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Experts perform double-bundle ACL Reconstruction to
treat an upcoming star of the Indian Women's Cricket team

ACL Reconstruction is one of the most common surgeries in Sports Orthopaedics today. In the USA alone around 60,000 to 100,000 ACL Reconstruction surgeries are performed every year as per the NHDS database. However, ACL Reconstruction is not like a “one size fits all” kind of surgery. There are at least 10-12 widely accepted variations of this procedure. The ideal approach has to consider patient factors and injury pattern to achieve good outcomes. Also, post-operative rehabilitation plays a pivotal role especially in the case when the player is trying to return back to the sport.

Ms. Keerthi James, one of the upcoming stars of the Indian Women's Cricket team, had an ACL tear and medial numerous mid to long-term studies in the western medical literature, failure rates are higher with cadaveric tissue grafts. Hence, the experts at Nanavati Super Speciality Hospital decided to go ahead with autograft.

There are a variety of options in autografts as well. Most commonly used grafts are Hamstring and Bone-Patellar tendon-bone graft (called BTB for short, it has bone plugs at either end). There are other less commonly used options like Peroneal Longus Tendon and Quad Tendon. These are generally reserved for revision purpose. Between Hamstring and BTB grafts, failure rates are marginally higher in Hamstring tendon grafts as per the studies. However, there is a slightly higher risk of developing anterior knee pain, especially while kneeling or squatting in the BTB group. These movements are important and sometimes inevitable in professional sports hence it was decided to use the dual Hamstring graft.



"Unlike professional sportspersons, most recreational athletes do not have access to good quality sports medicine infrastructure and expertise in India. To solve this problem, we have started a comprehensive sports medicine facility here at Nanavati Hospital. It includes services of Sports Orthopedic surgeon, a team of sports Physiotherapists, Sports Nutritionists and Sports Physicians. It is this team approach that sets us apart from the average Sports Orthopedic setups."
– Dr. Yajuvendra Gawai

Single-bundle versus double-bundle reconstruction:

ACL Reconstruction can be performed in either of the above techniques. In a single-bundle reconstruction, only one cylindrical graft is used to replace

meniscus posterior horn tear and was brought to Nanavati Super Speciality Hospital, Mumbai. The specialist's team at the hospital decided to perform a double-bundle ACL reconstruction using dual hamstring graft and all-inside meniscus to treat her.

One factor to consider in ACL Reconstruction is graft choice. There are classically two choices- Allograft, which is cadaveric tissue and Autograft, which is the patient's own tissue. Due to lack of cadaveric tissue processing and storage facilities, allograft tissue is not freely available in India. It can be imported if requested.

However, importing increases the cost of the procedure significantly. Also, as per the native ACL. In a double-bundle reconstruction, two smaller bundles are used which are more anatomical. In numerous clinical studies, there have not been any statistically different outcomes as regards to single and double-bundle reconstructions. However, biomechanical studies have established that double-bundle reconstruction more closely mimics a normal ACL. Also, the failure rates are slightly lower for doublebundle reconstructions. And, because of all these reasons, the team decided to go ahead with the double-bundle technique



Modes of fixation: There are plethora of fixation devices to fix the grafted tissue. Most commonly used ones are cortical buttons and interference screws. Studies have shown that fixation methods do not significantly alter the outcomes. Hence, we decided to use cortical buttons on the femoral side and biocomposite screws on the tibial side.

After the surgery, structured rehabilitation is equally important in achieving a good outcome. It may last for anywhere between 6-8 months for return to play. Sometimes even upto a year or more in a professional athlete. The challenge here is to hold back the sportspersons who are quite eager to get back into the thick of action- especially, when it means representing one's country, there is a degree of pride and responsibility attached to it as well.

Currently, Keerthi is having her rehabilitation at the Kerala Cricket Association facility under the close supervision of our doctors. The Nanavati Super Speciality Hospital family wishes her a speedy recovery and hopes she gets back into her normal form soon and makes us all proud.