ACL rupture in the immediate build-up to the Olympic Games: return to elite alpine ski competition 5 months after injury and ACL repair

Abstract

Anterior cruciate ligament (ACL) rupture in the immediate build-up to a major international competition can preclude an athletes' participation due to the prolonged period of rehabilitation that is typically required after ACL reconstruction. ACL repair is an alternative strategy that has been postulated to confer the advantage of rapid rehabilitation and earlier return to sport. A 33-year-old professional alpine skier sustained a right knee ACL rupture in September 2017. The athlete indicated that she wanted to participate in the 2018 Olympics. Arthroscopic ACL repair and reconstruction of the anterolateral ligament was undertaken. At 3 months, Lachman’s test revealed a hard end point, a negative pivot shift and no side-to-side laxity difference. MRI at 6 and 12 weeks demonstrated a continuous ACL with no intraligament signal change. At 20 weeks postoperatively, she successfully participated in the slalom at the 2018 Olympic Games.

Background

There is a resurgence in interest in anterior cruciate ligament (ACL) repair. Despite its increasing popularity, there is little evidence available to support the suggestion that this strategy is associated with a shorter period of rehabilitation or that it allows an earlier return to competitive sport. Conventional ACL reconstruction is typically associated with a delay of 6–8 months between surgery and return to competition. However, because of this delay, ACL reconstruction may not always be a viable option, especially for professional athletes in the build-up to a major competition such as the Olympic Games.

The importance of this case lies in the fact that it demonstrates that the strategy of combined ACL repair and anterolateral ligament (ALL) reconstruction is a good option in elite athletes sustaining injury in the build-up to a major competition because it can allow a rapid return to competition. Furthermore, the case provides a unique comparison of the outcome of ACL repair, with both non-operative treatment and ACL reconstruction, which the skier underwent for a contralateral ACL rupture 4 years earlier. On that occasion, she was unable to return to competition following non-operative treatment and underwent ACL reconstruction. The rehabilitation period precluded her participation in the 2014 Winter Olympics. The patient’s perspective provides a unique insight into the advantages of combined ACL repair and ALL reconstruction over conventional ACL reconstruction.

Case presentation

A 33-year-old, female, professional alpine skier with a ruptured right ACL was evaluated in our clinic on 18 September 2017. She suffered injury following an episode of forced flexion while practising in a training session on 10 September. She had been training since the summer of 2017 in preparation for the Pyeongchang Winter Olympics to be held in February 2018. Clinical examination revealed a positive Lachman’s test, grade 2 pivot shift, a side-to-side laxity difference of 6 mm on Rolimeter (Aircast Europa, Neubeuern, Germany) testing, but no effusion or evidence of other ligamentous injury. The clinical impression of ACL rupture was confirmed on MRI, figure 1.

Figure 1.

MRI images of the right knee: (A) preoperative sagittal fat sat proton density MRI; (B) Day 1 postoperative sagittal fat sat proton density MRI demonstrating repaired anterior cruciate ligament (ACL); (C) Day 1 postoperative coronal fat sat proton density MRI demonstrating anterolateral ligament graft (white arrows); and (D) 3 months postoperative MRI. Isometric 3D Space Proton Density demonstrating normal appearances of ACL.

In 2013, the athlete had suffered a partial left ACL rupture just 4 months before the 2014 Winter Olympic Games. With insufficient time for rehabilitation after ACL reconstruction and before Olympic participation, she made an informed choice to undertake non-operative management. Three months after monitored rehabilitation and physiotherapy, she had a firm end point on Lachman’s test, a negative pivot shift and a side-to-side laxity difference of 2 mm on Rolimeter testing. As a result, she was cleared to participate in the Olympic Games. Unfortunately, during a practice session before the Olympics, she experienced a complete rupture of the left ACL and was unable to participate. She, therefore, underwent left ACL reconstruction surgery and returned to ski competition 8 months following surgery. Since that time, she has remained asymptomatic with regards to her left knee.

