ACL Reconstruction Treatment Options

Not everyone with an ACL injury will require surgery. Conservative and non-surgerical management is ideal in older non-active patients as it is possible to compensate for the injured ligament with strengthening exercises or a brace.

However, it is currently recommended that ACL rupture in young active patients is treated by reconstruction surgery since it is menisci-protective. 

Surgery is indicated if the patient in unable to live with their current level of stability of the knee and if they are wish to maintain an active lifestyle.

Surgical techniques for ACL reconstruction have improved dramatically during the past ten years. Complications are now less frequent and recovery time is much quicker than in the past.

 

Surgical Approaches 

The surgery is performed arthroscopically. A/Prof Munjed Al Muderis is skilled in All-Inside ACL Reconstruction which is a minimally invasive surgical alternative to traditional ACL reconstruction surgery. 

Both traditional ACL reconstruction surgery and All-Inside ACL reconstruction surgery involve replacing the ACL with a tendon graft. The ruptured ligament is removed and the bone prepared in order for it to accept the new graft which replaces the old ACL. Options for the tendon graft are outlined below. The difference between traditional ACL surgery and All-Inside ACL surgery is the approach taken, in particular the drilling of a tibial tunnel. Traditional ACL reconstruction techniques involve drilling a tunnel from the outer tibial cortex into the proximal tibia and knee joint. Through this tunnel the ACL graft is inserted and securely fixed onto the tibia. This tibial tunnel is a significant source of pain following ACL surgery.

However, with All-Inside ACL reconstruction such a tibial tunnel is not created. Instead a specialised tool called a reamer is used to create a tibial socket, which does not violate the tibial cortex as it does in traditional ACL surgery. All-Inside ACL surgery also doesn’t involve any formal incisions, only three to four small arthroscopy incisions.

The advantages of All-Inside ACL surgery include less pain and a faster recovery time than traditional techniques. Due to the specialised instrumentation used All-Inside ACL surgery can also help to create a more anatomic ACL reconstruction.

 

ACL Grafts

There are a number of different surgical options that can be used to reconstruct the ACL ligament. These include the use of autologus hamstring or patellar tendon graft, cadaveric donor grafts and synthetic graft (LARS). From the literature there is no overall significant difference between any of the options; but each method has its own advantages and disadvantages. The best option is the one that is most suited to both the individual patient and their injury. 

The graft of choice is then prepared in order to take the form of a new tendon and is passed through into the bone.

The new tendon is then fixed into the bone with various devices to hold it into place while the ligament heals into the bone (this usually takes about six months).

 

There are pros and cons for each graft option:

Graft Type

Pros

Cons

Hamstring tendon

  • Biological
  • Eventually fully replaced by new tissue
  • Scar is reasonably small and causes no irritation
  • Relatively weaker
  • May stretch
  • Donor site pathology (weakness in hamstring)

Patellar tendon

  • Biological
  • Eventually fully replaced by new tissue
  • Stronger than hamstring
  • Scar cause irritation especially kneeling
  • Donor site pathology (weaker patellar tendon and bone)

Cadaver graft

  • No donor site pathology
  • Faster operation than previous hamstring or patellar tendon
  • Eventually fully replaced by new tissue
  • Chance of rejection
  • Chance of transmission of infection
  • Weakest of all options
  • Depends on availability

LARS

  • No donor site pathology
  • Fastest of all the graft options
  • New tissue integrates with it
  • Minimal scar
  • Strongest of all the methods
  • Faster return to full activity
  • Requires good surgical experience with the technique and the material
  • Implant does not dissolve with time

 

Osseointegration Group of AustraliaNorwest Advanced OrthopaedicsDrummoyne Advanced Specialty ServicesThe Sports & Arthritis Clinic NorwestNorwest Advanced Specialty Services