Are you an athlete who participates in sports that involve jumping or quick stopping? If so, you may be at risk of tearing your anterior cruciate ligament, or ACL. An ACL injury is one of the most common injuries suffered by athletes. ACL specialist, Dr. Mark Getelman provides diagnosis and both surgical and nonsurgical treatment options for patients in Los Angeles who have suffered an ACL injury. Contact Dr. Getelman’s team today!
An Overview on Anterior Cruciate Liagment Reconstruction (ACL Reconstruction)
The anterior cruciate ligament (ACL) is located in the front (anterior) of the knee and crosses (cruciate) in front of the posterior cruciate ligament (PCL). The ACL is responsible for providing knee stability during rotational movements or twisting actions. The ACL is the most commonly injured ligament in the knee joint in the athletic population. An ACL tear can occur from a sudden stop or change in direction, typically found in soccer, basketball, tennis, football and gymnastics. An ACL repair, typically an ACL reconstruction, is required in the majority of patients to return knee stability and function. Dr. Mark Getelman, knee surgeon, specializes in ACL surgery in patients living in the Van Nuys, Westlake Village, Thousand Oaks and Los Angeles, California communities.
Many patients who experience an ACL injury hear a “pop” and then experience knee pain, swelling and instability. The ACL does not heal on its own due to the ligament’s environment. An ACL reconstruction is usually recommended by Dr. Getelman to restore patient’s knee function and mobility. In older, less active patients, a physical therapy and rehabilitation program may be recommended instead of an ACL repair.
A surgical ACL repair is known as an ACL reconstruction and involves a new graft being placed along the course of the torn ACL. Dr. Getelman will begin ACL surgery by examining the knee joint to fully evaluate the extent of ligament damage. He will also view the other ligaments and surrounding structures to determine if additional damage is present. If other knee injuries are present, Dr. Getelman will typically plan to repair all injuries during the same ACL surgery.
Using an arthroscope and special instruments, Dr. Getelman will remove the damaged ligament and create bone tunnels for the new ACL. The ligament is then reconstructed using a graft similar in size to the native ACL. ACL reconstruction grafts include:
- Allograft: donor tissue is harvested from several sources including tibialis anterior or posterior, the Achilles tendon, or the patella, quadriceps tendon and used to reconstruct the damaged ACL.
- Autograft: The patient’s own tissue is harvested from his/her patellar tendon, hamstring or quadriceps tendon and is used to reconstruct the torn ACL.
It is important to note the ACL must be reconstructed rather than repaired due to its limited healing ability. It is also important the replacement graft is placed in the exact anatomic position of the original ACL to allow for proper healing and knee function. This is best approached through an accessory anteromedial portal which Dr. Getelman has championed and uses routinely. Dr. Getelman will discuss each patient’s injury and graft options, as well as the benefits and risks of each surgical option prior to ACL surgery.
ACL Reconstruction Repair Protocols
Following surgical ACL repair, a patient will be placed in a brace and instructed to use crutches for a brief period of time. Dr. Getelman will prescribe a detailed physical therapy program designed to increase range of motion, strengthen the knee joint and return overall joint mobility. A functional knee brace may be recommended by Dr. Getelman for return to sports in certain patients involved in athletic activities or active job requirements.
For additional information on an ACL reconstruction, or for more resources on non-surgical ACL repair, please contact the orthopedic office of Dr. Mark Getelman, knee surgeon located in the Van Nuys, Westlake Village, Thousand Oaks and Los Angeles,, California area.
ACL Reconstruction FAQ
What is ACL Reconstruction surgery?
ACL reconstruction surgery creates a new ligament to take the place of the torn ACL. Usually the new ligament will be constructed using tissue from somewhere else in the injured person’s body or from a donor. Surgery should be considered based on the symptoms (the degree of knee instability) the injury has caused and the examination findings by a doctor. The majority of ACL reconstruction surgeries are performed arthroscopically (by inserting instruments for surgery through a small incision made in the knee). And they are performed under regional (spinal) or general anesthesia by an orthopedic surgeon.
How is an ACL reconstruction done?
ACL reconstruction uses a graft taken from some part of the injured person’s body. Those sources are: the patellar tendon of the kneecap, which attaches the bottom of the kneecap, or patella, to the tibia (shin bone); a hamstring tendon, which connects the long muscles in the back of the leg to the back of the knee; and the quadriceps, the tendon at the front of the thigh (this is reserved for taller or heavier patients or patients who have had unsuccessful grafts). Another option is what’s called an allograft, which is tissue taken from a cadaver.
