ACL Reconstruction

Everything You Should Know About ACL Reconstruction

If you follow sports to any degree you’ve heard the term “ACL” on a pretty frequent basis. In this guide we’re going to look at the various types of ACL injuries along with ACL reconstruction, how it’s done, what it costs and what you can expect afterward by way of a recovery process.

What is the Anterior Cruciate Ligament?

The anterior (front) cruciate ligament or ACL is one of the most important components of the knee. In simple terms it works in concert with the posterior (rear) cruciate ligament or PCL to bind the upper leg to the lower leg. Because the knee only bends to the fore the ACL absorbs as much as 85% of the force applied to the knee joint when it is flexed. Therefore it is far more susceptible to injury and/or wear and tear than the PCL.

What is an ACL Injury?

Enormous stresses are brought to bear on the ACL when people engage in physical activity. And this is true whether a person is a professional rugby player or just someone running to catch the subway train in the morning. These enormous stresses are often times too much for the ligament to bear and the result is an injury to the ACL or a “torn ACL”. ACL tears are rated by their severity which can range from mild (a small tear in the ligament) to severe (where the ligament is torn through or where it separates from the bone taking a piece of the bone with it). Left untreated a mild ACL tear will make the knee far less stable and make walking painful and playing sports nearly impossible. Over time the person will develop what’s called Chronic ACL Deficiency where bones begin to rub against one another and other components of the knee such as cartilage also sustain damage. While a severe injury to the ACL can render the knee useless.

What is ACL Injury? Part II

While ACL injuries are most common among athletes or those engaged in sporting activities they can also happen to average people who overexert themselves or are involved in different types of accidents. ACL injuries typically occur when the knee joint is bent backward, twisted in an aggressive or unnatural way or bent to one side or the other. If more than one of these potential causes is in play at any one time the risk of injury is increased. There are any number of things that can cause these types of harmful movements including contact with another person (which is why so many athletes wind up with torn ACLs), landing awkwardly after jumping, or changing direction quickly when running. People often injure their ACL when they miss a step on the staircase or fall from their bicycle. Those over 40 stand a greater chance of sustaining an injury to the ACL simply due to natural weakening of the ligament over time.

Symptoms of ACL Injury

An injury to the ACL is one of the most debilitating injuries a person can suffer as it affects every aspect of your mobility. ACL injury symptoms include:

• Hearing a pop in the knee at the time of the injury or feeling the knee become dislodged from its normal position.
• Immediate pain in the knee joint sometimes on the outside, sometimes in the back of the knee and sometimes both.
• Swelling of the knee. This usually commences almost immediately and becomes noticeable within a short time after the injury. In most cases the faster the swelling occurs the more severe the damage to the ACL. Swelling may also indicate internal bleeding within the knee joint.
• An immediate feeling of the knee no longer being stable or strong. The knee may actually give out if you try to walk on it after an injury to the ACL.
• Restricted movement in the knee due to swelling or pain or both.

If the ACL tear is mild you may be able to walk afterward. You are still, however, likely to be in some pain, may feel the knee is unstable and may experience some degree of swelling. Non-athletes often dig themselves a deeper physical hole by assuming the injury was no big deal because they can still walk afterward. As such they don’t seek treatment and oftentimes end up with Chronic ACL Deficiency as outlined above.

Diagnosis

An injury to the ACL can sometimes mimic the symptoms of a torn meniscus so it is important that you have a professional diagnosis before deciding what type of ACL injury treatment may be right for you. An orthopaedist will be able to determine if fairly short order if you do indeed have a torn ACL by examining the knee and asking a series of relevant questions such as:

• How did you injure the knee?
• Have you ever injured this knee in the past?
• Did you hear any sound when the injury occurred?

The orthopaedist will also check your range of motion and check the stability of the knee. He or she may also call for X-rays and if they are inconclusive, may order an MRI. The MRI provides a more comprehensive view of the knee joint and can reveal muscle, tendon, cartilage or ligament damage an X-ray cannot. Once the proper diagnosis has been made treatments can be discussed.

What to do Following an ACL Injury

If you have reason to think you’ve experienced an injury to the ACL it’s important to administer first aid (as opposed to treatment) right away. First aid includes applying the RICE method which is Rest, Ice, Compression and Elevating the leg. In other words get off your feet as soon as possible, wrap ice or a cold pack around the knee to prevent/reduce swelling and elevate the leg to take any pressure off of it. Take over the counter pain medications to reduce pain and swelling and make an appointment to see an orthopaedist ASAP. If the injury is severe you may want to visit the local emergency room. If you wait a couple of days to see a doctor it’s important you keep the knee immobilized in the interim. That will likely mean calling in sick to work.

