Management options for ACL injuries

An ACL injury is common in competitive sports such as football, rugby, and basketball.
While people may assume that ACL injuries happen more in contact or traumatic events
during a game or training, research shows that noncontact injury mechanisms are more
prevalent in competitive sports. In addition, women generally have a higher risk of an
ACL tear than men due to different biomechanics, such as ligament laxity and a larger
quadriceps angle.
When this unfortunate event happens, there are two treatment methods to consider:
conservative and surgical.

Conservative management

• Involves non-invasive approaches to rebuild the ACL, such as strength and
  neuromuscular training
• If there are meniscus injuries involved, conservative treatment can be considered
• The recovery timeline is estimated at around 6 months only if no knee instability
  is observed

Pros and Cons of conservative management

• Pros
  o Less expensive
  o No risks of complications from the surgery
  o Faster recovery
• Cons
  o Risk of early onset of osteoarthritis in the affected knee
  o Risk of secondary injuries to surrounding structures
  o If this approach fails, the recovery timeline will take even longer than the
  surgical approach

Surgical approach

•  Practitioners usually perform arthroscopic reconstruction, which is less invasive
  than open surgery and allows patients to recover more quickly

The two most used tendon graft sites:

• Hamstring grafts – one of the most popular site due to its favorable
  biomechanical profile and the ease of harvesting the tendon graft
  • Pros: less quadriceps muscle weakness and atrophy, high load resistance
    following procedure, small harvest incision, less postoperative pain
  • Cons: slower soft tissue-graft tunnel healing, the potential for tunnel
    widening, laxity
• Patellar tendon grafts
  • Pros: structural similarity to ACL, allows for early vigorous rehabilitation,
    less stretching, proper ultimate strength, and stiffness
  • Cons: high potential of anterior knee pain, patellar tendinopathy,
    increased joint stiffness, weakness, or atrophy of quadriceps
• Allograft – tendon, either synthetic or sourced from an organ donor, another
  option if the patient already had multiple knee injuries that required the usual
  graft sites to be used

There is very little to no difference between the first two options regarding their
effectiveness. Both have been shown to provide good subjective outcomes and
objective stability. Allografts have been observed with significantly higher failure rates.

Recovery timeline – after ACL reconstructive surgery

• Return to sport: around 9 months
• With an additional meniscus injury: will take longer, around 12-15 months
• The recommended hospital stay will be around 1-2 days. Before discharge, the
  surgeon will check the knee mobility and the knee wound, and whether the
  patient has sufficient maneuverability using elbow crutches.
• Typically, the patient will be able to walk on the same day, following the operation
  • Allow for full weight-bearing walk with elbow crutches (commonly 1-2
    weeks until the balance is returned and pain has dissipated) if only the
    ACL has been affected but not other weight-bearing structures
  • However, for an additional meniscus repair, a non-weight-bearing walk
    with elbow crutches (4-8 weeks) is the common approach in order to
    protect the repaired meniscus. Following this period, there will be further
    test to determine next stage of recovery.

Eligibility for management options

If both options are available to people who suffer from an ACL tear, what is the
indication to pursue a surgical or a conservative approach?

There are 6 criteria that determine the best course of action for the individual suffering
the injury. These criteria will be established during the initial consultation, upon which a
suitable injury management plan will be created.

1. Complete or partial tear of ACL
The anterior cruciate ligament stops the
anterior tibial translation and limits rotational
knee movements. There are three grades of
ligamentous injuries, from grade 1 to 3.
Surgical treatment is recommended for
those with a complete (grade 3) ACL tear.
You may not need surgery for a partial tear
(grade 2) of the ACL or a strained ligament
(grade 1).

2. Instability
When patients experience repetitive knee
buckling and instability, despite undergoing
proper conservative rehabilitation,
reconstructive surgery is recommended.
Patients can assess their instability during twisting and pivoting movements and
provide a subjective rating of knee instability, or schedule an appointment with
one of our therapists to perform a ligament laxity test. The results of the test will
help determine whether surgery is necessary or not.

3 Other structural damage
Usually, patients who experience an ACL injury along with either a high-grade
meniscus tear or a medial collateral ligament (MCL) tear will need surgery to
restore the stability of the knee. These structures are highly involved in knee
stability, therefore reconstruction and repair of the damaged soft tissue will be
necessary.

4. Return to low or high demand activities
For those whose jobs do not involve heavy physical activity or live sedentary
lifestyles, reconstructive surgery may not be necessary, provided that no or
limited knee instability is observed. However, for those who engage in high-
demand sports that involve jumping, cutting, and pivoting, it is essential to have
stable knee joints to prevent any secondary injuries.

5. Age
The reconstructive surgery is usually not recommended for those whose growth
plates are still open. Growth plates usually close near the end of puberty. For
females, around 13-15 years of age; for males, it is usually when they are 15-17
years of age. However, recent research shows that the traditional transtibial
technique and a newer technique, called transposal ACL reconstruction, can
both protect the opened growth plate as much as possible. It is best to discuss
this with the surgeon upon making the decision.

6. Patient preferences

Personal preference. Discussing the decision to undergo surgery can enhance
patient satisfaction and outcomes. The desire to return to sports or activities, the
potential risks and benefits of surgery, recovery time, and impact on daily life are
perceived differently among individuals. Understanding personal preferences in
the treatment approach can align with the goals and expectations of the patients.

==================================================================
=======NO need

Who can consider this treatment approach?

• Non-professional athletes
• Partial tear or grade 2 tear of ACL
• No knee instability episode at all
• Does not have immediate or high-level athletic demands, can wait for 3 months then decide whether an operation is needed

Who can consider this treatment approach?

• Elite athletes, patients who are less than 25 years old and are doing high-impact
  sports or patients who opted for conservative treatment but still experience knee
  instability