Anterior cruciate ligament injury is an important stability structure of the knee joint and can produce significant anterior and rotational instability of the knee joint after injury. If the ACL injury is not properly treated, it can lead to damage to the articular cartilage, meniscus and other major structures on top of the knee instability, resulting in early onset of knee degeneration and osteoarthrosis, thus aggravating the knee damage and seriously affecting the knee function, which can cause premature loss of athletic career in athletes. Because ACL injuries are common, serious and can cause secondary damage to the knee, their diagnosis and treatment are difficult and demanding, and as medical technology continues to advance, so do the techniques and concepts of ACL reconstruction surgery.
In our daily work, we find that many patients have some knowledge about ACL injuries, but since most of this information comes from the Internet, it can be considered mixed, sometimes making patients and their families feel confused and at a loss. When working in outpatient clinics and wards, patients often ask several questions (whether they should operate, when to operate, which procedure, which graft, etc.), and doctors sometimes get bored with the repetitive questions. Therefore, we take the opportunity to update these questions and let you know about the latest international progress and opinions (based on the common answers, the answers are divided into three categories: radicals, conservatives and wise doctors).
1. Should I have surgery to reconstruct the ligament after ACL rupture?
Radicals: Surgery is necessary because failure to do so can lead to degeneration of the articular cartilage and meniscal damage.
Conservative: Surgery is not required. As long as you do not participate in strenuous sports, you can have surgery if you feel instability even in daily activities.
Wise doctor: The decision should be made on a patient-by-patient basis.
Patients who need surgical treatment for ligament reconstruction.
(1) Young patients should be treated surgically as early as possible
(2) Patients who have re-torsional injuries.
(3) Those who have a feeling of joint instability
(4) Those with meniscal injuries.
(5) Patients with 1-2 cartilage injuries.
Patients who do not require ligament reconstruction surgery
(1) Elderly patients without significant joint instability.
(2) Patients who have had ligament rupture for many years, with very serious cartilage damage and deformed joints.
2. Which is better: arthroscopic surgery or incisional surgery?
The answer is surprisingly consistent: arthroscopic surgery is less traumatic and has faster recovery, so of course it is better! But you must find an experienced surgeon!
3.When is the best time for surgery?
Radicals: The sooner the better!
Conservative: No surgery if it does not affect walking.
Wise doctors: Generally, surgery should be performed after the acute period (1-3 weeks), when the joint is swollen and can be fully flexed and extended.
4.What kind of tendon should be chosen as a replacement for ACL reconstruction?
Radical: artificial ligament or allograft tendon.
Conservative: only autologous tendon.
The wise surgeon: for simple ACL rupture, the autologous tendon is usually used as a graft (no rejection and fast healing) to reconstruct the ruptured ligament. In the case of revision surgery (failure of the first surgery, or re-rupture of the ligament after surgery), an allograft tendon may be required due to widening of the bony tract. In addition, simultaneous rupture of multiple ligaments usually requires the use of allograft tendons for repair (autologous tendons are not enough!) . Artificial ligaments are not biologically active and will theoretically rupture eventually, so they are not used as a mainstream internationally, but are mostly used in athletes who are eager to compete in important competitions in a few months.
5.Is single-bundle reconstruction better or double-bundle reconstruction?
Radicals: Double beam reconstruction is better.
Conservative: Single beam reconstruction only.
Wise surgeon: Anatomical reconstruction (fixing the tendon graft in the anatomical position of the original ligament) is the most important. The ACL is made up of thousands of tiny fibers, and it can be said that each fiber is a bundle. Therefore, the so-called single bundle reconstruction and double bundle reconstruction are inaccurate, and the current international emphasis is on anatomical reconstruction without paying attention to whether it is a single bundle or a double bundle.
The key to ACL reconstruction surgery is the position of the bone tract. As long as the position of the bone tract is correct, the reconstructed ligament can basically replace the function of the original ligament in its original anatomical position. On the contrary, if the bone tract is incorrectly positioned, the reconstructed ligament will be prone to rupture and the joint function will not be good, regardless of whether single-bundle reconstruction or double-bundle reconstruction is used.
6.What are the risks and sequelae of ACL reconstruction surgery?
Radicals: There is no risk.
Conservative: There are risks such as infection, joint ankylosis, and various anesthesia accidents and surgical accidents, which are more dangerous.
Wise doctors: Infection is a possible complication that comes with any surgery. According to numerous clinical studies at home and abroad, the infection rate is generally below 0.5%. In regular hospitals, there are strict principles and norms of aseptic operation, and the possibility of infection can be further reduced by preoperative and postoperative use of antibiotics and attention to recuperation after surgery. Joint ankylosis and adhesions are usually caused by untimely and incorrect post-operative rehabilitation. Early post-operative ACL reconstruction (day 2) should be followed by joint flexion and extension exercises instead of prolonged cast immobilization. Only if the correct rehabilitation exercises are adhered to, joint stiffness will not occur.
An experienced team of surgeons (operator, assistants, anesthesiologists, nurses, and rehabilitators) can minimize the risks and complications of surgery without undue concern.
In general, we recommend that young and middle-aged patients with ACL rupture should undergo surgery after the pain and swelling of the joint has disappeared and the mobility of the joint is normal, using an autologous tendon (N cord tendon) graft and arthroscopic dissection to reconstruct the ACL.