Anterior Cruciate Ligament Surgery
An anterior cruciate ligament tear can cause knee instability and the patient often feels insecure when moving the joint. In addition, it is common slight knee twists to occur, especially when the patient rotates the body over joint, which can cause injury to other structures, such as the menisci, cartilage and other ligaments. For this reason, in most cases, surgery to reconstruct the anterior cruciate ligament is indicated. This surgery is performed by video, using arthroscopy. The objective of the surgery is to replace the torn ligament with a graft. So, the graft heals and joint stability can be restored.
Preparation for surgery
Once the surgical procedure has been indicated, the patient should clarify all doubts with the orthopedic surgeon. It is important that all stages of the treatment are understood so that the best possible result is reached.
PRE-OPERATIVE REHABILITATION - In general, after an anterior cruciate ligament tear that will require surgical treatment, the patient is referred for pre-operative rehabilitation, with motor physiotherapy. This initial muscle rebalancing is very important to avoid excessive muscle loss after the ligament injury.
PRE-OPERATIVE EXAMS - The doctor usually requests some pre-operative exams so that possible health conditions that increase the risk related to surgery can be identified. The necessary exams must be individualized for each patient, as they depend on the patient's age and underlying diseases the patient may have, such as diabetes, hypertension, anemia, among others. Routinely, the exams involve a blood count, a coagulation test, a chest X-ray and an electrocardiogram, in addition to imaging exams to identify ligament tears.
SURGERY REQUEST - In Brazil, the doctor's office requests the surgical procedure at the chosen hospital. All necessary reports are prepared, the imaging exams reports are attached and all documentation is sent to the hospital.
Anesthesia
The choice of anesthesia is a very common concern among patients before surgery and it is made after a discussion between the orthopedic surgeon and the anesthesiologist, before the procedure. There are several anesthetic options, but, in general, anterior cruciate ligament reconstruction is performed with spinal anesthesia, associated with sedation. After surgery, our team usually performs a peripheral block near the knee, known as an adductor canal block, to improve analgesia after the surgery. This combination of anesthesia provides the patient with a few hours of pain relief after the procedure.
What the patient notes after an ACL tear
After the joint twist, the patient's knee usually hurts a lot and an important effusion occurs. In some situations, the patient may hear a popping sound at the moment of the twist. Often, it is difficult to the doctor to evaluate the knee immediately after the injury due to the intensity of the symtpoms. However, after providing adequate analgesia and talking to the patient, it is possible to perform a careful physical examination to look for injuries.
After some time, the person who has torn the anterior cruciate ligament may feel the knee a little loose, or feel a lack of confidence in the joint, depending on the movement.
It is worth remembering that ACL injuries can be total or partial and that even partial injuries can cause knee instability.
It is important to see an orthopedic surgeon after suffering a knee twist.
Necessary Exams
Some imaging exams can help the doctor when there is a suspicion of a torn anterior cruciate ligament, such as X-rays and magnetic resonance imaging. In addition, since those exams visualize the ligament itself, they allow a more detailed evaluation of other structures that may be injured with the sprain, such as the bone, cartilage, menisci, other ligaments, among others.
Visualization of the intact anterior cruciate ligament on knee MRI
Treatment
When torn, the anterior cruciate ligament usually does not heal sufficiently, meaning that even after healing, the knee remains unstable. This residual instability can damage other structures of the joint. Some factors are taken into consideration when choosing the best treatment for injuries, such as age, occupation and level of sporting activity.
Non-Surgical Treatment
In some specific situations, non-operative treatment may be considered. When there is a partial tear of the ligament that does not cause instability, physical therapy may be appropriate for the patient's rehabilitation. In addition, when the patient has a complete tear of the ligament but does not play sports that involve changes of direction and does not complain of recurrent instability, non-operative treatment may also be considered.
Surgical Treatment
Since a torn anterior cruciate ligament causes great instability in the knee, the patient usually feels insecure when moving the joint after the injury. In addition, it is common to experience small repeated twists, which can cause injury to other structures of the joint, such as the menisci, cartilage and other ligaments.
For this reason, in most cases, surgery to reconstruct the anterior cruciate ligament is indicated. This surgery is performed by video, through arthroscopy.
The objective of the surgery is to replace the torn ligament with a ligament graft. So, the graft heals and joint stability can be restored.
Graft Options (Ligament Substitutes)
Ligament grafts are the tissues used to replace the injured structure. When it comes to the anterior cruciate ligament reconstruction, the most frequently chosen substitutes are the hamstrings (gracilis and semitendinosus), the patellar tendon, the quadriceps tendon and grafts from tissue banks (cadaver). In Brazil, the most commonly used grafts are the hamstrings, and these tendons are my first choice of grafts in anterior cruciate ligament reconstruction surgeries.
What is Anterior Cruciate Ligament Reconstruction Surgery?
Anterior cruciate ligament reconstruction surgery follows certain steps depending on the surgical technique used.
ANESTHESIA - Surgery begins with anesthesia. Most often, we use the spinal anesthesia, which is performed on the lumbar area. This anesthesia provides excellent analgesia during the surgical procedure and for a few hours after the surgery. It is important to note that the patient remains sedated throughout the procedure, i.e., asleep. Another option is general anesthesia, usually associated with another anesthesia near the knee, called peripheral nerve block. The choice of anesthesia is made after a discussion between the surgeon and the anesthesiologist and must have the patient's consent.
LIGAMENT RECONSTRUCTION - After anesthesia and preparation of the patient, the surgery begins. A small incision is made in the inner area of the knee. Through this, the gracilis and semitendinosus tendons are harvested and prepared to be used as ligament substitutes. Then, small incisions are made in the joint region of the knee. A camera is placed through one of them and the instruments used for joint manipulation are inserted through the other. The next step of the surgery is to check for joint injuries and remove the remaining part of the torn ligament. Then, two bone tunnels are drilled: one in the femur and other in the tibia. The prepared graft is then passed through the tibial bone tunnel, through the joint and through the femur bone tunnel. After the graft is correctly tensioned, it is fixed to the bone. There are also some fixation devices available, but, in general, the femur is fixed with an absorbable screw or a small plate; and the tibia is fixed with an absorbable screw. After the graft is fixed, a new joint inspection is performed to check the positioning and range of motion of the knee. In addition, we usually perform some maneuvers to check the stability of the joint. After all the checks, the surgical incisions are closed with stitches and a dressing is applied. After the surgical procedure is completed, the patient is taken to the anesthesia recovery room and then to the room.
AFTER SURGERY AND HOSPITAL DISCHARGE - Rehabilitation begins in the first few hours following the surgical procedure, when the patient is encouraged to move the operated knee and get out of bed to walk. A pair of crutches may be used along the first two weeks after surgery, if the patient does not feel confident to walk without them. This initial training for walking with crutches is carried out inside the hospital, with the help of a team of physiotherapists. Generally, patients who have undergone anterior cruciate ligament reconstruction surgery are discharged from hospital the day after the procedure. In some situations in which the surgery is ended early in the morning, the patient can go home in the same day.
Rehabilitation with Physiotherapy
Post-operative rehabilitation with physiotherapy is essential for the success of the treatment. Initially, rehabilitation consists of modalities to improve pain and inflammation in the knee, as well as manipulation to restore range of motion. Progressively, the treatment upgrades according to the protocols, so the patient gradually restores muscle strength, stretching and balance.
Learn More
