ACL Reconstruction

Dr. Rahul Damle – ACL Reconstruction Specialist

Introduction

The Anterior Cruciate Ligament (ACL) is a major stabilizer of the knee joint. This key knee ligament is commonly torn during sports activities and road traffic accidents.

When the anterior cruciate ligament (ACL) in the knee is torn or injured, surgery will be most often needed to replace it. There are many different ways to do this operation. One is to take a piece of the hamstring tendon from behind the knee and use it in place of the torn ligament. The hamstring graft has nearly the same strength as other available grafts used to reconstruct the ACL.

Anatomy

Ligaments are tough bands of tissue that connect the ends of bones together.The ACL is located in the center of the knee joint where it runs from the backside of the femur (thighbone) to the front of the tibia (shinbone).The graft used in ACL reconstruction is taken from the hamstring tendon (semitendinosus) along the inside part of the thigh and knee. Also commonly included is a tendon just next to the semitendinousus, called the gracilis.

Symptoms

Patients with a deficient ACL have a feeling of insecurity and giving way of the knee, especially when trying to change direction on the knee. The knee may feel like it wants to slip. This will lead to pain and swelling in the affected knee.

Rationale

The main goal of ACL surgery is to keep the tibia from moving too far forward under the femur bone and to get the knee functioning normally again.
This helps to prevent instability and buckling of the knee while running / pivoting etc.
This prevents further injuries to the knee eg. Meniscal tears, cartilage injuries etc, which can predispose the knee to develop osteoarthrosis at a younger age than otherwise !
There are two grafts commonly used to repair a torn ACL.
One is a strip of the patellar tendon below the kneecap (called a BTB graft)
The other is the hamstring tendon graft.

Surgical Procedure

This surgery is usually performed arthroscopically. Only small incisions are needed during arthroscopy for this procedure. The surgery doesn’t require the surgeon to open the knee joint.

A small incision about 3-4 cm is also made along the inside edge of the knee, just over where the hamstring tendons attach to the tibia. Working through this incision, the surgeon takes out the semitendinosus and gracilis tendons.
The tendons are quadrupled, which increases the strength of the graft. The surgeon stitches them together to hold them in place.
Next, the surgeon prepares the knee to place the graft. The remnants of the original ligament are removed. Holes are then drilled in the tibia and the femur to place the graft. These holes are placed so that the graft will run between the tibia and femur in the same direction as the original ACL. The graft is then pulled into position through the drill holes. Screws and Endobuttons / Tightropes are used to hold the graft inside the drill holes.

Complications

As with all major surgical procedures, complications can occur.
Some of the most common complications following hamstring tendon graft reconstruction of the ACL are
1. Thrombophlebitis /DVT
2. Infection
3. Problems with the graft
After surgery, the body attempts to develop a network of blood vessels in the new graft. This process, called revascularization, takes about 12 weeks. The graft is weakest during this time, which means it has a greater chance of stretching or rupturing if pushed too hard !

After Surgery

Each patient will have an individualized physiotherapy program depending upon other concomitant injuries & reconstructions done .
You may be given a continuous passive motion (CPM) machine immediately afterward to help the knee begin moving and to alleviate joint stiffness.
Most patients stay one night in the hospital Post-operatively. The tube placed in your knee at the end of the surgery is usually removed after 24 hours.
You will wear a protective knee brace for a few weeks after surgery. You’ll use crutches for two to four weeks in order to keep your knee safe, but you’ll probably be allowed to put a comfortable amount of weight down while you’re up and walking.

Rehabilitation

Patient-specific exercises are designed to help control the pain and swelling from the surgery. The goal is to help you regain full knee extension as soon as possible.
The physical therapist will choose treatments to get the thigh muscles toned and active again.
Patients are cautioned about overworking their Quadriceps in the first six weeks after surgery.
As the rehabilitation program evolves, more challenging exercises are chosen to safely advance the knee’s strength and function. Specialized balance exercises are used to help the muscles respond quickly and without thinking. This part of the treatment is called neuromuscular training.
When you get good knee movement, your knee isn’t swelling, and your strength and muscle control are improving, you’ll be able to gradually go back to your work and sport activities. Some surgeons prescribe a functional brace for athletes who intend to return quickly to their sports.
Ideally, you’ll be able to resume your previous lifestyle activities. However, most athletes are usually advised to wait at least 6 months before returning to their sports.