Anterior cruciate ligament or ACL tears are getting more and more common each day and can be devastating when they happen at a young age as their implications are more often than not, lifelong. They usually occur among athletes, and even though 80 percent of them do get back to sports, it is alarming that 20 percent of them will not, and the most worrisome thing is the re-tear rate which goes as high as 20% despite the reconstruction and rehabilitation phase.
It is estimated that over 70 percent of ACL injuries occur due to non-contact activities, while only 30 percent happen from direct contact with another object or person. Cutting, pivoting, or bad landings can all lead to complete ACL tears, and immediately after the injury patients report pain and swelling, and their knees feel unstable.
When is the Surgery Not Necessary?
Surgical treatment is often advised for people with complete ACL tears, especially when it comes to the combination of injuries, such as ACL tears and other injuries to the knee. It is perfectly reasonable to decide against surgery for select patients and most likely, non-operational treatments are advised to the patients with complete ACL tears and no symptoms of knee instability who can still perform in low-demanding sports and are willing to give up the sports with the high-demand pressure on the knee. Also, people who live a sedentary lifestyle and do mostly light manual work will not need to be operated on. Additionally, non-operative methods are preferred on patients whose growth plates are still open, i.e. children.
If the patient is, for example, in a senior season of a sport they play and they do not plan to go to the next level, there are other ways of treatment that are non-invasive and can result in quite a good quality of life. Also, for patients who are willing to give up pivoting and jumping sports, running, racquet sports, etc.
When is Surgery Necessary?
When it comes to surgical procedures, there is no “one size fits all” solution. Usually, if an MRI shows a tear, and especially if that tear is followed by a torn meniscus, surgery might be the best option for a recovery. Fixing the torn ACL will prevent the further damage to the knee and abnormal movement that can damage the cartilage and the meniscus. When the ACL is torn, the meniscus cartilage between the tibia and the femur is under a great impact, which can lead to osteoarthritis.
The key thing to do is to assess the time frame between the injury and the surgery. The longer the time frame, the more injury is possible. Nowadays, the reconstructive ACL surgery involves the replacement of the ligament with a tendon graft which can be taken from the person’s hamstring tendon, quadriceps tendon, patellar tendon, or an allograft taken from a cadaver. There are reports that show that patients that undergo an ACL surgery have long-term success rates of 82 percent up to 95 percent.
So, when it comes to assessing the patient, it is important to note that the level of activity, not age, is the determining point of consideration. Adult patients who are active in sports or jobs that require a lot of turning, pivoting, heavy manual work, and hard-cutting, are usually advised to undergo a surgery. In children, however, it is much harder to make a choice, as a surgical procedure can damage their growth plate, and lead to bone growth problems. In these cases, the doctor will most likely delay the surgery until the patient is of age, and reaches skeletal maturity.
In cases of the infamous “unhappy triad”, i.e. the injury of the ACL, combined with damaged medial meniscus and medial collateral ligaments (frequently seen in skiers and football players), or in cases of the combination of ACL injuries and injuries to the articular cartilage, joint capsule, and other parts of the knee, surgical treatment will give the best results and the highest chance of recovery.
Pros and Cons
Now that we have established that surgery for a complete anterior cruciate ligament tear is not always necessary, let’s look at some pros and cons of surgical and non-surgical treatment.
Pros. The first positive thing about surgical treatment for a complete ACL tear is that you will be able to return to any type of sport or other activity that requires twisting, pivoting, heavy manual work, and hard-cutting. Also, having a surgery for your ACL tear will help protect your knee from the possible future damage to the cartilage and other parts of the knee. It offers a great potential for a high functioning knee, which is also a plus.
Cons. Of course, ACL surgery brings some cons as well. One of the main ones is that the surgery is not always a 100 percent effective, as some patients may never fully recover, i.e. get the normal functionality of the knee. Also, there are a lot of activities that can be performed quite normally even without the surgery, so for some people, it may not be necessary at all. Last but not least, there are risks and complications that follow every surgical procedure, including the ACL one.
There are a few things you should consider before you decide to undergo an operation for a torn ACL. Listed below are the most common complications.
Infection. One of the common complications of any surgery is the risk of infection. Reports say that the infection after the ACL reconstruction ranges from 0.2 to 0.48 percent. Also, there have been reports of deaths due to the bacterial infection from an allograft tissue which was improperly sterilized or procured.
Viral transmission. Allografts are linked with the risk of viral transmission despite all the precautions when processing and screening. The most common viral risks include the HIV and Hepatitis C, and the chance of getting a bone allograft from an HIV-infected donor is, fortunately, less than one in a million.
Blot clots. One of the potentially life-threatening complications is a blood clot in the veins of the calf or thigh. A blood clot can travel to the lungs which cause pulmonary embolism, or to the brain which can cause a stroke. The reported risk is approximately 0.12 percent.
Instability and stiffness. A recurrent sense of instability which happens due to the rupture or stretching of the ligaments or bad surgical treatment is also possible and, thankfully, is as low as 2.25 percent, but can go as high as 34 percent. The stiffness or the loss of motion of the knee has been reported to happen between 5 and 25 percent of patients.
Bleeding and numbness. Rare risks of the ACL reconstruction surgery include the bleeding from the acute injury of the popliteal artery and the weakness and paralysis of the leg or the foot. It is quite common to experience the numbness of the part of the upper leg where the incision is, and it can be permanent or temporary.
Growth plate injury. This usually happens in young children of adolescents with an ACL tear, as the ACL surgery performed at a young age can create a risk of the growth plate injury, which leads to the bone growth problems. In these cases, the surgery can be delayed until the child is of age, i.e. until it reaches skeletal maturity.
Pain in the kneecap. Knee pain is quite common after the patellar tendon autograft ACL reconstruction, and the studies have shown that the pain behind the kneecap can vary between 4 and 56 percent.