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Panel discusses treatment of ACL injuries in athletic patients

Issue: December 2014

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ACL injuries are common in sports and during strenuous work and recreational activities. In the United States, approximately 200,000 ACL injuries are sustained annually for which 100,000 patients to 125,000 patients will undergo ACL surgery. In a recent systematic literature review, of 5,770 patients studied, 63% of the patients returned to pre-injury level. This is an alarming low percentage.

There continues to be differences in opinion on the most effective treatment for ACL injuries. The purpose of this two-part Orthopedics Today Round Table is to obtain opinions and insights from some of the leading orthopedic surgeons and physical therapists on how to most effectively treat patients with ACL injuries. I hope you find this Round Table interesting, insightful and useful to your practice.

Kevin E. Wilk, PT, DPT, FAPTA
Moderator

Kevin E. Wilk, PT, DPT, FAPTA: Does every patient who tears their ACL need to have it reconstructed? If not, what type of patient may try not to have surgery?

K. Donald Shelbourne, MD: The need for surgery is largely based on the desired level of activity the patient wishes to have. If the patient wants to return to sports or activities that require pivoting, planting and change of direction, then an ACL reconstruction is advisable to prevent recurrent giving-way episodes. Recreational athletes who are primarily interested in straight-line activities to maintain cardiovascular fitness (running, elliptical, cycling, etc.), will likely be able to return to this level of activity with nonoperative rehabilitation after an ACL tear.

James R. Andrews, MD: There is no such thing as “always” and “never” with an ACL injury. For me, it depends on activity level, and not so much age. If a patient is an active athlete at any level of sports, even recreational, he is better off having his ACL reconstructed. I have let an occasional player delay surgery until the season is over, and then we reconstruct the ACL, but only under unusual circumstances.

Basically, it is an automatic operation in most cases. As you get older, there is no age limit for an ACL reconstruction in an active individual. Thus, it depends on activity level. Certain sports obviously require more cutting maneuvers and reconstruction is indicated regardless of age. By the way, braces are not always that protective. I have let an occasional football senior college lineman finish the season before reconstruction, but not often.

Frank R. Noyes, MD: The non-recreational, sedentary patient often avoids ACL surgery. However, educate the patient that a partial or full giving-way episode may occur walking on uneven ground, or turning/twisting events at home.

James J. Irrgang, PT, PhD, ATC, FAPTA: There is sufficient evidence that some patients with an ACL injury may do well without surgery. Furthermore, there is no evidence that ACL reconstruction prevents the development of post-traumatic knee osteoarthritis in the long-term. This does not mean no treatment — patients would need to undergo rehabilitation to restore range of motion (ROM), quad/ham strength and neuromuscular control. This treatment option could be appropriate for individuals with an isolated ACL injury who do not wish to return to very strenuous or strenuous knee-related sports activities.

Generally, this would be appropriate for patients older than 25 years to 35 years who are willing to make the appropriate lifestyle modifications to avoid further injury to the knee. For young competitive athletes who wish to return to very strenuous or strenuous knee-related sports activity, surgery would be recommended. For this reason, there should be a discussion between patients and their surgeons/physicians and physical therapists to discuss the available treatment options, including the risks and benefits of both so patients can make an informed shared decision as to the best treatment for them given their age, activity level and expectations.

Wilk: If surgery is performed, what graft do you prefer to use in a primary ACL reconstruction in a young skeletally mature active patient? Does the graft choice change if the patient were 45 years old or older?

Noyes: A bone-patellar tendon bone (BPTB) graft is favored in high-demand athletic patients, particularly for large body size or any associated physiologic laxity. A semitendinosus graft (STG) is favored in recreational athletes or older active patients due to easier rehabilitation.

Andrews: My gold standard is still an autogenous patella tendon graft. The graft choice may change as the patient is 45 years or older. I will have a tendency if the patients are not super active to do a hamstring and, in some cases, even a non-radiated cadaver graft could be used. However, I will still use a patella tendon graft even in real active and aggressive patients older than 45 years.

Shelbourne: I prefer to use a BPTB autograft harvested from the contralateral knee. After 30 years of using the patellar tendon autograft and 20 years of taking it from the contralateral knee, our research has shown this to be a reliable graft source in a wide variety of situations.