Once the doctor has examined you he may recommend a rehab regimen (if you have a mild tear) or he may recommend surgery if the injury is severe. Surgery will also require several months of rehab (minimum) afterward. The exact ACL reconstruction protocol and the length of your rehab will depend on the severity of the injury and whether any other parts of the knee were injured as well. Other factors that will weigh on your rehab time include your age, weight, overall health and how long you waited before seeking treatment.

What is ACL Reconstruction?

Knee ACL reconstruction is typically indicated for severe ACL injuries or situations where a mild injury was not properly treated and degenerated into Chronic ACL Deficiency. Different types of acl reconstruction surgeries involve repairing the ACL and in some cases reconstructing other aspects of the knee joint that may have suffered because of the injury itself or because of the effects of Chronic ACL Deficiency.

• In most cases the surgeon will use an ACL reconstruction hamstring graft to actually replace the torn ACL. In other cases a section of the quadriceps tendon is used as a graft. In still other cases an extant ACL taken from a deceased donor may be used. However, these cases are rare.
• In some cases the ACL itself is intact but part of the bone where the ACL was attached has broken away. In these cases the surgeon will reconnect the separated part of the bone which will restore the proper structure of the knee and return the ACL to its proper position.

Some injuries will call for open ACL reconstruction surgery, where the knee joint is opened up via a large incision. In other cases the surgeon will perform an arthroscopic ACL reconstruction procedure. This is done by making a series of small incisions into which the necessary instruments can be inserted. We’ll get into arthroscopic surgery in detail below.

Arthroscopic Surgery

In most cases arthroscopic ACL reconstruction is the preferred method of reconstructive ACL surgery because it:

• Is less invasive than open knee surgery.
• Presents less risk of infection than open surgery.
• Means a shorter recovery period than open knee surgery.
• Can be done at the same time the diagnostic arthroscopy is performed.
• Can often (not always) be performed using a local anaesthesia.
• Presents fewer potential negative side effects.

The Arthroscopic Surgery Process

Most people have heard the term “arthroscopic surgery” though few have a clear idea of exactly what the term means.

• The process of arthroscopic ACL surgery begins with making several small incisions in the area around the knee. There may be as many as 3 of these incisions and they will be used to insert the tools necessary to get the job done.
• A saline solution is typically pumped through one of these incisions into the knee joint to clean it out and make it easier to see the area where the surgery will be performed.
• An arthroscope will be inserted into another of these incisions. The arthroscope gives the surgery its name. It is a device with a light and camera at the end. The camera sends a real time view of the knee to a TV monitor in the operating room allowing the surgeon a clear, close up view of the injury site. The surgeon then operates ‘remotely’ by watching the TV monitor.
• A surgical drill is then inserted through another incision and used to create small holes in both the upper and lower bones of the leg. These holes will be used to anchor the new ligament material.
• The new material is then pulled through these new holes at both ends and secured with screws or staples. Any other repairs to the surrounding components of the knee are performed and then the tools are removed and the incisions closed with stitches.
• The knee is then bandaged and the patient is taken to the recovery room for a short period of observation. The total ACL reconstruction surgery time in this case is 1 – 2 hours.

In some cases arthroscopic ACL surgery can be performed on an outpatient basis; meaning the patient does not have to stay overnight in the hospital. In other cases however it may be necessary to spend 1 or 2 days in the hospital after ACL surgery. It will be up to your surgeon to decide. Keep in mind that whether you have open or arthroscopic surgery your knee will be swollen after surgery and you will likely feel fatigued for a couple of days. Remember also not to get the incisions wet and to keep your eyes open for signs of post ACL reconstruction infection.

The Goal of ACL Surgery

Regardless of whether you undergo open or arthroscopic ACL surgery the goals are the same: to restore normal movement and stability to the injured knee and prevent the injured ACL from creating a cascading series of problems with other knee and leg components. Surgery will typically be indicated if:

• The tear is significant enough to seriously affect stability in the knee or the ligament is torn completely through.
• A rehab program you undertook for a partial tear was unsuccessful.
• You depend on your physical abilities to make a living. That is if you are a professional athlete or construction worker etc.
• You suffer from Chronic ACL Deficiency due to an injury to the ACL that was left untreated.
• Other parts of your knee or the surrounding area were injured at the same time as your knee.

