ACL RECONSTRUCTION
"Tape Locking Screw”
With respect to long term consequences of ACL injury certain things are well known. The first of which is in an ACL injured knee versus a normal knee there is an increased risk of arthritis regardless of whether and ACL reconstruction is performed or not. No study has been able to show that an ACL reconstruction will prevent arthritis. However, studies have shown that an ACL deficient knee is at increased risk of further cartilage and meniscal injury requiring surgery than an ACL reconstructed knee. It is known that these subsequent injuries increase the risk of arthritis definitively. There was also a significant increase in the Tegner activity score with ACL reconstruced patients.(4) Whilst non-operative treatment remains an option for some patients, most active patients will suffer from the consequences of future episodes of instability without a reconstruction.
References
1. Grindem, H., Snyder-Mackler, L., Moksnes, H., Engebretsen, L. & Risberg, M. A. Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. Br. J. Sports Med. Epub ahead of print (2016). doi:10.1136/bjsports-2016-096031
2. Kyritsis, P., Bahr, R., Landreau, P., Miladi, R. & Witvrouw, E. Likelihood of ACL graft rupture: not meeting six clinical discharge criteria before return to sport is associated with a four times greater risk of rupture. Br. J. Sports Med. bjsports-2015-095908 (2016).
3. Lopes, R., Klouche, S., Odri, G., Grimaud, O., Lanternier, H., Hardy, P. Does retrograde tibial tunnel drilling decrease subchondral bone lesions during ACL reconstruction? A prospective trial comparing retrograde to antegrade technique. Knee. 2016 Jan;23(1):111-5.
4. Chalmers, Peter N. MD; Mall, Nathan A. MD; Moric, Mario MS; Sherman, Seth L. MD; Paletta, George P. MD; Cole, Brian J. MD, MBA; Bach, Bernard R. Jr. MD. Does ACL Reconstruction Alter Natural History?: A Systematic Literature Review of Long-Term Outcomes. JBJS: February 19th, 2014 - Volume 96 - Issue 4 - p 292–300
ACL reconstruction is an arthroscopically assisted operation aimed at restoring stability and function to the knee.
The details of the procedure, including the potential risks, the post-operative course and the expected outcomes will be detailed at length by Dr Beer at your appointment.
You will be provided with written information regarding your surgery and rehabilitation at your appointment.
Any questions you have will be addressed at this time.
Please see below article written by Dr Beer regarding ACL reconstruction.
There are more scientific articles written about the ACL than any other ligament in the body. However, operative technique, graft choice and rehabilitation guidelines for remain varied and numerous.
Generally speaking, depending on the pre-injury level of activity, around 70-80% of patients who have undergone ACL reconstruction will return to their pre-injury level of activity, if so desired. The key attributes for a successful and safe return to sport include a stable knee and a functional return to 85-90% of the normal knee as measured on objective testing. These tests include, quadriceps and hamstring strength, single leg hop, triple hop and agility. An early return to sport can lead to an increased risk of graft re-rupture and therefore needs to be carefully considered. Some recent studies have shown that a 50% reduction in all knee injuries(not just ACL) can be achieved with every month a return to sport is delayed post 6 months up to 9 months following ACL reconstruction.(1,2) An experienced physiotherapist, with an interest in these type of rehabilitation protocols, working closely with the treating surgeon is an integral requirement for a successful outcome in this setting.
Certain groups of patients are at an increased risk of recurrent injury despite a successful surgery and rehabilitation. The attributes of these groups include: age less than 20, ligamentous laxity, contact/high impact sport and degree of rotational instability prior to reconstruction(and subsequently there-after). It is these groups of patients who require careful consideration and often an extra-articular reconstruction (“lateral tenodesis”) in combination with a standard ACL reconstruction.
Then comes graft choice. The most common options include: short single tendon hamstring, 4 stranded hamstring and bone-patella tendon-bone(the patient’s middle one third of patella tendon and its bony attachments). Your surgeon will have his or her own reasons for their graft choice as there is no perfect graft with each having their pros and cons.
Personally, I use a single tendon (semitendinosus) short graft reconstruction (‘Tape Locking Screw”).
The main reasons for this are: graft thickness(grafts<8mm in diameter have an increased rate of revision than those 8-10mm), it is tissue sparing(only using 1 hamstring tendon compared to 2), graft stiffness both due to the preparation technique and the length of the graft and a strong fixation method.
Furthermore, the technique utilizes a gentle hand reaming process to create the sockets for the graft that MRI studies have shown reduces surgically induced bone bruising and pain in the early post-operative period.(3) This may reduce post-op quadriceps inhibition and therefore reduce the need for post-op splinting and may promote an earlier return to full range of motion as well as normal walking.
Whatever your surgeon’s preference, with sound operative technique, appropriate graft choice, and a modern function-based rehab, the vast majority of patients can expect a good outcome and a successful return to pre-injury activity.