Play Forever : How to Recover from Injury and Thrive (9781544526775) by Stone Kevin R

Author:Stone, Kevin R.
Language: eng
Format: epub
Publisher: Bookbaby
Published: 2021-01-15T00:00:00+00:00

Biologic Treatments

Anterior Cruciate Ligament (ACL)

The knee joint

The ACL is a broad, thick cord the size of your index finger, with long collagen strands woven together in a way that allows it to withstand up to five hundred pounds of force in young, healthy people. It connects the thigh bone to the shin bone and is a key stabilizer of your knee, guiding your tibia (shin bone) through a normal, stable range of motion. When the ACL tears, it unravels like a braided rope and does not heal on its own.

The ACL is the most commonly injured ligament in the knee—three hundred thousand tears each year in the US alone. Females, for many different reasons, are more likely to injure their ACL than males. People often tear the ACL by twisting the knee while changing direction rapidly, slowing down from running, or landing from a jump. The thigh bone moves past where the ligament can stretch, producing the famous “pop.” Once broken, it may partially heal to the surrounding tissues, but the ligament rarely regains its normal connections. While some patients have “ACL independent” knees and don’t develop significant instability after rupture, most athletic people need their ACL to provide stability and to protect the meniscus tissues that rest upon the tibial plateau. Left unstable, approximately 80 percent of injured people will eventually go on to develop meniscus tears and 50 percent will develop knee joint arthritis.

Once torn, the optimal time to restore stability is immediately. While there has been considerable debate about the timing of surgery, all collagen-based tissues start scarring and shrinking within minutes of tearing. The ACL fibers are similar to a climbing rope, which once stretched past their limit, suffer from internal disruptions of most of the fibers—even when the outside sheath looks intact.

Efforts to perform suture repair of the torn ACL tissue have had only selective success, despite efforts to add scaffolds, stem cells, and growth factors to the injured tissue. And those limited successes were obtained only when most of the ligament was still intact, acting as a scaffold to which the injured tissues could adhere.

In my hands, primary repair works well when the tear is partial, located near the ligament origin on the femur, and the patients are older. Young, healthy, aggressive males rarely protect their primary repairs long enough to provide a successful outcome. Future devices most likely will be designed to work as temporary ligaments while inducing normal tissue remodeling.

In the initial assessment of ACL injuries, a common diagnostic error is missing associated knee injuries when confronted with the more obvious ACL rupture. When the ACL ruptures, more than just the ACL is stretched. The most common secondary injuries involve the meniscus, the articular cartilage, and the secondary ligamentous tissues, such as the outside back corner of the knee. If these tissues are ignored or resected, and not surgically repaired, the knees fail quickly.

ACL reconstructions with patients’ own tissues—usually hamstring or patella tendon grafts—have not evolved very much. In the twenty-first century, we should not be taking one part of a person to rebuild another part.

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