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Anterior Cruciate Ligament Tear

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Anterior Cruciate Ligament Tear


Anterior Cruciate ligament is torn while its ability to withstand the load is overcome by the force of injury. ACL is commonly injured with

  • Twisting injury to the knee
  • Hyperextension Injury
  • Abnormal sideway opening of the joint ( varus or valgus)

Depending on the amount of force, other structures are injured along with ACL. These include Meniscus, PCL and collateral ligaments. ACL injury is actually a spectrum of injury ranging from an isolated ACL injury (e.g., sports, low velocity injury) on one end to debilitating multi-ligament injuries (road accidents) on the other.

Like many other joint structures, ACL also has very poor blood supply and hence it has very poor healing potential. The healing potential is further compromised by the presence of joint fluid, which inhibits clot formation and healing response. Most of the time ACL is torn completely. Partial tears are rare and may progress to complete tears.

Clinical Features

When an ACL is torn the patient may feel a "pop" like sensation in the knee and may have difficulty in standing immediately after surgery. In most of the cases, a knee swelling (hemarthrosis) develops within few minutes due to the bleeding from the torn ligament. However, ACL can be torn without a knee swelling also. The subsequent disability of the patient depends on ACL deficiency as well as the amount of injury to the associated structures of the knee. If only the ACL is torn, the patient will be able to walk, but the knee will buckle (give away) when he changes the direction while walking (pivoting and cutting). Additional injuries to meniscus and cartilage will result in episodes of locking, pain and joint swelling.

Diagnosis

Most of the ACL injuries can be diagnosed by clinical examination. Clinical diagnosis may be difficult if the patient is having a lot of pain and spasm. In this situation, an examination is performed at a later stage. An MRI is valuable in diagnosing ACL as well as other injuries and is useful in some patients.

Treatment

Because of the poor blood supply, repair (bringing together the torn ends by suturing) will fail invariably and is no longer practised. Reconstruction of the ACL is the ideal treatment. In this method a band of tissue (Graft) is harvested from around the knee and is placed in the original position of the ligament. Two common grafts are practised in Ortho One.

  • The Bone Patellar Tendon Bone Graft (BPTB) graft consists of the middle third of the patella tendon, a small piece of bone from the knee cap and from the tibia
  • Another graft source is the tendons of Hamstring muscle, semitendinosus alone or with gracilis. Allografts are tissues taken from dead donors. Though available abroad, currently we do not use them here.

For fixing the grafts, passages (tunnels) are made in the tibia and femur, and the grafts are passed and fixed using implants. A variety of fixation techniques and implants are available. Reconstruction of the ACL is one of the most common surgeries performed with predictable results. More than 3,500 reconstructions have already been performed at Ortho One. The surgery is done arthroscopically, but to harvest the graft, we make a 3 to 4 cm skin incision below the knee.

Authored By : DR. DAVID V RAJAN

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