Arthroscopic Ligament Surgery

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What is ACL?

Inside the knee, there are two enormous ligaments that cross deep inside the joint, each about the size of your little finger. The Anterior Cruciate Ligament (ACL) and posterior cruciate ligament (PCL) connect the femur (thigh bone) to the tibia (shin bone) (shin bone). They serve to stabilize the knee and allow it to glide through a smooth range of motion as you bend and straighten the leg. The ACL is the ligament in the front and the
one most commonly injured.

ACL is one of the important ligaments present in the knee joint. It is present within the joint in the anterior (front) aspect of the knee joint. It prevents the leg bone (tibia) from moving forwards.

Why is it important?

Without the ACL the knee is less stable. Without its stabilizing influence, the knee can buckle suddenly as it is used and this leads to meniscal injury, cartilage damage, and eventually arthritis.

Usually, there is no problem with “straight-ahead” activities such as walking or jogging. It can, however, be a significant issue in athletic, daily, recreational, and work-related activities that require twisting, turning, jumping, climbing stairs, or abruptly changing direction. Examples of these activities include most sports (especially basketball, football, volleyball, etc.) and many jobs (such as carpentry, warehouse, refinery, etc.).

Is anything else damaged inside my knee?

When the ACL is ruptured, the meniscus cartilage inside the knee is damaged around half of the time. Additionally, there can be damage to the articular cartilage the cartilage stuck on the ends of the bone from a shear force. If present, these injuries are something that can be taken care of at the same time ACL surgery is performed. On examination, you can typically identify if there is a torn cartilage, but this can be difficult in some cases. An MRI study can assist in the diagnosis of associated injuries when performed in conjunction with a thorough history and physical exam.

What would happen if I did nothing about this injury?

The pain and swelling usually fade away within weeks of tearing the ligament, and the knee begins to move normally. The knee usually starts to feel nearly normal. The problem comes when you try to twist the knee as in jumping, climbing stairs, sports, etc. Without the stabilizing influence of the ACL, it will likely buckle and give way.

Patients usually end up with a “trick knee” that gives way (unstable) unexpectedly. The problem with this (beyond the embarrassment) is that with each episode of buckling, the meniscus and the cartilage are damaged leading to arthritis. Some people who elect to live less active lives (no jumping, cutting, pivoting, running sports) can get by without this ligament. Currently, the correct way to treat the injury is with reconstructive surgery, if you plan to remain active or have an unstable knee with episodes of your knee “giving out” or “buckling” during any activity.

How is the ligament fixed?

U have to undergo arthroscopic (keyhole) surgery to restore the normal function of the ACL and in turn knee joint. Tunnels are made in the thigh and leg bone arthroscopically and graft is passed through these tunnels and fixed with buttons or screws. There are three main choices for the graft to reconstruct the torn ACL. The center third of the patellar tendon (which runs from the knee cap to the shin bone), two hamstring tendons (which run behind the thigh), or a tendon from an organ donor are all options.

Do the screws ever come out?

Almost never. They are actually inside the bone and rarely cause any discomfort.

Doesn’t this weaken the hamstrings/patellar tendon?

There are five hamstring tendons. I use two. The remaining three compensate by getting stronger and there is a chance that the two tendons re-grow so you won’t miss them. If I use the patellar tendon, the remaining portion is strong enough while scar tissue fills in the defect.

Will I need a brace?

This reconstruction is strong enough that you rarely need a brace for more than a few weeks to a month. There are a couple of exceptions.

The most common occurrence is when both the MCL (on the inside of the leg) and the ACL (on the outside of the leg) are torn at the same time.

When the MCL and ACL are ruptured together, patients must wear a brace for four to six weeks. I often recommend a “sports brace” for the later stages of physical therapy and for sporting activities for the first year after surgery, much like many football players wear on the field.

When can I walk on my leg after surgery?

If there was no meniscus repair, then you walk the same day as the surgery as long as your leg is in the brace and straight.

Will I need rehab or physical therapy?

