The ACL (anterior cruciate ligament) is a major ligament in the knee that helps stabilize the knee. It is a strong ligament inside your knee that allows you to turn, cut, twist and pivot. While a torn ACL used to be an injury exclusive to athletes, with today’s active lifestyles it is becoming more common in any age group and at various activity levels. There may also be other structures in your knee that are injured at the same time. These may include your meniscus (fibrocartilage cushion in your knee), or other ligaments. The treatment plan will be influenced by what structures are involved, your current activity level, and what your desired activity level will be. The final plan of care will be decided upon by you and your doctor.
There are four ligaments that connect the knee joint. The best known of these ligaments is the ACL. The ACL connects the tibia, a bone of the lower leg to the femur, the bone of the upper leg. It prevents the tibia from sliding (translating) too far forward from the femur. The ACL is especially crucial in sports where it provides stability during stop/go/pivot motions (basketball & football). Most injuries to the ACL occur when an individual makes a sudden cut or turn and the foot stays planted on the ground. Injuries can also take place when landing improperly from a jump (volleyball & basketball). An injury to the ACL may require surgery followed by an aggressive rehabilitation program for a healthy return to high levels of activity. If you suspect that you have injured your knee, seek out a qualified physician for an evaluation.
Some individuals who tear their ACL in an occasional recreational activity may choose to have only rehabilitation to treat their knee and may elect not to have surgery. People who decide not to have surgery usually don’t participate in sports that would place stress on the knee. Most people with this type of lifestyle will be able to function normally without having surgery to reconstruct their ACL.
If you are one of these patients, you will be referred to physical therapy to work on walking normally, strengthening, range of motion, and controlling your swelling and pain.
Even if surgical reconstruction is elected, patients will still need rehabilitation prior to surgery. Most patients are required to achieve normal walking, nearly full motion and strength, and reduced swelling. This helps to minimize problems with motion and strength postoperatively.
Once you have decided on surgery to treat your torn ACL, you will contact one of the surgical schedulers. This is who will help you set a surgery date, and schedule your follow-up visit with the doctor. Some patients may require a preoperative clearance from their primary care doctor.
Since a repair (or suturing together) of torn ACL fibers is not effective, another piece of tissue (graft) is chosen by you and your doctor to place within your knee using the arthroscope. Autograft means your own tissue. These choices include two of your hamstring tendons or less commonly part of your patellar (the tendon from your kneecap to the bottom leg bone). Allograft tissues come from a donor. These tissues include either a patellar tendon or other soft tissue including most commonly the tibialis anterior and Achilles tendons. In scientific review of autograft choice, the graft does not influence outcome. Rather, the accurate placement by surgeons, stable initial fixation of the graft, patient compliance, and rehabilitation are believed to optimize the results. Your surgeon performs the surgery through the arthroscope. The skin incisions are only for the surgeon to harvest the graft if you choose autograft and to drill tunnels at the original site of the ACL. The graft is placed within the tunnels and fixed by a variety of choices to provide immediate stability prior to healing and to help stabilize the graft to the bone.
Surgical Techniques in Patients with Open Growth Plates
ACL injuries often occur in younger children with open growth plates. The growth plates also called the physis, are the areas of the bone that allow it to grow in length. Treating this injury in children is challenging. Using adult surgical techniques to reconstruct the ACL in a child can cause damage to the growth plates and may lead to a shortened or an angled leg. To avoid damage to the growth plate, Dr. Gambacorta may recommend the use of a special surgical technique called physeal sparing ACL reconstruction. This is an accepted method for reconstructing the ACL in young children that minimizes the risk to the growth plate.
Risks of Surgery
Risks of surgery include bleeding, infection (around 1%), nerve or vessel injury (most commonly an area of numbness on the skin adjacent to the incision), failure of the graft (2 to 10%), knee stiffness (5 to 25%) and need for further procedures. Rare risks include bleeding from acute injury to the popliteal artery (overall incidence is 0.01 percent), weakness or paralysis of the leg or foot, and a blood clot in the veins of the calf (0.12%). The goal of the ACL reconstruction surgery is to prevent instability of the knee. It does not make the knee completely normal or return it to its pre-injury status. Patients will still have an increased risk of developing arthritis in the knee after an ACL injury, even if surgery is performed.
Risks Specific to Allograft Use
Allografts are grafts taken from cadavers and are becoming increasingly popular. Advantages of using allograft tissue include elimination of pain caused by obtaining the graft from the patient, decreased surgery time and smaller incisions. Although there is some theoretical risk for disease transmission, including viral or bacterial infection, the use of allografts that have undergone rigorous donor screening, serological testing, and formal processing has significantly reduced this risk. The FDA has regulated this field very closely since 1993 to ensure the safety of allograft transplant.
Over the past decade, more than five million musculoskeletal allografts have been distributed to surgeons for transplant into patients with a remarkable record of safety.
