ACL Reconstruction Surgery

Arthroscopic ACL repair surgery is a procedure to repair a torn ACL (anterior cruciate ligament) using a special device called an "arthroscope". The ACL is one of the key ligaments of the knee that connects the femur (thighbone) to the tibia (shinbone). It provides rotational stability to the knee by preventing the tibia from sliding out in the front. The ligament is prone to damage when it stretches or tears, as seen during high-impact sports like soccer or football. Arthroscopic ACL repair surgery is indicated when the ligament has avulsed (broken off from the bone) but is still intact. During the procedure, the ligament is reattached to the bone and held in place so that it can heal.

An arthroscopic ACL repair surgery is a minimally invasive (less traumatic) procedure performed to stitch and reattach the torn parts of the anterior cruciate ligament. It utilizes a special medical device known as an arthroscope, a hollow tube consisting of a camera and a light source. The procedure involves the insertion of the arthroscope through multiple keyhole-sized incisions (cuts), guiding the surgeon to gain access to the surgical site. This is possible through images captured by the camera projected on a large screen. Later on, tiny sutures attached to surgical tools are inserted through other keyhole-sized incisions to stitch the torn ACL together. The stitched ligament will gradually heal over a while. 

An anterior cruciate ligament (ACL) tear or sprain is one of the most common knee injuries. Athletes participating in high-impact sports like football, soccer, etc., are more likely to injure their ACLs. The severity of the injury can be classified into the following grades:

• Grade 1: There is mild ligament damage that is slightly stretched without any knee instability. 
• Grade 2: The ligament stretches to a point where it becomes loose. This is referred to as a partial ACL tear.
• Grade 3: This ACL injury grade is a complete tear, where the ligament has been torn and pulled directly off the bone (avulsed).

Arthroscopic ACL repair surgery is recommended:

• For Grade 2 ACL injury.
• In older patients who are excluded from an ACL reconstruction (a procedure involved in treating a complete ACL tear by placing a graft between the torn ligament).
• In active patients where surgical reconstruction of the ACL is not possible.
• When you need to preserve the healthy structures surrounding the ACL.
• When non-operative treatments like knee bracing cannot treat a partial (Grade 2) torn ACL. 

Preparation before any surgical procedure is important to minimize stress and anxiety. It prepares your body for a successful surgical outcome with fewer post-op complications.

• If you notice symptoms of knee injury like severe pain, swelling, and joint instability, you must consult an orthopedic (a doctor specializing in diagnosing and treating disease related to the bones, cartilage, or ligaments) surgeon.
• You must inform your surgeon about:
  • Presence of any pre-existing medical condition like diabetes (increased blood sugar levels), hypertension (high blood pressure), etc. 
  • Current medications that you are taking, such as blood thinners, NSAIDs (non-steroidal anti-inflammatory drugs), or other herbal supplements. 
  • History of any previous injury, surgery, or radiation therapy.
• Your surgeon will examine your injured knee for swelling, tenderness, and range of motion.
• Your surgeon will order a few diagnostic tests to evaluate the extent of ACL injury. These include:
  • X-ray of your knee: To check the presence and extent of ACL tear.
  • MRI (Magnetic Resonance Imaging) scan: To rule out other bony pathologies.

Your doctor will determine the type of ACL surgery (repair or reconstruction) required according to the severity of the ligament tear. 

• You must undergo a few general tests to check if you are fit for the surgery. These include:
  • Blood tests evaluate the levels of the blood components like red blood cells, etc., and the presence of any infection.
  • Chest X-ray rule out pathologies of the lungs.
  • ECG (Electrocardiogram) checks the general condition of your heart.
• You must stop your medications (blood thinner, etc.) at least 2 weeks before the procedure.
• You should not smoke or consume alcohol for 2 to 3 weeks before the surgery.
• You should fast 8 to 12 hours before the procedure since it is performed under general anesthesia.
• Arrange for someone to drive you back home after the procedure.

Additionally, you must ensure your home is accident-proof for a safe and optimal recovery. 