Yes, this is very important. The likelihood of regaining normal knee function following surgery is considerably boosted by effective rehabilitation. In fact, it takes a great commitment from the patient to get to the therapist and do the exercises with the appropriate diligence. It is also important to do only the correct exercises, as doing the wrong exercises can be more damaging than doing none at all. Unless otherwise instructed, you should start supervised physical therapy a few days after your surgery. First and foremost, we aim to reduce swelling, then PT will focus on restoring your full range of motion and performing some strengthening exercises. As your motion improves, more emphasis is placed on strengthening.

ACL Reconstruction Rehabilitation Protocol:

The following is the expected progress of your recovery after ACL, reconstruction:

Hospitalization : 1 day
Bed rest : Only for one day, on the day of surgery.: From 2nd day of the operation, you will be able to go to the toilet with the support of one crutch
Up and about in the house : For two weeks after surgery, you will be required to be in the house with a crutch
Out of the house for a sitting job : From 3rd week with the help of a hinged knee brace.
Car driving : After 4 weeks.
Stair climbing : One foot at a time 3 weeks. Normal after 6 weeks
Fieldwork : After 8 weeks
Jogging : After 3 months
Running : After 4 months
Light sports : After 6 months
Unrestricted sports : After 1 year

A gradual workout program is necessary following ACL surgery. During your post-operative appointments, we will teach you the exercises appropriate to your level of recovery. Depending on your needs, you will need to perform these exercises at home for 3-4 months. Most patients respond well to home therapy programs; however, some require more frequent visits to our therapist.

The following are the anticipated recovery objectives:

• 2 weeks to make the knee totally straight (not even slightly bent).
• To minimize knee swelling for 3 weeks, aspiration of fluid from the knee may be required.
• To bend the knees up to 90 degrees in three weeks and fully in six weeks.
• It takes 1-6 months to strengthen the muscles around the knee joint.

What should I do to prepare my knee for surgery?

The amount of swelling and stiffness you have after surgery is proportional to how much swelling and stiffness you had prior to surgery. To put it another way, it’s critical to get rid of as much swelling and stiffness as possible before surgery. If your knee injury is old, it may bend well and have no swelling, indicating that you’re ready for surgery. When a fresh injury occurs, there is usually a lot of swelling and stiffness, and you’ll require “prehab” to get your knee ready for surgery. This consists of exercises and ice to ensure that your knee is in the greatest possible condition for surgery (full range of motion and no swelling). Prehab is particularly advantageous because it allows you to become acquainted with some of the exercises you’ll be undertaking in the early postoperative period.

When will I be able to return to work?

This is determined by the type of work you undertake. Deskwork can usually be resumed after three to five days. When you feel comfortable, jobs that require a lot of walking can normally be resumed after two or four weeks.
It normally takes a few weeks before you are able to drive safely. For up to three months, you won’t be able to climb or push/pull big loads. Those jobs should be avoided for the time being. Again, because everyone is different, all of this is subject to change.

Risks of Surgery (possible, but still rare):

  • The most common issue is stiffness. That is why, prior to surgery, I want your knee to be flexible with full knee movements. When your therapy is over, I fully expect you to regain your normal range of motion.
  • Blood clots are also a possibility, but they are uncommon (less than 1 percent ). This risk is also reduced by keeping your leg flexible. If we discover additional risk factors (smoking, birth control pills, past clots or phlebitis, etc.) based on your age and history, we will prescribe a blood thinner.
  • Infection is also uncommon, but it is conceivable (less than 1 percent ). To avoid this, we sterilize your leg and administer antibiotics.
  • The graft can be stretched or torn again. Because the graft is weak for the first six months, you should avoid twisting or cutting activities. You can still tear the graft once it has matured.

As arthroscopic knee and shoulder surgery is my specialty, I am convinced that by working together, we will be able to design a knee that will allow you to resume your chosen activities.

Schedule of visits for Therapy:

One appointment prior to surgery for an evaluation and to learn about the rehabilitation process. Therapy should be done under supervision three times a week for the first six weeks after surgery, then once a week for the next six weeks.

Note: The preceding information gives you an idea of how long it will take you to recuperate from surgery. The rate of progress varies from one patient to the next.

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