After an anterior cruciate ligament (ACL) injury, where the knee ligament that joins the upper leg bone to the lower leg bone is torn, you may consider ACL surgery.
What is ACL Surgery?
ACL surgery is designed to restore normal functioning of the knee and prevent future injury to or degeneration of other structures in the knee. During ACL surgery, an orthopedic surgeon repairs or reconstructs the ACL. A repair surgery is less common and is used when the ACL and a piece of bone has separated from the rest of the bone (an avulsion fracture). The separated piece of bone is reattached. More commonly, reconstruction surgery grafts a section of tendon from another part of the body (often from the kneecap, hamstring, or quadriceps) to reconstruct the ACL. In some cases, tissue is instead taken from a deceased donor.
Generally, ACL reconstruction is done arthroscopically, through the insertion of a tiny camera into a small incision. Through fiber optic technology, the orthopedic surgeon can see the inside of the knee joint displayed on a television monitor. The surgeon can then insert instruments through other small incisions to perform the reconstruction. The surgeon can also use arthroscopic surgery for diagnostic purposes. Occasionally, a surgeon will perform open surgery, cutting a large incision across the knee.
What to Expect During Arthroscopic ACL Surgery
If your doctor recommends ACL surgery, they may advise you to undergo surgery immediately or to wait until the swelling reduces and you regain some strength and range of motion in the knee joint.
Arthroscopic ACL reconstruction surgery is done under regional or general anesthesia. The surgery begins when the surgeon makes two or three small incisions around the knee. The surgeon then pumps a saline (salt) solution into the knee through one of the incisions to wash blood from the area and to expand the knee for better visibility. Into another incision, the surgeon inserts a tiny camera that transmits a picture from inside the knee to a television monitor.
Using surgical drills inserted through the small incisions, the surgeon drills tiny holes into the leg bones where they meet at the knee joint. If the patient’s own tendon tissue is being used as a graft, the surgeon will create another incision in the knee and take out the replacement tissue. The surgeon then anchors the tendon graft through the drilled holes and secures the graft with screws or staples. The surgeon closes the incisions with stitches or tape.
If other parts of the knee are injured, such as a torn meniscus, broken bones, or other damaged ligaments, the surgeon may repair those during the surgery. Once the knee is bandaged, the patient will be taken to a recovery room for 2-3 hours. Arthroscopic surgery is generally an outpatient procedure and does not require an overnight stay at the hospital.
Recovery from Arthroscopic ACL Surgery
After arthroscopic ACL surgery, you may feel tired for several days. You will have swelling at the knee and possible swelling and bruising down to the ankle and foot. You may also experience numbness at the incision sites. Ice can help reduce the swelling. Keep the incision clean and dry, watching for signs of infection. Within several days, you should begin seeing improvement in the knee.
Returning to normal activities after surgery varies for each person, but most people need at least 6 months before they can return to activity. In rare situations, people continue to have pain and instability and need an additional surgery (revision ACL reconstruction), which is generally not as successful as the initial surgery.
Risks of Arthroscopic ACL Surgery
Though complications from surgery are always a possibility, ACL reconstruction surgery is generally safe. Complications are uncommon, but those that could arise from the surgery or during rehabilitation include:
- Blood clots in the leg
- The usual risks of anesthesia
- Numbness at the incision sites
- Infection of the incisions
- Damage to structures in and around the knee
- Problems with the graft tendon or the screws attaching the graft
- Limited range of motion
- Grating of the kneecap against the thighbone
- Pain when kneeling at the site where a graft was taken or attached
- Repeat injury to the graft
The type of graft (from your body or from a donor), the location of the graft (if from your body), and the placement of the graft all have different associated benefits and risks. Talk with your doctor about your options.
Determining Whether Arthroscopic ACL Surgery is Right For You
Surgery is not required for all ACL injuries. Your doctor may recommend non-surgical treatment like rest and physical therapy. In other instances, surgery may be recommended.
Surgery may be appropriate in the following circumstances:
- Your ACL is completely torn, or your ACL is partially torn but your knee is very unstable
- You have gone through a rehab program, but your knee remains unstable
- You want or need your knee to be as strong and stable as it was before your injury because your job requires it or because you are very athletically active
- You are willing to commit to a lengthy recovery process
- Your knee is unstable because of chronic ACL deficiency, and the instability is negatively impacting your life
- Your ACL is not the only part of your knee that has been injured. Your meniscus or other ligaments or tendons also need to be repaired.
Surgery may not be appropriate in these circumstances:
- You have a minor tear in your ACL that can heal with rest and physical therapy
- Your work does not require a particularly stable knee, and you are not very active athletically
- You are willing to stop doing activities that require a stable knee at the same level of intensity
- You are willing to live with some knee instability but could complete a rehab program that would reduce the risk of future injuries
- You are not willing to commit to a lengthy recovery process
- Your other medical problems make surgery too big a risk
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