This graft allows us to push for full ROM equal to the opposite knee immediately after surgery and does not require any other rehabilitation or weight-bearing restrictions. Our long-term data has shown that full, symmetric ROM is imperative for a good long-term outcome after ACL reconstruction, so this is a distinct advantage over some of the soft tissue graft choices.

Donor site rehabilitation is often overlooked in the rehabilitation process, but is especially important with the use of a patellar tendon autograft to prevent anterior knee pain upon return to sports/activities. During surgery, I suture the defect together to facilitate healing, but high repetition of low-load strengthening exercise must also be performed to stimulate regeneration of the tendon and allow for full strength to be regained. This type of exercise is recommended once the patient has regained full knee flexion and extension. In the case of ipsilateral graft harvest, this strengthening phase of rehabilitation must be delayed several weeks until full ROM has been restored and swelling is gone. The benefit of using a contralateral graft is that it allows the patient to begin this high-repetition, low-load strengthening immediately after surgery since the graft harvest itself has little effect on knee ROM. The patient is then able to work on ROM of the ACL knee and the donor site rehabilitation simultaneously.

Wilk: How do you treat grade 3 medial collateral ligament (MCL) sprains with a complete tear of the ACL?

Shelbourne: Whenever a patient has an ACL tear, it is my practice to delay surgery until the acute inflammatory phase has subsided, full symmetric ROM has been restored, the effusion has been resolved, and the patient demonstrates good quadriceps muscle control with a normal gait pattern. In the situation of a combined ACL/MCL tear, I advocate for nonoperative treatment of the MCL first, followed by ACL reconstruction once valgus stability is restored and the acute inflammation has subsided.

In the case of a grade 3 MCL sprain, this requires a period of immobilization to allow the MCL to heal. I have found braces still permit more medial/lateral movement of the knee than is desirable, so I prefer to place the patient’s knee in a cylinder cast with the knee in 20° to 30° of flexion. This allows the patient to continue to be full weight-bearing with the necessary support to allow for healing of the MCL to occur. The cast is removed 1 week later, valgus stability is tested, and the cast is reapplied on a weekly basis as necessary until the patient is no longer point-tender over the MCL and a solid endpoint is restored with valgus stress testing.

Once the casting phase is discontinued, rehabilitation begins to restore full, symmetric ROM equal to the opposite normal knee, improving quadriceps muscle control and restoring a normal gait pattern. Surgical reconstruction of the ACL is then performed once the patient has met these preoperative goals.

Noyes: A so-called grade 3 MCL means 10 mm or more increased medial joint opening at 20° knee flexion and also close to this abnormal opening at 0° with major disruption of the superficial MCL and posteromedial corner (posterior oblique ligament). In athletes, I perform open surgical repair of all tissues, including medial meniscus attachments. In non-athletes, I use a stick-down cylinder cast for 4 weeks, bivalved with the physical therapist performing protected ROM to prevent arthrofibrosis. However, make sure the superficial MCL is not displaced into the joint or medial meniscus is extruded requiring operative repair.

Andrews: It depends on where the MCL is torn. If they are torn distally and banjoed up like a Venetian blind and retracted out from under the pes or into the joint, then I will do a limited repair of the MCL. I am certainly allowing all grade 3 MCLs to heal without a surgical procedure. If they are torn at the joint line off the meniscus or if the posterior oblique ligament is really torn up posterior medially, then they should be repaired acutely. If you have good physical therapy and control of the patients, I do the ACL graft and the MCL repair at the same setting in an acute case within the first 10 days. This takes special rehabilitation and good control of the patient. Otherwise, you wind up with a stiff knee.

Wilk: How do you treat a grade 2 MCL sprain with a complete ACL tear?

Andrews: Generally, I will go ahead and do the ACL surgery and allow the MCL to heal. It is okay certainly to let the MCL heal for 4 weeks to 6 weeks and then do the ACL. It depends on the circumstances. I do not have a set rule.

Shelbourne: An approach similar to what was described above for the combined ACL tear with a grade 3 MCL sprain, but immobilization in a cylinder cast is usually not necessary when the MCL sprain is a grade 2 sprain. Instead, the patient begins rehabilitation focused on restoring a normal gait pattern, improving/maintaining good quadriceps muscle control, and restoring full, symmetric ROM with an emphasis on symmetric extension. Pain and swelling is controlled through the use of a cold-compression device. Once these goals are achieved, the patient may proceed with surgical reconstruction of the ACL if desired.

