Vail ACL Tear
Diagnosis and Treatment
Not all patients who tear their Anterior Cruciate Ligament (ACL) need ACL reconstruction surgery. Treatment is individualized based on patient age and activity level. By gently examining the knee in his office, Dr. Cunningham can often determine the grade (1–3) of the tear and whether further investigation is necessary.
In patients who have torn their ACL, but who do not experience episodes of giving way, surgery may not be required. This is especially true if these patients are willing to avoid cutting and pivoting sports, so that they do not experience giving way of the knee and further damage the knee. Linear activities such as walking, cycling, and swimming do not require a functioning ACL.
In the acute phase after an ACL tear, we would recommend “RICE” (rest, ice, compression and elevation). Physical Therapy is also prescribed to restore normal range of motion of the knee, followed by strength training. Riding a stationary bike is especially helpful in the acute phase of recovery.
Most of Dr. Cunningham’s patients are very active and are unwilling to give up high demand sports, such as skiing. These patients typically want to get back to all the activities that they enjoy without experiencing recurrent episodes of knee instability and feelings of knee weakness. Given this, Dr. Cunningham does a large volume of ACL reconstructions every year.
By stabilizing the knee, patients can return to all sporting activities, and avoid further giving way episodes of the knee, which risks further damaging the meniscus and articular (the coating cartilage on the end of the femur and tibia) cartilage in the knee. By stabilizing the knee with ACL reconstruction surgery, the knee may avoid premature degenerative changes and arthritis, which can develop with the increased shear forces that the knee experiences when being ACL deficient. Patients who do physical work on uneven ground and who are also ACL deficient should consider ACL reconstruction for the same reasons.
Dr. Cunningham arthroscopically reconstructs all ACL’s. The knee joint is not violated with a big incision, but rather the surgery is done through 3–4 tiny incisions (each about ¼ inch).
The ACL is not sewed back together end to end as this technique has a very high failure rate. Rather the ACL is replaced with a tendon graft. This tendon graft can come from the patient (autograft) or from a cadaver (allograft).
Autograft Tendon Graft
Dr. Cunningham typically recommends using autograft tissue in young, active people who still participate in cutting and pivoting sports as recent studies have shown a higher retear rate when using allografts rather than autografts. He feels that patients incorporate their own tissue better than a donor tendon. There are several good sources or autografts. One is using several of ones medial hamstring tendons to reconstruct the ACL. By utilizing 2 of the 3 medial hamstrings for the reconstruction, the patient's leg is not significantly affected with long-term pain or weakness. Moreover, the hamstring tendons that are utilized actually grow back! Another good autograft choice that Dr. Cunningham commonly utilizes for ACL reconstruction is a quadriceps tendon autograft, in which a portion of one’s quad tendon is harvested and inserted in place of the torn ACL in the knee. This makes for a large, healthy ACL.
Using the central third of the patellar tendon is also a good graft choice. However, Dr. Cunningham does not utilize this graft in most patients, as orthopaedic studies have demonstrated an increased risk of kneeling pain and anterior knee pain after taking this graft. Moreover, there are somewhat higher rates of knee arthritis developing in the knee when using this graft compared with other grafts.
ACL surgery is done on an outpatient basis with patients typically going home that day. Dr. Cunningham works with a group of very skilled anesthesiologists who utilize nerve blocks and other methods to limit one's pain after surgery.
For somewhat older patients (over 45–50 years of age), an allograft tendon works very well. Dr. Cunningham obtains donor tendons from a licensed tissue bank that does not utilize radiation to sterilize these tendons, as radiation has been shown to compromise the integrity of the donor tendon. There is less pain after surgery with allografts, but the time it takes to integrate these grafts into the knee is slower than when using one's own tendons.
Graft choice is a discussion that Dr. Cunningham has with all ACL surgery patients, and ultimately the choice lies with the patient. He will thoroughly discuss all the pros and cons so that you can make an informed decision.
Allograft Tendon Grafts
For PCL reconstruction or reconstructing multiple ligaments, allograft tendons are always utilized as the patient simply does not have enough tendons to harvest to reconstruct more than one torn ligament, without causing the patient other problems.
Hardware is utilized to hold the tendon graft in position. The hardware is only necessary for the first few months, as after this the patient's bone grows into and holds the tendon graft in place. Dr. Cunningham uses one or more newer devices to hold the graft in position. These devices are much less prominent than the big metal screws and washers used in the past. Furthermore, they are typically made of biocompatible materials, not metal, and these slowly turn into bone over time. Furthermore, these newer biocomposite implants do not distort MRI images if another MRI of the knee is required.