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Anterior Cruciate Ligament is one of the four ligaments that provide stability and strength to the knee joint and also prevent undue movement and twisting of the knee joint. ACL reconstruction surgery is one of the most commonly performed ligament reconstruction surgery, done arthroscopically with small incisions to restore the knee stability and strength like before.
Any type of undue force can tear the knee ligament apart. ACL is one of the most commonly injured knee ligaments that runs diagonally in the centre of the knee from the base of the femur to the Tibia and prevents it from slipping forward, in the front of Femur. Unfortunately, once torn, it does not possess the capacity to regenerate or repair.
Q1.How is knee joint formed?
A1. Knee joint comprises of three bones namely Femur(thigh bone), Patella(knee cap) and Tibia(shin bone) stabilized together with the help of thick fibrous bands of connective tissue called ligaments. They are Medial collateral ligament(MCL), Lateral Collateral ligament(LCL), ACL(Anterior Cruciate Ligament) and PCL(Posterior Cruciate ligament).
Q2 What is the basic anatomy of the Anterior cruciate ligament?
A2 ACL consists of two functional bundles of tissues namely Anteromedial(front) and Posterolateral(back) bundles responsible for the forward movement of tibia beneath femur and rotational stability of the knee such as in jumping,twisting,pivoting, running respectively.
Q3. What are the causes of ACL ligament injury?
A3. Anyone can have ACL injury. However, those who are involved in sports such as football, soccer, basketball are highly vulnerable. Usually, the ACL injury is accompanied by injuries to other knee tissues as well but may occur alone.
Q4 What are the symptoms and signs of ACL injury?
A4. Anyone who suffers from ACL injury may present with the following signs and symptoms:
Pain and tenderness in the knee joint
Swelling that increases eventually.
Complete loss of range of motion
Difficulty in walking
Q5 How is ACL injury diagnosed?
A5 Diagnosis is made through
History of trauma to the knee(Contact or Non contact)
Signs and symptoms pointing towards presence of ACL Injury, as mentioned above elicited through careful physical examination.
X-rays to rule out any fracture.
MRI scan of the knee to confirm if ACL is injured, extent of injury and if other tissues of the knee also involved such as menisci,articular cartilage and/or other knee ligaments. However, it is not mandatory.
Q6 What treatment options do I have in case of ACL injury?
A6 Everyone who has ACL tear does not require surgery. You may need only rehabilitation or surgery with rehabilitation. The best treatment protocol will be determined by your specialist. The two treatment options that You may have in case of ACL injury are:
Non surgical treatment- It includes progressive physical therapy and rehabilitation along with hinged knee brace for people who choose not to have surgery. Also, patient education regarding how to prevent occurence of instability episodes. However, there is always a risk of secondary injury to the knee as a result of repetitive instability(subluxation) episodes.
Surgery, usually recommended in
Q7 What are the indications for non surgical treatment of ACL tears?
A7 Patients with isolated ACL tears may have an option of non surgical treatment under the following conditions:
Partial tear without knee instability symptoms
Complete tear without knee instability symptoms during low intensity sports. High intensity sports cannot be pursued and you are willing to give up on them.
Leading a Sedentary lifestyle
Children with open growth plates.
Q8 Can torn ACL be repaired?
A8 No. ACL once injured, are generally not repaired as they tend to fail over a period of time. They need to be replaced with a substitute graft of tendon.
Q9 Which are the commonly used grafts to replace torn ACL?
A9 There are mainly of two types:
Autograft:Procured from the patient himself/herself.
It can be from a
Allograft: Procured from a Cadaver. It can be a
Q10 What is the outcome of the ACL reconstruction surgery?
A10 ACL reconstruction surgery has around 95% success rate. However, in some patients recurrent instability and graft failure may be seen.
Q11 What is the goal of the ACL reconstruction surgery?
A11 The ACL reconstruction surgery is carried out to
Q12 Do I need ACL reconstruction surgery?
A12 Your activity is a major determinant for deciding whether to undertake the ACL reconstruction surgery or not. An active adult who is engaged in highly demanding sports or job, intense manual labour is recommended surgery as a viable option.
However, in children or adolescents, early ACL reconstruction surgery is better avoided in case of ACL tears due to the possibility of injury to the Growth plate, resulting in bone growth issues. ACL surgery is generally delayed until child reaches skeletal maturity or the surgeon may change his surgical technique to avoid injury to the growth plate.
ACL tear with remarkable functional instability in a patient is a clear indication for the surgery in order to prevent secondary knee damage that might eventually ensue and result in degenerative arthritis.