Once the tissue is procured, the tendon is outfitted with “bone plugs” (anchor points) that graft the tendon into the knee. In surgery, a small incisions is made in the front of the knee to fit an arthroscope (a thin tube with a fiber-optic camera and surgical tools). The arthroscope allows the surgeon to see inside the knee during the procedure. After removing the torn ACL, the surgeon will clean the area. The next step is to drill small holes into the tibia and femur so that bone plugs can be attached. The attaching devices are screws, posts, staples or washers. Once the new ligament is attached, the surgeon will test test the knee’s range of motion and tension to be sure the graft is securely in place. The opening will then be stitched, and the wound, dressed. The knee is also stabilized with a brace. Typically, the patient goes home the day of surgery.
When is ACL reconstruction surgery necessary?
A doctor may use the the Lachman’s test as one determinant of having ACL reconstruction surgery. While the patient lies flat, the doctor will bend the knee just slightly, at 15- to 20-degree angle. Next, the doctor stabilizes the thigh and pulls the shin forward. Between the shifting of the shin bone and the feel of the endpoint of movement, the doctor will learn how damaged the ACL is. Damaged ACLs may show more movement and less firm endpoint (the ligament may feel less solid or “soft”).
Doctors grade the results of the Lachman’s test on two criteria:
- The endpoint. If the endpoint is firm, that’s a sign that the ACL is limiting the amount of movement in the knee joint and is doing its job. A soft endpoint means that the ACL, and other secondary stabilizers, are not doing its job of limiting movement in the point. pivot-shift test.
- The amount of laxity (or movement) of the joint. That’s based on a comparison of the injured knee to the noninjured knee.
The measurements will determine if surgery is recommended.
Another widely used clinical test is the pivot-shift test, which tests for instability. It’s performed when the patient is relaxed, but reproducing that instability is unpleasant, it’s often done under general anesthesia. For this test, the patient lies flat with legs extended. While keeping internal rotation of the tibia (shin bone), the knee is slowly flexed to 25-30 degrees. The doctor will feel for a subluxation (or dislocation) of the lateral tibia as it moves back to normal position. The exam is conducted in three positions of rotation. If an anterior subluxation is felt during extension or tibia’s position on the femur reduces while the knee is flexed 30-40-degree, the ACL tests positive for instability and surgery will be recommended.
When to repair ACL
ACL repair is a treatment for a complete ligament tear that results in instability of the knee. Instability can be determined by performing the pivot-shift test or Lachman’s test. A torn knee ligament may prevent a person from doing normal activities that involve turning or twisting the knee. The knee may also buckle or “give way. There is also a risk that not addressed surgically, another injury will occur or degeneration of other structures in the knee. A repair surgery in only done in cases where there is an avulsion fracture (which is a separation of the ACL and a piece of the bone from the rest of the bone). In this surgery, the bone fragment connected to the ACL is reattached to the bone. This type of injury is more common in children than in adults. For best outcome of an avulsion fracture, repair surgery is performed as soon as possible.
How long does ACL repair last?
Success of ACL repair surgery depends on various factors. The repair involves stitching or suturing the torn ends together, and is only done when the ACL tears off from the tibial side along with a piece of bone. Surgery, usually arthroscopy (using a scope that allows the doctor to see inside the joints), combined with a post-operative rehab program to strengthen the knee is critical. The rehabilitation program may last as long as a year, but is also crucial to a successful, lasting outcome.
How long is ACL surgery recovery?
The recovery from ACL surgery varies depending on the patient, and is also influenced by the type of activities the patent wants to pursue. Rehabilitation plans also vary depending on the type of graft used in reconstruction surgery and any associated injuries (such as a tear to the meniscus). The surgery is often “out patient,” with the person discharged the same day. Some patients can start exercises to increase their range of motion and to regain their strength shortly after surgery. But complete recovery takes time. It may take 12 months for the ligament tissue to completely heal. Tissue taken from a cadaver graft generally takes longer to revitalize than tissue grafted from the patient’s own body. The week after surgery, patients are encouraged to do straight leg raises, without help, while lying on their backs. By the end of the second or third week, patients should be walking without crutches. Physical therapy often starts seven to 14 days after surgery. In the first three months post-surgery, accepted exercises are usually limited to riding a stationary bike and doing lightweight leg presses to strengthen the quadriceps. Generally swimming or running isn’t recommended for five months, possibly longer. This is all dependent on the extent of the injury and progress made during recovery.
When can I run after ACL surgery?
Recovery from ACL surgery starts as soon as the patient wakes up from surgery. Walking without crutches should begin as you are able to tolerate bearing weight, usually within the first two weeks. Physical therapy will start with core strengthening exercises, eventually progressing to stationary bike riding. But be aware of pain and swelling as a sign of limits to your progress. Depending on the level of strength and balance achieved thus far, you may be able to start jogging for slow, short distances (avoiding hills) at the 4-6 month mark, with the focus of adding time each week. After nine months and, most importantly, clearance from your orthopedic surgeon, you may be able to run up hills and stairs to build leg strength. However, running down hills and stairs may be restricted, as it could irritate the knee or cause a tear in the meniscus (a crescent-shaped structure, made of cartilage, that helps distribute body weight across the three bones in the knee joint).
