Anterior Cruciate Ligament Surgery

Anterior Cruciate Ligament Surgery

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Overview

Knee joint is the largest joint of the body. It is an articulation between 3 bones namely thigh bone (femur), shin bone (Tibia) and knee cap (patella). A smaller bone (fibula) stands parallel to shin bone and articulates with the knee joint.

What are causes of ACL injury?

  • Stopping suddenly or rapid change in direction
  • Falling from height
  • Extreme hyperextension like while jump or landing incorrectly
  • Directly getting hit while playing like in contact sports such as hockey, football, etc

What are symptoms of ACL injury?

  • Feeling of “popping or joint noise” inside the knee
  • Swelling and deformity in and around knee within few hours post-injury
  • Severe pain in the knee ( common in partial ACL tear)
  • No pain in knee especially in case of a complete tear of the ligament
  • Blue or black discoloration around the knee ( due to bleeding in knee joint)
  • Feeling of a knee buckling, "give way" or "give out" while you stand

How is ACL injury diagnosed ?

The doctor examines the knee and performs a certain manual test to diagnose the tear. If the examinations suggest a significant ACL injury, he may ask you to go for a magnetic resonance imaging (MRI) scan or execute a camera-guided surgery (arthroscopy) to inspect the damage to the ACL.

What are grades of ACL injury?

Based on physical examination and review of diagnostic imaging, the ligament injury is graded into following types -

  • Grade 0: Normal ligament
  • Grade I- This is categorized as a mild injury, where there are microscopic tears in the ACL. Tiny tears stretch the ligament and turn them out of shape. The ability of the knee to support the body weight is not affected completely.
  • Grade II- This is categorized as a moderate injury where there is a partial torn ligament. Knee can be unstable and may “give away” sometimes when a person stands or walks.
  • Grade III- This is a severe injury to the ACL where the ligament is completely torn and making the knee very unstable.

How is ACL injury treated ?

Non-surgical treatment: Patient suffering from grade I and II ACL injury are instructed to follow the RICE rule:

  • Resting the joint
  • Icing the injured area to reduce swelling
  • Compressing the swelling with an elastic bandage
  • Elevating the injured area

The doctor may prescribe nonsteroidal anti-inflammatory medications to relieve pain and ease swelling. As the pain subsides gradually, your doctor will start with a rehabilitation program to strengthen the weakened muscles and improve stability.

Surgical treatment: Surgery is considered when the patient is not responding well to non-surgical treatment or when the injury is severe. Usually, the torn ligament is replaced with an alternative graft made of a tendon.

  • Hamstring tendon autograft: Semitendinosus hamstring tendon is used to create hamstring graft. Some doctors suggest that hamstring graft shows less problems in comparison to patellar tendon autograft.
  • Patellar tendon autograft: In this surgery, the graft is taken from the patient's own body. The middle section of the patella tendon just below the knee cap is taken out by the surgeon. The graft includes the patellar tendon, along with attached plugs of bone on each end. This is also known as bone-patellar-tendon-bone graft.
  • Quadriceps tendon autograft: Usually, this autograft is used in patients who have failed ACL reconstruction already. In this procedure, the patient's middle third of quadriceps tendon and bone plug from the upper end of the knee cap are used. The fixation is less solid in comparison to patellar tendon graft because there is a bone plug only on one side. Though this technique provides a larger graft for patients who are heavier and taller.
  • Allograft: Allografts are grafts taken from cadavers and used in patients with failed ACL reconstruction or to repair or reconstruct more than one ligament. Allograft have advantages like there is smaller incision involved, decreased surgery time and no pain while obtaining graft as it is taken from cadavers.

What happens after ACL repair surgery?

The incision site is closed with stitches or surgical clips and covered with sterile bandages. You may experience painful bruising and swelling around the knee joint. However, these are temporary symptoms and will improve over time. You will be discharged home the next day with a knee brace in place.Continue physiotherapy after discharge from hospital for at least 6 to 8 weeks. Low intensity exercises will be performed initially. Avoid weight bearing for the initial few weeks and walk with the help of a walker or crutches. Gradually after 1 month your knee will regain strength and bending and straightening your knee will become easier. Walking off crutches can also be done. You can resume driving after consulting your doctor.

Three months after surgery you can start with swimming and cycling. You will also be able to resume most of the normal activities. However, regaining complete strength may take 6 months to a year.

What are complications of ACL repair surgery?

  • Anaesthesia complications: Small number of patients suffer from problems with anaesthesia. However, it is always recommended to discuss this with your doctor.
  • Thrombophlebitis (blood clots): This may occur after any surgery but is more likely in patients undergoing surgery on the pelvis, hip, or knee. Though there are many ways of reducing this risk like using pressure stocking and taking blood thinner medications after consulting with your doctor.
  • Infection: Post surgery, there is risk of infections, although use of antibiotics can help in keeping a check on it.
  • Problems with the graft (failure): After surgery, our body makes an effort to develop blood vessels around the new graft which takes around 12 weeks. The graft is very weak during this process and there are higher chances of rupture or stretching. When blood vessels are built completely, the graft gradually develops the strength. Although one may have to undergo another surgery if the graft is torn.
  • Problems at the donor site: Taking tissue from donor may sometimes create scars at site, this may create problems like inability to move knee properly.

Tips for prevention

  • Always do stretching and warm up before any workout or sport activity.
  • Practice strengthening exercise for the knee joint.
  • Avoid sudden high intensity training programs. Always increase your intensity gradually.
  • Always wear comfortable and well fitted shoes.

Tips to speedy recovery

  • Surgical wounds should be kept dry for at least 2 weeks.
  • Keep your weight under check.
  • Elevate your leg while applying ice packs to reduce swelling.
  • Wearing compression stockings reduces the risk of developing blood clots.
  • Taking iron supplements will promote tissue healing.
  • Topical pain relieving gels/ointments should be preferred over oral pain medications.
  • Perform regular light exercises to maintain strength and mobility.
  • Regular walking for 20 to 30 minutes, at least 3 or 4 times a week.

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