A Renowned Surgeon Discusses New Approaches to ACL Repair
Bert R. Mandelbaum, MD, DHL (Hon)
|January 06, 2016
Reviewing the Video Evidence
The field of anterior cruciate ligament (ACL) repair is rapidly changing.
The more we learn about the knee and the more we experiment with new techniques,
the better we are able to tailor our treatment to the individual athlete.
In my practice, one size definitely doesn't fit all.
Among other factors, the widespread availability of video and new findings
concerning the anterolateral ligament have changed the way I proceed.
I always start with trying to understand how the injury occurred. Was it
perturbation, contact, full contact, or noncontact? There are videos where
I can tell exactly what type of injury occurred.
I search aggressively for video of the injury. It's amazing how many
people have videos of games, all the way down to games in the under-14-year-old
age bracket. Someone's got one—if not a broadcaster or a trainer,
maybe a spectator or even someone who works with the opposing team.
Once I obtain a video, I slow it down, take a look at what happened, and
review it with the patient. It's a good way to partner with the patient
and the patient's family. I ask the patient and other witnesses what
happened. Did the patient feel or hear a "pop"? How was the
patient moving and interacting with other players when the injury occurred?
The answers to these questions give me clues about what type of damage
has occurred. And they tell me whether there are instability patterns
that need to be addressed.
The Importance of Imaging
Imaging techniques help me confirm or discard these ideas about what has
happened inside the knee. One of the questions I need to answer with radiographs
is whether there is a Segond fracture.[1] I fix them all. The recent work of Steven Claes, MD, of the University
of Leuven in Belgium[2] has shown that the anterolateral ligament is attached to that piece of
bone and has an important role in stabilizing the joint.
Next I get to the MRI, which can tell me something about the extent of
the ACL damage. ACL tears are scalable; some are incomplete; and some
could be in anteromedial bundle, the posterolateral bundle, or both.
Anatomical Assessment of Injury
It's also important to assess associated damage to the meniscus and
the articular cartilage, because they are associated with greater risk
for osteoarthritis later on.[3] If I see this type of damage, I plan to manage it at the time of surgery.
Lastly are the associated ligaments. I find it helpful to locate the anterolateral
ligament and study it, starting on the lateral side between the femur
and tibia, looking for injuries. There are surgeons who will routinely
bolster this ligament with graft material even if it's not ruptured,
on the theory that they can reduce the risk for reinjury. Dr Bertrand
Sonnery-Cottet, of the Centre Orthopedique Santy in Lyon, France, has
popularized this belt-and-suspenders approach.[4]
I perform this procedure in the course of a revision situation and in those
individuals who have the most instability. When I do, most of the time
I perform a concurrent tenodesis of the iliotibial band.
I also look for injuries to the iliotibial band, the fibular collateral
ligament, the biceps tendon, and the capsule on the lateral side.
In addition, I try to identify bone marrow lesions. These lesions are common
in ACL injuries, are associated with increased amounts of cytokines, and
may be associated with the potential for osteoarthritis later on. There
is nothing we can do about them during the ACL reconstruction, but it's
important to keep an eye on these lesions in the coming months. Most will
heal on their own, but some will cause ongoing pain and even collapse
of the joint cartilage if not eventually treated.
Next, I search for injuries to the medial column, which includes the deep
and superficial medial collateral ligaments, the posterior oblique ligament,
and the capsule. Bigger injuries on the medial and lateral side can be
repaired either at the same time as the ACL or in stages. Where there
is significant damage to the collateral ligaments and medial or lateral
column, I repair these in one procedure, then later reconstruct the ACL
arthroscopically.
Conducting the Physical Exam
With the information from the MRI, I move on to the physical exam to see
how the picture I have formed of the interior of the knee is affecting
the patient's range of motion and pain.
The physical examination includes the Lachman test, anterior drawer test,
and pivot shift for the ACL, and then an assessment of medial or lateral
laxity to check for damage to the collateral ligaments.[5] After I've assessed the knee, I review my findings with the patient
and the patient's support team. In the case of a youth athlete, that
typically includes a parent, a coach, and sometimes a trainer. In the
case of a professional athlete, an agent may also be involved.
In the case of a college athlete, I discuss such issues as whether we can
"redshirt" the athlete. I discuss the status of athletic scholarships.
A high school athlete may be a candidate for a scholarship, or hopeful
of signing with a top college team.
Risks With ACL Reconstruction
Of course, there are risks with ACL reconstruction, as with any surgery,
and not everyone with a torn ACL should have it reconstructed. A patient
who is a cyclist or who practices yoga and has mild to moderate deficiency
from the injury won't need reconstruction. A patient who has high
instability that interferes with daily living is a candidate for reconstruction.
There are some patients who can't walk to the bathroom after their
ACL is torn.
An athlete who does pivoting and landing—as in football, basketball,
or soccer—must have the stability to the knee to perform those activities.
For these athletes, a torn ACL is like having loose bindings for a skier.
Then I get into issues of timing. Do I operate right away, or wait 3 weeks?
I find that delaying is not as critical for most young athletes. But for
the older athlete, it's important to let the swelling go down and
let them get range of motion back.
The patient's age and athletic plans factor into the choice of graft
materials, whether to use platelet-rich protein, and the approach to rehabilitation,
all of which I'll discuss in my next column.
References
1.Gottsegen CJ, Eyer BA, White EA, Learch TJ, Forrester D. Avulsion fractures
of the knee: imaging findings and clinical significance. Radiographics.
2008;28:1755-1770.
Abstract
2.Claes S, Vereecke E, Maes M, Victor J, Verdonk P, Bellemans J. Anatomy
of the anterolateral ligament of the knee. J Anat. 2013;223:321-328.
Abstract
3.Englund M, Guermazi A, Lohmander SL. The role of the meniscus in knee
osteoarthritis: a cause or consequence? Radiol Clin North Am. 2009;47:703-712.
Abstract
4.Sonnery-Cottet B, Thaunat M, Freychet B, Pupim BH, Murphy CG, Claes S.
Outcome of a combined anterior cruciate ligament and anterolateral ligament
reconstruction technique with a minimum 2-year follow-up. Am J Sports
Med. 2015;43:1598-1605.
Abstract
5.Benjaminse A, Gokeler A, van der Schans CP. Clinical diagnosis of an
anterior cruciate ligament rupture: a meta-analysis. J Orthop Sports Phys
Ther. 2006;36:267-288.
Abstract