Anterior Cruciate Ligament Reconstruction Dr. Anthony Abene, MD

What Is The ACL?

ACL stands for Anterior Cruciate Ligament of the knee. The knee is the largest and most complex joint in your body. It depends on four ligaments and other muscles and tendons to function properly. There are two ligaments on the sides of the knee: the Medial Collateral Ligament (MCL) and the Lateral Collateral Ligament (LCL), and two crossed ligaments in the center of the knee, the Anterior Cruciate Ligament (ACL) and the Posterior Cruciate Ligament (PCL).

The ACL connects the front part of the shin bone to the back part of the thigh bone and keeps the thigh bone from sliding forward.

How Is The ACL Injured?

One of the common ways for the ACL to be injured is by a direct blow to the knee, which commonly happens in football or a fall when skiing. In this case, the knee is forced into an abnormal position that results in the tearing of one or more knee ligaments.

However, most ACL tears actually happen without contact between the knee and another object. Such non-contact injuries happen when the athlete is planting the foot and cutting, landing on a straight leg, or making an abrupt stop. These movements are common in basketball, football, volleyball and soccer.

What Are The Signs Of An ACL Tear?

In many cases, when the ACL is torn, you will feel the knee give way with an audible “pop”. The injury is usually associated with a moderate amount of pain and continued activity is usually not possible. Over the next several hours, the knee becomes very swollen and walking becomes difficult. The swelling and pain usually are the worst for the first two days and then begin to subside.

How Is An ACL Tear Diagnosed?

ACL tears usually cause enough discomfort to cause the injured person to seek medical attention. The physician will examine the knee, and, in most cases, be able to identify which ligaments are injured. However, there may also be injuries to the joint surface that are more difficult to diagnose. In addition, swelling may sometimes make it difficult to diagnose a tear. Further evaluation with a MRI or arthroscope may be necessary to completely evaluate the injury.

Will I Need Surgery?

The most frequently asked question after an ACL injury is will I need surgery? The answer varies from person to person. Many factors must be considered by the patient and the physician when determining the appropriate treatment. These factors include the activity level and expectations of the patient, whether there are associated injuries, and the amount of abnormal knee laxity, or looseness. A young patient, who wants to return to competitive sports and has a knee that is very unstable on examination, is more likely to need surgery for a satisfactory outcome than an older patient, who wants to return to recreational jogging and has only mild laxity. If surgery is not indicated, rehabilitation of the knee begins with exercises to help restore full range of motion. Strengthening exercises for the muscles around the knee follows this. A return to sports with or without a brace is allowed only after leg strength, balance and coordination have returned to near normal.

How Are ACL Tears Treated Surgically?

Many different surgical approaches have been tried for the ACL injured knee. Years of experience have shown that simply stitching the ligament together is rarely successful. Therefore, current techniques involve reconstructing the ACL by building a new ligament out of tissue harvested from one of the other tendons around the knee or from a cadaver. This tissue is passed through drill holes in the thigh bone and shin bone, and then anchored in place to create a new ACL. Over time, the new ACL regains its blood supply and cells and becomes a living ligament anchored to the bone on each end.

What Happens After Surgery? Rehabilitation of the knee after ACL reconstruction requires time and hard work. Time off from work depends on the type of job, with people who work at desk jobs able to come back in one or two weeks, and construction workers usually not able to return to the job for six months. The same is true for athletes, with returning to golf occurring more rapidly than returning to football.

The overall success rate for ACL surgery is very good. Many studies have shown that over 90% of patients are able to return to sports and workplace activities without symptoms of knee instability. Although some patients do complain of stiffness and pain after surgery, these problems have been minimized by current surgical techniques and aggressive rehabilitation.

This is a general description of the average course of events before, during and after surgery. Reading this carefully may help to answer many of your questions, allay some of your fears, and in general allow you to be a better-informed participant in your care and rehabilitation. Your actual experience may differ slightly depending on your particular injury, physical capabilities, the time of your surgery, and other such circumstances. We do strive to continually update our techniques and protocols, so as to provide you with the safest, most effective and reliable treatment available.

