ACL reconstruction

ACL stands for Anterior cruciate ligament and ACL Reconstruction refers to a type of surgery to replace the important ligament i.e. the anterior cruciate ligament (ACL) in the patient's knee. ACL injuries are the ones, which usually occur while playing sports especially the sports including quick direction changes, jumps, fast running and sudden stops e.g. volleyball, soccer, basketball, hockey, skiing, and football. ACL injuries happen when the ACL gets stretched and is resultantly teared off. ACL is an essential part of the knee as it helps in binding and keeping the knee stable. It is present between the tibia and the femur bones and prevents the slipping of the tibia. Its main function is to provide complete strength to the knee when the knee moves from one side to the other side. Damaging the ACL may result in discomfort or difficulty in playing sports, walking, jumping or running. Injury of ACL may take a lot of time to heal and requires continuous doctor consultations and physiotherapy. If the ACL damage is severe, the doctor will advise getting the ACL replaced through a surgical process especially in athletes and young people.


Why it’s done? What are the risks? How to prepare for the procedure? Expected results from the procedure FAQ Section

Ligaments are considered to be strong tissue bands, which help in connecting one bone to the other. The main function of the ACL is to provide stability and strength to the knee when it moves from one side to the other side. The ACL Reconstruction surgery is performed in order to repair a torn ACL and reattain the movement and the lost stability. The doctor advises this reconstruction surgery only for athletes, young people or to the ones who have severe and intolerable pain. Few reasons or the cases wherein an ACL reconstruction surgery is recommended or performed are as mentioned

  • Uncontrollable knee pain
  • Unstable knee felt while performing routine activities.
  • Injury of other neighboring cartilage and ligaments
  • Unable to go back to routine activities or playing sports (in especially athletes).
  • Tearing of meniscus
  • Severe pain even while walking and climbing stairs

An ACL reconstruction is a surgical procedure, which involves replacement of the anterior cruciate ligament present in the knee. The procedure involves certain risks and limitations as mentioned below.

  • Bleeding from the site of surgery
  • Blood clots
  • Infection at the surgical site
  • Persistent knee pain, weakness or stiffness even after the ACL reconstruction surgery.
  • Unable to move or discomfort in moving the knee
  • Failure in attaining symptom relief
  • Lack of proper healing of the graft
  • An ACL tear in children increase the chances of getting growth plate injuries. These plates are placed at the end of the bones in the legs and the arms. These growth plates assist in bone growth. Sometimes, these growth plates result in injuries and lead to shortening of bones.

However, apart from the above-mentioned risks, the AAOS (American Association of Orthopedic Surgeons) reports that approximately 82% to 90% of the ACL reconstruction surgeries have provided complete stability of the knee and have resulted in stupendous results and increased patient satisfaction.

Some patients may have problems with the anesthesia given before the surgery. The anesthesia might cause shortness of breath, nausea, vomiting or allergic reactions in some patients.

 

At least two weeks before the surgery:

  • The patient is advised to inform the doctor about any medications or supplements he/she is taking specifically for flu, cold, herpes, fever or any other problems or illnesses, before the surgery. The doctor will assess the medication and would advise accordingly whether to continue the medicines or stop for some time.
  • Quit smoking as it delays the healing process of bone and any wounds in the body. If the patient is not able to quit smoking, he/she is advised to inform the doctor as the doctor might prescribe some nicotine tablets, which would help the patient in quitting smoking for some time.
  • Avoid alcohol, or do not take more than 1 to 2 drinks a day.
  • Avoid taking blood-thinning drugs e.g. ibuprofen, aspirin, naproxen, etc. as these drugs do not allow quick healing.
  • The patients need to inform the surgeon about any prevailing condition such as diabetes, heart disorders or any other medical problems. Prior information would enable the surgeon to talk to the concerned doctor in case of any emergencies during or after the surgery.
  • The patients are advised to start taking physiotherapy treatments many weeks before the surgery, as it may help in reducing any swellings or pain to some extent before the surgery. If the patient goes for the surgery with inflammation in the knees, then there may be chances of delayed healing and improper movement of the knee.

The day of surgery:

  • The patient is asked not to eat or drink anything at least 6 to 12 hours before the surgery.
  • If any medications are prescribed before the surgery, the patient is advised to take the same with a small sip of water.

