ACL Surgery

In this episode of PodMD, experienced Orthopaedic Surgeon Dr Murilo Leie will be discussing the topic of ACL surgery, including what an ACL injury consists of, the current treatment options, recent developments in treatment, the likelihood of recurrence, when to refer and more.


  • Transcript
    Please note this is a machine generated transcription and may contain some errors.
    *As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.

    Today I’d like to welcome to the PodMD studio Dr Murilo Leie

    Dr Murilo Leie is an experienced Orthopaedic Surgeon specialising in conditions of the Hip and knee. Dr Leie is practising in Joondalup as well as the surrounding hospitals.

    Dr Leie completed his MBBS in Brazil in 2011 and went on to achieve a Master’s in Surgical Science in 2017. Murilo pursued multiple fellowships, including Knee Surgery in Sydney and Perth, focusing on ACL surgery, knee replacement, and robotic procedures. In 2021, he finalised his studies with a fellowship in Robotic Hip and Knee Arthroplasty and is now qualified in five different subspecialties and fellowships.

    Today, we’ll be discussing the topic of ACL surgery.

    *We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
    If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.

    Murilo, thanks for talking with us on PodMD today.

    Murilo : Thank you for having me.

    Question 1
    The topic of today’s discussion is ACL surgery. Can you describe for our listeners what an ACL injury is?

    Murilo: So ACL stands for anterior cruciate ligament and the injury consists of as a cell injury, complete or partial of the fibres of the ACL. Also of time the injuries called mid substance, which is in the middle of the fibres. But sometimes you can have proximo or distal avocation type of injuries. This might demand a different approach and treatment strategy.

    Question 2
    How would a patient with an ACL injury typically present?

    Murilo: Though most of the time the diagnosis can start from the history, so usually a patient with an ACL tear is one involving high pivoting or torsional sports or activities. Here in Australia, one of the countries with the highest incidence of ACL injuries, and this is certainly related to the high level of participation in sports. Which is netball footie rugby, soccer amongst others.

    The patient, usually we report a history of playing or being tackled or jumping and landing in awkward positions, and usually it’s followed by a feeling of knee dislocating or patients report they felt a snap or a pop in the knee. Most of the time this follows well for a large infusion the needs so the knees swelling up after that initial injury, and that’s the most classic history, right? But of course there are other mechanism of injuries such as motor vehicle injuries, and that can be more complex in involving other ligaments as.

    Question 3
    What are the risks of the condition?

    Murilo: So yes, we understand that female patients have at least 4.5 times higher rate of ACL tears compared to males and particularly those females who are younger than 20 years old and participate in high pivoting sports such as, as I say, and netball, soccer and others. So unfortunately in Australia especially, the incidence of ACL injuries appears to increase more rapidly than in all the countries, and it is expected to be at least double by 2030, reaching 77 for 100,000 patients and that’s a lot. OK, this is more than 1.5 fold compared to other countries and this is very significant. Australians in particular are at risk and one of the factors is, as I said, participation in multiple pivoting sports and we can mention many of them like Aussie Rules.

    Question 4
    What are the treatment options?

    Murilo: OK, as most of the knee injuries, so most of the times options are between non operative and operative. And I would consider non operative treatment for patients with isolated ACL injuries, for example, who are middle-aged and not involved in pivoting activities or not doing any sports that demand rotational stability of the knee. But however, for younger patients participating in pivoting activities or with a desire to play contact sports or those with associated injuries, and that’s very important, such as meniscal injuries or all the ligaments involved or chondral injuries, so. The preferred treatment is ACL reconstruction.

    The type of surgery will depend on what type of injury we have, so for some guys we have a proximal or distal a version of the fibres of the ACL, sometimes even a small or large body fragment attached to the ACL can be seen on scans and in that situation, they perform mental treatments to repair, and when we say repair means using specific implants to reattach the native ligament to the native footprint. So this is what we call repair.

