ACL SURGICAL NEWS: ALLOGRAFT VS. AUTOGRAFT

When the ACL is torn, is can rarely be repaired. Surgery is often required to reconstruct the ACL. If reconstruction is not performed, the knee is at increased risk of cartilage damage, meniscal tear and osteoarthritis. Especially in younger patients, surgical repair is recommended following an ACL tear.

Surgery is performed arthroscopically and the ACL is either repaired or replaced. If the torn ligament cannot be repaired, the ACL is replaced with a tissue graft. The surgeon and patient have the option to use autograft tissue or allograft tissue.

Autograft tissue is a tendon from another location on the patient’s body. Most commonly a surgeon would use a hamstring tendon or patellar bone tendon bone. With the patellar bone tendon bone, the middle third of the tendon is removed and used as the new ACL.

Allograft tissue is a cadaver tendon that is taken from another person. In this case, the surgeon would use the achilles tendon, patellar bone tendon bone or a hamstring tendon.

Autograft is recommended for patients 30 years old or younger. The failure rate of allograft tendons is much higher in those under the age of 30 and the risk of infection is very low. The downside of using the patient’s tissue is that the operation is more involved and painful. The surgeon must surgically remove the autograft tendon and then also repair the ACL. The patient is undergoing two procedures as opposed to one. 

Allograft tendons are preferred in patients over the age of 30. The advantage of allograft is that it involves less surgical time and is less painful. The disadvantage of allograft is increased risk of infection and rejection. It is important to mention that the advances in allograft testing and sterilization have improved significantly in recent years. Risk of infection and disease is extremely low. Another advantage with allograft is that there are now numerous options to choose from, which allows the surgeon some flexibility in deciding which option is best for each individual patient.

In summary, if you are having surgery on your ACL, it is best to talk to your orthopedic surgeon about which option is best for you. Each case is unique and should be evaluated thoroughly before making a final decision.  

ACL Injury and Prevention

ACL injuries are common and on the rise. These injuries can cause young athletes to sit on the sidelines for months, lose out on valuable scholarship money and lead to long term osteoarthritis. It is estimated that over 50,000 high school and college age female athletes suffer from ACL injuries each year.[1] While some of these incidents cannot be prevented, there are steps that can be taken to reduce the number of injuries. 

One common misconception about ACL tears is that they are a result of player-to-player contact and little can be done to prevent occurrence. While ACLs are injured/torn in this manner, most occur as a result of the following: 

• Sudden change in direction
• Cutting maneuvers coupled with a sudden stop
• Awkward landing following a jump
• Pivoting with knee fully extended while foot is planted on the ground

Unfortunately, female athletes are more susceptible to ACL injury. Anatomical differences, such as a greater Q-angle, are primarily to blame. Other factors include weak muscle groups, bad habits, improper form and decreased range of motion. The good news is that while we cannot change the anatomy, we can identify risk factors and help reduce the chance of injury. 

A few suggestions for prevention would include: 

• Strength training – especially the smaller muscles around the knee and the hamstring 
•  Jump routine exercises emphasizing proper form and landing
• Pivoting exercises – also focusing on proper form

These tools are most successful when implemented in early adolescence. By utilizing prevention tools early in life, we can ensure that kids are learning proper form and technique from the beginning. This alleviates the need to undo risky habits in the future. 

Many organizations are implementing pre-season screening programs where professionals can assess athletes and determine if they are high risk for ACL injury. If you have access to one of these programs, take advantage of it and use the prevention tools provided. In future posts, we will also highlight exercises and routines that could be helpful.

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[1] Stopsportsinjuriesnow.org

What is the ACL?

There are four major ligaments in the knee. The ligaments attach three bones: the thighbone (femur), the shinbone (tibia) and the knee cap (patella). There are 2 groups of ligaments in the knee; the collateral ligaments and the cruciate ligaments. The anterior cruciate ligament or ACL is one of the cruciate ligaments.

The two collateral ligaments are known as the medial collateral ligament and the lateral collateral ligament. The medial collateral ligaments are on the side of the knee and control sideways motion of the knee. These bands of tissue are intended to protect the knee from extending too far to either side.

The two crutiate ligaments are known as the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL). These two bands cross each other to form an “X”. The ACL is in the front and runs diagonally across the middle of the knee. The ACL and PCL keep the knee from moving too far forward or backward.

The ACL is the most commonly injured of all the ligaments in the knee. The ACL is key to providing stability in the knee and minimizing stress within the knee joint. When injured, surgery is typically required to recover from the injury. 

In future articles, we will discuss ACL injuries and injury prevention in greater detail. If you feel you may have injured your ACL it is extremely important to consult an orthopedic surgeon.

Why are women more susceptible to ACL tears?

In recent years, there has been discussion on why women and young girls are more susceptible to ACL tears. There are many theories on the reasons why, but today we will examine a main anatomic difference between men and women that is a contributing factor: the Q-Angle and wider pelvis.

The Q-angle is the angle at which the femur (upper leg bone) meets the tibia (lower leg bone). The Q-angle is determined by three areas of the human anatomy – the Anterior Superior Iliac Spine (ASIS), the center of the kneecap (patella) and the tibia tubercle.  The Q-angle is basically a line drawn from the ASIS down to the center of the kneecap to the tibia tubercle (see picture below).

The Q-angle in women is greater because women are anatomically built with a wider pelvis than men.  A normal Q-angle in men is 14 degrees, while women have a normal angle of 17 degrees. The greater the angle, the more at risk the person is for knee injuries, including ACL tears.

The fact that the q-angle is more pronounced in women than men leads to more stress on the knee joint and makes it less stable when put under stress. For this reason, when a woman participates in sports involving jumping, running or pivoting, she is naturally more likely to suffer an ACL tear. 

What can we do to prevent ACL tears in women?

Recently, emphasis is being placed on neuromuscular training programs.  Neuromuscular training teaches the body better biomechanic movements to improve the control of the dynamic knee stabilizers (the ACL and major ligaments that surround the knee).  Exercises that are included in a neuromuscular training program include stretching, plyometrics and strength training.  The goal of these programs is to teach athletes how to land, pivot and control the knee without placing as much force on the ACL.  One program was developed by the Santa Monica Sports Medicine Research Foundation and is known as the PEP Program: Prevent Injury and Enhance Performance. To learn more about this program, please visit http://smsmf.org/files/PEP_Program_04122011.pdf.  

If you suspect that you have an ACL tear or other orthopedic injury, it is important to see an Orthopedic Surgeon.  Skyview Orthopedic, the office of John Vitolo, MD is available to treat all your orthopedic injuries and concerns.  Our office is focused on treating each patient individually and offering the highest quality orthopedic care.  John Vitolo, MD holds dual board certification in Orthopedic Surgery and Sports Medicine. For more information call the office, 973-300-1553 or visit us online at www.skyvieworthopedic.com.