You may decide not to have ACL surgery if:

• Your injury is a minor tear that may heal with rest and rehab.
• You are not someone who is on their feet all the time or otherwise physically active.
• You are willing to give up certain physical activities.
• You have medical issues such as severe diabetes that may make surgery inadvisable.
• You are willing to live with a small amount of instability in the affected knee.

Success Rates for Reconstructive ACL Surgery

Success rates for reconstructive ACL surgery are generally excellent although a small percentage of people may experience a degree of instability and/or pain after ACL reconstruction surgery. If either is severe revision ACL surgery may be called for. Again however, such cases are typically rare.

Risks and Complications

Although both open and arthroscopic ACL surgery are typically safe and rarely require revision surgery there are nonetheless some risks and potential ACL reconstruction complications involved any time you perform any type of surgical procedure. In the case of reconstructive ACL surgery those risks and potential complications include:

• The graft material may loosen or stretch over time or the screws used to hold it in place may need to be removed.
• You may experience numbness in the surgical area which may or may not pass with time.
• There may be damage to the nerves around the knee or damage to the blood vessels of the knee.
• Reattached bone segments may come loose again in time.
• You may experience a limited range of motion after surgery where you are unable to completely straighten the leg or completely fold it under.
• Pain at the site where the graft was removed. This is particularly true if the graft was taken from the patellar tendon.
• And of course infection.

ACL Reconstruction Surgery Cost

All the prices listed below are current as of this writing. As you can see having your ACL reconstructive surgery performed at the Orthopedic Riga clinic makes tremendous financial sense.

ACL Reconstruction Recovery Timeline

Following your ACL surgery you will be referred to a physical therapist who will work with you to implement a rehab program that will take the specifics of your surgery, your age and your overall conditioning into consideration. While most rehab programs will have slight tweaks incorporated to account for those factors they will all more or less adhere to the same goals. The best thing you can do following ACL surgery is to listen to the recommendations of the physical therapist and do what is suggested in your ACL reconstruction recovery plan.

Post ACL Reconstruction: Immediate Aftermath to 4 Weeks

• During the initial consultation with your physical therapist after surgery an ACL reconstruction rehabilitation program will be devised and milestones laid out. You’ll be told when you can expect to be walking again and when you’ll be able to return to more strenuous activities like jumping and running.
• The compression sleeve around the knee that has likely been there since surgery will be removed at this time and you will get your first look at the reconstructed knee. It will likely be an unattractive, bruised and swollen sight but fear not; it will get better over time.
• Once the rehab timeline has been established and you are clear on the goals and what will be expected the first priority will be to reduce the pain and inflammation.
• Once inflammation has been reduced you can get to work re-establishing knee extension. This is crucial because even a tiny degree of constriction in your ability to extend the knee is going to throw off your mechanics and could lead to a cascade of other issues. In addition, if you do not restore full extension of the knee as soon as is practically possible scar tissue may develop inside the surgical area that will make it impossible to do so.
• You will slowly be weaned off of crutches and gradually get accustomed to bringing more and more weight to bear on the reconstructed knee. You’ll simultaneously work on regaining range of motion.
• Proper blood circulation around the knee is also important to re-establish and so it will likely be recommended that you ride the stationary bike to get the blood flowing. The stationary bike can also help re-establish range of motion.
• You may also need to undergo some form of balance training the exact details of which will be up to the physical therapist to determine.

4 to 6 Weeks After Surgery

• You may continue to experience periodic swelling during this portion of your ACL injury recovery time but the instances should be fewer and any swelling less severe than before.
• You will continue to work on range of motion and building strength in the leg as a whole and the knee in particular.
• By now you should be largely free of crutches. You may need them from time to time and/or you may use a cane to assist yourself walking from time to time but it shouldn’t be a full-time thing.
• The more athletically inclined patients will likely start working on re-establishing lateral strength and agility. This will be essential to their ability to return to their sport and play at pre-injury levels.
• Full extension should also be well established by this time and riding the stationary bike should be a regular part of your daily routine to improve circulation and knee strength. You may also start working on the stair climber at this point.

6 to 10 Weeks After Surgery

• By now your ACL reconstruction healing is well under way. Instances of swelling should be rare or non-existent. You should have full leg/knee extension and full range of motion.
• You should start to shift your emphasis from extension and range of motion to regaining overall strength and balance via ACL injury exercises.
• Toward the end of this period you may begin some light jogging (this will depend on several factors including your age and the condition of your other knee).

