ACL reconstruction surgery has come a long way in recent years. Using advanced, minimally invasive, arthroscopic techniques, patients are able to quickly recover and return to the same level of sports performance or physical activity prior to their injury. If your surgeon determines that surgery is the recommended course of action, a tailored surgical treatment plan will be provided for each patient. This treatment plan will detail pre-operative preparation along with providing information about the surgery. Once arthroscopic knee surgery is completed a full rehabilitation plan will be set in place. Rehabilitation is essential for a successful recovery.
Surgery Versus Conservative Treatment
The ACL does not heal naturally due to poor blood supply and general anatomy of the knee. Depending on the type of ACL injury, surgery is not always required. Surgery will depend on the patient’s age, activity level before surgery, and ongoing athletic and fitness goals post-operatively. Most patients under the age of 40 will be recommended to have ACL reconstruction surgery so that the risk of a meniscus tear and arthritis can be reduced. Instability is also a critical symptom following an ACL injury. Instability is troublesome for patients, and for patients with unstable knees, surgery is recommended. Patients who are older and lead a more sedentary lifestyle may not require surgical treatment. In such cases, patients will be offered physical therapy and encouraged to wear a knee brace.
In most cases, the ACL will be treated arthroscopically using the least invasive, “all-inside” or “no incision” techniques. Arthroscopic knee surgery involves the use of a fiber optic camera (smaller than a pen), which is put into the joint through a keyhole sized arthroscopic portals. The arthroscopic camera allows your physician to gain a complete visual of the inside of the knee joint as the image is displayed and viewed on a high definition (HD) television. While inside the knee joint, additional instruments will be inserted through another portal so that your physician can feel and assess the knee structures. This will allow for a better diagnosis as well as proper steps to repair, reconstruct, or remove damaged tissue.
ACL Reconstruction Grafts
In knees that have ligament damage and need ACL reconstruction surgery, which is the case for the vast majority of knee reconstructions, your physician will use a certain type of graft during the process. A replacement graft is precisely positioned in the joint at the site of the former ACL, and then fixed to the thigh and lower leg bones with adjustable TightRope buttons, or in some cases bioabsorbable screws. There are currently several options for replacement grafts. Regardless of the graft material chosen, the most important aspect is that the ligament graft is placed and secured precisely. Accurate graft placement is essential for a good result and securing graft placement permits early, more aggressive rehabilitation after surgery.
Choices for the type of replacement graft include:
- Autograft: This graft uses tissue from the patient. The tissue will most likely come from the quadriceps tendon, hamstring tendon, or the patella tendon. Autografts offer great success rates because they result in a strong graft, secure fixation, and excellent biological in-growth. Since the graft comes from the patient, there is little risk of disease transmission. A disadvantage is donor site morbidity, but using an all-inside technique, your physician is able to reconstruct the ACL using minimal native tissue. Following a strict post-operative rehabilitation program, patients are typically able to resume full activities with few complications.
- Allografts: In some cases, your physician will recommend using an allograft. This is donor tissue taken from tissue banks. Similar to an autograft, these also yield very good success rates and are strong and healthy to use. Because an additional surgery site is not needed on the patient (as is the case using an autograft), the surgery time and recovery time tend to be quicker, with less pain, and a faster recovery time. Therefore, an allograft is frequently selected for patients greater than 40 years of age. Although, there is a risk of infectious disease, donor tissue is obtained only from a reliable tissue bank. The tissue is rigorously screened and treated to prevent the spread of infectious disease. The risk of contracting infectious disease from an allograft is very small (less than one in eight million). Rejection of the graft is also possible, but this is a very rare occurrence since the tissue is not living material. Rather, the graft is a scaffold, which allows in-growth and remodeling using the patients own cells and own DNA.
- Synthetic grafts: This graft is available for use in certain situations, but most are experimental and do not work as well as allografts and autografts. Synthetic ACL grafts cannot be recommended at this time.
After ACL Reconstruction Surgery
Arthroscopic knee surgery for an ACL tear typically lasts one or two hours. After the operation, patients will be taken to the recovery room to be monitored to make sure all vital signs are stable, and that the anesthesia is wearing off properly. Patients will go home the same day, and be given specific instructions to follow at home. Exercises will begin the day after surgery, and formal physical therapy will be introduced in less than 7 days. It is critical that patients follow the post-operative protocol that your physician specifies. Rehabilitation becomes as important as the surgery itself.