Noyes: I strongly believe in the stick-down program of a cylinder cast, bivalved with protected ROM by the physical therapist. I frequently see patients with a residual abnormal medial joint opening where initial treatment was a postoperative brace, which is insufficient to keep the medial joint closed during the initial protected healing phase.

Wilk: In revision ACL surgery in an active young patient, what would be your graft choice?

Andrews: I would either use a PTG or a hamstring graft. If it is a high-level active professional athlete or college or even a high school athlete who is at a high level, I still prefer the PTG. I would go to the opposite knee after informed consent and take the graft for a redo. I do not use cadaver grafts (allografts) very often, even in the case of redos.

Noyes: I strongly prefer a BPTB autograft and suggest caution in using an allograft which has known decreased biological remodeling and strength after implantation.

Shelbourne: My graft choice is the patellar tendon autograft, ideally from whichever knee has not been previously harvested. If the contralateral patellar tendon has not been previously used, then that is my first choice. Previous graft harvest is not an absolute contraindication for graft use and we have previously published data which showed good results when the same patellar tendon was used as a graft source more than once. In the case of a previous graft harvest from the contralateral knee, I will usually elect to use the ipsilateral patellar tendon, but several patient characteristics are taken into consideration in this decision (time from surgery, quadriceps strength in the harvest knee, width of the intercondylar notch, level of sports participation, etc.).

Wilk: Do you have criteria that must be met before ACL reconstruction is performed?

Noyes: I strongly believe full ROM, no major effusion, return of neuromuscular control in ambulation, off crutches, and the ability to perform appropriate light exercises (open and closed chain). Patients need to understand the postoperative rehabilitation to return to function and prevent arthrofibrosis.

Shelbourne: During the early years of my practice, I had a significant number of patients who struggled with ROM loss after ACL reconstruction. I was able to nearly eliminate this problem entirely by altering my treatment protocol to include delayed ACL reconstruction with preoperative rehabilitation, the discontinuation of any type of immobilization or ROM restrictions after surgery, and the use of the cold-compression device and continuous passive motion machine.

I require all of my patients to meet the following criteria prior to ACL reconstruction:

• full, symmetric knee extension, including hyperextension, to match the opposite, normal knee;
• full, symmetric knee flexion;
• minimal to no effusion;
• good quadriceps muscle control (able to perform an active heel lift);
• normal gait pattern; and
• good understanding of the surgical procedure, rehabilitation process, goals and probable timeframes for the various stages of recovery and return to sport.

Andrews: Yes, that is minimal pain and adequate range of motion. That does not necessarily mean you have to wait 2 weeks to get the motion back. In some cases, motion is not good even at 2 weeks and I have waited as long as 6 weeks. There are other cases where you do not get a lot of bleeding and you can get their motion back within a few days in these cases. I will go ahead and operate on the patient often a couple of days after the injury. So it depends on how the knee looks. If there are any questions, you need to wait. If there is any question in your mind about adequate ROM and pain, then there is certainly not reason to rush to the procedure.

Wilk: When do you become concerned about knee joint stiffness?

Shelbourne: If the graft is placed correctly and preoperative ROM was symmetric, full-symmetric knee extension should be achieved intra-operatively and should also be attainable immediately after surgery. We become concerned if the patient demonstrates any knee extension ROM loss at any point after ACL reconstruction. The first action we take is to decrease emphasis on knee flexion and focus more aggressively on extension ROM and quadriceps control. If a quadriceps muscle shut-down occurs, this can also lead to slight extension ROM loss due to the activity of the hamstrings being unopposed.

If knee extension is not restored during the immediate postoperative phase when the graft is remodeling, it will be impossible to regain fully at a later time without further surgical intervention. During the immediate postoperative phase, knee flexion will be somewhat limited due to the effusion, but gradual progress should continue and full, symmetric knee flexion is usually attainable by 1 month after surgery.

