Thursday, 12 January 2012
Monday, 2 January 2012
ACL Injury—an undetected epidemic!
As
a society we are gradually beginning to become obsessed with sports apart from
cricket. This phenomenon is amply evident by emergence of star sports persons
in various fields like tennis, boxing, hockey, golf, badminton, athletic,
wrestling etc. They are adored and looked upon as role models by young and old
alike. At recreational level, sports allows an escape from pressures of daily
life and at elite level, sports is well established as a part of entertainment
industry with enormous rewards for the professionals. At both these levels,
sports related injuries especially knee ligament injuries remain a constant
threat of a prolonged layoff or even a career ending event. These injuries are
not only commonly seen in contact sports like football and rugby but also in
noncontact sports like golf(Tiger Woods), Cricket (Yuvraj Singh), Badminton
(Gopichand), all three sustained an ACL (Anterior Cruciate Ligament ) injury, the commonest ligament to be injured (60% of
all ligament injuries) in the knee. The
number of women suffering ACL tears has dramatically increased. This is due in
part to the rise in women's athletics. But studies have shown that female
athletes are two to four times more likely to suffer ACL tears than male
athletes in the same sports. Recent research has shown several factors that contribute
to women's higher risk of ACL tears. Women athletes seem less able to tighten
their thigh muscles to the same degree as men. This means women don't get their
knees to hold as steady allowing them to twist easily. Also, shape of their
thigh bone(Femur) puts them at a higher risk of the ACL rubbing on the bone in
the event of a twisting injury.
Data from the western world clearly show that
knee injuries may require surgical treatment, prolonged rehabilitation and are
the most common cause of permanent disability after a sporting injury. A study
done in USA on the prevalence of ACL injuries in the general population has
estimated the incidence as 1 case in 3,500 people, resulting in 95,000 new ACL
ruptures per year. National Health Service UK (NHS) website reports a similar
incidence of 30 cases of ACL injuries for every 100,000 people or a total of
approximately 18000 ACL injuries across a population of 60 million every year. At a similar rate we should see 3.6 lacs
patients of ACL injuries per year. This may be a conservative estimate due to
low average age of our population compared to the western world. So we may already
be in the midst of an epidemic!!
These
injuries are easily missed since X-rays are usually normal. A study from
British Medical Journal showed an average delay of 22 months before these
injuries were diagnosed despite the fact that the patients were seen in the
emergency departments of the Hospitals at the time of injury. Infact, 30 % of
these patients were assessed by an Orthopedic surgeon without the diagnosis
having been recognised. So we may be in
the midst of an undetected epidemic!!!
The symptoms following a tear of the ACL can vary. Usually, the knee
joint swells within a short time following the injury. This is due to bleeding
into the knee joint from torn blood vessels in the damaged ligament. The
instability caused by the torn ligament leads to a feeling of insecurity and
giving way of the knee, especially when trying to change direction on the knee.
The knee may feel like it wants to slip backwards.
The pain and swelling from the initial injury will usually be gone
after two to four weeks, but the knee may still feel unstable. The symptom of
instability and the inability to trust the knee for support are what require
treatment. Also important in the decision about treatment is the growing
realization by orthopedic surgeons that long-term instability leads to early
arthritis of the knee.
Diagnosis
needs a careful clinical evaluation by an expert knee surgeon as ligaments and
tendons do not show up on X-rays. Magnetic
Resonance imaging (MRI) is probably
the most accurate test for diagnosing a torn ACL without actually looking into
the knee.
Treatment of ACL injury does not necessarily
involve surgery in all patients. Physiotherapy and bracing may be attempted
initially. If the symptoms of instability are not controlled by a brace and
rehabilitation program, then surgery may be suggested. The main goal of surgery
is to keep the tibia from moving too far forward under the femur bone and to
get the knee functioning normally again.
Even when surgery is needed, most surgeons will
have their patients attend physical therapy for several visits before the surgery.
This practice also reduces the chances of scarring inside the joint and can
speed recovery after surgery.
Arthroscopic reconstruction (Keyhole surgery) of
ACL injury is the standard of care and
open surgery is not recommended. Key-hole
surgery is most often done with the aid of the arthroscope, although small incisions
are usually still required around the knee, but the surgery doesn't require the
surgeon to open the joint. The arthroscope is used to view the inside of the
knee joint as the surgeon performs the work. The torn ACL ligament is reconstructed with a
piece of Hamstring muscles tendon or
with a part of patellar tendon. This tendon connects the kneecap (patella) to
the tibia.
Most ACL reconstructions are now done on an outpatient
basis, and many patients go home the same day as the surgery. Some patients
stay one or two nights in the hospital if necessary.
View an animation of the arthroscopic reconstruction of ACL here...
Recovery
following surgery involves in a progressive rehabilitation program for four
to six months to ensure the best results. During first few weeks following the
surgery supervised physiotherapy may be needed followed by self administered
exercises at home over the four to six month period.
For further information on ACL injury and its treatment visit www.gurgaonkneeandshoulderclinic.com
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