Arthroscopic Ligament Surgery
Patient education for ACL Reconstruction
What is ACL?
ACL is the short name for a ligament of the knee called Anterior Cruciate Ligament. Ligaments are tough chord-like structures which join the bones. These provide strength to the knee. There are four such ligaments in the knee - one on the inner side (MCL), one on the Fig. 1: Normal knee outer side (LCL), and two in the middle. The two middle ligaments cross each other, and are therefore called cruciate ligaments. Of these, the one in front is called Anterior Cruciate Ligament or ACL.
What happens if ACL is torn?
- The usual history is the twisting injury of the knee followed by pain and swelling. Often, a cracking sound (pop) is heard.
- The patient may experience that his knee has moved in an odd way.
- X-rays are usually normal, and hence this injury is often considered a ‘minor’ sprain. The patient may gradually improve, and feel almost ‘normal’ over a period of time. He almost forget about the knee, when one fine day he twists his knee again, and feels pain, swelling and instability.
- Feeling of instability (giving way) of the knee prevents one from rigorous activities such as running, jumping etc. People with low-level physical activity may be able to manage despite a ruptured ACL, but in others the knee feels weak.
- One may feel ‘unsure’ of the knee or the knee may actually give-way off and on. Each episode of ‘giving-way’ causes further damage to the knee by rupturing the meniscus (cushions). This, in turn, way of diagnosing a torn ACL causes injury to the soft caps covering the bones, the cartilage. The natural squeal of such con_nuing insult to the knee is early wear and tear of the knee (osteoarthritis). This becomes a source of constant pain and swelling.
- MRI is one way to confirm the diagnosis of a torn ACL. Often, it is not possible to differentiate a partial tear from a complete tear. Clinical examination, followed by arthroscopic viewing, is the only sure way of diagnosing a torn ACL.
What are the different ways of treating ACL tear?
- Treatment with physiotherapy: In patients with low level of physical activity (office kind of a job), treatment with physiotherapy may ‘tune’ the knee to control itself, despite a torn ligament.
- Reconstruction of ACL: If a patient’s body does not adapt to a torn ACL, one may have to resort to surgery. It is not possible to repair a torn ligament, as it is like a rubber band, and the two ends cannot be joined. The only option is to make a new ligament (reconstruction). This is done by placing a substitute ligament (graft) next to the torn one. The graft is made from dispensable tendons around the knee and fixed where the original ligament was. With time the ‘new ligament’ takes blood supply from the body, gets incorporated, and functions somewhat like the original ligament.
Will I need surgery?
It is possible to lead a normal life despite a torn ligament provided you are willing to modify your lifestyle, which means low on physical activity and sports. If you are not confident about your knee (walking on irregular ground, running and stair climbing) then you need surgery. If you want to pursue active sports life, surgery is a must.
If you do not follow these restrictions and continue to play with a weak knee, it will lead to repeated injuries further damaging the knee. Such repeated injuries eventually lead to permanent damage to the knee. Surgery of ACL reconstruction is never an emergency, you can give it time and a trial of physiotherapy to see whether your body adapts to torn ligament.
"Modify your life to fit your knee or modify your knee to fit your life" is the standard quote.
How is ACL reconstructed?
ACL reconstruction is done by two methods : open surgery or key - hole ( arthroscopic ) surgery. The operation consists of the following steps.
- A diagnostic arthroscopy to re-confirm the diagnosis (which of course would have been already confirmed by MRI), and take stock of the associated damage to other structures inside the knee such as meniscus etc.
- Graft harvested from the knee.
- Graft designed to the shape of a ligament.
- Graft is inserted in the knee through tunnelling technique, without opening the knee.
- The Graft is fixed at two ends. By modern fixation devices, for which no extra cutting is required.
All this is done arthroscopically, without opening the knee. There are minimum scars.
How much does the surgery cost ?
Cost may vary from case to case depending upon the technique and the implants used. These surgeries are generally covered under medical insurance. You may discuss the details when you come for fixing the date for the surgery.
How long is the procedure?
The actual duration of the surgery is approximately 45 mins. to 1 hour. One needs to spend some extra time in the OT area before and after surgery.
Our Technique of ACL reconstruction
We are pioneers in ACL reconstruction, doing nearly 300 cases every year for the last 20 yrs. We have standardized our technique for getting best results. Following are the salient features of our technique:
- It is a minimal cutting technique, We perform the whole operation through key holes. The biggest cut is approx. 1 inch, to take out the spare graft from below your knee.
- We take Hamstring tendons, the relatively unimportant tendons on the side of the knee. There is almost no side-effect due to removal of these tendons.
- Our technique involves using Hitech devices (Radiofrequency prob, motorized shaver etc.), which are one time use. These make it possible to do surgery with minimal tinkering inside the knee, while maintaining highest standards of sterility.
- We preserve whatever torn ligament remains. Though it makes the surgery technically demanding, but to preserve patient’s own ligament is better for the knee.