• You must arrange a room on the same floor as your living area to avoid climbing stairs.
• Adjust your bed height to get in and out comfortably.
• Fix rails or support bars near your toilet and shower area.
• Adjust your toilet seat to a comfortable height to prevent any strain on the operated knee.
• Use sturdy chairs with a footrest to elevate the leg to control post-op swelling.

Arthroscopic ACL repair surgery is a daycare procedure that does not require hospitalization. 

Preparation 

You must ensure to be on time for your surgery. Your nurse in charge will begin the pre-surgical preparation before you are taken to the operating theatre. Your vitals (blood pressure, pulse, oxygen level, and sugar levels) will be checked through the monitors connected to your body. An IV line will be introduced to administer anesthesia and other fluids during the procedure.

The surgical site will be disinfected using an antiseptic solution to help reduce the surface contaminants. The anesthesiologist will administer general anesthesia (a numbing agent that puts you to sleep) through IV infusion. 

• Your orthopedic surgeon will repair the ligament under all the necessary sterilized protocols. 
• Multiple, keyhole-sized (2 to 3mm) incisions or cuts will be made on your knee near the ACL tear by your surgeon with a surgical knife (scalpel). 
• An arthroscope will be introduced into one of the cuts to gain access to the surgical site through images captured by the camera. 
• Under the image guidance of the arthroscope, your surgeon will introduce special surgical tools with sutures attached to them through other keyhole-sized cuts. 
• The surgeon will stitch the torn pieces of the ACL carefully and secure the ligament to its original position. 
• The surface incisions will be closed through sutures (stitches) that will be removed 5 to 7 days after the surgical repair. 
• Your surgeon will cover the sutures with a surgical dressing and place a knee brace for support and protection.

The arthroscopic ACL repair surgery takes 60 to 90 minutes, depending on the ligament tear.

You will be observed in PACU (Post-anesthesia care unit) for 1 to 2 hours until you are under anesthesia.

2 to 3 hours post-surgery

• Once you regain consciousness, your surgeon will check your operated knee and prescribe painkillers and antibiotics to manage pain, swelling, and infection.
• You will be allowed to take sips of water and later progress to a liquid or semi-solid diet (juices, soups, mashed fruits, vegetables, etc.)

4 to 5 hours post-surgery

• A physical therapist will encourage you to walk and instruct you about rehabilitation exercises to be performed at home for quick recovery.
• Once your vitals are stabilized and you can walk without support, you will be sent home.

At home

• You must rest on the day and the following day of your surgery.
• There are no bathing restrictions however, avoid swimming, saunas, and tub baths for at least 4 weeks. 
• Swelling can be controlled through ice packs, massage, or electric stimulation with the help of physical therapy. 
• Being active is crucial during your recovery period to avoid the formation of blood clots. You will be advised to use crutches that support you while walking.
• Avoid lifting heavy objects and strenuous exercises for 3 to 4 weeks, as this can put an unwanted load on your operated knee. Light activities and exercises can begin 3 weeks post-surgery.
• 4 weeks post-surgery, your surgeon will remove your protective knee brace during your follow-up visit.
• You can resume driving and other activities once the knee brace is removed.
• Complete recovery may take around 3 to 4 weeks, depending on the severity of the ligament tear.

Arthroscopic ACL repair surgery is a minimally invasive procedure with the following benefits and risks.

Benefits Of Arthroscopic ACL Repair

• The procedure does not involve extensive incisions and bone drilling; hence there is minimal bleeding and scarring.
• There is no requirement for graft placement.
• Effectively aids in preventing or slowing down the development of arthritis (joint inflammation).
• Significantly restores or improves your knee stability.
• Ensures faster recovery with optimal healing so you can resume your routine activities as quickly as possible.

Risks Of Arthroscopic ACL Repair

• Risk of bacterial infections due to improper sterilization techniques.
• Temporary or permanent numbness around the surgical site due to injury to the nearby nerves.
• Blood clot formation can cause life-threatening complications such as pulmonary embolism when the clot dislodges into the bloodstream and travels to the lungs.
• Loss of motion or knee stiffness due to poor surgical technique.
• Allergic reactions to anesthesia may cause skin rash, hives, itching, swelling around your eyes or lips, nausea, vomiting, dizziness, and breathing difficulties. 

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