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- Question: Who needs operative treatment?
Answer: Younger and/or active patients who are unwilling, or unable, to modify their activities, such as eliminating cutting and pivoting sports.
Additionally, patients with instability while performing non-strenuous activities, or activities of daily living, do not do well with non-operative treatment.
The majority of patients with injuries to multiple knee ligaments have better outcomes with operative treatment.
Rehabilitation following ACL surgery takes considerable commitment from the patient to help ensure a good surgical outcome. A specific recovery timeline will be outlined by the surgeon and physical therapist. Patient willingness to follow the protocols is critical to the success of the procedure.
- Question: How long after the injury should the surgery be performed?
Answer: In order to prevent post-operative stiffness and obtain optimal results, the timing of ACL reconstruction is important. Surgery should be delayed until the patient?s initial inflammation has subsided. Three important signs which demonstrate this are:
Adequate Range of Motion
Functional quadriceps musculature
Reduced Swelling
In order for all three requirements to be met, it typically takes three weeks of physical therapy pre-operatively.
- Questions: Are there different types of surgeries for ACL injuries?
Answer: Yes, there are three different fundamental types of procedures:
Direct repair
Extra-articular procedures
ACL reconstruction
Double-Bundle Reconstruction
The direct repair method sutures the torn ends of the ligament back together in an attempt to promote healing. However, the ligament does not heal reliably, if at all. For this reason the procedure has largely been abandoned.
As the term implies, extra-articular means outside the joint. In this type of procedure knee stability is attempted to be regained without reconstructing the torn ACL. Instead, a portion of a tendon outside the knee (typically the iliotibial band) is secured across the knee joint in order to increase knee stability. However, because the location of the tendon is outside the joint, it is unable to perform the same biomechanical function as the ACL. Therefore, the stability provided by the procedure is either not adequate or interferes with normal knee functions. Like the direct repair method, the results of the procedure are inferior to an ACL reconstruction. There are some rare occasions where surgeons will need to use this technique.
Currently the standard operative treatment for an ACL injury is an ACL reconstruction. This procedure replaces the torn native ACL with another form of soft tissue called a graft. The graft is obtained from somewhere else in the body. ACL reconstruction has consistently demonstrated the best results of all operative techniques used for ACL injuries and is considered the standard.
- Question: What exactly is an ACL reconstruction?
Answer: An ACL reconstruction is a surgical procedure that involves replacing the patient?s damaged ACL with a graft. A graft is another form of soft tissue, typically a tendon from somewhere else in the body. The graft can either come from the patient (called an autograft) or the graft can be donated by another person (called an allograft) at the time of death.
Regardless of whether the graft used is autograft or allograft, the purpose of the graft is to replace the patient?s damaged ACL and provide the same type knee stability as a real ACL. This is accomplished by placing the new ACL graft in the same anatomic location and orientation as the patient?s damaged ACL.
Recreating the anatomy of the original ACL involves first removing the damaged ACL and next drilling tunnels in the both the tibia and the femur. These tunnels need to be in the exact orientation of the natural ACL, in order to ensure that the newly placed graft will act in the same manner as the original ACL. The tunnels serve to place the ACL graft in the proper orientation and as a point of fixation of the graft to bone.
Initially, after a new ACL graft has been placed in correct position, i.e., spanning the inside of the knee joint and inside tunnels on both sides of the knee joint, the graft must be fixed in position. This is typically accomplished with screws or some other sturdy device. Regardless of the type of fixation used, the device plays only a temporary role until the graft has healed to the insides of the tunnels. Once this is accomplished, the initial fixation device no longer serves a purpose, because the ultimate strength comes from the soft tissue graft healing to the surrounding bone tunnels. This process takes several months to be complete.
- Question: What types of grafts are commonly used for ACL reconstructions?
Answer: The two most commonly used grafts to replace the ACL are the patellar tendon and the hamstrings.
The patellar tendon is the tendon that connects the patella (the knee cap) to the tibia. Its function is to connect the large quadriceps muscle to the tibia by way of the patella. It is therefore an excellent graft source because it is large and strong. Additionally, it is obtained with bone ends attached to the patella and the tibia, which allow for bone-to-bone healing at the graft tunnel interface. Bone-to-bone healing is the fastest and strongest healing in the body, which has made this graft a very popular choice. The disadvantages include increased post surgical pain, increased incidence of ?frontal knee pain? during rehabilitation, as well as long term pain when kneeling.
