Current Orthopaedics (2000) 14, 325328 2000 Harcourt Publishers Ltd doi: 10.1054/ cuor.2000.0136, available online at http://www.idealibrary.

com on

Mini-SymposiumSoft tissue knee surgery

(i) Advances in the management of anterior cruciate ligament injury

S. Bollen

INTRODUCTION The anterior cruciate ligament (ACL) is perhaps the most valuable piece of collagen in the human body. The recent, and well publicized, case of a soccer player about to sign for Manchester United for 20 000 000 being reduced to nothing overnight following his ACL injury, shows the devastating effect that rupture of this 35 mm long piece of connective tissue can have. The last 10 years has seen an explosion in the published literature concerning all aspects of management of this very common injury. We know from previous studies1 that there is an incidence of approximately 30/100 000 population/year and so a mediumsized hospital in the UK should see about two fresh injuries a week. Despite the wealth of publications there are very few randomized, controlled trials of management and, as Mark Twain said, the great advantage of medicine is the large amount of conjecture to get from such a small investment in fact! Whilst this makes evidence-based practice difcult, there have been some reasonable studies on assessment, surgical techniques and rehabilitation.

ASSESSMENT In 1983 Frank Noyes published a seminal paper2 in which it was observed that the diagnosis of ACL rupture was made by the original treating physician in only 6.8% of cases. This aspect of care was studied in

S. Bollen MB FRCS FRCSEd(Orth), Consultant Orthopaedic Surgeon, Orthopaedic Department, Bradford Royal Inrmary, Duckworth Lane, Bradford BD9 6RJ, UK

the UK some 12 years later and the results published in 1996.3 Surprisingly, despite the explosion of literature and the increasingly high prole of this injury, the diagnosis of ACL rupture was made by the original treating physician in only 9.8% of cases, hardly a signicant improvement. Perhaps even more worrying is the fact that 30% of cases had been seen by an orthopaedic consultant and the correct diagnosis was not made, whilst 28% of the patients had an arthroscopy or arthrotomy and ACL rupture was still missed. It may be argued that the increasing use of MRI may reduce the incidence of missed injuries but MRI has been shown to be less sensitive and specic than an experienced clinical examiner4 and it rarely, if ever, alters clinical decision making.5 As a classical history can be obtained in approximately 90% of cases, the routine use of MRI to establish the diagnosis in suspected cases of ACL cannot be supported. It was appreciated in the early 1990s that the symptom questionnaires that existed were not directly comparable.6 Assessment of symptoms and function in an objective fashion, permitting results from different series to be compared, has undergone steady evolution since that time. The IKDC (International Knee Documentation Committee) is now the gold standard for recording data with respect to ACL injury and surgery. The latest and thoroughly validated version is available for downloading through the AAOSM website. Part of the IKDC assessment relies on arthrometric measurements of knee laxity, despite the fact that this has never been shown to correlate with a patients symptoms and function. Indeed a study published in 19977 showed there was no correlation between anterior laxity, as measured by both KT1000 and on stress radiography, and patient symptoms and function. This conclusion was reinforced by subsequent similar
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Current Orthopaedics such as the Endo-button marketed by Smith and Nephew or the Transx system marketed by Arthrex offer theoretical advantages in terms of the load to failure of their femoral xation, and the weakest xation is with soft tissue interference screws. The laboratory data is not supported by clinical observation however. Some of the best series of results that have been published are by surgeons using sutures tied over a button for patella tendon grafts and interference screw xation for hamstring grafts!11,16 These conundrums remain to be solved but at least part of the answer may be that in the laboratory a biological healing response does not occur, and certainly there are anecdotal reports that occassionally, after bone-patella-bone graft, some degree of bony union has been demonstrated on CT scanning as early as 2 weeks after surgery. In terms of the timing of surgical intervention there is a general consensus that it is sensible to wait until the initial inammatory response has subsided and a full range of motion has been regained.17,18,19 There appears to be no long term disadvantage of this approach and the problematic complication of arthrobrosis is much reduced. There is still debate about whether early ACL reconstruction is justied. Certainly there is some evidence that early ACL reconstruction, when the rest of the knee is normal, can diminish the likelihood of meniscal damage and slow down the progression of radiographic osteoarthritis.20,21 Also, the functional results of early reconstruction are better.22 It must be remembered that patient populations from series in different countries of the world are very different. In the USA the denition of a chronic ACL injury is often anything over 6 weeks post injury! In the UK the mean delay to diagnosis is in the region of 2 years,3 and then there is often a waiting time of at least a further 12 months before surgery can be carried out. By this time many patients will have suffered further injury to the articular surface and menisci, but even in this situation ACL reconstruction has been shown to reduce symptoms and improve function.23,24 Similarly, age is not a preclusion to ACL reconstruction if symptomatic instability is a major problem. In my own practice the oldest patient undergoing ACL reconstruction with a successful result was 72!

