Jason Haseldine December 2002
This paper discusses the recent literature on anterior cruciate ligament (ACL) surgery and rehabilitation.
The ACL is one of four major knee ligaments. The ACL and posterior cruciate ligaments reside deep within the knee joint. The other two ligaments are located on each side of the knee.
Dr Greg Keene states in Common Knee Complaints: Anterior Cruciate Ligament (ACL) Injuries that “ACL injuries are extremely common in athletically active young people especially in sports with a lot of high pressure twisting and jumping such as netball, basketball and football.”
The human body cannot heal a torn ACL. The treatment for a torn ACL is via reconstructive surgery. A patient can elect against surgery and hence cease playing physically demanding sports.
The two common methods of reconstruction are the patellar tendon and hamstring tendon technique. These methods are described in more detail within this paper.
Finally, this paper discusses the rehabilitation process required to achieve the following four protocols as identified by the Orthopaedic Associates of Portland in their paper “Anterior Cruciate Ligament Reconstruction Rehabilitation Protocol 2001”, being;
1. “Regain normal motion in the knee as soon as possible
2. Increase weight bearing to minimize limping as early as possible.
3. Early recognition and treatment of any problems i.e. pain, stiffness, swelling or sever muscle weakness.
4. Return to normal activities as soon as possible.”
ACL reconstruction surgery is a replacement of the torn ligaments. The damaged ends of the ligament are removed and a new ligament is obtained from a remote site, usually by removal of either a hamstring tendon or part of the patella ligament. The new ligament is anchored to the femur and tibia bone with a secure fixation device.
Graham and Parker state in their journal publication Anterior Cruciate Ligament Reconstruction using Hamstring Tendon Grafts that the “Replacement tissues to reconstruct the ACL can be categorized as:
3. Xenograft and
4. Artificial replacements.
Historically, xenograft and artifical replacements have failed dismally. As a result, autograft and allograft tissues commonly are used to reconstruct the ACL. Autograft tissue currently is the most common source for grafts used worldwide. The two most common autograft tissues are the Patellar and Hamstring tendons.”
There are many published articles associated with the practices of both Patellar and Hamstring tendon grafts. Fox et al. in their journal publication “ACL Reconstruction with Patella Autograft Tendon” highlight the differences between the two methods as “subtle, except for the consistent finding of an increased activity level in the Patellar tendon group.”
Further, Beynnon et al undertook a clinical trial on 56 patients. 28 underwent Patellar grafts and the other 28 underwent Hamstring grafts. The results published in their article titled “ACL Replacement: Comparison of Bone-Patellar Tendon-Bone Grafts with Two-Strand Hamstring Grafts” identifies the “Patellar graft as superior to those of the Hamstring Graft based on knee laxity, pivot-shift grade, and strength of the knee flexor muscles. However the two groups had comparable results in terms of patient satisfaction, activity level and knee function.”
Dr Greg Keene states in Common Knee Complaints: Anterior Cruciate Ligament (ACL) Injuries that “the patella tendon technique is far superior to the alternative hamstring tendon technique in maintaining tightness of the new ligament and in rates of successful return to high level sport.”
An accelerated rehabilitaion program commences following surgery to regain normal motion and a return to high level sporting activity.
A number of published articles were reviewed which identified rehabilition programmes lasting on average 6 months. Beynnon et al identify in their article “The Science of ACL Rehabilitation” that “After ACL replacement, immobilization of the knee, or restricted motion without muscle contraction, leads to undesired outcomes for the ligaments and muscular structures that surround the joint.”
From my personal experience, having had a knee reconstruction performed by Dr Greg Keene in 1997, the two most important rehabilition goals was to ensure straightness of the leg and to gain a range of motion (ROM) to 130o.
The rehabilitation programe is very active and taxing to the patient. A series of exercises are sequentially introduced to increase muscle strengthening via exercise bikes introduced after 3 weeks, hydrotherapy after 6 weeks then weights and light jogging.
Dr Keene states “Full strengthening and maturing of the graft for a safe return to sport will take a minium 6-12 months. The success rate is high and in the 90% category if measured in terms of a successful and safe return to sport with a stable knee.”
Injury to the ACL is a common but severe injury to the knee. ACL reconstruction surgery is a replacement of the torn ligaments.
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