Anterior Cruciate Ligament (ACL) Reconstruction

ACL injuries are common among people who play sports. The ACL (anterior cruciate ligament) is a band of tissue within the knee. It gets damaged when it stretches or tears. This can happen if you turn sharply or move suddenly while you’re running or jumping.

If you strain or slightly tear your ACL, it may heal over time with your doctor’s help and physical therapy. But if it’s completely torn, you may need to have it replaced especially if you’re young and active or an athlete who wants to keep playing sports. If you’re older or less active, your doctor might recommend treatments that don’t require surgery.

Your doctor will remove the torn ligament from your knee and replace it with new tissue. The goal is to get your knee stable again and give it the full range of motion it had before you got hurt.

Doctors typically use arthroscopic surgery on your ACL. This means they insert tiny tools and a camera through small cuts around your knee. There’s less scarring of the skin with this method than with open-knee surgery.

Symptoms

Signs and symptoms of an ACL injury usually include:

• A loud “pop” or a “popping” sensation in the knee

• Severe pain and inability to continue activity

• Rapid swelling

• Loss of range of motion

• A feeling of instability or “giving way” with weight bearing

Causes

Ligaments are strong bands of tissue that connect one bone to another. The ACL, one of two ligaments that cross in the middle of the knee, connects your thighbone (femur) to your shinbone (tibia) and helps stabilize your knee joint.

ACL injuries often happen during sports and fitness activities that can put stress on the knee:

• Suddenly slowing down and changing direction (cutting)

• Pivoting with your foot firmly planted

• Landing awkwardly from a jump

• Stopping suddenly

• Receiving a direct blow to the knee or collision, such as a football tackle

When the ligament is damaged, there is usually a partial or complete tear of the tissue. A mild injury may stretch the ligament but leave it intact.

FAQ

Why this treatment done?
-This treatment is done to treat multiple ligament tear of ACL which are either non responsive to conservative therapy or for patient with knee instability (patient who gives away knee) or patient presents late to the clinician i.e. after 2-3 weeks when acute phase has subsided or there’s no point in giving a conservative treatment.

What are the complication that can arise after this treatment?
-The most common complications after this surgery include persistent anterior knee pain and motion deficit or motion inability. Other intraoperative complications include patellar fracture, injury to femur, graft fracture, incorrect bone placement, incorrect tunnel placement, laceration of sutures i.e. tear of sutures.

How can I prevent this disease from occurring?
-ACL Tear is common in athletes so precaution to be taken includes use of appropriate footwear, maintenance of proper posture, special workouts and warm ups, strength enhancing workout specially in athletes and visiting the specialist in case of pain and restriction of movement because ACL Tear are difficult to diagnose.

What are the precautions that I have to follow after this treatment?
-1) Limited or no mobilization protocol is advised to decrease postoperative pain and motion loss.
-2) Legs raised above heart level by placing one or two pillows below legs to decrease swelling
-3) One has to ensure that bandage or knee cast isn’t too tight otherwise it will hamper healing, and dressing should be dry.

How many days of hospitalization is required after the treatment?
-The patient can be discharged after a day or two depending upon his/her condition .As ACL reconstruction is 2-2.5 hour surgery you can get discharge on the same day. Hospital stay generally varies from hospital to hospital settings and patient’s wellbeing.

What are the types of treatment?
-Conservative treatment: It consist of immobilization of knee with a cast or knee immobilizer for grade 1 and 2 injuries
Surgical Treatment:
1) Repair of the ligament: It is performed for grade 3 injuries
2) Reconstruction: Reconstruction is done in patient presenting late with knee instability.

What is the procedure or steps for Intra ACL Reconstruction?
-Intraarticular reconstruction involves graft selection, graft placement, graft tension, graft fixation.

What are types of Intra ACL Reconstruction?
-1) Anterior Cruciate ligament reconstruction with Bone-Patellar Tendon-Bone graft
-2) Anterior Cruciate ligament reconstruction with hamstring
– 3) Combined Intra and Extra Articular approach

What are types of Graft?
-Autograft: Derived from other part of ligament or from other ligament
Allograft: Derived from donor.

What precaution should be taken before allografting?
-Donor should be free from autoimmune disease like Rheumatid arthritis,SLE etc.
Blood testing should be done for Heb B, HIV,HepC
Tissue should be preserved at appropriate conditions
It should be disinfected.

What are the long term complication of this disease?
-Knee instability: Unhealed ligament leads to instability. Patient can lose confidence on his knee and give away
Osteoarthritis: Further damage to knee in the form of meniscus tear, chondral damage.

How long do I have to keep the knee brace is advised after surgery?
– For complete immobilization Knee braces to be applied for 5 weeks. It is gradually withdrawn.

What activities to be avoided after this treatment?
-Total knee extension activities
Leg balancing activities like standing on operated leg

How long it will be before I return to work?
-Full recovery generally takes 6-12 months but sports and other routine activities can be resumed after 3-4 months.

What exercises and physiotherapy are needed after this treatment?
-Week 1-2: Icing and Elevation of leg to reduce swelling, Quadriceps strengthening exercise or patella movement exercises, passive extension ,active and passive knee flexion ,Active hip movement
Week 3-4: Partial weight bearing with walker or crutches in addition to above
Week 5-9: Balancing exercises plus increase strength to above exercises
Week 10: Forward, backward and lateral dynamic movement and isokinetic exercises.
Month 3: Functional exercises like walking and running
Month 4: Acceleration and deceleration, variation in running. Cutting manoeuver improves arthokinetic reflexes ton prevent development of new trauma.

How is this disease diagnosed?
-Pain and swelling of knee with history of deforming force at knee with sound of something breaking.
Positive Anterior Drawer test
Plain x-ray may be normal but abnormal opening on stress x-ray may be seen
Sometimes Arthroscopy under local anesthesia may be required.

Who are more prone to this disease?
-It is common in players of basketball, Tennis, Volleyball, Cricket due to sudden jerk to ligament.