Following the 2017 injury to the right knee, the athlete expressed that she still wanted to participate in the 2018 Olympics. Non-operative and operative options were discussed in detail. Her previous experience of both failed non-operative management and prolonged rehabilitation after ACL reconstruction led to consideration of ACL repair, which offers the advantage of rapid return to competition.¹ In addition, an ALL reconstruction was also considered. The rationale for this was based on the high-grade rotational instability detected on clinical examination and also concerns about the risk of re-rupture. It is recognised that high grades of pivot shift are indicative of injury to the anterolateral structures,² and in these situations an ALL reconstruction is significantly more likely to restore normal knee kinematics than an isolated intra-articular procedure.³ Furthermore, recent clinical study has demonstrated that ALL reconstruction (ALL-R) significantly reduces ACL graft rupture rates compared with isolated ACL reconstruction.⁴ This is also attributed to restoration of more normal knee kinematics and load sharing⁵ with the ACL. The concept of performing a lateral extra-articular procedure at the time of ACL repair has previously been described.^{1 6}

With a clear understanding of the risks and benefits of the different treatment options presented, the patient gave informed consent to proceed to ACL repair and an ALL-R using semitendinosus allograft (STA).

Treatment

Surgical technique

Combined arthroscopic ACL repair with concomitant ALL-R was performed in a standard arthroscopy position, with thigh and foot support. ALL-R was performed as previously described.⁷ The steps of the surgical technique performed are summarised in table 1 and supportive illustrations are shown. The first step in the procedure was to perform an arthroscopic evaluation of the ACL tear. The prerequisites that must be met in order to proceed with a repair instead of a reconstruction are a proximal tear and good quality tissue. Probing of the ACL remnant is required to accurately assess the tear pattern and the ability to reapproximate the remnant back to the ACL femoral insertion. In this case, arthroscopic exploration revealed a complete, proximal, Type II ACL tear (proximal femoral stump of 20% and a distal tibial stump of 80%) according to the classification of Sherman et al. ⁸

Table 1.

Surgical steps: arthroscopic ACL repair and ALL-R with STA

ALL-R with STA (figure 2) Step 1	Two convergent tibial sockets are created with a 5 mm drill 1 cm distal to joint line. One is placed just posterior to Gerdy’s tubercle and the second is placed just anterior to the fibular head. These two sockets are converted into a single tunnel in a subcortical manner using a right-angled clamp.
Step 2	The proximal end of the allograft is fixed in a 5 mm diameter femoral socket, just proximal to the lateral epicondyle with a Swivelock device (SwiveLock; Arthrex, Naples, Florida, USA).
Step 3	The free end of the allograft is then shuttled under the iliotibial band, through the tibial tunnel and then shuttled back to the femoral incision where it is subsequently fixed
ACL repair (figure 3) Step 4	Minimal debridement of the intercondylar notch and microfracture of the notch wall to aid healing response
Step 5	A 4 mm wide tibial tunnel is drilled in an ACL remnant-sparing manner
Step 6	A FiberStick (Arthrex) protected in a plastic tube is placed through the tibial tunnel and ACL remnant (figure 3A), and pulled out through the anteromedial portal. The plastic tube is left in the ACL remnant
Step 7	ACL stump sutures are placed using two No 0 FiberLink and TigerLink sutures (Arthrex) through the remnant stump using the Knee scorpion (Arthrex) (figure 3B).
Step 8	A 4 mm femoral tunnel is created using an outside-in femoral guide (Arthrex)
Step 9	FiberStick and TigerStick sutures are introduced into the knee through a cannulated reamer and pulled out through anteromedial portal. The FiberStick is attached to the two ACL stump sutures (FiberLink and TigerLink [Arthrex]). The TigerStick is retrieved through the ACL stump and the tibial tunnel using the initial FiberStick and used as shuttle suture from the femur to tibia.
Step 10	The internal brace (Arthrex) is loaded on a tightrope button (Arthrex) and then shuttled through the tibial tunnel, ACL stump and femoral tunnel and flipped on lateral femoral cortex under arthroscopic guidance.
Step 11	The FiberStick attached to the two ACL stump sutures (FiberLink and TigerLink) is shuttled through the femoral tunnel (figure 3C). Fiberlink and TigerLink are securely tightened over the TightRope button with knee in 90° of flexion (figure 3D).
Step 12	The InternalBrace is fixed under tension on the tibia using a 4.75 mm suture anchor (SwiveLock; Arthrex) with the knee in extension
Step 13	With the knee in extension and neutral rotation, the free end of the ALL allograft is secured to the femur with multiple knots intertwined using sutures from the SwiveLock anchor; previously used for first part of ALL graft fixation.

ACL, anterior cruciate ligament; ALL-R, anterolateral ligament reconstruction; STA, semitendinosus allograft.

Figure 2.