studies,8,9,10 and it is perhaps curious that such emphasis is placed on this measurement by some surgeons. This emphasis has, especially in the USA, led to the terms instability and laxity becoming almost synonymous whereas they have very different implications for the patient.

SURGICAL TECHNIQUES There have been no radical changes in the surgery for ACL injuries but a steady consolidation of existing techniques. The use of synthetic ligaments has all but faded from the scene, although they may still have a place in the older patient or for salvage procedures. The main thrust of clinical research has been to compare results of different autograft reconstructions and various methods of graft xation. One particular debate that has been to the fore over the last 5 years has been that of the advantages and disadvantages of hamstring versus patella tendon reconstructions. There is, however, no one graft that is suitable for all patients. Patients with kneeling occupations or those involved in sports with a lot of eccentric loading, such as netball, may not be suitable for a middle third patella tendon graft. Patella tendon grafts have stood the test of time as far as professional sportsmen go and offer more dependable and quicker biological xation. Studies have shown however that there is little to choose between patella tendon and hamstring grafts in the long term,11 so the graft should be selected to suit the patient and not the patient to t the graft. If a surgeon is performing large numbers of ACL reconstructions he or she will undoubtedly have to face the situation of graft failure and the requirement for revision. Then, a variety of less common reconstruction techniques, such as utilizing quadriceps tendon grafts12 or allografts,13 may be called upon. A useful adage for the prospective ligament surgeon is you dont play a game of golf with only one club in your bag! The search still continues for the ideal form of graft xation. Interference screws for the xation of patella tendon graft are the most commonly used technique and initial xation strengths are able to cope with the loads placed on the graft by activities of daily living. Recent years have seen the introduction of bioscrews, which offer the theoretical advantage of slow absorption over a period of 25 years. Certainly laboratory and clinical data show they do not differ signicantly in their initial xation properties from traditional titanium screws.14,15 The ideal xation for hamstring reconstructions is much less clear-cut. There have been concerns about the effect of cyclical loading on hamstring reconstructions producing graft loosening. A good deal of laboratory work has been done comparing the various xation techniques. Certainly suspensory xations

REHABILITATION It is perhaps in the eld of rehabilitation following ACL injuries and surgery that we have moved furthest forward in the last 10 years. Ten years ago it was common practice to brace or even plaster patients postoperatively, often restricting the range of movement and making the patient partial- or non-weight bear for prolonged periods. It is to Don Shelbourne that we owe the greatest debt for moving things forward. He critically reviewed

