Abstract
Anterior cruciate ligament (ACL) reconstruction is a common procedure; HIC figures for 1999 in Australia include 4652 primary reconstructions, and 279 revisions (6%). We all see many good results, with some being excellent; but I also see a lot of ‘ordinary’ knees, and large group of unhappy patients following this type of surgery. Second opinions are frequently sought, because the patients feel that they have not progressed as expected. I looked prospectively at 50 patients in this category. The most common symptoms were pain, crepitus, catching, and functional insecurity or instability - and subsequent failure-to-progress. They presented four months to 15 years following ACL surgery, many having unrealistic expectations, often brought about because of media reports. Many patients complained of ‘failure of communication’ with their surgeon, and were prompted to seek a second opinion by a vocal third party. Their problems were generally complex combinations of:
-
Ligamentous laxity.
-
Meniscal, chondral, or other internal derangements of the knee.
-
An inflammatory response.
-
‘Neuromotor dysfunction’ (this group struggles from the start, often develops patellofemoral symptoms with persisting quadriceps wasting and insecurity).
-
Those with significant degenerative arthritis. Failure to distinguish instability of patellofemoral and neuro-motor origin; from that of ACL deficiency; can lead to inappropriate revision surgery.
Reviewing these patients who sought second opinions, emphasises the importance of a surgeon’s being an excellent technician, (as 60% of those reviewed had anterior placement of the drill holes); but equally being a team leader; understanding tissue responses, psycho-emotional factors and having good communication skills, time to listen to patients and offer adequate follow up.
The abstracts were prepared by Professor A. J. Thurston. Correspondence should be addressed to him at the Department of Surgery, Wellington School of Medicine, PO Box 7343, Wellington South, New Zealand
