ACL Reconstruction Surgery
Listed below is the step by step procedure of ACL surgery:
- What is ACL Reconstruction Surgery?
- Why is ACL Reconstruction Surgery Required?
- Pre-operative Preparation
- Day Before Surgery
- Procedure Day
- Methods/Techniques of ACL Reconstruction Surgery
- Post Procedure
- Risks and Complications
What is ACL Reconstruction Surgery?
ACL reconstruction surgery is intended for restoring function of the knee. ACL, also known as Anterior Cruciate Ligament, joins the thigh bone (femur) with the shin bone (tibia). People who play lots of outdoor games may get their ACL injured. When non-invasive methods of healing the ligament do not work, an ACL reconstruction surgery is the last resort. Here the torn ligament is replaced by a graft in order to restore the normal functions of the knee.
Why is ACL Reconstruction Surgery Required?
The prime function of anterior cruciate ligament is to prevent hyperextensibility of knee (The angle between shin bone and thigh bone should not extend more after the leg has been straightened completely.). It also maintains rotational stability of the knee. ACL injuries are common in athletes who perform a lot of cutting or pivoting movement of the knees, such as the ones who play basketball, football, skiing, dancing etc. Women are more prone than men to these types of injuries because of variations in bone structure, muscular control and coordination and the effect of estrogen on the ligaments' healing ability.
- ACL reconstruction is considered in patients with 'unhappy triad' – damage to medial meniscus of knee, medial cruciate ligament and anterior cruciate ligament. This triad is common in football players.
- People who play high intensity sports involving too much of cutting, pivoting or sidestepping movements
- Someone with torn ACL and functional instability should consider this option.
- This is not the preferred technique in young children because this surgery has chances to damage the growth plate in their bones.
- ACL damage along with that of menisci (joint compartment) or articular cartilage should be considered for surgery.
You will be asked to undergo a series of tests before the ACL surgery. This is just to check your present health status. Nothing to worry about. During the exam, the orthopedic specialist will check for signs of tenderness and swelling. He/she may ask you to perform some ranges of motion with your affected and unaffected knees.
- X-ray: X-ray will rule out the possibility of a bone fracture. The only problem is that they can only visualise hard tissue like bone, not the tendons and ligaments.
- MRI (Magnetic Resonance Imaging) scan:
This scan offers a clear image of the soft tissues in the knee using strong magnetic fields. It can also show the extent of tissue damage. A benefit of MRI scan is that it produces lower radiations as compared to many other imaging studies.
- Ultrasonography: Sound waves are used to generate images of underlying soft tissues, and detect injuries if present.
- Arthrogram : A dye is injected into the knee joint area which will outline the areas of injury.
- Arthrocentesis: Also known as joint aspiration, a sample of synovial fluid (shock absorber of the knee joint) is taken out with the help of needle and syringe. Studies may show indicators of inflammation.
- Lachman's test: The orthopedic surgeon performs this physical examination to assess the damage done to the ACL with the help of certain physical maneuvers which involve passive movement of the tibia.
Before the surgery, the orthopedic surgeon will also advise you for a few routine tests. This is necessary because the surgery will be carried under anesthesia and that it should go on smoothly without any complications to you or the surgeon.
- Blood workup:
Complete blood count (CBC), blood pressure (BP), blood sugar, bleeding disorders are checked. An excess of white blood cells may indicate the presence of infection. High BP may hinder the operation, so precautionary measures can be taken against it. Diabetes is a very important consideration, because its presence may delay wound healing.
Presence of blood, sugar, proteins, pus cells is checked. Specific gravity, color, consistency are seen to rule any pre-existing pathology.
This is a routine procedure done to evaluate heart function. Leads are attached to your chest and the readings are taken in the form of a graph on paper.
You will be asked if you have been suffering from any other medical condition before this surgery. It can be any heart condition, respiratory disease, liver pathology or hereditary condition. It is important that you keep the doctor in loop. It would help him/her prepare for any possibility of complications later on.
Always tell your doctor which medications you are taking. Painkillers, blood thinners are especially important because they affect the clotting of blood.
- Smoking and alcohol:
If you are a smoker or consume alcohol, you would be asked to stop before the surgery. Smoking affects healing post surgery.
If you are pregnant, let the doctor know as soon as possible.
- Oral contraceptives:
If you are on birth control pills, you may have to stop taking them 2 weeks before surgery.
Day Before Surgery
Here are a few things one should keep in mind before going for the surgery:
- Try keeping the knee area very clean. Wash it a few times daily to prevent any infection. Take care your knee doesn't get any scratches, cuts or bruises. Shaving in that region isn't necessary.