ACL injuries often occur along with injury to other tissues of the knee. 50% of the ACL injuries are combined with menisci damage. 30% combined with articular damage and again 30% with damage to the collateral ligaments. Joint capsule may also be injured or in some cases a combination of all of them. Football players and skiers are frequently seen with an ACL injury combined with injury to the MCL(Medial collateral ligament ) and medial meniscus.
Combined ACL injuries necessitate surgery and generally have better outcome. Half of the meniscus repair heal better if combined with ACL reconstruction surgery.
In nutshell, it is usually advisable to undergo surgery for ACL injury keeping in mind its importance in providing stability to the knee joint and its role in carrying out day to day activities of running, jumping, climbing stairs and especially for sports. Moreover, with each instability or subluxation event, the knee becomes prone to more secondary damage to other tissues such as menisci, articular cartilage, other ligaments resulting in degenerative arthritis.
Q13 I just suffered from ACL injury. When can I have ACL reconstruction surgery?
A13 In order to undergo ACL reconstruction surgery:
Knee swelling should subside.
Range of motion(Bending and extension) of the injured knee must be restored to a great extent, comparable with that of uninjured knee.
Knee should be able to straighten indicating good quadriceps muscle control
Q14 Will I experience pain after surgery?
A14 You will have mild to moderate pain around knee for around 1 to 2 wks after surgery which is well managed with pain killers, ice application and rest.
Q15 When can I get back to my sports activity?
A15 It usually takes 6 to 9 months post surgery to get back to sports as before. By this time:
ACL graft gets incorporated well into the knee.
Knee is properly rehabilitated.
Strength and coordination needed for the sports activity is re-established.
Q16 Is it normal to have swelling after surgery?
A16 Yes, a patient may experience swelling on knee after ACL reconstruction surgery.
Q17 What is the duration of the ACL reconstruction surgery?
A17 It usually takes 30 to 45 minutes to carry out the ACL reconstruction surgery.
Q18 When can I start Physiotherapy?
A18 Physiotherapy will comence from the day of the surgery itself. A detailed physiotherapy and rehabilitation protocol will be given during your first post operative follow up visit. It has to be continued atleast for next 6 months after surgery and will be determined by your response to the physiotherapy sessions, your medical condtion and your physical capacity. The rehabilitation protocol will be well tailored to your needs.
Q19 When can I drive?
A19 Driving is usually allowed after 6 weeks for 4 wheelers and 12 weeks for 2 wheelers.
Q20 For how long do I need crutches?
A20 Crutches are generally required for around 2 to 3 weeks post surgery. However, the duration may vary from patient to patient dependng upon if any additional procedure on other tissues of the knee such as menisci, articular cartilage or other knee ligaments are also carried out. Patient may do away with the crutches once he /she feels confident about good control of the leg and hence walking without them.
Q21 For how long do I need to put on my knee brace?
A21 Generally, a knee brace is needed for around 4 weeks after surgery. For first 2 weeks it has to be worn throughout only to be removed while doing exercise. For next two weeks you have to wear it only at night or while sleeping.
Q22 What signs and symptoms do I need to watch for after surgery, that call for doctor's immediate attention?
A22 The following signs and symptoms after surgery call for doctor's immediate attention:
Fever above 101o F
Excessive pain, tenderness, warmth, swelling and redness around the surgical site.
Yellow discharge (Pus) from the incision
Blood soaking the bandage
Pain and swelling in the calf region
Sudden shortness of breath, chest pain or pain while breathing
Q23 How much weight can I afford to put on my leg post surgery?
A23 Usually, full weight bearing is allowed as long as its within the pain bearing capacity of the patient from the day after surgery, with the help of the crutches. However, the time may vary if an additional procedure on the meniscus, cartilage or other knee ligaments has also been carried out.
Dr Jayant Arora
MRCS (Edinburgh), CCBST (Royal College of Surgeons, UK)
DNB (Orthopedics), MS (Orthopedics), MBBS
VSP, Belgium, Knee Arthroplasty
Senior Consultant, Dept. Of Orthopedics
Columbia Asia Hospital, Gurgaon,Delhi NCR.
Dr Mudit Khanna
MBBS, MS(Ortho), MCh(Ortho) UK, MRCS(UK)
Senior Consultant, Advanced Joint Replacement Surgery
Wockhardt Hospital, Mumbai
Dr Darius F. Soonawalla
MBBS, MS(Ortho), DNBE(Orthopedics), FRCS(England)
Orthopedic and Joint Replacement surgeon
Wockhardt Hospital, Mumbai
Dr Abhay M. Nene
Consultant Spine Surgeon
Wockhardt Hospital, Mumbai
Saket, New Delhi
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