Intraoperative images of the right knee. (A) A suture passer is routed through the tibial tunnel. This allows a suture shuttle to be placed and the graft to be subsequently routed through the tibial tunnel. (B) One limb of the semitendinosus allograft is secured with the suture anchor (SwiveLock; Arthrex) in a femoral socket located proximal and posterior to the lateral epicondyle. (C) The free limb of the allograft is then routed under the iliotibial band toward the posterior tibial stab incision, passed through the tibial tunnel and shuttled back to the femoral stab incision.

Rehabilitation

The patient was allowed immediate brace-free weight bearing with crutches, and active/passive knee range of motion exercises. An important aspect stressed during the rehabilitation was to perform frequent quadriceps activation exercises.

A milestone-based approach was adopted for guiding progression of rehabilitation. The patient underwent close monitoring by a team consisting of an experienced orthopaedic surgeon, a physiotherapist and a professional sports trainer. When progressing to higher milestones, her performance was collectively monitored by the team. From 6 weeks to 3 months postoperatively, she participated in physical training under the supervision of a team of professional sports trainers.

Outcome and follow-up

The patient was able to maintain good quadriceps muscle bulk and strength before and after surgery and throughout the rehabilitation period. By the end of 2 weeks postoperatively, she could walk independently fully bearing weight. In between the second and fourth weeks, she was able to exercise on a stepper; after 4 weeks was able to perform antigravity running. At 6 weeks, she was able to commence running.

Clinical examination at 12 weeks postsurgery revealed a firm end point on Lachman’s test, a negative pivot shift and no side-to-side laxity difference on Rolimeter testing. MRI imaging at both 6 and 12 weeks demonstrated a continuous ACL without intraligament signal change. Due to reassuring imaging findings and excellent clinical improvement, she was allowed to return to skiing at only 12 weeks after surgery, and the competition was at 17 weeks. On 28 January 2018, she participated in a world cup slalom ski-race where she finished third in the second run and qualified to be a part of the February 2018 Winter Olympics, where she carried the Slovakian flag. At 20 weeks postsurgery, on 16 February 2018, she successfully participated in both runs of the Olympic Slalom Alpine skiing and finished 17th. She retired from her sports career after the Olympic Games.

Discussion

Alpine skiing is a popular but injury-prone winter sport. There is a reported preponderance of lower limb injuries (58.1%),⁸ with ACL ruptures being among the most frequently encountered (35.6% of all skiing injuries and 67.9% of knee injuries).^{8 9} Despite a focus on injury prevention, ACL rupture rates among competitive alpine skiers have remained relatively unchanged over the last 25 years.¹⁰

ACL injury has profound effects on the professional career of elite skiers. Not all of them are able to return to competitive skiing following ACL reconstruction. However, it is reported that professional skiers have a higher rate of return to competition (87%),¹¹ compared with athletes in general (55%),² but the timing of return to sport is also important in the elite athlete, particularly in the build-up to major international competition. Recently, Ardern et al reported that only one-third of athletes were able to return to competition within 12 months of ACL reconstruction, whereas the majority of the remaining athletes were able to return by 2 years.^{12 13} To the knowledge of the authors, specific data for mean duration between an ACL rupture and return to competitive skiing after ACL reconstruction is not reported.

In this case, the athlete had previously missed the 2014 Olympic Games due to a contralateral ACL rupture that was also sustained in the immediate build-up to the event. On that occasion, non-operative management was attempted. Although this has a low success rate (16%), it does have the potential advantage of rapid return to sport.¹⁴ Unfortunately, this strategy did not allow her to compete and she went on to have ACL reconstruction and an 8-month period before return to competition.

The high incidence of ACL injuries and the potentially devastating effects on the career of professional alpine skiers pushes are important reasons to innovate new surgical options with the aim of an expedited return to competitive skiing. With conventional ACL reconstruction, successful return to competitive skiing has been described by Erickson et al,¹¹ and Haida et al,¹⁵ but the published data do not specify the mean duration between an ACL rupture and return to competitive skiing after ACL reconstruction. However, the literature highlights on the fact that professional athletes usually require longer rehabilitation than advocated for successful return to competitive sport after ACL reconstruction.^{12 13 16}

This case report provides evidence to support a strategy of combined ACL repair and ALL-R surgery (figure 3E) for professional alpine skiers.

Figure 3.

Intraoperative arthroscopic images of the right knee. (A) A 4 mm tibial tunnel is drilled over a guidewire placed in the centre of the anterior cruciate ligament (ACL) stump and a FibreStick is passed through the entire ACL remnant. (B) Two stitches are placed in the ACL remnant with the knee Scorpion device. (C) Intra-articular view of the final appearance of the ACL repair. (D) Arthroscopic view of the lateral gutter with the two limbs of the FiberLink and TigerLink tensioned and knotted over the Tightrope button. (E) Illustration of the ACL repair and anterolateral ligament reconstruction with allograft.

