ACL ruptures in elite athletes: why surgical precision matters
The recent news that Kvicha Kvaratskhelia, the Paris Saint-Germain and Georgia winger, will undergo surgery following a ruptured anterior cruciate ligament (ACL) highlights one of the most significant and worrying injuries that athletes can suffer.
For elite footballers, an ACL rupture is far more than a routine sporting injury. It can threaten a player’s career, affect future earning capacity, and potentially alter the trajectory of a professional sporting life.
From a medical negligence perspective, ACL injuries also provide an important example of how surgical errors can have far-reaching physical, psychological and financial consequences.
What is an ACL rupture?
The anterior cruciate ligament (ACL) is one of the principal stabilising ligaments within the knee joint. It runs diagonally through the centre of the knee and helps to prevent excessive forward movement of the tibia, control rotation, enable rapid changes in direction, and facilitate cutting, pivoting and landing movements. It is fundamentally important to a number of movements relied upon by high performing sporting individuals, including elite footballers, rugby players, skiers and other athletes involved in high-speed, multidirectional sports.
An ACL rupture occurs when the ligament is completely torn or severely damaged because of a sudden change of direction, a twisting movement, awkward landings or hyper extension. The injury will often be associated with hearing (or feeling) a ‘pop’ within the knee, followed by pain, swelling and instability.
Why is an ACL injury so significant?
Unlike many muscle injuries, the opposing ends of a torn ACL cannot heal together by themselves, and this will result in:
- loss of knee stability;
- reduced athletic performance; and
- recurrent episodes of the knee ‘giving way’.
Many people who sustain an ACL injury do not rely routinely on rapid changes of direction and pivoting movements, and can manage without the ligament. Consequently, they may not require surgery. However, elite athletes depend upon explosive acceleration, deceleration, and rotational control, and an unstable knee can significantly impair all of these functions. As such, ACL reconstruction surgery is normally required.
ACL reconstruction surgery
ACL reconstruction typically involves:
- removal of the torn ACL remnants;
- the creation of tunnels within the tibia and femur;
- placement of a tendon graft (from, for example, the hamstring or quadriceps) to act as a replacement ligament;
- securing the graft using fixation devices.
The aim of treatment is not merely to restore daily function but to return the athlete to elite sporting performance. It is a technically demanding operation and its success typically depends upon selecting the correct type of graft, precise positioning of the new tunnel within the tibia and femur, and secure fixation of the new graft.
One of the most common causes of failure following ACL reconstruction is incorrect positioning of the newly formed graft tunnels in the femur or tibia. If they are positioned even a few millimetres outside of where they should be, the biomechanics of the knee can be altered. This can result in residual knee problems which, for elite athletes operating at the limits of physical performance, can have profound consequences.
What happens if ACL surgery is performed incorrectly?
When ACL reconstruction is performed below an acceptable standard, complications may include:
- blocked movements – it may feel as though there is a physical block preventing the knee from moving fully into extension or flexion;
- persistent instability – the knee may buckle, give way, and the athlete may lose confidence when running or changing direction. This may affect an athlete’s speed and agility, and persistent instability issue can cause greater damage within the knee, including osteoarthritic changes; and
- graft failure – this may lead to total loss of stability and often requires revision surgery. A second ACL reconstruction is typically more complex and may need to be performed during two separate operations. Revision ACL reconstructions are also associated with less predictable outcomes.
Financial consequences of failed ACL surgery for an athlete
The financial implications for high performing sports people can be enormous if their ACL reconstruction is performed below the acceptable standard. For an elite footballer, for example, absence from competition may result in losses extending well beyond salary. They may sustain losses associated with contractual bonuses and continued absences may affect sponsorship, advertising and commercial opportunities in the future.
Moreover, and often more importantly, long-term absence from competition for a high performing athlete may force them into premature retirement, particularly if their employer loses faith that they will be able to return to their previous elite levels of performance. The impact may also extend into future coaching opportunities, if injuries sustained following poorly performed surgery are debilitating. For high-profile athletes, financial losses can be significant over a career.
Not every poor outcome following ACL reconstruction results from negligence. Even well performed surgery carries recognised risks and complications do not prove that negligence has occurred. However, post-surgery issues experienced by athletes are worth exploring due to the significant impact that the injury can have over the athlete’s career.
Conclusion
The ACL rupture suffered by Khvicha Kvaratskhelia serves as a reminder of both the seriousness of this common sporting injury and the importance of expert surgical management.
Modern ACL reconstruction techniques can produce excellent outcomes, allowing many elite athletes to return to the highest levels of competition. However, because athletic performance depends upon precise knee function, errors in surgical technique can have life-changing consequences.
For professional sportspeople, the effects of a failed ACL reconstruction may extend far beyond physical symptoms. They can influence career progression, reputation, earning capacity, and long-term financial security. Khvicha Kvaratskhelia’s season is very likely over and he will have a long road of recovery ahead of him. From a medical negligence perspective, few orthopaedic injuries demonstrate more clearly how a technical surgical error can translate into substantial losses both on and off the field.