Wednesday, July 13, 2011

ACL Reconstruction FAQs

This is another favorite of mine since I am doing a lot of sports medicine in my practice and treat a number of these injuries, Could be a long one here folks. A lot of information to cover. There is an excellent review article on the AAOS site which has all of the key references related to this topic should you wish to investigate that, so I won't bog everyone down with the references here in this blog, You can find the article here
1) What's an 'A-C-L' and what's all the fuss about it? The ACL or 'anterior cruciate ligament' is a ligament in the knee which connects the femur or thigh bone to the tibia or shin bone. If this ligament tears, that connection between the 2 bones is lost. This can result in the knee becoming unstable, wobbly with certain activities particularly recreational and or sports and therefore will limit one's ability to participate in those activities. This can lead to further cartilage injury, most notably meniscal cartilage tears. ACL tears receive a lot of attention these days due to their frequent occurrence in the professional sports world esp NFL.
2) I tore my ACL playing soccer. Do I need surgery? The bigger question of course is what are the indications for surgery for a torn ACL? Believe it or not this is not written in stone even today. Many factors need to be considered such as , associated meniscal and or other ligament tears, level of activity of the individual and severity of the resulting instability to name a few. For example, a 43 year old male who trips over a dog toy and tears his ACL, currently works as an accountant, activities include walking and biking and on exam has minimal degree of instability with an MRI showing only ACL tear, no other injuries, may not do any better long term with ACL reconstruction than without. ACL surgery does not protect the knee from arthritis later on (see article referenced above). In fact many studies show no difference in the development of arthritis between reconstructed and non-reconstructed knees over time. However, the presence of meniscal damage regardless of what is done with the ACL does seem to relate to osteoarthritis development over time.
Indications for reconstruction depend on the following:
 A) Participation in a level 1or 2 sport on a competitive or regular basis (Football, basketball, soccer etc) or 200 hours a year of recreational activity involving pivoting, planting turning or short stops and starts
 B) Severity of static instability. This is usually determined clinically in the office by examining the knee and assessing stability difference between injured and uninjured knees..
 C) Severity of dynamic instability. This is more subjective but in part relates to the patient's symptoms of giving way
 D) Presence of meniscal cartilage damage. Particularly if this damage consists of possibly reparable tears, the success of any meniscal repair will require operative stabilization of the knee i.e. ACL reconstruction.
 E) Presence of associated ligament injury i.e. 'combined' ligament injury.

Generally the presence of a combined ligament injury by itself is an indication for surgery. After that, activity level and degree of instability are probably the 2 most important determining factors.

3) I tore my ACL and apparently will need surgery. How long can I wait? If the ACL tear is isolated meaning no meniscal tears, then even a several week delay should not change the outcome as long as activities are modified to minimize the risk of the knee 'giving out' and causing more damage. We will often brace the knee if a lengthy period is anticipated before surgery. Generally we strongly encourage knee rehabilitation exercise BEFORE surgery to maintain muscle tone and conditioning. This greatly facilitates the post-surgical rehab. If there is a combined ligament injury, then it depends on what the 'other' ligament is that is torn. Often a collateral ligament will need to heal first before ACL surgery can be done. This amounts to possible a month or so. We generally do not recommend ACL reconstruction before 2 weeks after injury. There have been studies suggesting increased incidence of stiffness problems after surgery if it is performed sooner than that. Finally if there is the presence of a large meniscal tear that most likely can be repaired, we would probably operate soon after the 2 week minimum.

4) How is the ACL repaired?
 Unfortunately the torn ACL cannot be just sewn back together. The ligament is bathed in a bloodless environment inside the knee joint and thus there is no way for the the ends to heal even if they are reattached. Therefore in order to restore the knee stability, you have to carry out what is called a 'reconstruction', meaning you have to use something in place of the original ACL. This is usually a tendon or ligament from another part of the knee, called a 'graft'.

5) What is the best graft to use?  At the time of this posting, there are primarily 3 different types of grafts used for primary ACL reconstruction (primary meaning first time injury as opposed to a re-injury of a previously operated knee): 4 strand hamstring graft, patellar tendon graft, allograft. The first 2 are usually obtained from the injured knee. 'Allograft' is a ligament from a cadaver (dead person). The 'hamstring' refers to couple of tendons in the back of the thigh that get looped over 1 time to produce a 4-stranded graft. The 'patellar tendon' is a strip of tendon along the front of the knee right below the kneecap. Folks, there is absolutely no data that conclusively favors one of these 3 grafts over the other. Please refer to the article at the top. People tell me: 'my doc said I'm too tall I shouldn't have a hamstring graft', or 'I was told allograft is better because you don't damage other parts of the knee' or 'I was told patellar tendon is no good because it screws up your kneecap'. Forget about it! They all work well. No significant differences in outcomes based on current data, period! Now there are issues specific to each graft type which your doc will discuss more than likely, but in terms of the bottom line, no difference.

6) How much time does the operation take? Approximately 1.5 hours average

7) Is it done with laser? No. The procedure is carried out arthroscopically. However the graft harvest is carried out through an open incision, the size of which depends on the type of graft.

8) Is it an outpatient procedure? Yes.

9) Does surgery require general anaesthesia? Usually. Often a combination of general and regional anaesthesia is used where the anaesthesiologist will inject a numbing medicine into the thigh before surgery. This will provide many hours of pain relief after surgery

10) How long is recovery? There are several stages of 'recovery'. Initially the knee is placed in a long leg brace to protect the knee during walking. This is anywhere from 2-4 weeks depending on whether or not a cartilage repair is done. However we do want the knee to start moving as soon as possible outside of the brace when not walking. Physical therapy starts the very first week. Most people are walking without crutches or other assistive devices by 3 weeks.If it's the dominant leg, average time to being able to drive is around 3-4 weeks. Full knee range of motion is achieved on average by week 6. Return to sports is no sooner than 6 months.

11) Can I do my own therapy? This would be very hard to do at the beginning. Some people have transitioned to home therapy after regaining their range of motion in the first 3-4 weeks or so. That happens not infrequently. In highly motivated individuals it certainly is not impossible.

12) Will it be 'good as new', like it never happened? Only if Santa Claus is real. Not trying to be facetious here, but the only way to make it like it was is to turn the clock back. We are able to successfully stabilize the knee so people can return to their sport and perform just as they did before. That doesn't necessarily mean the knee is 'like it was before'.Now an individual can be back on the field in 6 months but usually their performance is not quite like it was before until the second season of play (total 1-2 years after surgery). Occasionally you see exceptions to this, but on average this is what usually happens. In 85-90% of the time the knee does feel like a normal knee to the individual, but the big question is what happens over a much longer period of time, for example many years. Some researchers are questioning whether the operation as is currently done alters the knee mechanics so that over a long period of time there is a chance that more cartilage damage occurs, not less. There are no conclusive studies on this to date. This research is ongoing.

13) Do I need a brace when I go back to sports? This is not required. The operation stabilizes the knee so you do not need a brace, and there is no evidence to suggest that bracing prevents re-injury. Some people feel more 'secure' with a brace on and prefer to use one, but again, not required.

14) What happens if it tears again? If it does happen again to a previously operated knee, the reconstruction can be repeated, a process called 'revision ACL surgery'. Results the second time around are not quite as good.

For more information on ACL injuries and surgery, you can find that here
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1 comment:

  1. Thank you for sharing this post about sports medicine nyc. I'm sure many athletes would be glad to come across this post.