ACL Repair versus Reconstruction

ACL ligament repair and ACL ligament reconstruction should both have a place in the knee surgeon's armamentarium.

Repair

Identification of ligament injury is confirmed following clinical history, examination and MRI imaging.

The repair technique involves drilling small tunnels in the femur and tibia. Sutures are then arthroscopically tied to the torn ends of the ACL drawing them together. Surgical tape is then passed alongside the ACL to reinforce the fixation.

Maintenance of the native ACL tissue results in an immediate improvement in proprioception and rapid restoration of normal biomechanics. The use of smaller tunnels reduces the risks of developing premature closure of the growth plate. The paediatric population also has excellent ability to heal, with an excellent bloody supply to the native tissue. Crucially no graft is necessary, thereby no violation of the patient’s own hamstrings allowing rapid progress in rehabilitation from an early stage.

The risk of failure is stated to the patient as being 1:5, the same as a reconstruction. Due to the significantly increased risk of re-rupture in the paediatric population, if the ligament repair is to re-rupture, one can perform the reconstruction in the standard fashion.

Reconstruction

Traditional methods of surgical management involve performing a reconstruction using the patient’s own hamstrings tendon. This procedure is commonly undertaken by adult knee surgeons due to their familiarity with the procedure in the skeletally mature. The reconstruction technique remains controversial as management of the growth plate accurate placement of both the graft tunnels are critical to a successful outcome. The high risk of re-rupture reported is testament to this.

The rehabilitation time is also extensive due to the need for the allograft to adapt to the stresses required for successful return to activity. Even so the time scale for return to pivoting sports is widely acknowledged to be between 10 and 12 months.

Rehabilitation comparison

The timescale for return to pivoting sport using the repair technique is between 3-4 months. The high level of early function permitted by the use of the patients existing tissue allows positive early rehabilitation. There is no disturbance to the patient’s hamstring therefore negating the need for any allograph to adapt to the stresses required. Compared to the 10-12 months required post reconstructive surgery the 3-4 months’ timescale following repair surgery is game changing and a truly unique selling point.

The timescale for return to pivoting sport using the repair technique is between 3-4 months. The high level of early function permitted by the use of the patients existing tissue allows positive early rehabilitation. There is no disturbance to the patient’s hamstring therefore negating the need for any allograph to adapt to the stresses required. Compared to the 10-12 months required post reconstructive surgery the 3-4 months’ timescale following repair surgery is game changing and a truly unique selling point.

Post-operative protocol

It is increasingly recognised that surgical management followed by skilled rehabilitation give excellent outcomes with successful return to sport and a reduction in the risk of arthrosis following a ligament injury.

The IOC in their recent consensus on management of ACL injuries in children identified skilled rehabilitation using staged exercise progression as paramount to successful return.

Ligament Repair London’s post-operative protocol is speciality designed to focus on accelerated rehabilitation optimising the patient’s ability to load early following the repair technique.

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