ACL Reconstruction Surgery

Overview

Arthroscopic ACL repair is performed to rebuild a torn anterior cruciate ligament (ACL) using a device called an arthroscope. This technique makes use of smaller incisions when compared to a traditional surgery. The torn ligament is normally replaced with a graft taken from the patient's own body or derived from a donor. This surgery is done to stabilize and restore the knee joint function, decrease pain, and prevent further harm. Other than smaller incisions, this technique offers certain other advantages such as reduced postoperative pain, faster recovery, and better cosmetic results. Read on to know more. 

What is an ACL Reconstruction?

ACL (Anterior Cruciate Ligament) reconstruction is a surgical procedure that is performed to repair a torn ACL in the knee. Here, the torn ligament is replaced with a graft that can be obtained from the patient’s tissues (autograft) or a donor (allograft). During the surgery, small incisions are made over the knee and an arthroscope, and other small surgical instruments are inserted through them to repair the ligament. The goal of ACL reconstruction surgery is to restore the stability in the knee and improve function. 

Why is an ACL Reconstruction Done?

Generally, an ACL reconstruction is recommended for individuals who have an ACL injury. Here are some conditions where an ACL repair is recommended:

• Restoring knee stability: ACL tears lead to a sense of instability of the knee joint, and you are at risk of it giving way or buckling during normal activities or sports. An ACL reconstruction helps restore knee stability.
• Preventing possible further long-term damage: An untreated ACL tear may result in further damage to your knee such as meniscal tears or cartilage injuries. Such complications can be prevented through an ACL reconstruction.
• Return to normal activity: You can return to normal day-to-day activities, including your desired sport or exercise routine with less chance of the knee giving way or re-injuring. 
• Preventing long-term complications: Not treating ACL tears early may lead to a chronically unstable knee (the knee gives way regularly), decreased function of the knee, or early onset of osteoarthritis (wear and tear). 
• Improve quality of life: This procedure will restore normal knee function and thereby improve your quality of life.

In conclusion, an ACL reconstruction is recommended to help individuals get back to their normal activities and enjoy life as before the injury.

Different Types of ACL Reconstruction

Here's a breakdown of some common types of ACL reconstruction and the differences between them:

It's critical to note that the choice of ACL reconstruction surgery completely depends on various factors like patient preference, surgeon experience, activity level, and related injuries. Patients should discuss the benefits and risks of each option with their orthopedic surgeon to ensure an informed decision.

Who Qualifies For an ACL Reconstruction or What Conditions Are Treated by ACL Surgery?

Individuals who are qualified for ACL reconstruction surgery generally should meet the following criteria:

• Diagnosis of a torn anterior cruciate ligament (ACL): Determination of an ACL tear may begin with a physical examination, along with an MRI, arthroscopy, or other imaging studies.
• Evident symptoms: Recognizable indicators of an ACL tear might include an unstable knee, an episode of giving out or buckling, swelling, pain, and difficulty walking.
• Desire to continue or return to physical activities: People who might choose an ACL reconstruction may be athletically active individuals who wish to continue or return to activities (often physically demanding) that require a stable knee.
• Healthy knees and overall health: Individuals undergoing the procedure should generally be in good health and free from conditions that might increase the risks associated with surgery and anesthesia.
• Realistic expectations: Understanding the goals, risks, and rehabilitation process associated with ACL reconstruction including a long rehab process.

Understanding the Anatomy of a Torn ACL

The Anterior cruciate ligament (ACL), is one of four major ligaments in the knee, that will provide stability, help prevent the tibia from moving anteriorly on the femoral of the posterior aspect, and provide a sense of stability in the knee. When the person has a tear in the ACL, it prohibits the normal function of the knee joint, causing the individual to have an unstable knee and other symptoms.

The anatomy of an ACL involves the following structure:
ACL: It runs diagonally in the center of the knee and plays a major role in knee function. The ACL stabilizes your knees by preventing the tibia from moving any further. It connects the femur (thigh bone) to the tibia (shin bone). 

• Femur: The ACL originates from the lateral wall of the intercondylar notch between the medial and lateral femoral condyles.
• Tibia: The ACL attaches to the anterior aspect (front) of the tibial plateau, near the medial eminence of the tibia.

The ACL runs diagonally from its femoral attachment to its tibial attachment, crossing over the PCL (Posterior Cruciate Ligament) to form an "X" shape within the knee joint. It is essential to understand the anatomy of an ACL tear to determine a course of therapy and facilitate recovery. The degree of ACL injury and related damage to the surrounding tissue is typically assessed using MRI imaging or physical examination.
 

How is ACL Reconstruction Done?

