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Date: 26 June 2018

Mr Deepu Sethi, Consultant Orthopaedic Knee Surgeon who has a specialist interest in sports injuries, discusses anterior cruciate ligament (ACL) injuries and emerging surgery techniques that could benefit patients.

What is the ACL and how can it be injured?

The Anterior Cruciate Ligament (ACL) is one of four important ligaments that stabilise the knee. It is especially important in providing stability during pivoting or rotatory movements of the knee. In the UK, men most commonly injure their ACL playing football followed by rugby and snow skiing. The most common mechanism of injury in women is snow skiing followed by netball.

How do you treat an ACL injury?

It is important to remember that not all people who injure their ACL need surgery - for less sporty individuals a course of specialist physiotherapy will enable them to return to their normally daily activities with minimal (or no) problems.

However, for people who want to return to twisting (or pivoting) sports, physiotherapy alone may not provide the stability they require to return to sports.

The standard surgical treatment for an ACL tear is an ACL reconstruction. Traditionally, it has not been possible to repair the ACL and therefore the standard treatment has been to reconstruct it using graft tissue from elsewhere in the body (either the hamstring tendon from the back of the thigh or the patella tendon from the front of the knee).

What is ACL repair and how established is the technique?

Through advances in surgical techniques there is a renewed interest in trying to repair the ACL rather than reconstruct it.

There are many theoretical advantages to repairing than reconstructing. A faster recovery, a faster return to sport (one would normally wait one year after an ACL reconstruction before you return to pivoting sports), preservation of normal blood vessels and nerves in the ACL which may result in a more ‘natural’ feeling knee after surgery.

The technique is creating a lot of interest in Europe and North America with many surgeons reporting excellent outcomes.

Who would benefit from ACL repair?

Not every patient would be suitable for an ACL repair. The location of where the ligament is torn is very important, a MRI scan is required to get an idea of where the ligament is torn, but the final decision about whether a repair is possible is made at the time of surgery.

A repair is probably more likely to be successful in the younger population (teenagers and young adults).

What are the downsides of ACL repair?

To maximise the chance of a repair being successful, it should probably be performed within the first month of injury. This of course poses a challenge in getting a MRI and seeing a specialist knee surgeon within the appropriate time window.

Of course not all repairs will be successful and if it fails an ACL reconstruction may need to be carried out.

How long does it take a patient to recover and get back to normal hobbies?

One of the big advantages of ACL repair is a much quicker return to sport, typically three to four months, as opposed to one year with a reconstruction.

What is your experience of treating ACL reconstruction and repair?

I am one of the highest volume ACL reconstruction surgeons in the UK, performing over 100 reconstructions a year. I have been interested in ACL repair for some years, but was waiting for more scientific evidence before performing the procedure. I now feel confident that there is now enough evidence to offer this procedure to some patients. Over the last year I have been developing and refining my own technique with excellent results.

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