    But for mid substance tears, which accounts for 80% of ACL tears, when you have injury to the in the middle of the fibre so that the standard treatment and the golden standard is ACL reconstruction, OK and that means. Removing is a procedure that we do arthroscopically all right through key hole where we can remove the remnants of the fibres of the ACL using small incisions. OK. And then we reconstruct using a graph in a graph. It’s usually coming from the from the patient. So some options are hamstring quadriceps or patellar tendon. And with that graph we attach to specific implants according to surgeons preference in the optimal ACL footprint.

    Question 5
    Have there been any developments in treatment in the last years or are there any in trials or development now?

    Murilo: Yes, for sure. As you see how it’s a very prevalent condition, it it brings a lot of research to look for optimal treatments, techniques and implants. So there are several trials being run at the moment and for example if you search on PUB Med ACL there are at least 29,000 thousand papers being published. You know, uh, since the beginning and most of them in the last 10 years. We are constantly improving treatment options to offer to our patients.

    And in the last few years, I would say different options of graft have been used. Traditionally, the hamstring was the preferred graft, but nowadays the quadratic graft when we harvest the middle third of the quadratic stand than is showing same if not better results than hamstring regarding outcomes. Also, recently what we call a different ligament was found, which is called anterolateral complex ligament, OK and nowadays for some patients, the anterolateral ligament has been addressed as an adjuvant treatment for ACL reconstruction.

    For patients who are at high risk of re-injury, such as those who are ligamentous lax, hypermobile patients, patients younger than 20 years old or patients who are going for a second ACL reconstruction, there is level one evidence to recommend a procedure or what we call lateral tendonesis as an adjuvant procedure for a standard ACL reconstruction to reduce the risk of reinjury, and this is a great concern, especially when we are dealing with athletes.

    Also, more advanced techniques are allowing surgeons to perform the operation with less invasiveness. With less than one centimetre cuts, using new implants instead of screws that we used to use in the past. Nowadays we use adjustable suspension fixations, which are implants that reduce patient morbidity and reduce the side effects caused by screw being inserted into the bone. So it’s yeah, it’s an evolving topic and always a hot topic in orthopaedics.

    Question 6
    Are there any warning signs a GP or their patient can look out for?

    Murilo: Yes, there are indeed warning signs that General practitioner can look out for a patient with a ACL injury. First the history and mechanics of injury are crucial, right as previous mentioned, so this could involve jumping, landing, being tackled, hearing a pop at the time of the injury and the knee. Swelling up. Uh post injury. OK, second examination, so that can be done. Uh, in the rooms by GPs physiotherapists or specialists. OK. And the the two most common tests utilise. One the Lachman test and two the pivot shift test you might be familiar with this test, but just to refresh your memory so the Luckman test, the patient lies flat on table with 30° of flexion of the knee. So the femur is stabilised and anterior translation of the tibia is applied.

    So always this test we compare with the contralateral examination considering patient has a normal knee on the other side and the key factors that we have to observe, uh, whether there is an end point, if it’s a firm end point or not, and the amount of translation of the tibia over the femur. OK, so the pivot shift test once you might be familiar with, so involves a patient laying flat in the table. You have full extension of the knee. Then the examiner applies light valves and internal rotation of the knee. And the knee is gradually banned from full extension to 90°, so around 30° of flexion. You might feel a pop or a pivotal, pivotal, uh mechanism of the tibia should be detected. So usually corresponds to the reduction of a subluxation that occurs when the the ACL is torn.

    The GPs may also encounter basically history of me giving wise sometimes during sports or inability to play sports due to a lack of trust in the knee. Sometimes patients don’t complain, but they basically give up sports and other activities because they just don’t trust me any longer. So, and that’s additional signs of instability, OK. One critical point I think for in the rooms it’s imaging, OK and for a suspected ACL tear imaging is critical and that would include plain X-rays, AP lateral and also a Mac Key view, a Mac View X-ray it’s a. Long length view of the lower limbs. OK, which gives the surgeon a better idea of overall patient alignment. So that’s very important when you have a knee injury, especially ACL tear to look at the patient alignment.

