Anterior Cruciate Ligament ACL Reconstruction
Overview
ACL reconstruction is surgery to replace a torn anterior cruciate (KROO-she-ate) ligament (ACL) — a major ligament in your knee. ACL injuries most commonly occur during sports that involve sudden stops and changes in direction — such as basketball, soccer, football, downhill skiing and gymnastics.
In ACL reconstruction, the torn ligament is removed and replaced with a piece of tendon from another part of your knee or from a deceased donor. This surgery is an outpatient procedure that's performed through small incisions around your knee joint.
ACL reconstruction is performed by a doctor who specializes in surgical procedures of the bones and joints (orthopedic surgeon).
Anterior cruciate ligament
Ligaments are strong bands of tissue that connect one bone to another. The ACL — one of two ligaments that crosses the middle of the knee — connects your thighbone (femur) to your shinbone (tibia) and helps stabilize your knee joint.
Why it's done
Most ACL injuries happen during sports and fitness activities that can put stress on the knee:
Suddenly slowing down and changing direction (cutting)
Pivoting with your foot firmly planted
Landing from a jump incorrectly
Stopping suddenly
Receiving a direct blow to the knee
A course of physical therapy may successfully treat an ACL injury for individuals who are relatively inactive, engage in moderate exercise and recreational activities, or play sports that put less stress on the knees.
ACL reconstruction is generally recommended if:
You're an athlete and want to continue in your sport, especially if the sport involves jumping, cutting or pivoting
More than one ligament or the meniscus in your knee is injured
The injury is causing your knee to buckle during everyday activities
You're young (though other factors, such as activity level and knee instability, are more important than age)
Risks
ACL reconstruction is a surgical procedure. And, as with any surgery, bleeding and infection at the surgical site are potential risks. Other risks associated with ACL reconstruction include:
Knee pain or stiffness
Poor healing of the graft
Graft failure after returning to sport
How you prepare
Before your surgery, you'll likely undergo several weeks of physical therapy. The goal before surgery is to reduce pain and swelling, restore your knee's full range of motion, and strengthen muscles. People who go into surgery with a stiff, swollen knee may not regain full range of motion after surgery.
ACL reconstruction is an outpatient procedure, so you'll be able to go home the same day. Arrange for someone to drive you home.
Food and medications
Tell your surgeon about any medications or dietary supplements you take. If you regularly take aspirin or other blood-thinning medications, your doctor may ask you to stop taking these types of drugs for at least a week before surgery to reduce your risk of bleeding.
Follow your doctor's instructions about when to stop eating, drinking and taking any other medication the night before your surgery.
What you can expect
General anesthesia is typically used during ACL reconstruction, so you'll be comfortable during the procedure. ACL reconstruction is usually done through small incisions — one to hold a thin, tube-like video camera (arthroscope) and others to allow surgical instruments access to the joint space.
During the procedure
Your surgeon will remove your damaged ligament, and then replace it with a segment of tendon. This replacement tissue is called a graft and it comes from another part of your knee or a tendon from a deceased donor.
Your surgeon will drill sockets or tunnels into your thighbone and shinbone to accurately position the graft, which is then secured to your bones with screws or other fixation devices. The graft will serve as scaffolding on which new ligament tissue can grow.
After the procedure
Once you recover from the anesthesia, you can go home later that same day. Before you go home, you'll practice walking with crutches, and your surgeon may ask you to wear a knee brace or splint to help protect the graft.
Your doctor will give you specific instructions on how to control swelling and pain after surgery. In general, it's important to keep your leg elevated, apply ice to your knee and rest as much as possible.
Medications to help with pain relief include over-the-counter drugs such as acetaminophen (Tylenol), ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve). Your doctor might prescribe stronger medications, such as meloxicam (Mobic, Vivlodex, others) and gabapentin (Neurontin). If opioids are prescribed, they should be taken only for breakthrough pain as they have many side effects and a significant risk of addiction.
Follow your surgeon's advice on when to ice your knee, how long to use crutches and when it's safe to bear weight on your knee. You'll also be instructed when you can shower or bathe, when you should change dressings on the wound, and how to manage post-surgery care.
Progressive physical therapy after ACL surgery helps to strengthen the muscles around your knee and improve flexibility. A physical therapist will teach you how to do exercises that you will perform either with continued supervision or at home. Following the rehabilitation plan is important for proper healing and achieving the best possible outcomes.
Results
Successful ACL reconstruction paired with focused rehabilitation can usually restore stability and function to your knee. Within the first few weeks after surgery, you should strive to regain a range of motion equal to that of your opposite knee. Recovery generally takes about nine months.
It may take eight to 12 months or more before athletes can return to their sports.
And Also:
ACL Surgery
A torn ACL (anterior cruciate ligament) is a painful and potentially debilitating condition. ACL tears are very common.