One of the major advantages in favour of combined ACL repair and ALL-R surgery is quicker return to competitive skiing (18 weeks). Furthermore, it is also our opinion that addition of ALL reconstruction to ACL repair should be considered mandatory for high-demand athletes. This philosophy is based on evidence that ALL-R can help to restore more normal knee kinematics and also helps to protect the ACL repair through load sharing. Table 2 provides a comparative summary of previously treated professional skiers at our institution (with an ACL tear managed by ACL reconstruction), with the case reported. As depicted in table 2, the duration between surgery and return to competitive skiing was shortest with ACL repair and ALL-R, when compared with the other professional skiers and also compared with the current patient’s own recovery following contralateral ACL reconstruction.

Table 2.

Return to sports in professional skiers undergoing ACL surgery at our institution

	Delay injury to surgery (weeks)	Running (weeks)	Free training (weeks)	Competition (weeks0
Left knee: isolated ACL reconstruction (Hamstrings) Patient 1	4	10	24	32
Left knee: revision ACL reconstruction+ALL (Hamstrings) Patient 2	3	14	22	30
Right knee: ACL reconstruction (Hamstrings) Patient 2	4	14	20	52
Left knee: ACL reconstruction + (Hamstrings) Patient 3	4	14	23	32
Right knee: ACL reconstruction ALL (Hamstrings) Patient 3	1	16	23	31
Left knee: ACL reconstruction+ALL (Hamstrings) Patient 4	2	14	27	48
Right knee: ACL repair+ALL (Allograft) Patient 4	1	3	10	17

ACL, anterior cruciate ligament; ALL, anterolateral ligament.

ACL repair and ALL-R with STA (for her right ACL rupture) was offered as a potential option based on the previously published literature pointing to clinical success at short-term and mid-term follow-up after ACL repair,^{17 18} and successful return to competitive skiing participation.¹⁸ The proximal location of the ACL rupture, near to the femoral footprint, made it an amenable tear morphology for repair.¹⁹ Interestingly, although Haida et al ¹⁵ described younger age (<25 years) as being an important determinant of return to competitive skiing after ACL reconstruction, the described skier was able to return to competitive skiing after ACL repair surgery, even though her age was 33 years at presentation.

The rapid and successful return to competition and Olympic Games participation after ACL repair and ALL-R is in considerable contrast to the lengthy rehabilitation required after the athletes' contralateral ACL reconstruction. Although it is impossible to objectively attribute this difference to a single determinant of outcome, some potential factors that may have contributed to this include the small size of tibial and femoral tunnels (4 mm), full preservation of the ACL stump and its mechanoreceptors, absence of donor site morbidity (no requirement for hamstring harvest) and the skier’s ability to start rehabilitation earlier. With vast experience of thousands of ACL reconstructions, we feel that in the postoperative period, the knee reacts quite differently after this procedure, and is more in keeping with the recovery observed after a simple meniscectomy, irrespective of the severity of pathology. We believe that further focused research is required to conclusively delineate the factors responsible for the long recovery after ACL reconstruction, in particular, in terms of muscle wasting.

Patient’s perspective.

My experience of ACL Repair and anterolateral ligament reconstruction was that it allowed a major improvement in my ability to quickly return to sport. I knew after my previous experience of non-operative treatment that I would not be able to compete in the 2018 Olympics if I did not have surgery but I also knew that the rehabilitation after reconstruction was too long. The recovery after ACL repair was dramatically faster, I had less pain and muscle weakness and could return to training very quickly. I was amazed at how quickly I could start training hard and that enabled me to compete at an international race just 17 weeks after injury and then the Olympic Games. I strongly recommend ACL repair and anterolateral ligament reconstruction for athletes who suffer ACL injury in the immediate build up to a competition.

Learning points.

• Combined anterior cruciate ligament (ACL) repair with anterolateral ligament reconstruction appears to offer important advantages for the patient with a quicker return to competition than ACL reconstruction.

• MRI imaging at 6 and 12 weeks showed a continuous ACL without intraligament signal change.

• Rapid return to competition is likely multifactorial and related to the small size of tibial and femoral tunnels (4 mm), full preservation of the ACL stump and its mechanoreceptors, absence of donor site morbidity (no requirement for hamstring harvest) and the skier’s ability to start rehabilitation earlier.