The anterior cruciate ligament (ACL) is one of the major stabilizing ligaments in the knee. It is a strong rope like structure located in the center of the knee joint where it runs from the backside of the femur to the front of the tibia.

ACL Repair

The anterior cruciate ligament prevents the femur moving forward and rotating abnormally on the tibia. The ACL is required for normal function of the knee. One of the main functions of the ACL is to provide stability during rotational movements such as turning, twisting, and sidestepping.

When it ruptures it does not heal itself, and the knee often becomes unstable or gives way. Repeated giving way can lead to damage to other structures of the knee and eventually lead to arthritis. Since the knee dislocates when the ligament ruptures, there is often damage to other structures in the knee such as bone, cartilage, or meniscus. These injuries may also need to be addressed at the time of
surgery.

The younger and more active you are, the stronger the recommendation for reconstruction. It is generally recommended to have surgery if you wish to get back to sports which involve twisting and pivoting. Many patients who do not have surgery find that their knee becomes more loose over time. This can lead to a knee that gives way during ordinary activities of daily living. These patients should strongly consider surgery to stabilize the knee.

Repeated instability or abnormal movement in the knee can cause ongoing damage leading to stretching of other structures around the knee, meniscal tears, or arthritis in the long term. If you do not elect to have surgery, it is strongly advised that you give up sports that involve pivoting, sidestepping, or rotation.

It is also recommend that people with dangerous occupations such as policemen, firemen, roof tilers and scaffolders proceed with surgery. This is a safety issue to prevent instability in ‘at risk’ situations.

There is no urgency in performing this operation and in fact, it is sometimes better to allow the knee to rest and regain close to full motion prior to surgery. Dr. Sherfey & Dr. Antebi will advise you on the timing in your particular case.

HOW IS IT PERFORMED?

During surgery local anesthetic is injected into the knee to reduce the amount of pain you will feel.

  • Dr. Sherfey or Dr. Antebi will begin the operation by making two small openings into the knee, called portals. The portals are where the arthroscope and surgical tools are placed into the knee.
  • Graft is harvested or prepared.
  • The remnants of the original ligament are removed and the ‘intercondylar notch’ is enlarged so that nothing will rub on the graft.
  • Holes are drilled in the tibia and the femur (bone tunnels) in the same direction as the original ACL. The graft is then pulled into position using sutures placed through the drill holes.
  • Screws or other fixation implants are used to hold the graft in place in the bone tunnels.

The surgical procedure takes 45 minutes to 1 hour.

After surgery, you will be moved to a recovery room monitored by nurses where you will remain for several hours while you recover from the anesthesia. You will most likely go home within a few hours after surgery.

After surgery, you will be moved to a recovery room monitored by nurses where you will remain for several hours while you recover from the anesthesia. You will most likely go home within a few hours after surgery.

ACL Repair

PREPARING FOR SURGERY

FOLLOW ALL PRE-OPERATIVE INSTRUCTIONS
given to you by Dr. Antebi & Dr. Sherfey.

  • Stop all Aspirin, blood thinners, and anti-inflammatory medications (Motrin, Aleve) 10 days prior to surgery as then can cause bleeding during surgery. DO NOT STOP your blood thinners without consulting your primary care physician first.
  • Stop any naturopathic or herbal medication 10 days prior to surgery as these can also cause bleeding.
  • Continue with all other medications unless otherwise specified.
  • Bring a list of ALL medication with you on the day of surgery to give to the anesthesiologist.
  • You are advised to STOP SMOKING for as long as possible prior to surgery.

REALISTIC EXPECTATIONS: An important factor in deciding whether to have surgery is understanding what the procedure can and cannot do. More than 95% of people who have surgery experience a dramatic reduction of pain and a significant improvement in the ability to perform common activities of daily living. However, surgery will not allow you to do more than you could before you developed arthritis. With normal use and activity, every replacement or implant begins to wear. Excessive activity or weight may speed up this normal wear and may cause the replacement or implant to loosen and become painful.

MEDICAL EVALUATION: Your surgeon may ask you to schedule a complete physical examination with your family physician several weeks before the operation. This is needed to make sure you are healthy enough to have the surgery and complete the recovery process. Many patients with chronic medical conditions, like heart disease, may also be evaluated by a specialist such as a cardiologist before the surgery.

TEST: Several tests, such as blood and urine samples, and an electrocardiogram may be needed to help surgeon plan your surgery.

MEDICATIONS: Tell your surgeon about the medications you are taking. He will tell you which medications you should stop taking and which you should continue to take before surgery.

DIET: Losing weight prior to surgery can help minimize stress on new hip and decrease surgical risks.

DENTAL EVALUATION: Although the incidence of infection after surgery is very low, an infection can occur if bacteria enter your bloodstream. To reduce the risk of infection, major dental procedures (such as tooth extractions and periodontal work) should be completed before your surgery.

