A
Guide to Anterior Cruciate Ligament Reconstruction
At
Booth Bartolozzi Balderston Orthopaedics, we are genuinely
concerned that our patients have a full understanding
of their injury, treatment options, and the rehabilitation
required for a full, speedy recovery. The following
information is meant to complement the information you
receive during your doctor’s visit. Our goal is to help
you make a fully informed decision about your knee.
As former medical providers
for the Eagles, Flyers and Phantoms, and currently
serving as providers for the Philadelphia KIXX professional
indoor soccer club and Rowan and West Chester Universities,
we have been entrusted with the medical care of many
of Philadelphia’s professional and collegiate athletes.
Our treatment philosophy for you is
the same as it is for the professional and collegiate
athletes under our care: we pledge to deliver the highest
quality care using state-of-the-art
diagnostic and treatment techniques.
What is the Anterior
Cruciate Ligament (ACL)?
The anterior cruciate ligament
(ACL) is one of the main stabilizing ligaments in the
knee. Running through the knee from the front of the
tibia (shin bone) to the back of the femur (thigh bone)
it assists proper movement of the joint and prevents
abnormal slippage of the bones. Abnormal slippage can
create an unstable knee that "gives way" during
activity.
How is the ACL injured?
While the ligament can be injured with a direct blow
to the knee, it is more common to tear the ligament
when pivoting or twisting on a planted foot or by hyper-extending
the knee.
How do I know my ACL
is torn?
Usually, a tear to the
ACL results in sudden pain, "giving way" of
the knee, or a combination of both. Many patients report
hearing a "pop" when they injure their knee.
The knee usually swells within 1-3 hours of the injury.
A doctor can examine the knee and is usually able to
identify any ligaments that are injured. The knee will
feel loose and/or you will have pain during the examination.
If there is a lot of swelling, the doctor may want to
drain the fluid from your knee. If the fluid is red
(meaning there is blood in the joint) you most likely
tore your ACL.
Do I need x-rays, MRI’s
or any other tests?
A set of x-rays is usually
ordered to make sure that there are no broken bones
in the knee. MRI’s can be helpful, but are not always
needed. As stated above, usually the doctor will know
what is wrong just from examining you. MRI’s are useful
if there is any doubt whether your ACL is injured or
to check for additional damage in the knee.
Is there usually other
damage to the knee when the ACL is torn?
Other ligaments in the
knee can be injured at the same time as the ACL is injured.
These injuries may need to be repaired, but in many
cases heal adequately without surgery.
The most common injury
that occurs with the ACL tear is a meniscus tear. Some
meniscus tears can be repaired but most must be trimmed
to make the torn edges smooth. Occasionally a badly
torn meniscus has to be removed. If the meniscus can
be repaired, it is usually done at the time of the ACL
surgery. One of the risks of repairing the meniscus
is that it will not heal. The implications of this condition
should be discussed with your surgeon.
Another common injury that
can occur with an ACL tear is damage to the cartilage
on the joint surface. Damage to these surfaces is very
serious and in some cases is the worst part of the injury.
It may require more complex surgery to repair.
Don’t I need my meniscus?
It is always best to have
your own normal meniscus. However, when a meniscus is
torn beyond repair it is best to remove the torn part.
Leaving a torn, unstable meniscus in the knee can result
in further damage to the joint surfaces.
Does a torn ACL have
to be fixed with surgery?
The ACL cannot heal on
its own, but not all tears of the ACL need to be fixed.
This depends largely on your activity level. People
participating in activities where they plant their feet
and twist or "cut" are susceptible to having
an unstable knee and may be better off with surgery.
People with strenuous jobs may also need surgery. People
who are unwilling or unable to modify their activities
and desire an unrestricted lifestyle are encouraged
to consider the surgery to have the best chance of returning
to their previous lifestyle.
On the other hand, people
who lead a more sedentary lifestyle may be able to get
by with exercise and a brace. However, even someone
with a sedentary lifestyle may experience "giving
way" with simple activities such as going down
stairs or stepping off a curb. In these cases surgery
is needed to restore normal, every-day activities and
to prevent further damage to the knee.
If I don’t have my ACL
fixed am I likely to hurt my knee again or get arthritis?
Even if the knee joint
does not become unstable (give way) it will still be
loose after an ACL injury. This looseness will make
you more prone to tearing your meniscus in the future.