- We have an aggressive, well -coordinated, goal oriented post-operative rehabilitation programme.
Needless to say, all operations are done by the senior surgeon himself.
What are the results of ACL surgery?
ACL surgery is one of the very successful operations. But, in a surgery which involves healing of tissues and creation of substitute of natural body parts, a lot depends upon a patient’s healing potential. Even in the best of hands this operation is successful in 90% of cases. There are 10% cases where the graft does not take blood supply from the body, and remains weak and sometime ruptures.
What is the procedure of getting operating?
You are admitted to the hospital for one day. Some tests are conducted on you to make sure that your body is fit for anaesthesia. The operation is usually carried out under a spinal anaesthetic (an injection in your back), or sometimes under general anaesthetic.
Before undergoing surgery you may be prescribed medication. Give us a list of all medicines that you are taking or have recently taken, as there may be cross reaction between medicines.
On the day of surgery
You may have to be fasting for 4-6 hours before surgery. The operation takes about 1 hour, but you will be in the operation theatre complex for nearly 4 hours.
After the surgery, the nurses observe your recovery to make sure that your blood pressure, pulse, other vital signs, and the operated site are normal. In the recovery ward, you may have a bandage or temporary brace on your knee. You will be discharged from hospital on the day after surgery.
You will be up and about with the support of a crutch on the second day after surgery. You will be using crutches for first 2 wks. You can start going to the office after 2 wks but with restricted mobility. It takes nearly 3 months of physiotherapy to feel normal in day to day actvities. It might take upto 6-9 months to become fit for sports.
We have devised a protocol of physiotherapy for ACL patients in 4 phases. You will need to be under supervised physiotherapy either at our centre or with our associate physiotherapists.
We advise that you contact our physiotherapy chief immediately after your surgey for well co-ordinated care.
Follow up visits with surgeon
On post operative Day 5 Day 21 Day 45
Care after surgery:
You will be advised the following:
- Application of ice packs for 20 minutes 4 times a daily for the first few days.
- The use of the crutches and occasionally a knee brace for a variable period.
- Medication to relieve pain and discomfort.
- Antibiotics to reduce the risk of infection.
Most patients will go home after 24 hours, and rest of the treatment will be at home. Depending on the type and extent of the surgery, you will be advised when you can resume your normal activities.
General Risks of Surgery:
- Wound infection: Treatment with antibiotics for long period may be needed.
- Haematoma (an accumulation of blood inside the knee and around the surgical site), may need aspiration under local anaesthesia.
- Slow or poor healing (most likely in smokers, people with diabetes, and in elderly people).
- Risks of anaesthesia: Anaesthesia techniques have become fairly safe now, but an odd patient still runs the risk.
- One of the most common complication following ACL reconstruction is loss of motion, especially loss of knee straightening (extension). Loss of knee extension has been shown to result in a limp, quadriceps muscle weakness and anterior knee pain. The highest incidence of knee stiffness occurs if ACL surgery is performed when the knee is swollen, painful, and has a limited range of motion.
ACL Reconstruction Rehabilitation Protocol
The following is the expected progress of your recovery after ACL, reconstruction:
|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 he 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 house for 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 moths|
|Unrestricted sports||:||After 1 year|
Rehabilitation after ACL reconstruction involves a progressive exercise program. We will teach you the exercises on your post- op visits as per the stage of rehabilitation. You would need to do these exercises at home yourself for 3-4 months depending on your requirement. Most patients do well with home therapy program; some need closer supervision by frequently visiting our therapist.
The following are the expected goals of recovery:
- To make the knee completely straight (not even slightly bent) – about 2 week.
- To reduce knee swelling 3 weeks, sometimes aspiration of fluid from the knee may be needed to reduce swelling at 3 weeks.
- To achieve knee bending –up to 90 degrees in 3 weeks, and full in 6 weeks.
- To build up the muscles around the knee joint- takes up 1-6 months
Schedule of visits for surgeon
|1st visit||:||approx 5 days after surgery, for dressing change and retraining of exercise|
|2nd visit||:||2 weeks after surgery, for stitch removal, and retraining exercise|
|3rd visit||:||6 weeks after surgery, monitor progress|
|4th visit||:||months after surgery
|It may be required to come more frequently in some cases.|
Schedule of visits for Therapy
One visit before surgery, for assessment and to understand the rehabilitation protocol. After surgery it is advisable that therapy be done under supervision 3 times per week for the first six weeks, and then once in a week for the next six weeks.
The above information presents an approximate picture of recovery after surgery. Exact progress varies from patient to patient
- PCL Reconstruction
- How often does this ligament get injured??
- The incidence of this injury is relatively less than an ACL tear.
- Do I always require to be operated??
- The PCL has a better propensity to heal than the ACL. However younger age, persistence of feeling unstable and feeling of weakness in the knee is an indication for ligament reconstruction.
How is the operation done?
