Due to the popularization of national fitness sports in China, the strengthening of sports level, and the increase of difficulty of movements in sports, the incidence of sports injuries is significantly higher, the anterior cruciate ligament (ACL) is the most important ligament of the knee joint, ACL injury is a common disease in sports trauma, and its incidence is also increasing year by year, American scholars reported that the incidence of ACL is about 1/3000 per year, according to According to Professor Ao Yingfang of the Institute of Sports Medicine, Peking University, ACL simple and combined injuries account for a total of 3.5%-20% of surgical treatment of knee injuries, while in our clinical practice, these injuries account for 1/3 to 1/2 of minimally invasive arthroscopic surgery.
Shenzhen, a city that has just passed its 30th anniversary, has a resident population of 10,357,900 and an average age of 28,75 years old, with 73,9% of the population being young adults (15 to 40 years old). ACL injury is a common disease in sports trauma, and its incidence is increasing year by year, and the medical cost of ACL injury in Shenzhen reaches nearly 100 million yuan every year, which brings a heavy economic burden to the people with sports trauma. Here we talk about the problems related to ACL injury on some clinical work experience.
1.The clinical diagnosis of ACL rupture is missed very seriously?
Every time I talk about this problem, I will be very painful, because in my clinic, almost every time there will be many patients with films to come to me, saying that for many years, the joint is always sprained without notice, and recently the joint is painful after a little walk, and has gone to many hospitals for a long time without success. For such patients, we often find that the ACL is ruptured on physical examination, and once MRI is taken, it is easy to find that the ACL is completely absorbed after rupture, and the ligament injury brings serious consequences: joint instability, and instability brings more serious consequences – joint meniscus, cartilage damage. It is heartbreaking to see such patients, because the results of such misdiagnosis will have far-reaching effects on the patient. According to incomplete statistics, the ACL in the non-sports medicine specialist underdiagnosis rate of up to 60%, many patients are sprained, go to the hospital to take an X-ray, found that the bone is fine and go back, do not know that the X-ray can not diagnose soft tissue ligament injury.
2, the consequences of anterior cruciate ligament injury?
Often many patients after listening to my diagnostic advice, for the need for surgery is very doubtful, because after the ligament injury, patients can usually still walk and daily life, but often sprained during sports. Many patients say, “Big deal, I’m not going to play sports anymore. Unbeknownst to them, it is this misconception that causes irreparable harm later.
The ACL is an important stabilizing structure in the knee joint, and the knee is one of the most weight-bearing joints in the body. The entire body weight is placed on this joint, especially during activity. When it is injured, due to the special conditions in the joint (the action of defibrinogen), the injured tissue in the joint does not form a hematoma and therefore does not heal, and the end result is that the ligament is slowly absorbed (over 2 months).
With the loss of the ACL, the joint is unstable in front and back and rotation, and the joint is always wobbling around, which inevitably leads to the wear and tear of other structures in the joint, such as the meniscus and cartilage, which can be repeatedly sprained not only during sports, but also in daily life, leading to joint degeneration, i.e., aging of the machine.
If this continues, even if you do not exercise anymore, the rate of joint degeneration will be much faster than normal, and the end result is that when you are 30 or 40 years old, your joints will have aged to 60 or 70 years old, and you will have pain and swelling when you walk. At that point there is no point in coming back for surgery or treatment! The only thing that can be done is joint replacement surgery! What a shame.
So, seeing such misdiagnosed and missed cases in the outpatient clinic is really a pity and reinforces our belief in the importance of increased awareness.
3. Is surgery required after an ACL rupture?
As I said earlier, after an ACL injury, the ACL cannot heal by itself due to the special situation in the joint, and it is not destined to be repaired, only reconstructive surgery can be performed, which means that the bone tracts will be punched at the upper and lower stops of the ligament under the arthroscope, and then other tendons taken from the body will be grafted in and fixed.
It can be said that ACL rupture generally needs surgery to be cured, but of course there are very few cases where the injury is not very serious and can be cured conservatively, and only a few patients in my clinic have been successfully treated conservatively. Of course, in older cases (>50 years old), surgery is not very meaningful because of their own conditions and the joint itself is in degeneration, etc. For most younger patients, on the other hand, surgery is absolutely necessary. The purpose is twofold: 1) to restore your athletic career; 2) to slow down your joint degeneration so that your healthy joints can last longer!
4.What kind of surgery is done after an ACL rupture?
The current mainstream surgery after ACL rupture is total arthroscopic surgical reconstruction. The surgery is very minimally invasive and you can be discharged from the hospital on the third day after surgery, but of course it takes longer to recover because the graft needs to heal inside the body (2 to 3 months). Return to weight-bearing is usually 4 to 6 weeks, return to daily life is usually 8 weeks, and return to sports is 3 months. Full return to sports is 3 months to 6 months.
5.Is it better to use autologous tendon or allograft?
The so-called autologous tendon refers to the tendon taken from other parts of the body, currently the most commonly used tendon is the N-cord tendon. However, in our clinical practice, we found that allogeneic tendons heal more slowly with the human body and take longer to heal, and the re-rupture rate is also higher, so they are usually used only when the tendon is not thick enough. Clinically, autologous tendons are still the gold standard.
6.Is double bundle reconstruction or single bundle reconstruction better?
Anatomically speaking, the ACL can be divided into the anterior internal bundle and posterior external bundle, so some years ago a group of scholars led by Prof. Fu from the University of Pittsburgh proposed double-bundle or even triple-bundle reconstruction of the ACL, believing that it could reconstruct rotational stability with better results. However, in recent years, this idea has been constantly questioned, and there is a growing view that double-bundle reconstruction only increases the difficulty, not the clinical results! Double bundle reconstruction means double trouble. However, we have concluded in our clinical practice that a successful double-bundle reconstruction does have better clinical results, except that a successful double-bundle reconstruction requires even better conditions: such as a fresh injury (subacute stage, within 3 months), a well maintained ACL stop footprint, a sufficiently thick own tendon, and intra-articular structures with characteristics suitable for double-bundle reconstruction. Individualized ACL double-bundle reconstruction surgery is performed following the footprint. Only in this way can the anatomical reconstruction conform to its own mechanical characteristics, and only in this way can the double-bundle reconstruction be successful and achieve better treatment results.
For the vast majority of patients, a single-bundle reconstruction can fully satisfy the patient’s sports and life needs!