ACL Injuries - Treatment: ACL reconstruction
What is an ACL reconstruction?
An ACL reconstruction is a surgical procedure that involves removing the remains of the damaged ACL and replacing it with another form of soft tissue, called a graft. The graft is either autogenous, which comes from the patient, or an allograft, which is tissue donated by an individual at the time of death.
In both cases, a portion of the patellar tendon is commonly used to replace the ACL. This is the tendon of the quadriceps muscles that attaches the patella to the tibia. This is a popular choice among surgeons because the patellar tendon is a large, strong tendon, and bone is taken at each end with the tendon section.
The bone ends are attached to the femur and tibia, allowing for bone-to-bone healing. The bone plugs fuse in place during healing and create the strongest fixation possible. This technique usually heals faster than when soft tissue is attached to bone.
Another popular graft choice incorporates strands from one of the smaller hamstring tendons (the semitendinosus) the gracilis replace the ACL. Although this graft requires soft tissue-to-bone healing, many surgeons prefer it because there is usually less pain associated with the harvesting technique of the graft. Some surgeons feel there is less chance of developing kneecap pain using the hamstring graft versus the patellar tendon graft.
A new technique for grafting uses a portion of the quadriceps tendon, from the quadriceps muscles. This tissue has bone at one end and soft tissue at the other. This procedure combines some of the advantages of the patellar tendon reconstruction and the hamstring tendons reconstruction.
An orthopaedic surgeon will usually prefer to use a patient's own tissue for the graft. The patient's own tissue heals faster and more reliably than allograft tissue. In addition, allograft tissue has a risk of disease transmission, although this risk is extremely small.
For some patients, allograft tissue may be the better choice. Patients who have had numerous knee surgeries may not have sufficient tissue available for grafting. An allograft might be the best choice for an older patient who needs the least amount of invasion of the joint in order to heal without complications.
There are many types of devices used to secure the graft to the bone. Some examples are interference screws, screw/ washer, endobutton, and cross pins. Some are metallic and others are absorbed by the body over time. The type of graft procedure the surgeon chooses will determine the fixation technique.
ACL reconstructions are almost always done arthroscopically, although compound injuries may require open surgery. The repair is done with visualization by the arthroscope. One or two incisions are made to take the graft, drill tunnels in the bone, and to position it correctly.
ACL reconstruction can either be performed in an out-patient setting, or as an inpatient procedure with an overnight hospital stay.
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