- Do not eat or drink anything 8-12 hours before surgery unless instructed otherwise by your doctor. Your procedure may get cancelled if you are not able to do so.
- If you carry crutches, take them with you.
- Wear comfortable clothing when you go to the hospital. Carry an extra set if you like.
- It's best to leave your jewellery and other valuables at home. Don't wear any ornaments on the day of surgery.
- Bring things that help you distract after surgery. Books, laptop with movies, anything that keeps you happy can help.
- Ask your doctor which medications you can and cannot continue taking before the surgery.
- Bring someone to stay with you throughout the process of surgery and after. Also do remember to arrange for transport to drop and pick you from the hospital facility.
- Once you reach the hospital, you will have to undergo a short workup before the surgery commences. The nursing staff and anesthesiologist will carry out all the procedures.
- Your blood pressure, pulse, temperature etc. will be checked. The doctor may ask you a few questions. If you have any doubts, feel free to clarify with them. You should be completely relaxed before the surgery.
- Then you are asked to wear a surgical gown, which is completely clean and sterelised.
- Before the surgery commences, don't forget to sign the consent form. It is important that you understand the procedure, results, risks and complications of the surgery and then give a go ahead.
- A typical ACL reconstruction surgery takes about one to one and a half hour for completion. It is done on an outpatient basis i.e., you can go home after the surgery on the same day.
Your anesthesiologist will discuss the options of anesthesia available for the procedure. Usually, two types of anesthesia can be administered in this case – general and spinal (epidural). In general anesthesia, you will be unconscious throughout the surgery using drugs which are given either intravenously or by inhalation. A tube is placed in your airway which helps you to breathe.
A spinal or epidural anesthesia numbs only a specific region of the body, which is the lower half waist down. You will be given sedatives along with this so that the procedure goes smoothly without you even realising it. An advantage is that less amount of anesthesia is used, so lesser complications. But a disadvantage is that because of lesser anesthesia and only sedatives to make you sleep, you might as well wake up during the surgery.
Methods/Techniques of ACL Reconstruction Surgery
To put it briefly, ACL reconstruction involves removal of the torn ligament, placement of a graft from your own body or other source with screws and suturing the wound together. The surgery begins with a technique known as arthroscopy.
- A device called arthroscope is inserted into the knee joint. It contains a small camera on its head.
- Next, saline is injected in the joint space which allows better visualisation with the arthroscope.
- The region is inspected for ligament tear and any other damage.
- Now, a graft is harvested either from donor or from your body itself. The graft must be thawed if from a donor and must be well trimmed and shaped according to the site to be placed on.
- In the next step, two tunnels will be dug in the bone; one will be a tibial tunnel (in the shin bone) and one a femoral tunnel (in the thigh bone). These two tunnels will hold the future anterior cruciate ligament.
- A pin is passed through these tunnels and the new ACL is attached to its end. It (ACL) will be now fixed to the femur and tibia using screws. Screws may be made of metals such as stainless steel, titanium, or plastic dissolvable material, or any bone growth inducing material.
- With time, the graft grows over the surrounding bone.
A graft is a piece of living/synthetic tissue that is inserted surgically into the body. Different types of grafts are used in ACL reconstruction:
The source of graft is patient's own body. Grafts used can be from the hamstring tendon or the patellar ligament. The quadriceps tendon can be used too in the place of patellar ligament. An advantage of autografts is that chances of rejection are less as compared to other grafts. A disadvantage is that, now the recovery would be for not one, but two incisions made on the skin.
Source is from another body, living or dead (cadaver). The Achilles tendon, patellar ligament or tibialis anterior tendon is used. These grafts are properly irradiated and sterelised before being adapted to their new site.
- Bridge-enhanced ACL repair:
A sponge like structure is used as a bridge to help repair ACL tears. It is in experimental stages but looks like a promising procedure. It is less invasive and has the potential to give better success rates.
The choice of graft is predetermined by the age and lifestyle of the patient. Also, how your surgeon places the graft and the stability of the surrounding structures are also key determinants for the success of grafts.
Of late, stem cells treatments are being explored for their potential to generate a new ligament themselves. Stem cells are multipotent in nature and can differentiate into any new type of cell if 'tweaked' the right way.
Since AC reconstruction surgery is done on an outpatient basis, you can leave for your home on the same day, or as the doctor recommends you. Since you would be under the effect of anesthesia, you can leave only after spending a few hours in the recovery room.