Another popular graft choice is the hamstring graft. This graft uses multiple strands of the smaller hamstring tendons (the semitendonsis and the gracilis tendons) to create a very strong composite graft. The benefits of a hamstring graft are typically a less painful harvest technique, a smaller more cosmetic incision, and less chance of anterior knee pain. The disadvantages include slower healing secondary to tendon-to-bone healing versus bone-to-bone, and thus one is more susceptible to accidental damage of the repair in the first six to eight weeks after surgery.
Another popular graft is an Allograft or cadaver graft. This involves taking tissue from a cadaver to make the new ACL. The advantage of using this technique is that you don?t have to "borrow" or "take" tissue from another area of the injured knee. Thus, there is less postoperative pain and a quicker recovery from surgery. The disadvantage is that there is a theoretical risk of disease transmission (because you are getting the material from outside the body). While the federal government has very strict criterion for disease testing, nothing is ever 100 percent guaranteed. There also have been cases of bacterial infection resulting from Allograft use.
Another graft technique which is less popular is the quadriceps tendon graft. The quadriceps tendon connects the quadriceps muscle to the patella. Therefore, the graft has soft tissue at one end and bone at the other end. It is a viable graft alternative, but its inconsistency in size and post-operative morbidity (loss of quadriceps strength) make it a clear back up choice.
- Question: Which graft is better, autograft or allograft?
Answer: The autograft is currently considered the standard graft choice by the majority of orthopaedists. This is because the patient's own tissues heal more reliably and faster than allograft tissue. However, there are a multitude of long-term studies that show allograft reconstructions to be equal to those done with autograft tissue.
- Question: When should allograft tissue ever be used?
Answer: Other than patient preference, there are some situations when allograft tissue is the first choice:
Patients with multiple previous knee surgeries, who do not have sufficient tissue available for grafting
Patients with multiple ligament injuries that need to be reconstructed
Patients who want the least amount of pain and downtime after surgery
Older patients who would benefit from the least amount of surgical trauma
- Question: What is the best type of fixation to secure the graft to bone?
Answer: There are several choices for graft fixation. Common examples include: screw/washers; interference screws; cross pins; and endobuttons. Fixation devices may also be absorbable or non-absorbable (metal). The fixation device chosen depends mostly on the graft choice used for the reconstruction, both of which are typically surgeon dependent. Currently, there is no single best answer, and it is generally believed that the best graft choice and fixation is whatever the surgeon feels most comfortable with and has had the most success with in the past.
- Question: Does the graft have to be human tissue?
Answer: Grafts made of synthetic materials have been studied in the past and have resulted in poor outcomes. Complications included both early failure rates and adverse reactions to the implanted material. For these reasons, and others, synthetic graft reconstructions have been abandoned and are no longer performed.
- Question: Are all ACL reconstructions done arthroscopically?
Answer: To some extent, yes. Open ACL reconstructions are generally not performed today in the United States. In some circumstances, such as revision cases or cases involving simultaneous multiple ligament reconstructions, portions of the procedures need to be performed open. However, for a first time ACL reconstruction, the surgery is almost always done arthroscopically, where the surgeon performs the reconstruction while visualizing surgery through the arthroscope.
- Question: Are there different types of Arthroscopic ACL reconstructions?
Answer: Yes, there are two main types: the single incision and the double incision technique. Both surgeries are fundamentally the same and produce the same results. The difference exists in how a surgeon drills the tunnel in the femur, and the number incisions in the knee.
- Question: Is ACL surgery out-patient or in-patient surgery?
Answer: ACL reconstructions can be performed in either setting, but the majority of cases currently performed today are in the out-patient setting.
- Question: What type of anesthesia is used for the procedure?
Answer: Usually a general anesthesia is used, but because of the short duration of the surgery (usually one hour or less) the patient is not paralyzed. A regional (or nerve block) is also used in addition to help with post-operative pain. Spinal anesthesia is also an option. The choice is usually a decision made between the anesthesia physician and the patient.
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