The week(s) before surgery If you have recently injured your knee (in the past 3 weeks) then this time will be used to allow any swelling or inflammation in your knee to decrease prior to the surgery. An anti-inflammatory medication may be prescribed to help accomplish this. Exercises and/or physical therapy can assist you in regaining full motion in your knee, which is a prerequisite to surgery.

The Night Before your surgery Arthroscopic surgical reconstruction of the anterior cruciate ligament (ACL) is considered major surgery. As is standard for all such surgeries, you should have nothing to eat or drink after midnight prior to your surgery. However, if you are required to take a daily-prescribed medication, we may have you take the medication with sips of water on the morning of your surgery. If you are on diabetic or heart medication, you should obtain specific instructions from you doctor as to how you should take your medication before and after the surgery. If you smoke cigarettes, we ask you to refrain from smoking, at the very least the night prior to your surgery. Smoking does increase the risks of anesthesia, and can increase complications after surgery. If you routinely drink more than two alcoholic beverages a day, please let us know, as this can affect the amount of medication you may require both during and after your surgery.

The Day Of Surgery The Anesthesiologist and his or her assistant will meet with you to discuss your anesthesia. The surgery is usually done under General Anesthesia (with you "asleep"), however, in some cases Epidural Anesthesia (with you "awake", but sedated ) may be offered to you as an alternative. This involves numbing you from the waist down through a needle-thin catheter inserted into your spinal canal in the operating room. Both types of anesthesia work well with this type of surgery and are equally safe and effective. • A general anaesthetic will put you completely out for the duration of the surgery and a small portion of the recovery. This is usually done via the oxygen mask that is placed over your mouth and nose just prior to surgery. A general will last for the duration of the surgery, and its effects will begin to wear off in the recovery room. It takes longer to recover from the effects of a general, and it may cause nausea afterward. It can also make it difficult to defecate and/or urinate for several hours after you have awakened. • An epidural, or spinal, block involves the insertion of a long needle into the cavity in the spine between your vertebrae and the spinal cord. The needle is withdrawn and a small catheter (similar to an IV) is left and taped in place. The anaesthetic is pumped through this catheter, and it deadens you from the waist down. A lighter general is also used with this type of anaesthetic. This also lasts 12-16 hours, and the immediate recovery is also less painful.

After the surgery, you will awaken from your anesthesia (if you have had general anesthesia) in the Recovery Room. You will find an Ace bandage on your knee, and a brace on your leg consisting of foam padding, aluminum supports, and Velcro straps. This is designed to keep your knee fully extended (straight). The pillows or blankets used to elevate your leg should be kept under your calf and heel, and not under your knee, to prevent your knee from resting in a bent or flexed position. A specialized cooling wrap may be placed around your knee connected by tubes to a cooler. A small motor circulates ice water through the wrap to cool your knee, helping to decrease pain, swelling and bleeding in the knee. There is a temperature gauge and control attached to the unit that should be adjusted to keep the temperature at about 45 degrees Fahrenheit (between 40 and 50). A pain pump catheter may be placed into your knee. This will allow for numbing medicine to be automatically introduced into your knee. The day of surgery you will be able to walk with crutches. If you have crutches, please bring them with you on the day of surgery. Do not be alarmed if you experience some throbbing or bleeding in your knee as you stand. This is normal and can be expected.

Immediately post-op Try to keep your knee elevated for the first 24 hours following surgery. You will be sent home with a prescription for pain medication, You can use Tylenol for less severe pain. Your dressing will be removed by our staff in the office at your first postoperative visit.

