In a previous post, we discussed what we believe to be the best explanation of the mechanism for how anterior cruciate ligament tears occur. This month’s post presents the initial method for treating these types of tears. This series of blogs will present the evolution of where we started and where we are now in our treatment of anterior cruciate ligament (ACL) injuries.
ACL tears require a surgical procedure in order to restore stability in the knee joint because when it tears, it tears from the bony attachment and does not heal on its own. The surgery is necessary for young, athletic individuals or individuals who are involved in high-risk activities involving construction, firefighting, recreational sports, etc., in order for them to return to these same activities. We do not provide different surgical options based on age or activity level of the patient, as we believe everyone wants the best outcome regardless of these factors.
This blog is not going to review the research that has shown that the patellar tendon graft is the “gold standard” graft for its reliability and predictability for obtaining a stable knee, but there is quite a bit of research available on this topic. We do believe that young athletes should have surgery to reconstruct the ACL as trying to play on an ACL-deficient knee can lead to further damage to the joint. For older patients, the choice of having surgery or living without an ACL is strictly based on the activity level the individual wants to maintain, as age is never the only factor. If a patient is willing to change their lifestyle to accommodate an ACL-deficient knee, then they can be educated on how to best live without it.
When Dr. Shelbourne started his practice in the early 1980s, he performed surgery how he was trained; with the use of the bone-patellar tendon-bone graft. He uses a mini-open technique and continues with this technique today, as does Dr. Benner, as it provides for best visual for proper graft placement in the femoral and the tibial insertion sites. Without the proper placement of the new graft, regardless of graft choice, the graft has a higher percentage of failing when returning to high-level activities. The bone-patellar tendon-bone graft has been shown to allow for faster rehabilitation because the healing is more predictable. This graft choice maintains its viability and can respond to the stresses of rehabilitation by becoming stronger as it remodels.
The mini-arthrotomy technique is an open procedure, where many surgeons have turned to the use of an arthroscopic procedure. There are many who feel the mini-arthrotomy is “old-school.” However, it has several advantages:
- The angle of drilling the femoral tunnel is enhanced.
- The medial approach allows the guide pin to exit at a desirable lateral position.
- The graft harvest can be delayed until the tunnels are prepared allowing for the size of the bone plug to be modified.
- Drilling of both the femoral and the tibial tunnels through this method allows for a complete overall view of the ACL placement, unlike viewing through a scope.
- It allows for retrieval of bone shaving for bone grafting of the donor site, while during an arthroscopy these bone shavings would be washed away.
From the time Dr. Shelbourne first started his practice in 1982 to 1994, there was a lot of observation and changes that occurred in his protocol pre and post-surgery. Dr. Shelbourne and staff spent a significant amount of time observing every patient and their individual outcomes to determine what worked well, and what needed improvement or changes to provide every patient the best outcome possible after a major knee surgery.
The Importance of Timing
The one important factor was the timing of surgery. When you hear many talk about ACL reconstructions today, they are taking patients into surgery faster than we believe they should, which can result in a poor outcome. Reconstruction of the ACL is not, and should not, be treated as an emergency. The long-term outcomes following ACL surgery involve allowing the knee to “calm down” after the initial trauma, which means getting the swelling under control, achieving normal gait, and, most important of all, having full normal knee extension. What is full normal knee extension? The injured knee should go as straight as the uninjured knee, and it should feel like the uninjured knee when walking and doing everyday normal tasks. The patient should also have full, or close to normal, flexion of the knee compared to the other side. The patient should also have good quad control. The patient should be mentally ready and prepared for what is going to be taking place during surgery and the rehabilitation after surgery, and be committed to this rehab. The patient’s school and work schedule should be clear enough to allow commitment to the time and effort required for the rehabilitation process. Lastly, every patient needs to have at least one caregiver who can be devoted to taking care of the patient in the first week and slightly less involved in the second week. When these guidelines are met, surgery is scheduled.
Regardless of age, patients want two good knees for the rest of their lives. When dealing with young highly active individuals our goal is to provide the best outcome, minimize complications, and perform surgery when the knee is physically ready and the patient is mentally ready.
Stay tuned for next month’s post as we continue this series and discuss how we do things differently than the rest of the world to get consistent outcomes postoperatively.