the best option for the patient.
What are the autograft options for ACL surgery?
There are 3 broad options to take tissue from your own leg to reconstuct an ACL.
-
Hamstring graft. This is the most commonly used graft in the UK and has been used for many years with succesful results.
-
Patella tendon. A very robust graft, again with a long track record.
-
Quadriceps graft. This has not been used as long as the other grafts, but is growing in its use with excellent results. It may have theoretical advantages over the other options.
Which is the best graft to use for an ACL reconstruction?
Each graft comes with advantages and disadvantages. Mr Sethi would be able to discuss all options with you, including your injury, sporting ambitions, as well as your size and build. Depending on these factors, Mr Sethi can discuss which may be the best option for you.
Graft options for Anterior Cruciate Ligament (ACL) Reconstruction
Video Animation illustrating an Anterior Cruciate Ligament (ACL) Reconstruction
Anterior Cruciate Ligament (ACL) Repair
Can my ACL be repaired?
In recent years there has been a renewed interest in repairing a torn ACL rather than reconstructing it with graft tissue.
There are many theoretical advantages in repairing the ACL rather than reconstructing it. The natural nerve and blood supply to the ACL is preserved and the healing time is shorter than an ACL reconstruction.
Patients who have an ACL repair often experience a faster recovery and faster return to sport than those who have an ACL reconstruction. They also often report a more "natural" feeling knee after an ACL repair.
It is important to appreciate that not all patients are suitable for an ACL repair. More recent syudies have suggested a higher failure rate with surgical repair than a reconstruction, especially in the more active younger patients - therefore is this population group, an ACL repair may not be the best option.
What are the risks of ACL surgery?
In general, ACL surgery is safe with a low level of complications. However there are some risks which you should be aware of, these include:
-
A low risk of infection.
-
A low risk of blood clots either in the leg (Deep Vein Thrombosis or DVT) or the lung (Pulmonary Embolism or PE). Mr Sethi will assess your individual risk for a blood clot and if necessary will modify your post-operative treatment to reduce your risk of blood clots.
-
Numbness - it is common to experience numbness around scars. With a hamstring graft ACL reconstruction, it is not uncommon to experience numbness in the shin - this often recovers (but can take some months), but sometimes can be permanent. If one experiences numbness in the shin, this does not generally interfere or inhibit function or activity.
-
Stiffness and swelling. Whilst knee stiffness and swelling is to be expected in the ealry phase of recovery, some patients experience persistant stiffness of the knee and build up of scar tissue. This can sometimes necessitate a futher key hole operation and "manipulation under anaesthetic" to regain movement in the knee and remove scar tissue. It is essential to start physiotherapy in the first 5-10 days following surgery to minimise stiffness of the knee.
-
Re-injury - sadly some patients do go on to re-tear their ACL graft. Risk of re-tear varies according to age, gender and level of sporting activity. Internationally, the risk of a re-tear is approximately 5%, though some patients may have a significantly higher risk than this. Some patients may benefit from an additional operation, a lateral tenodesis to reduce the risk of re-injury. Read about a lateral tenodesis here.
Return to Sport following ACL surgery
How long does it take to return to sport?
Recovery from ACL surgery can take some time. Structured, supervised rehabilitation from a specialist physiotherpist is essential for a good outcome. Inadequate or unsupervised rehabilitation can lead to a poor function and a higher re-injury rate. Some patients may benefit from an additional operation, a lateral tenodesis to reduce the risk of re-injury. Read about a lateral tenodesis here.
Whist some professional atheletes may return to sport at approximately 9 months following surgery, the majority of patients with a normal "day job" would take at 12 months to be ready and confident to return to sport.