While there is no direct evidence showing that people
who tear their ACL develop arthritis, the ACL injury
may contribute to the early onset of arthritis in your
knee.
How is the ACL fixed?
The ACL is reconstructed
with arthroscopic techniques. The arthroscope is a fiber
optic instrument (narrower than a pen) which is put
into the joint through a small incision. A camera is
attached to the arthroscope and the image is viewed
on a TV monitor. The arthroscope allows the surgeon
to fully evaluate the entire knee joint. Small instruments
ranging from 3-5 millimeters in diameter are inserted
through additional incisions so that the surgeon can
feel the various joint structures, diagnose the injury,
and then repair, reconstruct or remove the damaged structures.
In ACL reconstruction a
replacement graft is precisely positioned in the joint
at the site of the former ACL and then fixed to the
thigh and lower leg bones with screws. There are currently
several options for replacement grafts. Choices for
the type of replacement graft include autograft (using
your own tissue), allograft (donor tissue) and synthetic
(artificial) grafts.
Autografts can come
from your patellar tendon, quadriceps tendon or the
hamstring tendons. The graft choice to be used is determined
by you and your surgeon. All of these graft options
offer a strong graft, secure fixation and excellent
long-term results. The results show that people are
able to return to their activities with few complications.
Since the graft comes from your own body there is no
chance of infectious disease transmission or rejection
of the tissue.
Allografts are donor
tissues taken from tissue banks. They also are strong
grafts with excellent long-term results. Because the
surgeon is not taking the tissue from your body, the
surgical time and operative pain are less. This allows
for easier rehabilitation in the early post-operative
stages. Although there is a risk of infectious disease,
donor tissue is received only from reliable tissue banks.
The tissue is rigorously screened and treated to prevent
the spread of infectious disease. The risk of contracting
infectious disease from an allograft is very small.
Although rejection of the graft is possible, the risk
of this is extremely low because the tissue is not living
material.
Synthetic grafts
are available for use in certain situations, but most
are experimental and do not work as well as allografts
and autografts.
Regardless of the graft
material chosen, the most important aspect of surgery
is that the ligament graft is placed and secured precisely.
Accurate graft placement is essential for a good result
and secure graft placement permits early, more aggressive
rehabilitation after surgery.
What are some of the
possible complications?
While complications are
not common, all surgery has associated risks. Possible
complications include excessive stiffness after the
surgery or pain in the knee or under the kneecap. Your
rehabilitation after surgery is specifically designed
to address these issues. Other complications can arise
from infection of the wounds, phlebitis, bleeding into
the knee, and nerve injury.
What do I need to do
to prepare for surgery?
Our staff will work with
you to set up the surgery through your insurance company
and will instruct you in matters that you will need
to take care of concerning your insurance paperwork.
Prior to surgery you may
be asked to perform some exercises at home or with a
physical therapist to prepare for surgery. These exercises
prepare the knee by decreasing the swelling, increasing
the motion and maximizing the strength of you leg. In
general, the better your leg is going into the surgery,
the better it will do after the surgery.
Two weeks before surgery,
you will need several medical tests, which are done
on an outpatient basis. Most patients need blood tests
and urinalysis. If you are over 40, you may require
a chest x-ray and EKG. Some patients may need to see
an internist or their family doctor to receive clearance
for the procedure. Again, our staff will work closely
with you in arranging these tests.
Note: You may not eat
or drink anything after midnight the night before your
surgery. If you must take medicine then you will be
permitted to do so with just a sip of water.
What type of anesthesia
is used?
Local, spinal, epidural,
or general anesthesia can be used. Except for when general
anesthesia is used, the patient can stay awake and watch
the procedure on the TV monitor. An anesthesiologist
is always present if there is a need for further sedation
or pain control. Prior to surgery, an anesthesiologist
will discuss with you the various options and answer
your questions.
Because our surgeons are
extremely experienced, the operation can be performed
rather quickly. The shorter surgical time decreases
the amount of anesthesia and limits side effects from
the anesthesia.
How long will I be in
the hospital?
Most people are able to
have surgery and go home the same day, while others
need to stay overnight. Usually one night in the hospital
is the most that is needed. How long you stay will depend
on several factors including your age, health status,
other damage in the knee, and the side effects of anesthesia.
What happens the day
of surgery?
The day before surgery
you will be told what time to report to the hospital
the next day. It is very important to arrive on time.
You will be admitted to the hospital and taken to a
pre-operative area where you will be prepared for your
surgery and then taken to the operating room.