The surgery is done completely via keyhole technique (arthroscopic surgery). The graft used is the patient's own hamstring tendons (semitendinosus and gracilis) like an ACL reconstruction. The only difference in the two techniques is that a small portal (1cm incision) needs to be made at the back of the knee for the keyhole surgery. The new ligament is fixed with specilaised implants on the thigh and leg bone.
Multiple ligament injuries:
The strength of the knee comes from four ligaments – one on inside of the knee, one on outside, and two in the middle. The one on inside is called MCL (Medial Collateral Ligament), the one on outside is called LCL (Lateral Collateral Ligament), and the two in the middle of the knee are called cruciate ligaments.
Usually, it is only one or sometimes two ligaments which get torn. Rarely, more than two ligaments, and sometimes all the four ligaments are torn. This severe damage occurs in serious road traffic accidents or high velocity sports.The knee often dislocates, or becomes severely unstable. It becomes impossible to even move the leg in one piece. Any attempt at putting load on the leg makes the knee give way. In early stages, there is bluish discolouration of the knee due to the blood seeping out under the skin. In severe injuries, there may occur damage to the nerves and vessels of the leg, and may make this injury limb threatening.In some low demand patients non surgical treatment may be considered. In all other cases the ligaments need reconstruction which are done in a combination of keyhole (arthroscopic) and minimally invasive surgery
What is the PCL?
PCL (posterior cruciate ligament) is a major ligament of the knee. It is situated in the middle of the knee in its posterior (back) part. It is responsible for not allowing the knee to move backward.
How is it injured?
It may be injured if the knee is hit from the front, for example in a head on crash where something from front hits the knee. Injury to this ligament is not as dramatic, and is missed often.
Does it need surgery if torn?
In the past, it was thought that PCL injury can be left as it is, and it does not cause much problem. But, it is now understood that PCL is an important ligament, injury to this ligament needs to be treated by surgical reconstruction in most cases.
How is it done?
This surgery is a keyhole (arthroscopic) surgery. The same hamstring tendons are harvested with an inch incision in front of the knee and fashioned into the new ligaments. This is introduced via an arthroscopic tunneling technique that involves a small 1 cm cut on the back of the knee too. It is fixed with specialized devices on the leg and thigh bones.
What are the results of PCL surgery?
They are excellent with a less than 5% chance of the graft not being accepted by the body. This however requires the right rehabilitation techniques.
What are the complications?
Apart from the standard possible complications associated with ACL surgery there is a possible chance of injury to the vessels at the back of the knee in these operations. However they rarely occur if done in the right hands.
What is the post operative rehabilitation?
Its almost the same as an ACL reconstruction.
The only difference is a support is kept under the back of the leg and the patient needs to wear a long knee brace for 6 weeks while walking.
Flexion and extension exrecises are done in prone position
The restrictions are slightly more than after an ACL reconstruction and near normal walking occurs at about 6 weeks.
Running and jogging at 4-5 months and sports after 6-9 months
MCL (medial collateral ligament) is often injured in a knee bending inward, or when hit from outside. This is one of the easier ligament, as it heals up in most cases by simple rest in brace. When associated with injury to other ligaments such as ACL, or in obese patients, tear of this ligament may also need reconstruction.
Do we always need to operate on it?
This is a rather friendly ligament and heal up in about half the cases when it is torn off from the thigh bone or the middle of its substance. This healing takes about 6 weeks and requires some element of immobilization like a brace.
When do we need to operate?
Surgery is required when the knee continues to open up from the inside after 6 -8 weeks, or if the injury is from the attachment to the leg bone. Sometimes when associated with injuries to multiple ligaments of the knee, early repair may be required.
What kind of operation is done?
There are two types
- Repair: This is done when the ligament has just come out of its attachment at either end. Then the original ligament is just repaired back to its place.
- Reconstruction: This is done when the ligament is completely torn and lacks its original structure. The hamstring tendons (semitendinosus/gracilis) is used to make a new ligament and fixed with specilaised devices.
What is the post op rehabilitation?
Depending if done in isolation or with another concomitant ligament reconstruction.
If in isolation, the patient is kept on a long knee brace for 6 weeks and is allowed to bend the knee out of the brace keeping the knee in a cross legged position. Walking is permitted with the brace using a walker/crutches. However for 6 weeks the patient needs to wear the brace while walking.
If present with other ligament reconstruction the rehabilitation depends on which other ligament is injured.
Posterolateral Corner injuries:
What is the posterolateral corner?
This is a part of the knee on the back of the outer aspect of the knee. It primarily consists of two parts the popliteus tendon and the lateral collateral ligament.
Does it require reconstruction?
More often than not it always requires reconstruction. It is usually never present in isolation and is associated with ACL or PCL tears that are reconstructed at the same time.
How is it reconstructed?
The other legs semitendinosus and gracilis (hamstring tendons) are fashioned into both or one of these ligaments and fixed to the thigh and leg bone at their respective locations
What is the post operative rehabilitation?
The patient is kept on a long knee brace for the first two weeks then a hinge knee brace with crutches or a walker.
Movement is permitted out of the brace but in prone position.