When the anterior crusciate ligament (ACL) tears, a knee is likely to become instable. The ACL provides stability to the joint and prevents the upper leg from sliding for- and backwards of the lower leg. Though in some cases the eccentric training of the muscles surrounding the knee is sufficient to regain stability, in most cases a reconstruction of the ACL is necessary to prevent further damage. This is done arthroscopically by transplanting part of the hamstring of or patella tendon into the original ACL position.
ACL reconstructive surgery is usually the best choice for repairing a damaged ACL. It is almost always performed arthroscopically and can be performed as an out-patient or in-patient procedure.
During ACL reconstruction, Dr. Millett will use one or two tiny incisions and will insert an arthroscope to view the ligaments within the knee. The surgery will involve removing fragments of the damaged ACL and replacing it with another form of soft tissue, called a graft. There are two types of grafts used during arthroscopic ACL reconstruction surgery:
- An autogenous graft will use soft tissue from the patient
- An allograft will use soft tissue donated from an individual at the time of death
Dr. Millett will usually prefer to use a patient’s own tissue for the graft. The patient’s own tissue typically heals faster and reduces other known risks (disease, rejection, etc.). These risks, however, are very minimal. In patients who are older or who have had prior knee injuries and who may not have sufficient tissue for grafting, an allograft might be a better choice.
In both grafting scenarios, a portion of the patellar tendon will be used to replace the ACL. This is the tendon of the quadriceps muscles that attaches the patella (the kneecap) to the tibia (the lower leg bone). This is a popular choice because the patellar tendon is a large, strong tendon, and bone can be taken out at each end of the tendon easily. The bone ends are then attached to the femur and tibia, allowing for bone-to-bone healing.
There are other surgical options involving the graft. One involves strands taken from of the smaller hamstring tendons (the semitendinosus) and another involves using a portion of the quadriceps tendon taken from the quadriceps muscles. Dr. Millett will evaluate each patient to determine the best grafting option to use.
There are many types of devices used to secure the graft to the bone. Some examples are screws, screw with a washer, and cross pins. Some are metallic and others are absorbed by the body over time. The type of graft procedure chosen will determine the fixation technique.
After ACL Surgery
Arthroscopic ACL knee surgery is often performed on an out-patient basis. Here are some things to remember about what to expect, as well as some helpful hints during the recovery process immediately following the procedure:
- After ACL reconstruction surgery, it is normal to have swelling and discomfort in the knee for several days following surgery. Apply ice bags or use the Cryocuff you were given to control swelling. Ice should be applied 20-30 minutes at a time, every hour or so. Be sure to protect your skin with a thin cloth. Icing is most important in the first 72 hours, although many people find that continuing it lessens their post-operative pain.
- If you had a nerve block during arthroscopic knee surgery, the local anesthetic may keep your leg numb for several hours. You will be given a prescription for pain medication when you are discharged from the hospital. If you find you do not tolerate it well, call our office and we will try another one.
- Keep the leg elevated. This will prevent swelling and help decrease pain. The leg must be elevated higher than the level of your heart.
- Perform very minimal post-knee surgery exercises until you begin physical therapy rehab. Pumping your ankles up and down is an example of what to do. This should be done several times an hour to keep the blood circulating in your leg and to help prevent blood clots from forming.
- Keep the post-op dressing clean and dry. Unless it becomes wet or too tight because of swelling, leave the bandages in place for at least 2 days, then remove them. Cover the small incisions with Band-Aids to keep them from snagging the sutures on clothes. You may shower then, but keep the incisions dry for the first 10-14 days. Do not wet your incisions directly (bathing or swimming) until at least 2 weeks post-op.
- The sutures are absorbable and do not need to be removed.
- Dr. Millett would like to see you back in the office 10-14 days after surgery. If you don’t have your first post-op visit scheduled, call our office to make one.
- Start your arthroscopic knee surgery post-operative rehabilitation/physical therapy right away. Your physical therapy program is key to a successful outcome. It should be started the day after surgery. A separate prescription will outline the protocol. It often helps to call before surgery to make an appointment with your physical therapist.
- Be in the care of a responsible adult.
- Abstain from drinking alcoholic beverages and from smoking.
- You may eat a regular diet, if not nauseated. Drink plenty of non-alcoholic, non-caffeinated fluids.
- Plan to take a few days off work.
Rehabilitation after ACL knee surgery can be a lengthy process involving a limitation of activities, physical therapy and rest that will need to take place for a period of months. Specific rehabilitation will vary according to each patient’s needs and you must adhere to your own protocol as established by Dr. Millett and your physical therapist. Please visit the ACL rehab manual on this website to learn more about the rehabilitation process following ACL reconstructive surgery.