ACL Tears in Female Athletes – an Overview:

Female athletes are three to five times more likely to have an anterior cruciate ligament (ACL) injury than male athletes. Due to the physical and chemical differences in female athletes, the ACL is at greater risk when participating in cutting twisting and pivoting sports like basketball, soccer, surfing, CrossFit and tennis. Any sport that requires quick pivoting motion, rotation of the lower extremities and quick changes in direction can result in injury to the ACL. Dr. Mark Getelman, orthopedic knee specialist, specializes in treating female athletes in Van Nuys, Thousand Oaks and the greater Los Angeles area who have sustained an ACL injury or tear.

What is the difference between an ACL repair and ACL reconstruction in female athletes?

During an ACL repair, Dr. Getelman repairs the torn ACL to regain movement and stability in the knee. During an ACL reconstruction, Dr. Getelman replaces the torn ACL with a tissue graft from either the patient (autograft) or a donor (allograft.) The two surgeries are very different and are used in different situations.

  • ACL Repair: Historically this option has been only performed when there is a fracture that has caused a piece of bone and the ligament to separate from the rest of the bone. The goal during this surgery is to reattach the bone fragment to the bone. Newer research and techniques have allowed for a resurgence of ACL repair for specific ACL injury where there is no fracture too. The role for ACL repair in these cases is limited to lower energy injuries and specific avulsion injuries when the ACL is avulsed from the bone and has less structural disturbance.
  • ACL Reconstruction: This preferred method of surgery is for the vast majority of injury where the ligament cannot be preserved. Patients who typically require ACL reconstruction are most often active individuals who experience persistent knee pain and instability following their injury. The goal of ACL reconstruction is to return the patient to their active athletic lifestyle.

Which is better: ACL reconstruction or non-surgical methods of healing a torn ACL?

The ACL, when torn, does not have the capacity to effectively heal itself, and often surgery is needed. Female athletes who want to remain active choose ACL reconstruction along with a post-operative rehabilitation program that can help them strengthen the affected knee. For athletes who want to return to sport, ACL reconstruction is the gold standard of care, typically restoring knee stability and the ability for patients in the Los Angeles area to return to the activities they love. However, some patients choose to forego surgery and opt for a non-operative approach. Patients who do not participate in cutting twisting or pivoting sports or who have underlying medical conditions in which surgery poses a risk may prefer a non-surgical approach for their torn ACL.

It is important to understand the outcome of an ACL reconstruction for any female athlete can vary widely and is often directly related to the experience and skill of their surgeon. Dr. Getelman has many years of experience in successfully treating ACL tears with reconstructive surgery.

Which is better, ACL reconstruction or ACL repair?

In the distant past, ACL primary repairs were often unsuccessful and patients did poorly, leaving the knee unstable and failing to alleviate painful symptoms. Studies showed a failure rate of these repairs to be anywhere from 20% to 80%. Because of this, ACL reconstructions were developed and have shown a much better, predictable outcome for athletes for many years. In fact, a well-done ACL reconstruction can function well for longer than 20 years in many female athletes.  Recently ACL primary repair, as an alternative to reconstruction, has made a resurgence and in select cases, ACL Repair may now be an option. The early results with the newly developed techniques are encouraging.  Dr. Getelman will evaluate the patient and the MRI images and advise which approach he feels would be best.

How is an ACL reconstruction done?

ACL reconstruction surgery involves replacing the torn ACL with tissue that is routed and secured at the normal attachment sites of the native ACL. In this specialized surgery, tunnels are created in the femur (thigh bone) and in the tibia (shin bone) and then the new ACL graft is secured within the tunnels using either screws or a surgical loop and button placed on the outside of the tunnels. A combination of cortical buttons or screws is usually required to secure the graft, often obtained from either the hamstrings, quadriceps or patella tendon.

Are there times when an ACL should be repaired?

The main time that an ACL can be repaired is when an anterior cruciate ligament is torn with a piece of bone off of the tibia. This type of injury is more common than an ACL that tears off of the femur with a piece of bone. When this occurs, the bone can be reaffixed at the normal attachment site and secured to allow the bone to heal. Dr. Getelman will monitor patients in these circumstances and decide to allow early motion, or to wait until further healing. The timing of early motion after this type of surgery is critical and it’s important to stay with an ACL specialist like Dr. Getelman.

Which type of graft is better for ACL reconstruction in female athletes?

There are two types of tissue grafts used to recreate a new ligament in the reconstruction of an ACL: the hamstring tendon and the patellar tendon.

  • The hamstring tendon is located on the back of the thigh. Dr. Getelman uses two of these tendons “bundled” together to form a new ligament. Using this tendon for the new ligament has the advantage of less pain, however the graft takes longer to become “rigid” and fixation can be affected by motion after surgery. Because of this, a knee brace is often used to immobilize the knee for a week or two after surgery so the new graft can heal properly.
  • The patellar tendon is the structure on the front of the knee that connects the kneecap to the tibia (shin bone). The patellar tendon most closely resembles the ACL, with a similar length that allows it to be placed in the bone where the ACL attaches. The disadvantage of this type of graft is post-operative pain in the front of the knee and the risk of post-surgery patellar fracture or a tear of the healing tendon.

What are the risks associated with ACL reconstruction?

ACL surgery is most frequently successful with predictable outcomes for most patients. The risks associated with ACL reconstruction are those associated with surgery in general, but stiffness and the development of osteoarthritis are more concerning. Patients who injure their ACL often also tear their meniscus at the same time. Meniscal tears also cannot heal and while repair is preferred, many tears often require some level of resection.  Female athletes who lose significant meniscus have a higher risk of developing osteoarthritis over the long term, due primarily to the lack of meniscus rather than to the ACL reconstruction.

Dr. Getelman will discuss with his patients the best approach to managing the ACL injury and will develop a treatment plan to help female athletes in Van Nuys, Thousand Oaks and Los Angeles, California area return to the sporting activities they love.