URINARY EVALUATION: People with a history of recent or frequent urinary infections should have a urological evaluation before surgery. Older men with prostate disease should consider completing required treatment before undertaking surgery.

SOCIAL PLANNING: Although you will be able to walk on crutches or a walker soon after surgery, you will need help for several weeks with such tasks as cooking, shopping, bathing, and doing laundry. If you live alone AVORS, a case manager, or a discharge planner at the hospital can help you make advance arrangements to have someone assist you at home.

AFTER SURGERY

Most patients go home the same day of surgery, but some may go home the following day.

YOUR RECOVERY at HOME: The success of your surgery will depend largely on how well you follow your surgeon’s specific instructions at home during the first few weeks after surgery. Some loss of appetite is common for several weeks after surgery. It is important to have a balanced diet (often with iron supplements) to promote proper tissue healing and restore muscle strength. Drink plenty of water!

WOUND CARE: You will be given wound care instructions when discharged home. It is normal to have some blood oozing under the dressing, however if the dressing becomes saturated, you can change the dressing with gauze and tape. Remove the dressing 4 days after surgery. You will have stitches, staples, or a glue sterile mesh (most commonly used) on the skin. The stitches, staples, or mesh will be removed at your follow-up appointment usually 2 weeks after surgery. You can shower after you remove the dressing 4 days after surgery. Wash the wound gently with soap and water while showering. Avoid soaking the wound in water such as a bath or jacuzzi. You may continue to bandage the wound to prevent irritation from clothing or support stockings.

PAIN: Surgery pain is a common concern for most patients. Dr. Sherfey or Dr. Antebi utilize advanced techniques in treating post operative pain. This includes medications given prior, during and after your surgery. After your surgery, you may experience a minimal amount of pain. Your surgeon will provide medication to make you feel as comfortable as possible. Ice packs should be used regularly to reduce swelling and pain.

ACTIVITY & EXERCISE: This is a critical component of healing, particularly during the first few weeks after surgery. You should be able to resume most normal activities of daily living within 3 to 6 weeks following surgery. Some pain with activity and at night is common for several weeks after surgery. Your activity program should include: A graduated walking program to slowly increase your mobility, initially in your home and later outside Resuming other normal household activities, such as sitting, standing, and climbing stairs Specific exercises several times a day to restore movement and strengthen your hip You will most likely be able to resume driving when your hip bends enough that you can enter and sit comfortably in your car, and when your muscle control provides adequate reaction time for braking and acceleration. Most people resume driving approximately 2 to 4 weeks after surgery.

TIME OFF WORK: This depends on your work requirements. Office workers usually require 2 weeks off and manual laborers 2 to 3 months off.

PREVENTING PNEUMONIA: It is common for patients to have shallow breathing in the early postoperative period. This is usually due to the effects of anesthesia, pain medications, and increased time spent in bed. This shallow breathing can lead to a partial collapse of the lungs (termed “atelectasis”) which can make patients susceptible to pneumonia. To help prevent this, it is important to take frequent deep breaths. Your nurse may provide a simple breathing apparatus called a spirometer to encourage you to take deep breaths.

AVOIDING FALLS: A fall during the first few weeks after surgery can damage your new hip and may result in a need for further surgery. Stairs are a particular hazard until your hip is strong and mobile. You should use a cane, crutches, a walker, hand rails, or have someone to help you until you have improved your balance, flexibility, and strength.

HOME PLANNING: Several modifications can make your home easier to navigate during your recovery. The following items may help with daily activities:

  • Safety bars or a secure handrail in your shower or bath & a stable shower bench or chair for bathing Secure handrails along your stairways & removing all loose carpets and cords.
  • A stable chair for your early recovery with a firm seat cushion, a firm back, two arms, and a footstool for intermittent leg elevation.
  • A toilet seat riser with arms if you have a low toilet.
  • A temporary living space on the same floor because walking up or down stairs will be more difficult during your early recovery.

POSSIBLE COMPLICATIONS OF SURGERY

Your hip needs time to heal, so be patient. Do not rush the recovery process.

INFECTION: It is important to follow your surgeons instructions carefully and make sure you are not pushing yourself too fast or too soon. Although the risk of infection is low, it may occur. Minor superficial wound infections are generally treated with wound cleansing and antibiotics. Major or deep infections may require more surgery and possible removal of the prosthesis.

PREVENTING INFECTION: Keeping your wound clean with antibacterial soap and water is crucial in preventing infection. A common cause of infection following surgery is from bacteria that enter the bloodstream during dental procedures, urinary tract infections, or skin infections. These bacteria can lodge around your replacement and cause a joint infection. Your surgeon will discuss with you whether taking preventive antibiotics before dental procedures is needed in your situation.