10 to 12 Weeks After Surgery

• The shift toward strength training and balance will continue.
• You may be allowed to engage in more slow, low impact jogging.
• You will continue to perfect your gait and will continue working on the stationary bike and stairmaster.
• You should be pain free and completely off pain medications. Swelling should no longer be an issue.

12 to 16 Weeks After Surgery

• Full extension and range of motion should be well established and the strength of the operated leg should be close or equal to that of your other leg.
• You may be able to introduce jumping exercises at the end of this period although you should only do so under the supervision of your physical therapist.
• Non-athletes may skip the jumping portion of the rehab after ACL reconstruction altogether.
• Athletes and the athletically inclined may also increase agility training by doing figure 8s and the like.

ACL Reconstruction Rehab: 4+ Months After Surgery

Over the following several months you’ll be able to:

• Increase the length of your jogging sessions.
• Increase resistance on the stationary bike to help build strength.
• Be able to climb stairs with the same ease as before surgery.
• Gain the ability to play low impact versions of basketball, tennis and the like. (Some non-athletes may not need such vigorous athletic training and will concentrate on walking and restoring pre-injury levels of function.)
• If you’re a golfer you may be able to resume playing although it should be in a relaxed form and not more than 9 holes until at least 8 months have passed.

While ACL reconstruction recovery time will vary, 9 months to a year after surgery you should be back to normal, whatever normal was for you prior to you injury. Many people who did not previously exercise much may even find that their conditioning a year after surgery is better than it was before they were injured.

What Not to do Following ACL Surgery

Just as important as the things you should be doing after reconstructive ACL surgery are the things you should not be doing. These include:

• Don’t over exert yourself – Big one here because a lot of people get impatient and try to rush the recovery process. Not good. In the first weeks after surgery don’t even think about jogging or jumping or lifting weights. Take your time and concentrate on the small but important tasks of re-establishing full extension, range of motion and circulation.
• Don’t ice your knee too much – We touched on this earlier but it bears repeating. If you wrap your knee in ice or with cold packs for an hour at a time or more you run the very real risk of causing nerve damage. 20 minutes at a time 3 or 4 times a day should be the limit.
• Don’t overdo it with the painkillers – You should never overdo it with the painkillers. Within a week or so of surgery you should be completely off the serious prescription painkillers and then after that you should make a point of weaning yourself from the OTC painkillers like ibuprofen as soon as possible. Abuse of painkillers can lead to addiction or cause you to damage the reconstructed knee because you don’t feel anything and overexert it.
• Don’t put too much pressure on your uninjured knee – Often people recovering from ACL surgery will tend to overcompensate by continually shifting body weight onto the undamaged knee. While a bit of this is understandable, doing it too much can cause damage to the previously undamaged knee. If you can’t put too much pressure on the reconstructed knee use a crutch or a cane. Don’t just shift everything to the good knee.
• Don’t sleep with your knee bent – Try to sleep with your leg as straight as possible. Sleeping in a fetal position with the reconstructed ACL bent can promote the growth of an ACL reconstruction scar which will in turn inhibit your ability to re-establish full extension and range of motion.
• Don’t forget your compression stockings – In order to avoid blood clots developing in your legs and travelling to your lungs or brain you’ll want to wear compression socks like people do for long airplane rides. Compression socks help maintain normal blood circulation in the lower legs and prevent the development of blood clots.
• Don’t lose focus – Rehab is a long and often tedious process. As such people often lose focus and start slacking off with their physical therapy for ACL reconstruction. This sort of thing cannot lead anywhere good and will only undermine your ability to return to normal physical activity. Stay in close touch with the physical therapist throughout the recovery process and do your best to reach all the performance milestones established at the start of your rehab.

Preventing Future ACL Injuries

Just as important as ACL injury recovery is learning ACL injury prevention methods and techniques. That way you won’t suffer from a repeat of this nasty injury. So just how do you prevent future ACL injuries? In a nutshell the best way is to strengthen the knee and leg muscles. This way they’ll be able to better help the ACL absorb the stresses and strains of physical activity. In addition you should avoid wearing cleats going forward as they catch on the ground and cause the knee to twist. If you’re a weekend warrior avoid contact sports or sports that require lots of twisting and redirection. You can also wear an ACL reconstruction brace going forward to buttress the strength of the knee joint.

Conclusion

Reconstructive ACL surgery can help you regain normal function in your knee after a serious ACL injury. If you have sustained an injury to the ACL give Orthopedic Riga a call on 0207 993 8535.