B Management Options

 

Operative versus Nonoperative Management

 

Issues

 

Knee function

Return to sport

Meniscal injury

Osteoarthritis

 

Knee function

 

Reijman et al BMJ 2021

- RCT of 160 patients

- randomized to early ACLR v rehabilitation and optional delayed reconstruction

- 50% in rehabilitation group underwent delayed reconstruction

- significantly better IKDC scores in early ACLR group at 2 years (85 v 80) but perhaps not clinical significant

https://pubmed.ncbi.nlm.nih.gov/33687926/

 

Frobell et al BMJ 2013

- RCT of 120 patients

- early ACL reconstruction or functional rehab with option of delayed reconstruction

- 1/3 of patients in ACL rehab group chose to have ACL reconstructed

- at five year follow up, no difference in early ACLR / delayed ACLR / rehabiliation alone

https://pubmed.ncbi.nlm.nih.gov/23349407/

 

Return to sport

 

Randsborg et al Am J Sports Med 2022

- 1000 patients 7 years post surgery

- 70% return to sport

https://pubmed.ncbi.nlm.nih.gov/35040694/

 

Meniscal Injury

 

Sanders et al Am J Sports Med 2016

- database study of 1000 patients with ACL tear

- matched to cohort of 1000 patients without ACL tear

- early ACLR v delayed ACLR v nonoperative

- at 13 years follow up, patients treated nonoperatively had a higher risk of meniscal injury, OA and TKR

https://pubmed.ncbi.nlm.nih.gov/26957217/

 

Osteoarthritis

 

Daniels Am J Sports Med 1994

- higher OA in reconstructed knee v non operative

- even if remove those knees that had meniscal surgery

 

 

 

 

Operative Management

 

Indications

 

1.  Continued instability not responsive to physiotherapy and strengthening

 

2.  Reparable bucket handle meniscus tear

Repairing in the setting of ACL deficiency has a lower success

 

3.  Adolescent

 

4.  Reinjury with meniscal or cartilage damage

 

Patient is demonstrating instability

 

5.  Wish to return to pivoting sports

 

Clinical scenarios

 

1.  ACL tear +  Meniscus tear

 

Displaced bucket handle meniscus and acute locked knee

 

Acute meniscus repair + delayed ACLR

- reduced rate of meniscus healing

- an unstable knee may retear the meniscus

 

Acute ACLR and meniscal repair

- advantage is single surgery / high rate meniscus healing

- problem is risk arthrofibrosis

 

Results

 

Majeed et al J Orthop Traumatol 2015

- level IV study of 83 patients with ACL injury and meniscal repair

- meniscal repair failure in 14.5% of patients undergoing early ACLR

- meniscal repair failure in 27% of patients undergoing delayed ACLR

https://pubmed.ncbi.nlm.nih.gov/25701256/

 

Korpershoek et al Orthop J Sports Med 2020

- systematic review

- level 3 evidence that ACLR in the ACL deficient knee protects the repair

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7388123/pdf/10.1177_2325967120933895.pdf

 

 

2.  ACL + Medial Collateral

 

Epidemiology

 

Grade II MCL

- 75% chance ACL rupture

 

Non-operative

 

Rehab MCL

- perform delayed reconstruction of ACL if symptomatic instability

 

ROM knee brace to limit extension

- 2 weeks 30-60°

- 2-4 weeks 30-90°

- 4-5 weeks 15˚ - 90

- 6th week 0 – 90˚

 

Indication for surgery

- MCL torn off tibia (usually off femur) and flipped up and over the pes anserinus

- won't heal in this position

- MRI all patients with MCL tenderness over tibal insertion

 

Patient with MCL and ACL instability

- reconstruct ACL

- reassess MCL at end of case

- if mildly unstable, advance / imbricate MCL on femoral side +/- tighten medial head gastrocnemius

- if severely unstable, reconstruct with hamstring or tendoachilles allograft

 

MCL Advancement

 

4.  ACL + large medial chondral lesion

 

Consider HTO + ACL

 

ACL HTO APACL HTO Lateral

 

Surgical Options

 

1.  Primary Repair

 

High failure rate

 

Reason

1. No clot formation 2° synovial fluid

2. Tension on ligament

3. Intrinsically poor healing potential

 

2.  Extra-Articular Augmentation

 

Lateral extra-articular procedures 

- prevent anterior subluxation LFC in extension

- unpopular due to poor long term results

 

1.  Ellison Procedure

 

A.  Strip of ITB Deep to LCL 

- placing it anterior in a bone trough

B.  Plication the capsular ligament

 

2.  MacIntosh Procedure

 

ITB left attached distally

- deep to LCL

- subperiosteal tunnel in LFC

- thru intermuscular septum

- back on itself distally

 

ACL Ellison APACL Ellison LateralMacIntosh ACL Scar ITB

 

3.  ACL Reconstuction

 

Graft Incorporation

 

1.  Central necrosis 

- 6 weeks post op

- strength of the graft if 70% of original at this time

 

2.  Synovialisation

- up to 6 months post op

 

ACL Graft 6 months0001ACL Graft 6 months0002

 

3.  Revascularisation

 

4.  Ligamentisation 

- 6 to 18 months

- longitudinal orientation of collagen

- normal tendon at 2 years

 

Theory

- acts as scaffold for fibroblasts

- graft undergoes ischaemic necrosis & then becomes enveloped with vascular synovial tissue

- occurs at 4-6 weeks post-op

- neovascularisation & cellular proliferation 3/12