Here are the general steps of the procedure:

• Anesthesia: The procedure will be done under general anesthesia. This means you will be asleep during the entire procedure.
• Graft Harvesting: The surgeon decides which graft is most appropriate for you. Grafts can come from different parts of your body or a donor (allograft). Choices for grafts include the patellar tendon, hamstring tendons, or quadriceps tendon.
• Arthroscopic Approach: The arthroscopic approach uses a few small incisions around the knee, in which the surgeon places an arthroscope (a thin, flexible tube with a camera) and tiny specialized instruments to view the inside of the knee joint.
• Removal of the ACL: Arthroscopic instruments are then used to carefully remove any remaining fragments of the torn ACL from the joint.
• Graft Placement: The graft is prepared and placed within the knee joint where it will serve as the new, replacement ACL. The graft is then secured into place. Typically the graft is secured via screws, buttons, or other fixation devices.
• Wound Closure: The incisions are closed with sutures or surgical staples and sterile dressings are applied to the surgical sites.
• Post-surgery Care: Patients are kept in the recovery area following surgery before being discharged home or to a hospital room. Pain control, swelling management, dressing care, and postoperative rehabilitation protocols begin with the goals of optimizing the return of function and returning the operative knee to its best possible condition.

When everything is considered, ACL reconstruction is a complex arthroscopic surgical procedure that is used to stabilize and function the knee after an ACL injury.

What Happens After an ACL Reconstruction?

Following an ACL reconstruction surgery, the healing process typically consists of many phases such as

• Recovery room: Patients are taken to the Post Anesthesia Care Unit also called the PACU where they are monitored for several hrs to watch for any complications. Patients are not taken to their room until they are stable with vital signs and the anesthesia has worn off.
• Pain management: Pain medications are given as needed to alleviate the post-op discomfort.
• Discharge: The patient is sent home or taken to their room when they are stable. The patient is sent home with instructions on post-op care and rehabilitation.
• Rest and ice: Applying ice to your knee for 10 minutes out of each hour before and after you exercise helps to decrease swelling and relieve pain.
• Physical therapy: Physical therapy begins soon after surgery to help regain the range of motion and strengthen your knee.
• Gradual return to activity: Based on the progress, the patient can start exercises and return to sports and other activities with the help of a physical therapist and surgeon.
• Follow-up visits: You have regular visits with your surgeon to check your recovery, reassess your home program, and make adjustments as needed.

Recovery and Outlook

Following ACL (anterior cruciate ligament) reconstruction surgery, there is quite a bit of variability regarding the recovery and outlook. Factors include the individual’s age, general health, preoperative condition, the extent of the injury, surgical technique, adherence to rehabilitation, and postoperative care. With that in mind, the following is a general timeline of what to expect:

• Initial swelling and discomfort: swelling and discomfort, which can be controlled with medication and rest.
• Gradual realization: Progressive rehabilitation with a physical therapist to improve the range of motion, strength, and stability of the knee.
• Gradual return to normal activities: Full recovery to previous activity level or sport usually occurs within 6 to 9 months.
• Importance of adherence: It is extremely important that you adhere to the rehabilitation program and closely follow your physical therapist’s instructions to achieve optimal results and prevent complications.
• Long-term outcomes: With successful rehabilitation and compliance with postoperative protocols, many patients return to their previous level of fitness/sports and have very good outcomes including good knee function, minimizing the risk to the knee, and continued activities/sports.

Risks / Benefits

Benefits 

• Restored knee stability: Surgery helps restore stability to your knee joint. Your knee may stop giving way when you move. You may be more likely to move better during your everyday activities. 
• Pain relief: You may have less pain and discomfort in your knee after surgery. You may be more comfortable while engaging in your everyday activities.
• Return to activity: ACL reconstruction allows you to return to sports physical activities, and work that requires knee stability and knee function. 
• Prevention of further damage: Surgery may prevent additional knee joint damage such as meniscal tears or cartilage injuries. Your knee may move more normally. 
• Improved quality of life: ACL reconstruction can improve your quality of life. You may have better knee function, less pain, and more confidence in your ability to engage in desired activities.

Risks

• Infection: Although the risk is low, there is a possibility of infection occurring at the surgical site. Steps will be taken to prevent this from happening and there will be a follow-up to ensure healing nicely.
• Blood clots: Small blood clots (deep vein thrombosis or pulmonary embolism) can form, especially in patients with limited mobility.
• Graft failure: In some cases, the new grafts used to reconstruct your ACL may fail to fully integrate or tear, requiring further surgery.
• Stiffness: Some patients find after their surgery that their knee joint can become stiff which can limit their knee movement and knee function.
• Nerve or blood vessel damage: The main blood vessels and nerves around the knee are very rarely damaged during surgery. If they are damaged, tell your orthopedic specialist straight away. Damage to the nerves or blood vessels around your knee can cause numbness, tingling, or circulation problems