Indications (Who Needs Surgery, When, Why, and Goals)
- Athletes who regularly perform sports that require pivoting, cutting, and jumping and landing
- Patients with recurrent giving way or knee instability, despite 3 to 6 months of an adequate rehabilitation program
- Patients with an anterior cruciate ligament (ACL) tear and a reparable meniscus tear
- Patients with an ACL tear and other ligament injuries in the same knee
The goal of the operation is to restore the function of the torn ligament—that is, to allow a return to sports that require pivoting, cutting, change of direction, and jumping and landing. ACL grafts undergo a degeneration process (the graft is usually at its weakest 6 weeks after the surgery) followed by a regeneration process, which may take up to 1½ years.
Contraindications (Reasons Not To Operate)
- In those individuals who do not perform sports that require pivoting, cutting, and jumping and landing frequently, surgery might not be required.
- Individuals who exercise by jogging, cycling, or swimming only may not require ACL surgery.
- Persons who demonstrate an inability or unwillingness to complete the postoperative program or to perform the rehabilitation necessary should not have surgery.
- Infection of the knee, current or previous, is a concern but not an absolute contraindication.
- If the patient is not yet fully grown (skeletal immaturity), surgery may not be recommended until the patient is fully grown, but this is not an absolute contraindication.
- Persons with severe knee arthritis should not have surgery.
- Infection; bleeding; injury to nerves (numbness, weakness, paralysis) of the knee, leg, or foot (it is not uncommon to have some numbness, temporary or permanent, on the outer part of the upper leg)
- Rupture or stretching of the reconstructed ligament, causing recurrent instability
- Knee stiffness (loss of knee motion)
- Rupture of the patellar tendon or patellar fracture (both uncommon)
- Pain from screw used to hold the graft (rare)
- Clot in the veins of the calf or thigh (deep venous thrombosis, phlebitis) that may break off in the bloodstream and go to the lungs (pulmonary embolus) or brain (causing a stroke)
Technique (What Is Done)
Surgery is usually performed with the assistance of an arthroscope; it is usually done on an outpatient basis (you go home the same day). The torn ACL is replaced by a graft. Grafts most commonly used include (1) the central third of the patellar tendon, from the same or opposite knee; (2) hamstring tendon; (3) quadriceps tendon; and (4) allograft (transplant from a cadaver) patellar tendon or tibialis tendon. Our preference is for allograft tissue. In our experience this allows for a faster return to daily activities, and the long term results for return to sports participation are equal to that obtained with your own tissue.
Other structures in the knee are examined at the time of reconstruction, including the meniscus and articular cartilage. Bone tunnels are drilled in the leg bone
and the thigh bone to place the ligament in almost the exact same position as the torn ACL was. The graft is held in position with screws or pins. We typically use bioabsorbable screws and pins, which are devices that are gradually replaced by your own bone over the course of about 2 years. We typically do not use any metal hardware. I am now performing a new type of reconstruction called a "two bundle" reconstruction, that uses two grafts to better recreate the normal knee anatomy.
Postoperative Course
- This surgery is often felt to be therapy dependent. In other words, much of the success of ACL reconstruction is dependent on the patient and therapist and being able to follow through and maintain the therapy schedule.
- Keep the wound clean and dry for the first 3 to 4 days after surgery.
- Ice the knee for 20 minutes every 2 to 3 hours while awake for the first 1 to 2 weeks after surgery. You will usually have a cold therapy machine.
- Your physician will prescribe pain medications. Take only as directed and only as much as you need.
- You will be given a knee brace after surgery which you will wear for about 2-3 weeks.
- Goals for rehabilitation of ACL reconstruction include reducing knee swelling, regaining knee range of motion, and regaining strength in the leg and thigh muscles. Check with your surgeon or physical therapist for the exact exercises to perform.
Return To Work and Sports
In general, I recommend that you take one week completely off from work and school, and during the second week work from home. Some people do return to work and school sooner, but I find that the schedule above is best if you can arrange it. You can drive a car with right knee surgery at 2-3 weeks, and with left knee surgery at about 1 and a half weeks. You may return to sports when there is no pain and when full knee range of motion, muscle strength and endurance, and functional use has been restored. This usually requires 4 to 6 months for non-contact sports that do not require cutting, jumping, or pivoting. If your sport requires contact, jumping, cutting, or pivoting, this will probably need 6 to 9 months following ACL reconstruction.
Notify Our Office If
- You experience pain, numbness, or coldness in the foot and ankle
- Blue, gray, or dusky color appears in the toenails
- You experience increased pain, swelling, redness, drainage, or bleeding in the surgical area
- You have signs of infection (headache, muscle aches, dizziness, or a general ill feeling with fever)
- New, unexplained symptoms develop (drugs used in treatment may produce side effects)
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