Post-op Concerns FEVERS: It is not unusual for bleeding inside a joint to cause a fever to 101 or 101.5. This will be accompanied by a warm feeling in the knee as well as discomfort. If you have repeated fevers to 101.5 or higher, then you should contact our office immediately. This could indicate an infection. Other signs of infection would be redness around the wound or purulent material draining from the wounds. It is unlikely for evidence of an infection to show within the first 48 hours following surgery. Abnormal swelling or red appearance of the wounds accompanied by fever after the first 48 hours is worrisome and you should call the doctor.

SWELLING: Swelling in the knee is fairly normal, especially early on after the surgery. It can cause quite intense pain in the knee, especially as the numbing medicine wears off. If the pain does not resolve with cool compresses, such as the cryo cuff and pain medication, then you should call the office to have the knee drained, which will relieve the pain. Swelling in the knee will often give the sensation of the knee buckling backwards. If you are in a lot of discomfort, then call the office and have one of the doctors drain the knee which will relieve the discomfort.

Post-op Weeks 1-3 Physical therapy will start 5-7 days post-op. We will emphasize range of motion. During the first month, we are most concerned that your knee is able to fully straighten (extend). A common cause of a less than optimal outcome from ACL surgery is the development of scar tissue which prevents the knee from fully extending. This is called a "flexion contracture," and may require additional surgery and delay your rehabilitation. All attempts are therefore made to prevent its occurrence. Weight bearing will range (depending on the specific case), but generally you will be able to stand with full weight while in the brace and advance to full weight bearing by 3 weeks. At this point we will discontinue the brace and crutches. Your sutures will be removed sometime around 10-14 days post-op.

When can I shower? Your incisions must be healing well and without any drainage before you can get them wet (about 7 days). If you want to shower before this time, cover your knee bandage with a towel and a plastic wrap, such as Saran Wrap, taping the edges of the plastic to your skin to keep the dressing dry. If they get very wet, you should change the dressing with 4" x 4" sterile guaze pads over the incisions, and a clean 4" or 6" elastic (Ace) bandage. All the sutures should be removed before you can actually submerse your knee in water

Post-op Weeks 4-8 You will continue training under the guidance of your physical therapist or athletic trainer, using a stationary bicycle, stair machine, or other "closed chain kinetic" exercises in which resistance against the sole of the foot is maintained throughout the exercise. These would include partial squats or leg presses with low weights, an exercise bike, stair machine or Nordic track. Leg extensions, heavy weights and power lifting are not allowed for the first six months.

When can I return to work or school? This depends on your job or school. A desk job or regular classes can be returned to in about 1 week. You should comfortable on your feet for 20-30 minutes at a time. Patients with jobs demanding physical labor, like athletes, must be individually evaluated before returning to their job or sport and may require 3 to 6 months before returning to their jobs. This depends on your job requirements and general physical condition.

Post-op Weeks 8-16 The final phase of rehabilitation. In general, most patients will be allowed (but not required) to start jogging on a treadmill or cushioned level surface and do most of their rehab on their own. Remember, it will have been 3 months or longer since you last ran, so start slowly at short distances and gradually build your mileage and speed. Additionally, proprioception exercises can be started by your physical therapist. Some knee cap discomfort is not unusual (if we use your own graft), but if this persists you may need to cut back on your activities. Proprioception is an important joint function. It is a feedback system that allows you to subconsciously and continually sense what position a joint is in, and respond in reflex to sudden changes in position and weight to avoid undue stresses to the joint. In significant joint injuries, such as a torn ACL, this joint function is lost and in general is one of the last functions to return during rehabilitation. Specific exercises can help restore it. You should also continue with your other strengthening exercises. You may also begin sport specific drills.

When can I return to my sport? This depends on your sport. Sports which require cutting and sudden changes in speed and direction require a well-healed graft and normal knee strength and proprioception. This generally requires about 6 months. There are exceptions to this rule, however, return to your sport sooner than 6 months might increase the risk of re-injuring your knee and damaging your graft. You will have to weigh this increased risk against your desire for an earlier return to your sport.