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Anterior Cruciate Ligament (ACL) Reconstruction
:: Introduction
The anterior cruciate ligament is one of the major stabilizing ligaments
in the knee. It is a strong rope like structure located in the centre of the
knee running from the femur to the tibia.
When this ligament tears unfortunately it doesn't heal and often leads
to the feeling of instability in the knee.
ACL reconstruction is a commonly performed surgical procedure and
with recent advances in arthroscopic surgery can now be performed
with minimal incisions and low complication rates.
:: Function
The ACL is the major stabilizing ligaments in the knee. It prevents the
tibia (Shin bone) moving abnormally on the femur (thigh bone). When
this abnormal movement occurs it is referred to as instability and the
patient is aware this abnormal movement.
Often other structures such as the meniscus, the articular cartilage
(lining the joint) or other ligaments can also be damaged at the same
time as a cruciate injury & these may need to be addressed at the time
of surgery.
:: History of Injury
- Most injuries are sports related involving a twisting injury to the knee.
- It can occurs with a sudden change of direction, a direct blow e.g., a tackle, landing awkwardly,
- Often there is a popping sound when the ligament ruptures
- Swelling usually occurs within hours
- There is often the feeling of the knee popping out of joint.
- It is rare to be able to continue playing sport with the initial injury.
Once the initial injury settles down the main symptom is instability or
giving away of the knee. This usually occurs with running activities but
can occur on simple walking or other activities of daily living.
:: Diagnosis
The diagnoses can often be made on the history alone.
Examination reveals instability of the knee, if adequately relaxed or not
too painful.
An MRI (Magnetic Resonance Imaging) can be helpful if there is doubt as
well as to look for damage to other structures within the knee.
At times the final diagnoses can only be made under anaesthetic or
with an Arthroscopy.
:: Treatment
Initial
- Rest
- Ice
- Elevation
- Bandage
Long term
Not everyone needs surgery. Some people can compensate for the
injured ligament with strengthening exercises or a brace.
It is strongly advised to give up sports involving twisting activities, if you have an ACL injury.
- Episodes of instability can cause further damage to important structures within the knee that may result in early arthritis.
:: Indications for surgery
- Young patients wishing to maintain an active lifestyle.
- Sports involving twisting activities e.g., Soccer, netball, football
- Giving way with activities of daily living.
- People with dangerous occupations e.g., Policemen, firemen, roofers, scaffoulders.
- It is advisable to have physiotherapy prior to surgery to regain
motion and strengthen the muscles as much as possible.
:: Surgery
Surgical techniques have improved significantly over the last decade, complications are reduced and recovery much quicker than in the past.
The surgery is performed arthroscopically. The ruptured ligament is
removed and then tunnels (holes) in the bone are drilled to accept the
new graft. This graft which replaces your old ACL is taken either from
the hamstring tendon or the patella tendon. There are advantages &
disadvantages of each with the final decision based on surgeons preference.
The graft is prepared to take the form of a new tendon and passed
through the drill holes in the bone.
The new tendon is then fixed into the bone with various devices to hold
it into place while the ligament heals into the bone (usually 6 months)
The rest of the knee can be clearly visualized at the same time and any
other damage is dealt with e.g., meniscal tears
The wounds then closed often with a drain and a dressing applied.
:: Post op
Surgery is performed as a day only procedure or an overnight stay.
You will have pain medication by tablet or in a drip (Intravenous)
Any drains will be removed from the knee.
A splint is sometimes used for comfort
You will be seen by a physiotherapist who will teach you to use crutches and show you some simple
exercises to do at home.
Leave any waterproof dressings on your knee until your post-op review.
You can put all your weight on your leg
Avoid anti-inflammatories or aspirin for 10 days.
Put ice on the knee for 20 minutes at a time, as frequently as possible.
Post-op review will usually be at 7-10 days
Physiotherapy can begin after a few days or can be arranged at your first
post-op visit.
If you have any redness around the wound or increasing pain in the knee
or you have temperature or feel unwell, you should contact your surgeon as soon as possible.
:: Rehabilitation
Physiotherapy is an integral part of the treatment and is recommended
to start as early as possible. Preoperative physiotherapy is helpful to
better prepare the knee for surgery. The early aim is to regain range of
motion, reduce swelling and achieve full weight bearing.