Management of the anterior cruciate ligament injury his postoperative patients and discovered that the patients who ignored the standard postoperative advice did just as well, or better, than the patients who were carefully nurtured after their surgery. He began to question whether protecting patients in this way was actually doing any good or whether in fact, it was causing problems in terms of range of poorer movement and return to functional activities. Mr Shelbourne started to publish data at the beginning of the 1990s25 and has continued to do so since. Certainly his approach of an immediate return to full hyperextension and early functional activity has not been shown to be deleterious to long term knee joint stability, a nding that has been duplicated in other centres.26,27 This also avoids troublesome joint stiffness and returns patients to activities of daily living within a few weeks and sporting activity by 6 months postsurgery. In addition to overprotection, other commonly used and popular postoperative tools such as continuous passive motion, cryotherapy and bracing have also been shown not to produce any signicant benet to patient recovery.28,29,30,31 Accelerated rehabilitation must not be confused with aggressive rehabilitation. Exercises utilized are those that are known to produce least strain in the graft32,33 and most postoperative protocols consist of a graduated functional programme that only needs to be supervised by a physiotherapist on an intermittent basis. Perhaps one of the most important aspects of rehabilitation is patient education so they can contribute to the care of their reconstructed knee. Whatever the graft choice, surgical technique and rehabilitation protocol the reconstructed ACL is no stronger then the one that God put in originally. Patients must understand that if the same set of circumstances arise as pertained at the rst injury then the end result will be the same! These choices are also less important than that the operation is performed correctly, with accurate graft placement. It is sobering to note that in a four centre survey on the causes of ACL failure in patients sent as tertiary referrals for revision ACL reconstruction the most common reason for failure, in nearly 75% of cases, was technical error on the part of the operating surgeon.34 As to the future, there are a number of promising developments on the horizon. The prospect of biological grafts of synthetic collagen implanted with the patients own broblasts with biological xation that will turn to bone is reasonably close. Whether society will be able to afford these developments is another matter. In any aspect of orthopaedics, when the potential morbidity of a procedure decreases the indications for performing it increase. The potential number of people who would benet from these advances is enormous. Whatever the outcome, we will still require surgeons who can place the grafts in the right place, time

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after time, and then this injury will no longer hold the fearsome reputation it currently has in active sportsmen and women of all abilities and disciplines.
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28. Richmond J C, Gladstone J, MacGillivray J. CPM after arthroscopically assisted ACL reconstruction: comparison of short versus long term use. Arthroscopy 1991; 7: 3944. 29. Witherow G E, Bollen S R, Pinczewski L A. CPM after arthroscopically assisted ACL reconstructionhelp or hindrance? Knee Surg, Sports Trauma, Arthroscopy 1993; 1: 6870. 30. Konrath G A, Lock T, Goitz HT, Schleider J. The use of cold therapy after ACL reconstruction. Am J Sports Med 1996; 24: 629633. 31. Risberg M A, Holm I, Steen H, Eriksson J, Ekeland A. The effect of knee bracing after anterior cruciate ligament reconstruction. A prospective, randomised study with two years follow up. Am J Sports Med 1999; 27: 7683. 32. Beynnon B D, Fleming B C, Johnson R J, Nichols C E, Johnson R J, Renstrom P A, Pope M H. Anterior cruciate ligament strain behaviour during rehabilitation exercises in vivo. Am J Sports Med 1995; 23: 2427. 33. Bynum E B, Barrack R L, Alexander A H. Open versus closed chain kinetic exercises after ACL reconstruction. Am J Sports Med 1995; 23: 401406. 34. Bollen S, Ng A, Bickerstaff D, Fairclough J, Nutton R. Failure of ACL reconstructionthe UK experience. Arthroscopy, in press.

21. Shelbourne K D, Gray T. Results of anterior cruciate ligament reconstruction based on meniscus and articular cartilage status at the time of surgery. Am J Sports Med 2000; 446452. 22. Karlsson J, Kartus J, Magnusson L, Brandsson S, Eriksson B I. Subacute versus delayed reconstruction of the anterior cruciate ligament in the competitive athlete. Knee Surg Traumatol Arthroscop 1999; 7: 146151. 23. Noyes F R, Barber-Westin S D. A C L reconstruction with autogenous patelar tendon graft in patients with articular cartilage damage. Am J Sports Med 1997; 25: 626634. 24. Shelbourne K D, Wilckens J H. Intra-articular anterior cruciate ligament reconstruction in the symptomatic arthritic knee. Am J Sports Med 1993; 21: 685689. 25. Shelbourne K D, Nitz P. Accelerated rehabilitation after A C L reconstruction. Am J Sports Med 1990; 18: 292299. 26. Barber-Westin S D, Noyes F R, Heckmann T P, Shaffer B L. The effect of exercise and rehabilitation on anterior-posterior knee displacements after anterior cruciate ligament reconstructions. Am J Sports Med 1999; 27: 8493. 27. Shelbourne K D, Davis T J. Evaluation of knee stability before and after participation in a functional sports agility programme during rehabilitation after anterior cruciate ligament reconstruction. Am J Sports Med 1999; 156161.