Initial treatment:
Once it has been detected that the ACL has been injured, the initial treatment is directed to minimize pain and swelling and regaining full movement at the knee. It consists of the following (RICE therapy)
Rest: During the first few days, rest is given to the knee. A hard knee brace that limits movement may be used.
Ice: Keep ice on the knee as fequentky as possible. This helps in reducing inflammation and swelling in the knee joint.
Compression: A compressive elastic banadage is applied. This needs to be reapplied at intervals as the swelling decreases.
Elevation: Keep the limb elevated on a couple of pillows.
With the RICE therapy, swelling and pain are decreased. One should not expect complete resolution of pain with this treatment. Once the inflammation has reduced, generally by 7-10 days, gentle knee movement is initiated and the patient is encouraged to attain good knee movement before further treatment. Following this initial phase, further treatment should be initiated.
What happens when ACL injury is not treated?
With the initial treatment as mentioned above, pain and swelling may subside. This however, does not mean that all is well with the knee. An injured ACL does not heal by itself. The knee loses its stability and most people feel instability with activities such as sports or even with walking. The biomechanics of the knee are altered. The weight bearing portions of the knee such as the cartilage and the meniscus are at higher risk of injury. 90 % of those with long term instability from ACL injuries suffer meniscal damage and the incidence of cartilage damage increases by 70%. When these become injured, it often leads on to arthritis of the knee joint that is not reversible.
Nonsurgical Treatment
In low demand patients without an active life style, physiotherapy and rehabilitation program may be able to strengthen the knee and bring it close to preinjury status. Such patients are at a higher risk of sustaining meniscal and articular cartilage injures, but such risk is acceptable in old and low demand patients. Physiotherapy program is designed to help the patient gain full knee range of movement and strengthen the muscles around the knee joint.
Nonsurgical Treatment
In low demand patients without an active life style, physiotherapy and rehabilitation program may be able to strengthen the knee and bring it close to preinjury status. Such patients are at a higher risk of sustaining meniscal and articular cartilage injures, but such risk is acceptable in old and low demand patients. Physiotherapy program is designed to help the patient gain full knee range of movement and strengthen the muscles around the knee joint.
Surgical Treatment
In surgical treatment of ACL tears, simple stitching of the torn ends does not work as it fails over time. This is therefore not practised anywhere. The ACL is reconstructed using a graft made of a tendon. ACL reconstruction restores the function of the torn ligament and stabilizes the knee joint. The feeling of instability in the knee is corrected.
Timing of ACL reconstruction
ACL reconstruction is usually done at least 2-3 after the initial injury once the initial swelling and inflammation have decreased and the knee has regained the range of movement. Surgery is not advisable immediately after the injury. This is because the knee is inflamed and the bone is contused and surgery in this early period has been shown to be associated with higher risk of complications. ACL reconstruction is therefore done as an elective procedure usually 2-3 weeks after the injury.
How is ACL reconstruction done?
ACL reconstruction is done arthroscopically using small incisions. The tendon which is to be used to reconstruct the ACL is harvested. The patellar tendon or the hamstring tendon which can be harvested from the knee with very little consequence are commonly used tendons. Once the tendon is harvested, the knee is viewed using a key hole incision and the stump of the torn ACL is identified and cleared. Tunnels are created in the femur and tibia to accept the graft. The graft is passed through the tunnels and secured using special bio absorbable implants. All this is under arthroscopic guidance.
Postoperative recovery
As ACL reconstruction is done using arthroscopic techniques, postoperative pain is less and recovery is faster. With the current methods of stabilization, we are able to use an accelerated course of rehabilitation. Following ACL reconstruction, crutches are generally used for support for 3-4 weeks after which one should be able to walk reasonably well. A physiotherapy program is designed for each individual to allow safe and quick recovery from the surgery.
How successful is ACL reconstruction?
ACL reconstruction has a very high success rate of over 90-95% in correcting knee instability. Approximately 8% may have some residual instability in the knee joint. When done in professional athletes 70% are able to return to their professional sport in a year.
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