The remaining rehabilitation will be supervised by a physiotherapist and
will involve activities such as exercise bike riding, swimming, proprioceptive exercises and muscle strengthening. Cycling can begin at 2 months,
jogging can generally begin at around 3 months. The graft is strong
enough to allow sport at around 6 months however other factors come
into play such as confidence, fitness and adequate fitness and training.
Professional sportsmen often return at 6 months but recreational athletes
may take 10 -12 months depending on motivation and time put into
rehabilitation.
The rehabilitation and overall success of the procedure can be affected
by associated injuries to the knee such as damage to meniscus, articular
cartilage or other ligaments.
The following is a more detailed rehabilitation protocol useful for patients
and physiotherapists. It is a guide only and must be adjusted on an
individual basis taking into account pain, other pathology, work and other
social factors.
ACUTE (0 - 2 WEEKS)
GOALS
1. wound healing
2 reduce swelling
3 regain full extension
4 full weight bearing
5 wean off crutches
6 promote muscle control
TREATMENT GUIDELINES
1 Pain and swelling reduction with ice, intermittent pressure pump, soft
tissue massage and exercise
2 patella mobilisation
3 active range of motion knee exercises, calf and hamstring stretching, contraction (non weight bearing progressing to standing), muscle control
and full weight bearing. Aim for full extension by 2 weeks. Full flexion will
take longer and generally will come with gradual stretching. Care needs to
be taken with hamstring co contraction as this may result in hamstring
strains if too vigorous. Light hamstring loading continues into the next
stage with progression of general rehabilitation. Resisted hamstring
loading should be avoided for approximately 6 weeks.
4 gait retraining encouraging extension at heel strike
STAGE 2- QUADRICEPS CONTROL (2-6 WEEKS)
GOALS
1 full active range of motion 2 normal gait with reasonable weight tolerance
3 minimal pain and effusion
4 develop muscular control for controlled pain free single leg lunge
5 avoid hamstring strain
6 develop early proprioceptive awareness
TREATMENT GUIDELINES
1 use active, passive and hands on techniques to promote full range of
motion
2 progress closed chain exercises (quarter squats and single leg lunge) as
pain allows. The emphasis is on pain free loading, VMO and
gluteal activation
3 introduce gym based exercise equipment including leg press and
stationary cycle
4 water based exercises can begin once the wound has healed,
including treading water, gentle swimming avoiding breaststroke
5 begin proprioceptive exercises including single standing leg balance
on the ground and mini tramp. This can progress by introducing body
movement whilst standing on one leg
6 bilateral and single calf raises and stretching
7 avoid isolated loading of the hamstrings due to ease of tear. Hamstrings
will be progressively loaded through closed chain and gym based activity
STAGE 3- HAMSTRING/QUADRICEPS STRENGTHENING (6-12 WEEKS)
GOALS
1 begin specific hamstring loading
2 increase total leg strength
3 promote good quadriceps control in lunge and hopping activity in
preparation for running
TREATMENT GUIDELINES
1-Focal hamstring loading begins and is progressed steadily throughout
the next stages of rehabilitation
a) Active prone knee flexion which can be quickly progressed to include a
light weight and gradually increasing weights
b) Bilateral bridging off a chair. This can be progressed by moving onto a
single leg bridge and then single leg bridge with weight held across the
abdomen
c) Single straight leg dead lift initially active with increasing difficulty by
adding dumbbells
With respect to hamstring loading, they should never be pushed into
pain and should be carefully progressed. Any subtle strain or tightness
following exercises should be managed with a reduction in hamstring
based exercises
2-Gym based activity including leg presses, light squats and stationary
bike which can be progressively increased in intensity as pain and control
allow. It is important to monitor any effusions following exercise
and if it is increasing then exercise should be toned down
3-Once single leg lunge control is comparable to the other side hopping
can be introduced. Hops can be made more difficult by including variations
such as forward/back, side to side off a step and in a quadrant
4-Running may begin towards the latter part of this stage.
Prior to running certain criteria must be met
- No anterior knee pain
- A pain free lunge and hop that is comparable to the other side
- The knee must have no effusion
- Before jogging start having brisk walks, ideally on a treadmill to
monitor landing action and any effusion. This should be done for
several weeks before jogging properly.