Noyes: I examine all of my knees the next day after surgery in the physical therapy clinic. The patient, who saw the physical therapist before surgery, starts immediate ROM and strength exercises from day 1. We published our ACL program and achieved full motion in all patients who stayed on the program. We also published a gently overpressure extension and flexion program to achieve ROM after surgery. At 2 weeks postoperatively, watch out for the patient who is behind return of motion expectations with decreased patellar mobilization, not performing exercises at home and comes to clinic with “cold” measurements of 10° to 70° knee flexion. This patient needs daily therapy. By 4 weeks, I expect a minimum is 0° to 90° motion and normal patellar medial-lateral glides. I will do gentle manipulation at 4 weeks to 6 weeks, but never beyond this time period. At 4 weeks to 6 weeks, you can literally move the knee joint and overcome small adhesions with only two finger pressure at the ankle. The biggest mistake I see is pushing knee flexion when there is contracted medial/lateral patellar retinaculum and decreased medial/lateral glide. This produces tremendous patellofemoral overload potentially damaging the cartilage. In our program, we only had to do an arthroscopic release in postoperative arthrofibrosis in three of 443 patients. The key is early and progressive rehabilitation.

Andrews: I am concerned from day 1. We use an adductor canal block and sometimes I augment that with the posterior tibial block. Using an adductor canal block, you block the cutaneous nerves that go to the knee and down the leg and that helps control patients’ pain and yet they can get their muscles functioning the next morning and start getting extension back. The main thing is proper rehabilitation so that the patients do not get stiffness. We start them with early ROM; we use pumps and leave the blocks in for 2 day to 4 days. It is all related to adequate immediate physical therapy and that way you can avoid stiffness.

By the way, patients who are type A personalities, for example runners with little adipose tissue who are lean and well-trimmed, are the ones who seem to get arthrofibrosis. You have to be careful with them and make sure you pay close attention to that type of patient. For me, they seem to have an increased chance to get arthrofibrosis. The best thing for the arthrofibrosis is prevention, obviously. I do not like to manipulate the patients early because sometimes if you get full motion in surgery at 6 weeks, for example, and the patients wake up and are right back in the same boat or even worse. So I am not quick to manipulate them. Usually it is somewhere around 3 months to 4 months with a scope to remove the scar then manipulation. I do not just do a quick manipulation until it is persistent.

Irrgang: Postoperatively, our milestones for restoration of knee motion after isolated anatomic ACL reconstruction (no meniscus repair) are to restore passive knee extension to 0° within 1 week of surgery, knee extension symmetrical to the contralateral knee, including hyperextension, within 2 to weeks, the ability to perform a straight leg raise without a quadriceps lag within 1 week to 2 weeks, 90° to 100° of knee flexion within 2 weeks and full knee flexion compared to the contralateral knee within 6 weeks. If the patient has not achieved these milestones and is not progressing with motion, then we would be concerned with loss of motion and would alert the surgeon. If we are not to 0° of knee extension within 2 weeks to 3 weeks and 90° to 100° of knee flexion, this would be cause for concern.

A note from the editors:

Look for Part 2 of this Round Table discussion with additional panelists in the January 2015 issue of Orthopedics Today.

References:

Barber Westin SD. Phys Sportsmed. 2011;doi:10.3810/psm.2011.09.1926.
Barber Westin SD. Arthroscopy. 2011;doi:10.1016/j.arthro.2011.09.009.

For more information:

James R. Andrews, MD, can be reached at the Andrews Institute for Orthopaedics & Sports Medicine, 1040 Gulf Breeze Pkwy., Suite 203, Gulf Breeze, FL 32561; email: info@theandrewsinstitute.com.

James J. Irrgang, PT, PhD, ATC, FAPTA, can be reached at the University of Pittsburgh, Department of Orthopaedic Surgery, Suite 911 Kaufmann Medical Building,  3471 Fifth Ave., Pittsburgh, PA 15213, email: irrgangjj@upmc.edu.

Frank R. Noyes, MD, can be reached at Cincinnati Sports Medicine & Orthopaedic Center, 10663 Montgomery Rd., Cincinnati, OH 45242; email: frnoyes@fuse.net.

K. Donald Shelbourne, MD, can be reached at Shelbourne Knee Center, 1815 N. Capitol Ave., Indianapolis, IN 46202; email: acldoc@aol.com.

Kevin E. Wilk, PT, DPT, FAPTA, can be reached at Champion Sports Medicine, 805 St. Vincent’s Dr., Suite G100, Birmingham, AL 35205; email: kwilkpt@hotmail.com.

Disclosures: Andrews, Irrgang, Noyes, Shelbourne and Wilk have no relevant financial disclosures.