Alternatives to Surgery
Surgical treatment is usually advised for patients who want to get back to activities that involve cutting and pivoting. However, deciding against surgery is reasonable for select patients. Non-operative management of isolated ACL tears is likely to be successful or may be indicated in patients:
- With partial tears and no instability symptoms
- With complete tears and no symptoms of knee instability during low-demand sports who are willing to give up high-demand sports
- Who do light manual work or live sedentary lifestyles
If you will be having surgery, you will have an evaluation with a physical therapist who is a member of the team responsible for your care. During preoperative rehabilitation you will be instructed on walking as normally as possible, decreasing swelling in your knee, getting your knee to straighten out all the way, and getting as much bend back in your knee as possible.
- Your preoperative therapy will:
- Decrease swelling
- Increase range of motion
- Improve gait so you walk without a limp
- Increase the strength in your leg
- Educate you on postoperative exercises
- Educate you on crutch walking
Your rehabilitation team will discuss these things with you, and show you exercises that will help you get ready for surgery and make your postoperative therapy easier.
Prior to your surgery you may be instructed to perform a series of exercises in order to build up your strength and maintain normal motion. This will greatly help your recovery process after surgery. Please perform all the following 1 to 2 times a day, and 3 sets of 10 repetitions on each exercise.
Here are a few things we will want to see prior to going into surgery:
- You must be able to demonstrate normal gait, or walk without a limp. Some of you, however, due to the extent of your injury, will be instructed to stay on your crutches.
- You must obtain at least 120 degrees of flexion or bend. If you have an additional injury in the knee, such as a meniscal tear, you may not be able to get this much motion in your knee prior to surgery
These are the exercises you can perform to help achieve this:
- Next you must have minimal swelling. You can achieve this by using an ice pack with elevation for 15-20 min. 3-5 times a day.
After surgery you will be given written instruction sheets, pictures of your surgery, a prescription for therapy, and a copy of rehabilitation guidelines. This information will answer most of the questions you may have during your recovery.
You will be going to physical therapy (PT) the day after your surgery. At the initial evaluation you will meet with the physical therapist or athletic trainer (ATC) who will be responsible for your rehabilitation. During this visit, you will be instructed in Phase 1 exercises, wound care and how much weight you should place on your operated leg. In addition, your therapist will ask you to help set your goals for rehabilitation. If you have an ACL reconstruction with no meniscal repair, you will be partial weight bearing when you are able to feel your leg again after surgery. If you have a meniscal repair along with your ACL reconstruction, you will be on crutches from 4 to 6 weeks.
The entire rehabilitation process will take 5 to 6 months. During the early phase of your rehabilitation you will be closely monitored. As you progress, you will be able to do more exercises on your own. If you have any questions concerning your rehabilitation process, they should be directed to your rehabilitation team.
To walk with crutches:
- Pull crutches under your arms and press them into your ribs.
- Move the crutches ahead of you 6 to 12 inches.
- Push down on the hand-grips as you step up to or slightly past crutches.
- Make sure to bear weight on your hands, not under your arms.
- Check your balance before you continue.
To sit down in a chair:
- Back up to the chair until you feel the chair on your legs.
- Put both crutches in your hand on the affected side, reach back for the chair with the other hand.
- Lower yourself into the chair.
To get up from the chair:
- Hold both crutches on your affected side.
- Slide to the edge of the chair.
- Push down on the arm of the chair on the good side.
- Stand up and check your balance.
- Put crutches under your arms, pressing crutches into ribs.
- Start close to the bottom step, and push down through your hands.
- Step up to the first step, remember the good foot goes down first!
- Next, step up to the same step with your other foot, making sure to keep the crutches with your affected limb.
- Check your balance before you proceed to the next step.
- Make sure someone is there to help if you need it.
- Start at the edge of the step, keeping your hips beneath you.
Slowly bring the crutches with your affected limb down the next step(the bad foot goes down first)!
- Be sure to bend at the hips and knees to prevent leaning too far forward, which could cause you to fall.
- Check your balance before you continue.
- Make sure someone is there to help if you need it.
Returning to Sports/Work
The type of activity you want to participate in will help determine when you can return to it after surgery. The other consideration is physiology, which cannot be influenced by anything other than time to heal. The most important thing you can do is to regain your strength. This cannot be accomplished without exercising your leg.
After the biology of healing has been considered, and your strength and stability fully restored, you should be able to return to the activity of your choice. Your doctor may, however, recommend lifestyle changes for you if you are presented with joint changes such as arthritis or instability that could not be corrected with surgery.
The rehabilitation team will help you relearn normal movements and pain free activities to meet your particular lifestyle needs. After you have successfully eliminated most of your pain and have returned to your normal function, it is important for you to continue to be involved in some form of orthopedic fitness to insure continued good physical health and activity levels. You should consider a lifestyle of organized physical activity to help prevent future complications. Your rehabilitation team can advise you on this step.
This information is intended for education of the reader about medical conditions and current treatments. It is not a substitute for examination, diagnosis, and care provided by your physician or a licensed healthcare provider. If you believe that you, your child, or someone you know has the condition described herein, please see your healthcare provider. Do not attempt to treat yourself or anyone else without proper medical attention.