5-Increased proprioceptive manoeuvres with standing leg balance
and progressive hopping based activity
6) Expand calf routine to include eccentric loading
STAGE FOUR-SPORT SPECIFIC (3-6 MONTHS)
GOALS
1-improve leg strength
2-develop running endurance speed, change of direction
3-advanced proprioception
4-prepare for return to sport and recreational lifestyle
TREATMENT GUIDELINES
1-Controlled sport specific activities should be included in the progression
of running and gym loads. Increasing effusion post running that isn't easily
managed with ice should result in a reduction in running loads
2-Advanced proprioception to include controlled hopping and turning
and balance correction
3-Monitor potential problems associated with increasing loads
4-No open chain resisted leg extension exercises unless authorised by
your surgeon
STAGE FIVE-RETURN TO SPORT (6 MONTHS PLUS)
GOALS
A safe return to sporting activities
TREATMENT GUIDELINES
1-Full training for 1 month prior to active return to competitive sport
2-Preparation for body contact sports. Begin with low intensity one on
one contests and progress by increasing intensity and complexity in preparation for drills that one might be expected to do at training
3-To improve running endurance leading up to a normal training session
4-Full range, no effusion, good quadriceps control for lunge, hopping and
hop and turn type activity. Circumference measures of thigh and calf to
within 1 cm of other side.
:: Risks & Complications
Complications are not common but can occur. Prior to making the decision
of have this operation. It is important you understand these so you can
make an informed decision on the advantages and disadvantages of surgery.
These can be Medical (Anaesthetic) complications and surgical complications
Medical (Anaesthetic) complications
Medical complications include those of the anaesthetic and your general
well being. Almost any medical condition can occur so this list is not
complete. Complications include
- Allergic reactions to medications
- Blood loss requiring transfusion with its low risk of disease transmission
- Heart attacks, strokes, kidney failure, pneumonia, bladder infections.
- Complications from nerve blocks such as infection or nerve damage.
- Serious medical problems can lead to ongoing health concerns, prolonged hospitalization.
The following is a list of surgical complications. These are all rare but can
occur. Most are treatable and do not lead to long term problems.
Infection
Approximately 1 in 200. Treatment involves either oral or antibiotics
through the drip, or rarely further surgery to wash the infection out.
Deep vein thrombosis
These are clots in the veins of the leg. If they occur you may need blood
thinning medication in the form of injections or tablets. Very rarely they
can travel to the lung (Pulmonary Embolus) which can cause breathing
difficulties or even death.
Excessive swelling & Bruising
This is due to bleeding in the soft tissues and will settle with time.
Joint stiffness
Can result from scar tissue within the joint, and is minimized by advances
in surgical technique and rapid rehabilitation. Full range of movements
cannot always be guaranteed.
Graft failure
The graft can fail the same as a normal cruciate ligament does. Failure
rate is approximately 5%. If the graft stretches or ruptures it can still be
revised if required by using tendons from the other leg.
Damage to nerves or vessels
These are small nerves under the skin which cannot be avoided and
cutting then leads to areas of numbness in the leg. This normally reduces
in size over time and does not cause any functional problems with the
knee. Very rarely there can be damage to more important nerves or
vessels causing weakness in the leg.
Hardware problems
All grafts need to be fixed to the bone using various devices (hardware)
such as screws or staples. These can cause irritation of the wound and
may require removal once the graft has grown into the bone.
Donor site problems
Donor site means where the graft is taken from. In general either the
hamstrings or patella tendon are used. These can be pain or swelling in
these areas which usually resolves over time.
Residual pain
Can occur especially if there is damage to other structures inside the knee.
Reflex Sympathetic Dystrophy
An extremely rare condition that is not entirely understood, which can cause unexplained and excessive pain.
:: Summary
Anterior Cruciate Ligament reconstruction is a common and very
successful procedure. In the hands of experienced surgeons who perform
a lot of these procedures 95% of people have a successful result. It is
generally recommended in the patient wishing to return to an active
lifestyle especially those wishing to play sports involving running and twisting.
The above information hopefully has educated you on the choices available
to you, the procedure and the risks involved. If you have any further
questions you should consult with your surgeon.
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Copyright
© Dr. Roger Brighton- Orthopaedic Surgeon Sydney Australia.