Each year in the United States, between 100,000 to 200,000 people tear their ACL. The ACL cannot heal on its own. Once torn, it will stay torn unless surgery is performed.
For some patients – mainly older people and others whose lifestyles do not include running or other rigorous excercise – conservative, nonsurgical treatments may allow them to successfully return to their normal routines.
However, anyone who has torn their ACL and returns to unrestricted activity without an intact ACL will likely experience some knee instability. Most people with active lifestyles, especially those who participate in competitive sports or other rigorous athletic activities, will need surgery to return to their prior level of activity and avoid future injury.
Without an intact ACL, a person is also much more likely to tear their meniscus. The meniscus is a pad of cartilage that cushions the bones that meet at the knee joint. There are two menisci on each knee: the medial meniscus on the inside of the knee and the lateral meniscus on the outside. A torn meniscus will cause knee pain and, sometimes swelling. More importantly, however, a damaged meniscus increases a patient's risk of developing osteoarthritis of the knee later in life.
Most people with active lifestyles, especially those who engage in competitive sports, will need ACL surgery in order to reduce the risk of future injury.
What does ACL surgery do?
In most cases, it is not possible to surgically repair or reattach a torn ACL. Most often, ACL surgery involves a complete rebuilding of the ACL. This procedure, called ACL reconstruction, is the current standard of care for surgically treating tears of the ACL.
The surgeons at the HSS Sports Medicine Institute have drafted guidelines for people who are considering ACL treatment.
How does ACL surgery work?
In ACL reconstruction surgery, a new ACL is made from a graft of replacement tissue from one of two sources:
a portion of the patient's own hamstring, quadriceps or patellar tendon
an allograft (tissue from a human organ donor)
The type of graft used for each patient is determined on a case-by-case basis.
ACL reconstruction surgery is performed using minimally invasive arthroscopic techniques, in which a combination of fiber optics, small incisions and small instruments are used. A somewhat larger incision is needed, however, to obtain the tissue graft. ACL reconstruction is an outpatient (ambulatory) procedure, in which patients can go home on the same day as their surgery.
At HSS, most patients who undergo ACL reconstruction are given an epidural nerve block during their surgery, rather than being placed fully unconscious under general anesthesia. This epidural is the same type of regional anesthesia many women receive during childbirth.
ACL reconstruction surgery steps
Reconstruction of the ACL follows a number of basic steps, although they may vary slightly from case to case:
The orthopedic surgeon makes small incisions around the knee joint, creating portals of entry for the arthroscope and surgical instruments.
The arthroscope is inserted into the knee and delivers saline solution to expand the space around the joint. This makes room for surgical tools, including the arthroscopic camera, which sends video to a monitor so that the surgeon can see inside the knee joint.
The surgeon then evaluates structures that surround the torn ACL, including the left and right meniscus and the articular cartilage. If either of these soft tissues have any lesions, the surgeon repairs them.
Next the graft will be harvested (unless a donor allograft is used). A section of tendon from another part of the patient's body is cut to create a graft, which is then attached at each end to plugs of bone taken from the patella and tibia. These plugs help to anchor the graft that will become the new ACL.
The surgeon inserts the new ACL into the femur and tibia using a flexible guide wire.
Screws are used to secure the plugs of bone. Over time, these plugs will be incorporated into the surrounding bone.
The surgical instruments are removed to complete the procedure.
How soon should you get ACL surgery?
ACL reconstruction is generally scheduled for between three and six weeks after the injury occurs. This allows inflammation in the area to subside. If surgery is performed too early, patients may develop a profound scarring response called arthrofibrosis.
Orthopedic surgeons gauge the appropriate timing of surgery based on:
whether there are other injuries present that need to be treated first
the physical appearance of the knee
the patient’s level of pain
the patient's range of motion and quality of muscle control when flexing (bending) or extending (straightening) the leg
What is the recovery time for ACL surgery?
It usually takes six to nine months for a patient to return to participating in sports after an ACL reconstruction, depending on the level of competition and the type of activity.
Patients are able to walk with crutches and a leg brace on the day of surgery. Very soon after surgery, the patient enters a rehabilitation program to restore strength, stability and range of motion to the knee. The rehabilitation process is composed of a progression of exercises:
Strengthening and range-of-motion exercises are started early in the recovery period.
Running exercises begin at about four months.
Pivoting exercises are started at around five months.
Return to playing competitive sports can begin as early as six months.
The degree of pain associated with ACL recovery varies and can be addressed successfully with medication. Recovery time also varies from patient to patient. The determination of when a patient has fully recovered is based on the restoration of muscle strength, range of motion and proprioception of the knee joint.
Arthroscopic surgical techniques have made recovery times quicker and easier, compared to when ACL construction was conducted through open surgery. But to achieve a successful outcome, it is critical to have the rehabilitation period carefully supervised by an appropriate physical therapist and to have follow-up appointments with the surgeon.