What are the risks and benefits of surgical treatment?

ACL reconstructions (ACLR) have been the primary treatment for ACL injuries for the past three decades. Recent advancements in imaging technology, such as MRI scans, and the surge in sports participation have significantly increased the prevalence of ACLR procedures.

Procedure Overview

Surgical intervention involves the arthroscopic removal of the torn ACL, followed by the insertion of a graft (connective tissue) in place of the damaged ligament. Common graft sources include the hamstring, patellar, or quadricep tendon. The graft choice is determined by surgeon recommendations, patient preferences, and individual factors like age, the type of sport, and previous knee injuries.

Graft Options

Hamstring Tendon

The hamstring tendon graft involves stripping one or two hamstring tendons, typically the semitendinosus and semimembranosus. These tendons are then intertwined to form the hamstring graft. Proper rehabilitation of the hamstring is crucial post-surgery to prevent any long-term issues.

Patellar Tendon

The middle portion of the patellar tendon is stripped to create the graft. Known for its strength and thickness, the patellar tendon graft significantly contributes to quadriceps strengthening, especially during the initial stages of rehabilitation.

Quadricep Tendon

A relatively newer graft option, the quadricep tendon, has gained popularity due to improved graft technique options and fixation technology. The advantages include more reliable graft size and thickness and increased strength compared to hamstring tendons. However, limited research exists on the long-term implementation of this graft.

Types of Grafts

Autograft

The autograft involves using a tendon graft from one area to another within the same individual. This is the most common graft type.

Allograft

The allograft entails using a tendon graft from one individual to another. This method is often chosen when a person has undergone multiple ACL reconstructions in the past, depleting their tissue resources.

As the field of ACL treatment continues to evolve, surgical intervention remains a key player in providing individuals with effective and personalised solutions for their ACL injuries.

Advantages of Surgical Intervention

Knee Stability

The primary objective of ACLR is to enhance overall knee joint stability by replacing the ruptured ACL with a graft, thereby reducing movement of the tibia (shin bone) on the femur (thigh bone). This intervention aims to minimise long-term meniscus and cartilage trauma. While ongoing debates question the validity of this claim, some studies support the notion that surgical intervention contributes to improved knee stability.

Return to Sport

There is a cultural trend towards early reconstruction for individuals wanting to return to sport, especially those sports requiring pivoting activities. However, we can’t predict early who is going to do well with or without surgery after their sport injury.

Current research does agree that surgical intervention proves to be a more effective strategy for individuals with ACL injuries accompanied by meniscus, cartilage, or other ligament injuries.

Disadvantages of Surgical Intervention

Cost

The financial burden of ACL reconstruction includes surgical expenses, which can range from £7000 upwards, and the substantial costs associated with the extended 10-18 month rehabilitation period. While non-operative management also involves rehabilitation costs, the financial impact is much less in comparison, and return to sport typically occurs around the 6-9 month mark.

Barriers

Financial constraints, along with challenges in adhering to rehabilitation protocols, work commitments, family obligations, and other lifestyle factors, can impede the successful completion of rehabilitation. Studies indicate that individuals facing fewer obstacles during rehabilitation tend to report higher satisfaction, are more likely to return to sport within 9-12 months, and can return to their previous activity levels.

Post-Operative Symptoms:

Following ACL reconstruction, immediate issues such as knee pain, disability, swelling and reduced function are common. While these post-operative symptoms tend to subside within the first few weeks, they can be challenging in the early stages of recovery.

Long-Term Knee Health:

Studies comparing long-term knee function and health between surgical and non-surgical interventions suggest that as non-operative management improves, the differences in outcomes diminish. Research spanning 5 to 15 years post-injury indicates no significant variance in the development of knee osteoarthritis or meniscus pathologies between the two treatment options. It is essential to recognise that surgery does not guarantee superior long-term knee health.

Conclusion

In conclusion there is a bias towards surgery but there has been research dating back to the late 1980’s that not all clients need surgery. Current research recommends exhaustive rehab should take place before reconstructive surgery. If there is repetitive swelling, pain, locking, or persistent episodes of giving way then surgery may be indicated.

If you have any questions on whether physio is the best option for you, or you have any questions about MVMNT in general, feel free to contact via email.

- Jay Towolawi, Specialist Sports Physiotherapist and MVMNT Founder.