- You will notice some bruising, redness and swelling down your shin and ankle. This is because of the synovial fluid leaking down your legs. This is normal and stays for a few days after surgery.
- A little drowsiness for 24-48 hours is expected. This is because of the effects of anesthesia.
- Pain killers and anti-inflammatory drugs are given to help deal with the pain after surgery. With time the pain will keep on decreasing.
- You may be given a cryocuff which has ice inside it. This helps to decrease the knee swelling.
- The nursing staff will change your dressing before you are discharged. You can take it off 4 days after surgery.
You are allowed to take a bath only after 4 days. Try that water doesn't come in contact with the incisions. A sponge bath is a good alternative. Always keep your wounds clean and dry. The absorbable sutures will fall off by themselves in a week or so. If small threads start coming out, you can go to the hospital and ask the nursing staff to take them off.
Post-operative Pain Control
The principle here to follow is – RICE (Rest, Ice, Compression, Elevation). Leg should be elevated above the level of heart. It should also be kept the same way after exercises. The goal is to avoid pooling of blood in the lower extremities. At night times too, this should be followed. Pain killers should be taken 30 minutes before exercising.
If you have crutches, use them. Put your weight more on them and put only that much weight on the affected leg as recommended by the doctor. Wear your knee braces and practice walking using them. Don't be overtly dependant on crutches. Once you start gaining confidence, start putting weight on the leg with knee braces to increases its strength. Your doctor will guide you through this.
- Some doctors may offer you with an equipment known as CPM (Continuous Passive Motion) machine. It is used in the initial weeks after surgery. It allows for compulsory extension and flexion movements of the leg while you are lying on the bed. It is advised that the CPM machine is used for 10 hours everyday for 5-7 days, after which you can start with physiotherapy.
You can tie up with your physiotherapist and discuss the various 'range of motion exercises' that are needed to be done. It can be started about a week after surgery. Exercises like leg lifts, hip abduction, toe curls, heel slides, prong hangs etc., help in regaining joint strength.
This can go on for as long as 24 weeks and more. You should discuss with your surgeon when you can resume sports if you are into it.
- As a general guideline, you can resume simple sedentary work after 2-6 weeks, light manual work by 3-4 months and heavy strenuous activities by 9 months.
- If you do consider resuming sports, start with swimming, or activities which do not involve too much of twisting, jumping or turning.
- A full recovery after an ACL graft takes about a year.
Post surgery, you should visit your orthopedic specialist first at 2-4 weeks, then once at 3 months, 6 months, 1 year and 2 years. Knee function is evaluated and change in physiotherapy exercises are advised. However, if you feel that something doesn't feel normal, contact your doctor at the earliest.
Risks and Complications
The success rate of an ACL reconstruction procedure is about 82-95%. However, it does have its share of risks such as:
- Infection: It can happen in the first 5-7 days after surgery. A short course of antibiotics will help in controlling the problem. In serious cases, surgery may again be required to remove the infection. An intravenous supply of antibiotics before the surgery counters any such problem.
- Clot formation in legs: Occurs 2-3 weeks after surgery, with the possibility of a deep vein thrombosis (deep vein blood clot). Can be treated with blood thinners.
- Pulmonary embolism: Blockage inside a major artery supplying lungs results in cutting off of all blood supply to the lungs. The health condition and symptoms which follow, comprise the pulmonary embolism.
- Damage: Blood vessels and nerves may lose their function
- Knee Physiotherapy: Rigorous physiotherapy is not advisable after a knee surgery.
- Hematoma (localised collection of blood) formation: It is self correcting after 3-4 weeks.
- Associated risks with the administration of anesthesia may occur. These include nausea, dizziness, vomiting, respiratory depression, etc.
Other Risks Include:
- The swelling and pain may not subside even after 3-6 months.
- The ACL graft may not adapt well to the body. This is because of resuming heavy physical activities too early or not following the physiotherapy properly.
- Will the ACL reconstruction be painful?
A. Your team of doctors will do their best to make the surgery as uneventful and risk-free as possible. Anesthesia used can be general or regional, depending on your preference and the surgeon's opinion. Pain after surgery can be managed with painkillers and anti-inflammatory drugs.
- Is the outcome favourable? Will I be able to do everything I normally could before surgery?
A. ACL surgeries have a good success rate (82-95%). Combined with appropriate physical therapy and precautions, a full recovery is possible in 1-2 years.
Injuries are a part of sports – they make us stronger. Each injury teaches us something. Keep your spirits high and never back down!