After the operation, you
will be taken to the recovery room to be monitored.
Here the staff will check that the effects of the anesthesia
are wearing off properly and they will provide you with
medication for any pain you are having. If you are going
home the same day, you will be given specific instructions
to follow at home and then discharged after you have
adequately recovered. If you are staying overnight,
you will be taken to your room when you are ready.
How should I care for
my knee after surgery?
Prior to your discharge
from the hospital you will be given specific instructions
on how to care for your knee. It is important to follow
these instructions. In general, you can expect the following.
Diet: Resume your
regular diet as soon as possible.
Medication: You
will be given a prescription for pain medication. Follow
the directions from your pharmacy.
Bandage: You will
have a thick dressing on the knee. Keep it on until
you are instructed to take if off.
Bathing: You may
shower after your dressings are removed. This is usually
two or three days after the surgery.
Brace: In most cases,
you will have a brace on your knee. In some cases you
will have a plaster splint (not a cast) on your leg.
You should leave it on unless you are instructed to
take if off by our staff. When walking, the brace should
be locked in a straight position. You can unlock it
(so it will bend) as needed for exercise.
Walking: You will
have crutches for walking. You may put weight on your
foot as tolerated as soon as possible after the surgery,
unless instructed otherwise. You MUST have the brace
on and locked straight when walking. Most people are
able to get rid of their crutches in 1-2 weeks.
Ice: You may receive
an ice machine that continually surrounds your knee
with cold water or you may apply ice over the dressings
for 20-30 minutes as needed. DO NOT put heat on your
knee.
Continuous Passive Motion
(CPM): You may have a CPM machine delivered to your
home that slowly moves your knee back and forth. You
will be instructed in its use. The CPM machine is not
used in all cases.
Continuous Pain Control:
In most cases, a continuous inflow of pain medication
can be administered via a catheter placed either in
the knee or in the nerve at the upper thigh. This is
usually used for two or three days.
Follow-Up Office Visit:
You will be instructed to follow-up at our office
during the first week after your surgery. At this time
you will see the nurse practitioner, physician assistant,
or the physician for your initial post-operative care.
You will be instructed on making further follow-up appointments
at this time.
Exercise: You may
be taught some exercises to do initially after surgery.
After 1-2 weeks most people are given a prescription
for formal rehabilitation to do with a physical therapist.
Return to work or school:
Most people are able to return to their jobs or school
within 3-5 days. The exception to this is for people
who have strenuous jobs that require them to be on their
feet a lot, lifting objects, climbing or driving.
What will rehabilitation
involve?
Your rehabilitation will
be based on guidelines we have developed. In general
we use an accelerated protocol which is based on several
goals: 1) early motion, 2) early weight bearing, and,
3) regaining control of the leg muscles as soon as possible.
Note that an accelerated program DOES NOT mean how soon
you may return to activities. You will start out with
very specific exercises and will be permitted to do
more as you recover.
How soon can I go back
to sports?
There is no simple answer
to this question. In general, you will be allowed to
return to sports when your knee function has fully recovered.
You must have good motion, strength and control of your
leg. How quickly you return depends on several factors
including: 1) your own rate of healing, 2) if you have
any complications after surgery, 3) how well you follow
our instructions, 4) how hard you work at your rehabilitation,
and, 5) at what level of activity you are going to return.
This whole process can take anywhere from 4-9 months,
but is truly different for everyone.
Will I have to wear
a brace while working or playing sports?
This will vary from patient
to patient. Using a brace is based on the surgeon’s
preference and the activity level of the patient. While
using a brace after surgery has never been proven to
prevent re-injury, some doctors feel it may help protect
the graft in the first year after surgery. After one
year, a brace can be used if the patient wishes to continue
using it.
Successful surgical
outcome
Overall, advances in diagnostic
capabilities, surgical techniques, and rehabilitation
have made ACL reconstruction a highly successful surgical
treatment of what used to be known as a "career
ending" injury.
Our commitment to our
patients
We
are committed to you the, patient. We understand that
you may be anxious about your injury and the need for
surgery. We have put in place a comprehensive program
using a team approach so that you have the greatest
chance of a full, speedy return to your activities.
You have the additional benefit of knowing that we will
treat you and your injury as we treat the injuries of
the professional athletes under our care. If you have
any questions regarding your treatment, please feel
free to contact our staff by calling 215-829-2222.