    So Mac if you. And of course, MRI scan. So MRI scan will provide a more comprehensive view, allowing an identification of location, combination of ACL, all the injuries, meniscus involvement, cartilage involvement or as I say, other ligaments and two scans that are not very useful in when we suspect ACL tier is an ultrasound and CTR, so I usually do not recommend request that stick to X-rays Mac review and MRI scan.

    Question 7
    What is the likelihood of recurrence of the condition?

    Murilo: Well, this is a big problem. The range rate of ACL it is around 10%, OK and most of the factors related to the injury are related to patient demographics such as, as I said, young patients with higher participation, competitive sport, but also unfortunately technical issues. Such as [inaudible] account for 80% of overall. Reasons for reinjury. OK, so this is a one of the most important factors in ACL reconstructions are precise tonal position, especially on the femoral side, and that can be very challenging for some orthopaedic surgeons, especially if, if not fellowship training in ACL surgery.

    Just to give an example. Some patients such as athletes is younger than 25% who return to a competitive sport. Their range rate can be up to 23%. So this is really high. And for those patients which are high risk, have high risk for reinjury, that’s when I would recommend an additional lateral tenodesis to address the anterolateral ligament at the time of the ACL reconstruction. For those patients, well, so I try to be more conservative in terms of rehabilitation and I usually recommend at least 12 months until they return to contact sports.

    I usually tell my patients what are the main four factors to guarantee. I mean I would say uh successful ACL operation and determine when patients are ready to return to sport. So the factor #1 is of course the operation needs to be accurately perform tunnels in optimal position. OK, so and this is surgical related, the factor #2 patient, neuromuscular rehabilitation and that is achieved with the with the help of a good physiotherapist. OK. 3rd maturation of the graph so which means a process called ligamentisation and in some case it can take up to 12 to 24 months for the graph to be fully mature. So that’s a very important factor to consider and the last but not least is the psychological feeling of a patient to be ready to return to sport. So most of the time, if you respect 4 main factors you will have a successful outcome and you will minimise reinjury rate for our patients so.

    Question 8
    When should a GP refer?

    Murilo: I would say if the patient is involved in recreational or competitive pivoting sports or activities or for those patients have a chronic case health there and have lost trust in the knee, I would recommend. Referring for orthopaedic surgeon, also those patients who have combined knee injuries. And that’s very important. So that’s why MRI is so important. Those patients have an ACL in a meniscal tear or an ACL [inaudible] injury or ACL and or the combined ligament. Usually, reconstruction and addressing all uh, injury part, so it’s critical. OK, so this is when I would, uh refer straight away for our topic surgeon.

    Question 9
    What role does the GP play in the treatment of the condition?

    Murilo: Uh general practitioner are critical, not only in making the initial diagnosis, and they do that very well, but most of GPs are already know what we call pre-rehabilitation. OK, so my instructions for patients have ACL tear would be to commence exercise to restore the range of motion. Even prior to see orthopaedic surgeon OK, I would recommend physiotherapy of course, but also exercise such as cycling, swimming.

    Those exercises will help to restore the range of motion, reduce the pain from the initial injury as well as reduce the swelling. But of course the patient should avoid running, changing directions or engaging pivoting activities until see an orthopaedic surgeon and usually. Operation is arranged so. So if the initial treatment is implemented, so patients will have a better outcome so and that’s a fact, OK. So we know that the length of recovery after ACL tear especially returned to sport is always sooner than better for the patient.

    Concluding Question
    Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on ACL surgery.

    Murilo: For sure. My pleasure. Thank you. So first of all, let’s say when the diagnosis might always look for combined injuries, look at the meniscus, look at the cartilage. Look at it all the ligaments. So MRI is critical. Second, start your patient rehabilitation prior to see orthopaedic surgeon that guarantees that outcomes OK and lastly, ACL surgery is an evolving field and correct treatment means updated. Fellowship trained surgeons that can tailor the operation to patient specific demands. There are different options of graph to be. Use many times adjunct procedures are needed to guarantee the success of the operation. So ACL has surgery has changed and evolved a lot, especially in the last few years. So make sure your patient will get the best to prevent re injury.

    Thanks for your time and the insights you’ve provided.

    Murilo: Thank you

*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.