ACL Reconstruction vs repair
Reconstruction and repair are used in very different situations. ACL reconstructive surgery is performed to repair a torn ACL and to regain stability and movement in the knee. It is not recommended in all situations that involve a damaged ACL. But it is recommended for patients who young and active, suffer from persistent knee pain; experience chronic knee instability (buckling during normal activities such as walking) and those who want to return to an active athletic level. Because the tear(s) cannot be stitched together, an orthopedic surgeon replaces the ligament with one of two types of tissue grafts — an autograft taken from one’s own body, or an allograft, which comes from donated cadaver tissue.
ACL repair surgery is usually only performed when there is an avulsion fracture, which means the ligament and a piece of the bone has separated from the rest of the bone. The surgery’s goal is to reattach the bone fragment to the bone.
ACL Reconstruction vs conservative treatment
There are pros and cons to each option. Some people with ACL injuries who have had reconstruction surgery develop arthritis of the knee 10 years after that surgery. Instead of surgery, a proportion of patients will do well with rehabilitation or physiotherapy, which helps people affected by an injury through movement and exercise. They may still have instability (the sensation that the knee “gives way” or buckles) but can manage those symptoms by modifying their lifestyles — in other words, changing their activity levels.
The risks and benefits of reconstruction surgery can depend on the type of graft and reconstructive procedure used. The surgery’s success may also be more dependent on the skills of the surgeon. Surgery may not be the right choice for someone who has other medical conditions that pose risks to surgery.
ACL Reconstruction vs Knee Replacement
Knee replacement surgery is performed when pain in the knee joint can no longer be controlled in non-operative ways. In this case, the surgeon removes the damaged surface of the joint and replaces it with an implant made of metal and plastic that will function as a new joint. The kneecap surface may also be replaced if the cartilage underneath is damaged. Knee replacement surgery is often seen as a last resort, for patients who’ve tried everything but surgery and still have significant pain while going about their daily routine. The problems that lead to knee replacement are chronic osteoarthritis and rheumatoid arthritis, but damage from an infection or injury can also lead to the need for a replacement knee.
Typically the events leading to ACL reconstruction are injury-related. For instance, sports that require landing and pivoting (such as basketball, football, skiing, soccer and gymnastics) and falling off of a ladder, jumping off a curb, stepping into a hole or missing a step when descending a flight of stairs. The procedure for an ACL reconstruction involves creating a new ligament with one of two types of tissue grafts (either from another part of the patient’s body or from cadaver tissue).
Patellar Tendon ACL Reconstruction vs Hamstring
When the ACL is surgically reconstructed, a graft of tissue is used to make a new ligament. That graft comes from different sources. If the tissue comes from the patient’s own body, the two common options are the patellar tendon and the hamstring tendon.
- Patellar tendon: The advantages of a graft from the patellar tendon (the structure on the front of the knee that connects the kneecap to the tibia, or shin bone) is that it most closely resembles the ACL. The length is roughly the same as the ACL, which means the bone ends of the graft can be placed into the bone where the ACL attaches, allowing for the desired “bone to bone” healing. The disadvantage to this kind of graft is the risk of post-surgery patellar fracture or a tear of the patellar tendon. Most commonly, the side effect in the patient is pain in the front of the knee.
- Hamstring tendon: In ACL surgery, two of the tendons of these muscles on the back of the thigh are removed and “bundled” together to form a new ligament. Unlike with the patellar tendon and the pain that can result in the front of the knee, the hamstring tendon is believed to result in much less pain. On the down side, it takes longer for a hamstring graft to become “rigid” and fixation can be affected by post-operative motion. In this situation, a brace is often used to immobilize the knee for a week or two after surgery.
What causes ACL Reconstruction Failure? When ACL surgery goes wrong. When ACL surgery fails. (only need one answer for this since they are all asking the same thing)
There are several causes of failure related to reconstruction of the ACL.
- Precise placement of the tunnels drilled for the placement of the graft is crucial. A slight variation of the tunnels drilled for the graft can create abnormal stresses and lengthen the graft. This can result in excessive laxity (looseness) and decreased range of motion.
- The failure of “fixation”: The fixation choice depends on the type of graft used. The fixation needs to secure the graft tissue in place, while the graft then becomes part of the bone tissue.
- Graft impingement: Caused by placement, the graft can be compromised, increasing the graft’s length and creating more wear, and ultimately, failure. The patient will experience decreased range of motion.
- Intrinsic graft failure: This can come from impingement or trauma. Immunologic reaction to an allograft (from cadaver tissue) can also weaken the graft and cause failure.
- Anthrofibrosis: This is the formation of scar tissue after both the injury and surgery that can lead to decreased range of motion.
- Trauma, which can cause excessive impact on the graft before it has fully healed. Significant trauma to the graft after it has healed can also cause failure.