 

During the surgery:

  • The patient is given general anesthesia by the anesthesiologist to make the patient unconscious during the procedure.
  • ACL reconstruction surgery is done by making 2 small incisions in the skin of the patient, around the concerned area (knee). Through one incision, the arthroscope (a small tube-shaped video camera) is placed inside the patient with one end held outside the body and through the other incision the surgical instruments are placed to reach the area to be treated.
  • The surgeon cuts and removes the impaired or damaged ligament and then replaces it with the good tendon piece from either the other leg of the patient or from a deceased donor.
  • The procedure is performed by drilling some holes or tunnels into the femur (thighbone) and the tibia (shinbone) bone in order to place the graft properly and firmly with the help of fixation devices or screws.

 

After the procedure:

  • The ACL reconstruction surgery is a long procedure and usually takes place in the outpatient department.
  • The patient is allowed to go home after the procedure. However, it is better to call a companion along with, to drive the patient home after the surgery.
  • Sometimes, after the surgery, the surgeon will advise the patient to wear a knee brace or crutches (splints) for at least 1 to 4 weeks.
  • Some people are allowed to and are able to move the knee easily, immediately after the surgery. This helps in preventing any kind of knee stiffness.
  • Patients are also advised pain relief medications after the surgery.
  • Patients are advised to start physiotherapy after the recovery of the patient from surgery. Physiotherapy helps the patient to regain the strength and flexibility back again to be able to perform normal activities e.g. walking or even running.
  • Patients are advised not to play sports that involve quick direction changes, jumps, fast running and sudden stops e.g. volleyball, soccer, basketball, hockey, skiing, and football, for at least 9 to 12 months after the surgery.
  • In order to get rid of the post-surgery pain, the patient can follow the I.C.E model which includes the following points:
    • Rest – Avoid too much movement and always use knee brace or crutches (splints) for at least 1 to 4 weeks.
    • Ice – Whenever possible apply ice on the affected knee at least for 20 minutes on a daily basis.
    • Compression – It is important to compress the affected area by either applying compression wrap or elastic bandage around the knee.
    • Elevation – It is important to always keep the affected knee elevated with the pillows while sitting or lying down.

Successful ACL reconstruction surgery along with continuous and regular physiotherapy improves the strength and flexibility of the patient very soon. Patients with successful surgery will have:

  • Stable knee very soon after the surgery
  • Early recovery
  • Less complications
  • Less amount of pain
  • Less stiffness
  • Able to perform daily activities very early

Q1. Are there any scenarios where ACL reconstruction surgery can be avoided?

A1. The anterior cruciate ligament does not heal itself in case of an injury. However, in some cases the doctor might suggest avoiding the ACL reconstruction surgery. These scenarios are as mentioned below

  • Patients who are very old with usually weak bones or less active in nature
  • Severe cases of arthritis, which are better treated by rehabilitation program as compared to ACL reconstruction surgery.

 

Q2. Are there different types of ACL reconstruction surgery, if yes then which is the best option?

A2. There are various types of ACL reconstruction surgeries available as mentioned below.

The tendon graft surgery involves the removal of the damaged part or tendon and replacement with a tendon from some other place like from patient’s own healthy tendon. Healthy tendon can be taken from multiple places like hamstring graft wherein the tendon is taken from the patient's hamstring, Bone-patellar tendon-bone graft wherein the tendon is taken from patellar tendon, Quadriceps graft wherein the tendon is removed from the quadriceps muscle and tendon may also be taken from tissue bank (allograft graft). Also, a combination of tendons may be used depending upon the severity or need.

 

Different types of tendon removal surgeries have their own benefits and risks. Usually, the best type of surgeries are the one wherein all the things are taken care of i.e. the type of graft used, specifications of the injured part, methods to secure a graft and proper rehabilitation procedure followed.

 

Q3. How much time does it take to recover after the ACL surgery?

A3. The time period of recovery varies from person to person. In some patients, the recovery might take a few months but in some patients the recovery might be slower and they may take up to an year to recover. The most important factor to be considered post-surgery and to have an early recovery is to follow the rehabilitation program properly. The rehabilitation program aims at regaining the range of motion first and then strengthening the muscles and bones. For the patients who are athletes, the rehabilitation program covers sports-exercises also at the end.

 

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