.
Arthroscopic surgery
Arthroscopic surgery is performed under spinal or general anesthesia.
During arthroscopic
ACL reconstruction, the surgeon makes several small incisions—usually two or three—around the knee. Sterile saline
(salt) solution is pumped into the knee through one incision to expand it and to wash blood from the area. This allows the
surgeon to see the knee structures more clearly.
The surgeon inserts an arthroscope into one
of the other incisions. A camera at the end of the arthroscope transmits pictures from inside the knee to a TV monitor in
the operating room.
Surgical drills are inserted through other small incisions. The surgeon
drills small holes into the upper and lower leg bones where these bones come close together at the knee joint. The holes form
tunnels through which the graft will be anchored.
The surgeon will take the autograft (replacement
tissue) at this point. If it comes from the patellar tendon, it will include two small pieces of bone called "bone blocks"
on both ends. One piece of bone is taken from the kneecap and the other piece is taken from a part of the lower leg bone (
tibia ) near the knee joint. If the autograft comes from the hamstring, bone blocks are not taken. The graft may also be taken
from a deceased donor (allograft). This tissue is usually the donor’s patellar tendon or achilles due to their strength.
The graft is pulled through the two tunnels that were drilled in the upper and lower
leg bones. The surgeon secures the graft with bioabsorbable screws and/or metal staples and will close the incisions
with stitches. A temporary surgical drain is inserted in the knee to decrease swelling and pain. The knee is covered with
a bandage, then a Ted hose, followed by an ice pad on the knee and finally a long brace. You are taken to the recovery room
for 1 to 2 hours.
During ACL surgery, the surgeon may repair other injured parts of the
knee as well, such as meniscus, cartilage and ligaments (MCL or LCL).
What To Expect After Surgery
ACL surgery is outpatient surgery. That means check in and out on the same day. Total time from check in to check out is
usually 4 hours.
You should keep your incision clean and dry and watch for signs of
infection.
Physical
rehabilitation after ACL surgery may take several months to a year. The length of time until you can return to normal activities
or sports is different for every person; it may range from 6 to 12 months.
Why It Is Done
The goal of ACL surgery
is to restore normal stability in the knee and the level of function you had before the knee injury, limit loss of function
in the knee, and prevent injury or degeneration to other knee structures.
Not all ACL
tears require surgery. You and your health professional will decide whether rehabilitation only or surgery plus rehabilitation
is right for you.
You may choose to have surgery if you:
· Have completely torn your ACL or have a partial tear and your knee is very unstable.
· Have gone through a rehabilitation program and your knee is still unstable.
· Are very active in sports or have a job that requires knee strength and stability (such as construction work), and
you want your knee to be as strong and stable as it was before your injury.
· Are willing to complete a long and rigorous rehabilitation program.
· Have chronic buckling of your knee that is affecting your quality of life.
You
may choose not to have surgery if :
· Have a minor tear in your
ACL (a tear that can heal with rest and rehabilitation).
· Are not very active in sports and your work does not require a stable knee.
· Are willing to stop doing activities that require a stable knee or stop doing them at the same level of intensity.
You may choose to substitute other activities that don't require a stable knee. (In sports, these other activities can
include cycling or swimming.)
· Can
complete a rehabilitation program that stabilizes your knee and strengthens your leg muscles to reduce the chances that you
will injure your knee again and are willing to live with a small amount of knee instability.
· Do not feel motivated to complete the long and rigorous rehabilitation program necessary after surgery.
How Well It Works
Between 80% and 90% of
people who have ACL surgery have favorable results, with reduced pain, good knee function and stability, and a return to normal
levels of activity. 1
Between 3% and 10% of people who have ACL surgery still have knee pain and instability and may need another surgery (revision
ACL reconstruction). 2 Revision ACL reconstruction is generally not as successful as the initial ACL reconstruction.
Risks
ACL reconstruction surgery is generally safe. Complications from surgery or that may
arise during rehabilitation and recovery include:
Problems
related to the surgery itself. These are uncommon but may include:
Numbness in the surgical scar area.
Infection in the surgical incisions.
Damage to structures, nerves, or blood vessels around and in the knee.
Blood clots in the leg.
The usual risks of anesthesia.
Problems
with the graft (loosening, stretching, reinjury, or scar tissue). The screws that attach the graft to the
leg bones may cause problems and require removal.
Limited
range of motion, usually at the extremes. For example, you may not be able to completely straighten or bend your leg as far
as the other leg. This is uncommon, and sometimes manipulation under anesthesia can help. Rehabilitation usually attempts
to restore a range of motion between 0 degrees (straight) and 130 degrees (bent or flexion). You may lack a few degrees at
either end of the range of motion after surgery and rehabilitation.
Grating
of the kneecap (crepitus) as it moves against the lower end of the thighbone (femur), which may develop in people who did
not have it before surgery. This may be painful and may limit your athletic performance. Rarely, the kneecap may be fractured
while the graft is being taken during surgery or from a fall onto the knee soon after surgery.
Pain or swelling
during activities ranging from daily activities to strenuous sports. About 40% to 80% of people have some pain or swelling
only when they play strenuous sports. The remaining people may have some pain or swelling with milder amounts of activity.
