What is the function of the ACL?
The knee joint is stabilized by four main ligaments: anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), and lateral collateral ligament (LCL). The ACL functions to stabilize the knee joint during cutting or pivoting maneuvers. When the ACL is torn, patients typically experience a feeling of giving way or instability when they plant their leg and turn to change directions. Some patients even experience painful giving way with simple day-to-day activities.
I was diagnosed with a torn ACL. Do I need surgery?
If you have a torn ACL, there are some important factors to consider in choosing the treatment option that is right for you. Many people are able to function normally by strengthening their secondary knee stabilizers (hamstrings) through physical therapy and using a brace for more strenuous activities (running, biking, etc.). This is a reasonable option if you are not an avid athlete and do not plan on playing high-risk sports (basketball, soccer, singles tennis, trail running, etc.). However, bear in mind that if you continue to experience painful giving way episodes with conservative treatment, even with the use of a brace, then you may be accumulating damage to the cartilage inside the knee joint, which could result in early arthritis. Studies show that patients who opt out of an ACL reconstruction surgery have a higher chance of sustaining tears in the meniscus that require arthroscopic surgery to debride. Furthermore, several studies have shown a correlation between meniscus debridement surgery and risk of arthritis. Therefore, taken together we can conclude that if you choose not to undergo an ACL reconstruction, you will be at higher risk of sustaining a meniscus tear and ultimately progressing to early arthritis.
Most young and active patients with a torn ACL opt to undergo surgical reconstruction to be able to participation to sports without limitations or the use of a brace. High-risk sports such as basketball, soccer, and singles tennis are often difficult to participate in when you have a torn ACL, even with the use of a brace. Additionally, although having an ACL tear seems to increase your risk of arthritis regardless of how it is treated, when you do undergo a reconstructive surgery you will have a lower likelihood of subsequent meniscus tears that can further accelerate the arthritic process.
What is the treatment for a torn ACL?
ACL tears are treated in a number of ways to restore the stability of the knee. Partial thickness tears may be tightened up with the use of an anchor, retaining the original ACL and promoting anatomic healing. Alternatively, platelet rich plasma (PRP) injections may be used for partial thickness tears to promote healing, if the patient’s main complaint is pain and not instability.
Full thickness tears have a poor potential for healing with direct repair, therefore reconstruction is the gold standard.
An ACL reconstruction is performed by using a tissue graft to build a new ACL. Tissue can be obtained by harvesting a part of your hamstring tendon, quadriceps tendon, or patellar tendon – called an autograft. Alternatively, you may have donated tissue used for the procedure – called an allograft. The advantages of autograft ACL reconstruction include no risk of disease transmission and no need for sterilization procedures that may weaken the graft tissue. The disadvantages of autograft include donor site morbidity and longer procedure time to include the tissue harvest. The advantages of allograft include shorter procedure times and no donor site morbidity. The disadvantages include potential disease transmission (extremely rare) and possible weakening and graft elongation during the healing process due to the sterilization process.
Both allograft and autograft have been used successfully in high-level athletes. There are certain important elements to consider when deciding which graft is best for you and Dr. Garabekyan will be happy to have this discussion with you.