Yair Kissin, MD
Insall Scott Kelly Institute
210 East 64th Street360 Essex Street, Suite 303
New York, NY10021Hackensack, NJ07610
Phone- (212) 434-4306Phone- (201) 336-8867
Fax- (201) 336 8873
ACL tear discussion:
With the diagnosis of a torn ACL, the treatment choices are nonoperative versus operative. The nonoperative success is approximately a 33% chance of the patient’s return to having a functional knee. By that, I mean back to their sports endeavors, and usually those are sports that do not require stability with twisting or lateral movement, such as bicycling. Two-thirds or patients for the most part and as a generalization will continue to have knee instability and go on to have such problems as tears in the meniscus, destruction of articular cartilage and eventually arthritis. These patients will usually be required to use a brace and must always participate in a conditioning (strengthening the muscles around the knee) program if they plan on participating in sports. The other option is operative intervention which today yields success rates ranging from 85-90%. Success is defined as an ability to return to a functional sporting lifestyle with or without a brace. In this case, I would, if the patient elects to have surgery, recommend an ACL reconstruction with either autograft bone-patellar tendon-bone or allograft Achilles tendon. Autograft is harvested through a separate 3-4 inch incision at the time of the ACL reconstruction from the central one-third of the patient’s patellar tendon along with bone blocks on either side of the tendon off of the patella and tibia. Autograft has the advantage of being the patient’s own tissue, but requires more surgical time to harvest the graft, which leads to considerably more pain in the early postoperative period and occasionally chronic pain in the front of the knee as a long term consequence. Allograft is cadaver graft which is inserted through a 1-2 inch skin incision. There are two major concerns in using allograft. For one, there is a theoretical albeit extremely rare risk of disease transmission of such viruses as HIV or Hepatitis. The statistical rate in the literature is around 1 in 2 million, but in reality, the risk to any one patient is really 0% or 100%. The second issue is the ability of the host (the patient) to incorporate the allograft. While at the present time, there do not seem to be any long term adverse consequences that negate the effectiveness of allograft reconstruction for ACL tears, the biology of healing on a microscopic level takes longer than that of autograft. Other than the lack of harvesting the patient’s own tissue, there are basically no differences in the surgical technique between the two graft choices. The choice of graft depends on many factors which were discussed in detail and a decision has been reached by both surgeon and patient. Whichever graft is used, it is positioned in the knee arthroscopically through bone tunnels made in the tibia and femur in order to recreate the normal anatomy of the ACL. The graft is then secured using either metal or bioabsorbable screws. In rare cases, one of the screws may need to be removed after about one year.
The procedure is done as an ambulatory surgery, pending medical clearance, with encouragement for range of motion (sometimes with a continuous passive motion machine) and partial to full weight-bearing with crutches right away. Crutches are usually disposed of within 2-3 weeks, unless meniscal repair or certain cartilage work was performed. Patients usually return to desk jobs within 1 week.
The motion stage of stage of therapy takes about 3 weeks while the strength stage averages 6-9 months, which is usually when patients return to sports. This is dependent on the operative leg being within 10% of the normal leg in terms of strength and range of motion. I have seen patients return in as little as 4 months, which may be unrealistic, and on the contrary, I have seen patients not take their rehabilitation seriously and take 2 years to recover. The main danger is returning to twisting activities before the muscle strength is able to support the knee, which can lead to the disastrous complication of retearing the ACL and risks further damage to the knee.
While the success rate for ACL reconstruction is high, there are possible complications as well, which generally occur less than 1% of the time. Complications include but are not limited to infection, peroneal nerve palsy which could affect foot function, loss of screw fixation, fracture of the patella or tibia and rupture of the remaining patellar tendon. One bizarre complication is reflex sympathetic dystrophy which means that a patient has pain which is out of proportion with the findings. This may require multiple manipulation procedures along with physical therapy and can become an overbearing part of a patient’s life for years after the surgery. Overabundant scarring can occur and may limit range of motion of the knee. This, too, may require multiple surgical procedures and physical therapy.
I have explained to the patient that that meniscus and/or articular cartilage may be injured along with the ACL. With meniscus tears, the basic idea is to repair (if possible) or remove as little of the tear as necessary. When either of these procedures is performed, the postoperative routine is successful in a large majority of cases, but complications are still possible as was previously mentioned. With articular cartilage damage, the surface can be shaved and in certain cases, fixed back in place. Sometimes, this is treated with microfracture, which creates small punctures in the bone for the possibility of stimulating fibrocartilage (scar cartilage) to grow (50/50 chance of success).
Further studies on these subjects are surely forthcoming, and at this point, this is the best information I can give the patient. I have informed the patient that any of the complications can result in a life-long disaster and can make them worse off than if they had chosen nonoperative treatment. I think the patient understands this and the percentage of success and failure. The choice of treatment is now up to the patient.
Graft options: Autograft (your own) versus Allograft (cadaver):
Autograft bone-patellar tendon-bone:
Pros: It is the gold standard throughout the country among ACL surgeons (no study has shownbetter results with any other graft); it's yours; no real chance of disease transmission;incorporated faster into your body (about 6 weeks), slightly more reliable than allograft in terms of stretching out over time.
Cons: More surgical time and an extra incision; along with that....PAIN (lasts 2-4 weeks for theacute period for most people, but controlled on pain meds USUALLY). Long term: good chance of anterior (front of) knee pain for life (since that's where the surgery was and there is always scar, sensitive skin, etc)
Allograft achilles tendon:
Pros: Very reliable graft; strongest of all the allografts; less operative time and less pain postoperatively
Cons: Risk of disease transmission (HIV and Hepatitis, among them at a risk of 1 in 2 million to1 in 8 million); Longer time to incorporate (6 months, since it's essentially DEAD tissue that needs to beincorporated into your body); small chance that it stretches 1-2 millimeters more than autograft over time (usually not noticeable to the patient, but we can tell when we yank on it in the office...inother words, the graft may be slightly more loose with time, but you will most likely not know whenyou play sports).
There are reports of patients under 40 with achilles graft failures. We have not seen that be the case in our patients, but retear rates are about 10% for under 18, 5-7 % for older patients, regardless of graft.
As for "full recovery"...there is rarely FULL recovery. Most patients regain 90%of their preinjury status and a majority of patients return to their sport, but sometimes at a slightly lower activity level. Autograftsreturn at an AVERAGE of 6 months and allografts at 9 months (since allografts take longer to incorporate).
With either graft, patients are encouraged to wear a custom fitted derotational brace (that my office arranges for you) once returning to twisting sports. The main criteria to return to sports is having a range of motion and strength within 10% of the healthy knee.