Warning signs of infection. Notify AVORS immediately if you develop any of the following:

  • Persistent fever (higher than 100°F orally)
  • Shaking chills
  • Increasing redness, tenderness, or swelling of the wound
  • Drainage from the wound
  • Increasing pain with both activity and rest

BLOOD CLOTS: Blood clots in veins are one of the most common complications of surgery. These clots can be life-threatening if they break free and travel to your lungs.

PREVENTING BLOOD CLOTS: Follow your surgeon’s instructions carefully to reduce the risk of blood clots developing during the first several weeks of your recovery. He may recommend that you continue taking the blood thinning medication you started in the hospital. Compression stockings should to be worn for three weeks after surgery.They can be removed for bathing.

Notify your surgeon if you develop any of the following:

  • Warning signs of blood clots in leg
  • Increasing pain in your calf
  • Tenderness or redness above or below your knee
  • New or increasing swelling in your calf, ankle, and foot
  • Warning Signs of PULMONARY EMBOLISM: If these occur go to the ER or call 911
  • Sudden Shortness of Breath or Sudden onset of Chest Pain or Localized Chest Pain with Coughing

IMPLANT PROBLEM: Although implant designs and materials, as well as surgical techniques, continue to advance, implant surfaces may wear down and the components may loosen. Motion may be more limited, particularly in patients with limited motion before surgery.

PAIN: A small number of patients continue to have pain after surgery. However, this complication is rare and the vast majority of patients experience excellent pain relief following surgery.

PAIN MANAGEMENT: After surgery, you will feel some mild pain. This is a natural part of the healing process. Your surgeon and nurses will work to reduce your pain. Medications are often prescribed for short-term pain relief after surgery. Many types of medicines are available to help manage pain including opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and local anesthetics. Your surgeon may use a combination of these medications to improve pain relief, as well as minimize the need for opioids. Be aware that although opioids help relieve pain after surgery, they are a narcotic and can be addictive. Talk to your doctor if your pain has not begun to improve within a
few days of your surgery.

NEUROVASCULAR INJURY: Although rare, injury to the nerves or blood vessels can occur during surgery.

GRAFT SELECTION

Dr. Antebi or Dr. Sherfey use 3 types of grafts to reconstruct the ACL. They will make their recommendation depending on your age and activity level.

The first decision is whether to use your own tissue (autograft) or donor tissue (allograft) from a cadaver. The
choice is dependent upon multiple factors. Some patients do not like the thought of having cadaver tissue in their
body, regardless of risks and outcomes; thus, autograft is chosen. The main disadvantage of autograft surgery is
the necessity of the harvest procedure and potential of associated complications from that procedure. The
harvest procedure differs depending on the type of autograft.

Allograft: Allograft is a tendon received from a cadaver donor. The most popular types of autografts are patella
tendon and hamstring tendons.

  • Major advantage of allograft is NO harvest procedure which can decrease the pain associated with surgery.
  • Disadvantages of allograft include risk of disease transmission and delayed healing of the graft tissue into the
    patient’s anatomy. The most popular allograft options are achilles tendon, patella tendon, and tibialis tendon grafts.

Bone Patella Tendon Bone (BTB) Autograft: The BTB autograft is the most common choice for surgeons who treat athletes. The patella tendon runs from the patella to the tibia.

  • Harvest procedure consists of making a vertical incision from the bottom of the patella down to the top of the tibia. The desired portion, usually the middle third, of the tendon is then cut and the bony portions of the patella and tibia are removed as well. The final autograft product is a portion of tendon bookended by two bone plugs from the patella and the tibia. The presence of the bone plugs on both sides of the graft aids in quicker incorporation, or healing, of the graft.
  • Advantages of BTB are no risk of disease transmission and quicker graft healing time.
  • Disadvantages of BTB are complications with the harvest procedure include fracture of the patella and rupture of patella tendon. Both require additional procedures to repair and a period of immobilization, which complicate and prolong the recovery period. Patients may also complain of increased pain in front of their knee in the acute and chronic settings, as well as more difficulty being able to straighten the knee completely after surgery. Some physicians advise people whose profession involves regular kneeling to avoid this type of reconstruction.

Hamstring Autograft:The hamstring consists of a series of muscles and their tendons. The hamstrings function to both bend the knee and straighten the hip.

  • Harvest procedure involves a small incision just below and towards the inside of the knee. The tendons are identified and carefully removed. The hamstring autograft has no bony portions, unlike the BTB autograft, and it involves taking one or two tendons, as opposed to BTB that only take part of the tendons.
  • Advantages of Hamstring Autograft is a less aggressive harvest procedure since no bone is being removed. When compared to harvesting the BTB autograft described previously, there is decreased surgical complication and decreased knee pain after surgery. No risk of disease transmission and quicker graft healing time than allograft.
  • Disadvantage of Hamstring Autograft is a decrease in strength to bend the knee and pain with sprinting. This would be problematic for high-level athletes. The size of the graft that can be obtained is unpredictable, and this is important because a graft too small may make it more likely to re-tear, in which case allograft may need to be added to make a larger graft.