ACL Injuries in the Knee

ACL Injuries in the Knee 364 200 Dr Paul Annett

Unfortunately the start of the season has come with the first bout of ACL tears – James Tedesco from the Wests Tigers and a few in the AFL pre-season games, including Andrew Krakouer from Collingwood. Around 70% of ACL injuries are non-contact in nature, as demonstrated by Tedesco’s injury, in which no one was around him.

ACL injuries appear to be more common around the start of the season. It has been suggested that ACL injuries are more common on harder grounds in drier conditions. The player’s game specific conditioning is also not as good early in the season, leaving them more prone to injury.

The most recent controversy regarding ACL reconstruction has been the use of the LARS artificial graft. This is a synthetic graft used to replace the torn ACL, instead of a standard reconstruction performed using a hamstring or patella tendon graft. Its main benefit has been that injured players are able to return to full sport a lot faster than the 6-9 months for a traditional ACL reconstruction. Some players have even returned within 3-4 months, or within the same season that they were injured. This does not occur with traditional ACL grafts, which are season ending.

The downside of all artificial grafts has been the fact that they will all fail at some stage. This may be an acute tear or chronic degeneration of the synthetic graft over time.  The experience of synthetic grafts such as carbon fiber and Dacron in the 80’s was poor, where they had high failure rates. When a synthetic graft fails then plastic particles are seeded within the joint, causing a nasty joint inflammation or synovitis. This inflammation in turn releases enzymes that may cause destruction of the lining cartilage of the joint. The upshot of this is that it is felt that knees that have synthetic ligaments in them are far more likely to develop osteoarthritis in a shorter time frame, which is a major concern for the long term prognosis for the joint.

At present the Australian Knee Society, a collective of experienced knee surgeons, does not support the use of LARS reconstructions as there is not enough evidence to support their widespread use, and the potential complications are significant.

The potential use of a LARS ligament may be reserved for the older athlete who may be trying to see out their last season (like Luke Covell from Cronulla, who made a successful return to NRL level Rugby League) and not wanting to miss the entire season. For a young player like 19 year-old James Tedesco then  a standard knee reconstruction using a hamstring graft is still the best long term treatment option.

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