ACL injuries in India

Current concepts in the treatment of the Anterior cruciate ligament (ACL) injuries of the Knee
Dr.A.K.Venkatachalam, Consultant Orthopaedic Surgeon, Chennai
www.kneeindia.com Tel 0 9282165002.

The anterior cruciate ligament (ACL) is one of four ligaments stabilizing the knee. Surgical treatment of its injury has assumed great significance in the last two decades. In the west and in India, sportspersons of almost all disciplines can suffer this injury and can jeopardize their careers. As vast amounts of money are involved in signing up professional sportsmen, this piece of connective tissue can be called as the most valuable piece of collagen (connective tissue) in the human body. A new branch of orthopaedic surgery called sports medicine has emerged to deal with mainly the surgical treatment of ACL injuries. Despite the proliferation of vast amount of scientific literature on this subject, the verdict on the effectiveness of its surgical treatment in preventing “Degenerative joint disease (DJD)” of the knee is yet to be confirmed by the “gold standard” of a prospective randomized controlled study. There is an ongoing study in Sweden on this topic. I present here the various advances in the assessment, surgical technique and rehabilitation of ACL injuries.
Assessment- Even in the NHS (National Health Service) of the UK, there is an incidence of missed diagnosis of ACL injury by consultants. The surgeon examining the patient on the first occasion after an injury got it right in only 10 percent of cases in a study in 1996. The patient’s symptom of a “popping or snapping sound” inside the knee at the time of injury is not to be neglected. This classical history can be elicited from the patient in 90 percent of cases. Routine MRI scans have been proved to be less effective than an experienced orthopaedic surgeon in establishing the diagnosis. An MRI scan does not contribute much to the clinical decision making. The decision making regarding surgery is to be done in conjunction with the needs of the individual patient, as everyone does not need an ACL reconstruction. Sportspersons involved in pivoting sports, will need this operation to continue participation in their favourite means of living. On the other hand the week end warrior who does not regularly play games but whose knee gives way only once in a while does not need an operation and can be managed with muscle building and braces. In recent years it is considered important to assess the damage to the articular cartilage and menisci of the knee, as poor outcomes have resulted from the neglect of their treatment. Articular cartilage is a smooth lining tissue of the ends of the long bones and helps in frictionless movement of joints. Damage to Articular cartilage starts off with a bone bruise. Once articular cartilage damage occurs, there is very little chance of spontaneous healing to take place. Repair or restoration of this precious tissue is possible only by surgical means. Operations are of two types- 1) In a restorative procedure, cartilage cells are harvested from the patient’s knee by an arthroscopic operation. The cells are cultivated in the lab and are re-implanted into the defective area in the patient’s knee by an open operation. 2) In a reparative procedure, an inferior but effective tissue called “fibro cartilage” can be encouraged to grow in the affected areas of articular cartilage loss. Presently reparative procedures for articular cartilage are available in Chennai but restorative procedures are available only in developed countries. Prohibitive costs of this restorative procedure deter the concerned companies from setting up business in India. An arthroscopic examination is the practical method to assess articular cartilage damage in India. Special modes of MRI called “Gadolinium enhanced articular cartilage imaging” are available in US for research purposes.
Surgical technique for ACL injuries-
The surgical treatment for an injured ACL is called an ACL reconstruction. In this operation, the torn ligament is reconstructed by another tissue taken from the vicinity. The two common sources are the patellar (knee cap) tendon or the hamstring tendon. Both common sources of graft (patellar tendon vs. hamstring tendon) have been found to be equally effective. In the first stage the tissue is harvested surgically. Bone tunnels are drilled in the leg-bone (tibia) and the thigh bone (femur). The graft is routed through these tunnels and fixed at both ends by some means. Arthroscopic assisted ACL reconstruction has become popular now, although some surgeons still use the open method. In an arthroscopic technique, the graft is harvested by an incision of about 4- 8 cm long. Preparation of the bone, routing and fixation of the graft is done under arthroscopic visualization. Newer methods of graft fixation include bio degradable screws. These screws are made up of synthetic materials and do not interfere with MRI scans. Patellar tendon graft is not recommended for people who participate in certain sports and occupations which involve kneeling and semi-squatting.
Synthetic materials are no longer used as tissue substitutes. Allograft (obtained from cadavers) is useful for a revision ACL reconstruction. There is no age limit to undergo an ACL reconstruction and even middle and elderly symptomatic people can be benefited by this surgery.
Rehabilitation-
It is in this field that most advances have been made in the last decade. Earlier, rehabilitation used to be slow. Now an “accelerated protocol” is possible for well motivated individuals. The emphasis is to get the knee straight as soon as possible after surgery. Earlier it was common practice to brace or apply plaster of Paris cast for a prolonged period postoperatively which resulted in knee stiffness very often. A knee brace and crutches are used now for only 2 weeks. Proprioception training, neuromuscular stimulation, bio feed back and gait training constitute the difference between former and current rehabilitative methods.
Whatever the improvements in the graft choice, fixation method and rehabilitation, it must be remembered that the graft is no stronger than the original ACL and a repeated injury can again lead to its rupture.
Exciting new prospects include synthetic collagen generated by tissue engineering techniques, augmented by the patients own connective tissue cells and fixed by biological screws.
You can contact the writer at akvenkat@kneeindia.com & akvenkat@gmail.com