3 A
thorough rehabilitation program and a slow, gradual return to activities will reduce the likelihood of pain and swelling.
Pain and swelling that persist may indicate a possible cartilage or meniscus injury
that happened when the ACL was torn.
Pain, when kneeling, at the site where the tendon graft was taken
from the patellar tendon or at the site on the lower leg bone (tibia) where a hamstring or patellar tendon graft is attached.
Repeat injury
to the graft (just like the original ligament). Repeat surgery is more complicated and less successful than the first surgery.
Problems related to the surgery itself. These are
uncommon but may include: Numbness in the surgical scar area.
Infection in the surgical incisions.
Infection in the surgical incisions. Damage to structures, nerves, or blood vessels around and in the knee.
Blood clots in the leg.
The usual risks of anesthesia.
Problems with the graft (loosening, stretching, reinjury, or scar tissue). The screws that attach
the graft to the leg bones may cause problems and require removal.
Limited range of
motion, usually at the extremes. For example, you may not be able to completely straighten or bend your leg as far as the
other leg. This is uncommon, and sometimes manipulation under anesthesia can help. Rehabilitation usually attempts to restore
a range of motion between 0 degrees (straight) and 130 degrees (bent or flexion). You may lack a few degrees at either end
of the range of motion after surgery and rehabilitation.
Grating of the kneecap
(crepitus) as it moves against the lower end of the thighbone (femur), which may develop in people who did not have it before
surgery. This may be painful and may limit your athletic performance. Rarely, the kneecap may be fractured while the graft
is being taken during surgery or from a fall onto the knee soon after surgery.
Pain or swelling during activities ranging from daily activities
to strenuous sports. About 40% to 80% of people have some pain or swelling only when they play strenuous sports. The remaining
people may have some pain or swelling with milder amounts of activity. 3 A thorough
rehabilitation program and a slow, gradual return to activities will reduce the likelihood of pain and swelling.
Pain and swelling that persist may indicate a possible cartilage or meniscus injury that happened when
the ACL was torn.
Pain, when kneeling, at the site where the tendon graft was taken from the patellar tendon or at the site on the
lower leg bone (tibia) where a hamstring or patellar tendon graft is attached.
Repeat injury to the graft (just like the original ligament). Repeat
surgery is more complicated and less successful than the first surgery.
What
To Think About
In an avulsion fracture,
repair surgery is always performed as soon as possible.
In reconstruction of a partial or complete
tear of the ACL, the best time for surgery is not known. Surgery immediately after the injury has been associated with increased
fibrous tissue leading to loss of motion (arthrofibrosis) after surgery. 4 Some experts believe that surgery should be delayed until the swelling goes down, you can move your knee again, and
you have regained any lost strength in the muscles in the front of your thigh (quadriceps). 4 Many experts recommend starting exercises to increase range of motion and regain strength shortly after the injury.
In
adults, age is not a factor in surgery, although your overall health may be. Surgery may not be the best treatment for people
with medical conditions that make surgery a greater risk. These people may choose nonsurgical treatment and try to change
their activity level to protect their knee from further injury.
Current research on the
surgical treatment of ACL injuries includes different techniques and places to attach grafts; different types of screws; different
types of grafts, such as tendon, muscle, or fascial grafts from your body (autograft); and grafts from a donor (allograft).
Grafts made of synthetic materials, such as Gore-Tex or Stryker Dacron (prosthetic ligaments), are rarely used anymore. When
choosing a graft, consider the following:
· The success of surgery may
be more dependent on the surgeon's skill and preference than the type of graft used.
· Replacement tissue
from the kneecap (patellar) tendon is one of the strongest grafts available to replace the ACL.
· A kneecap graft
may result in pain when kneeling.
· A hamstring graft may result in some hamstring
weakness.
·
There is no difference in how the knee functions between a kneecap and hamstring
graft. However, a kneecap graft is overall more stable in the long term. A recent study indicates that kneecap and hamstring
grafts resulted in a similar level of knee function after 3 years. 5
·
A kneecap graft entails more rehabilitation considerations than a hamstring graft,
such as increased pain and swelling that may limit exercises for the thigh muscles.
References
Citations
1. Fu FH, et al. (2000). Current trends in
anterior cruciate ligament reconstruction. American Journal of Sports Medicine, 28(1): 123–130.
2. Noyes
FJ, Barber-Westin SD (2001). Revision anterior cruciate ligament reconstruction: Report of 11-year experience and results
in 114 consecutive patients. AAOS Instructional Course Lectures, 50: 451–461.
3. Barber-Westin SD, et al. (1997). A rigorous
comparison between the sexes of results and complications after anterior cruciate ligament reconstruction. American Journal
of Sports Medicine, 25(4): 514-526.
4.
D'Amato MJ, Rach BR Jr (2003). Anterior cruciate ligament reconstruction in
the adult section of Anterior cruciate ligament injuries. In JC DeLee, D Drez Jr, eds., Orthopaedic Sports Medicine,
2nd ed., vol. 2, pp. 2012–2067. Philadelphia: Saunders.
5. Feller JA, Webster KE (2003). A randomized
comparison of patellar tendon and hamstring tendon anterior cruciate ligament reconstruction. American Journal of Sports
Medicine, 31(4): 564–573.
