ACL treatment: FAQ’s answered!!

ACL injury is a common OPD diagnosis and missed more frequently due to a negative primary skiagram and absence of a sports physician at the primary consultation. General physicians at first go might miss and diagnose it as a soft tissue injury. What is important is to diagnose it early and take precautions for prevention of re-injury.

ACL injury is a common cause of knee instability & pain .

Treatment essentially remains conservative for initial two weeks and focuses on range of motion exercises and reducing inflammation. Once patient is relieved of pain the physician might seek an MRI scan after clinical examination to be sure before planning a surgical intervention. MRI also helps in ruling out associated cartilage, meniscal, other ligament and bony contusions.

Once the diagnosis is confirmed the patient is counselled for the procedure of surgery and pre-anesthetic checkup. This usually involves a battery of basic tests to assess the patient’s fitness for undergoing the surgery. The surgery is usually performed under spinal anesthesia. The surgical time usually remains 45 minutes to an hour and the patient is discharged on the second day of surgery after first post-operative dressing. The arthroscopic procedure has an advantage of minimal scar, early rehabilitation and functional recovery.

Post ACL reconstruction scar heals in two weeks. About 4 to 5 stitches in total aroung the knee

The procedure related frequently asked questions have been answered in the article to solve out the queries of patients who are preparing for undergoing the surgery for an ACL reconstruction. 

Do I need to get this fixed only with Surgery?

If you have symptoms of instability or under-confidence while running, walking on a uneven surface, jumping from a height, walking down a ramp, changing direction while brisk walk or any mechanical symptoms (locking, catching) you are a likely candidate for surgery who will benefit majorly with the surgery.

What are the disadvantages of not getting surgery done??

Studies have reported a higher and early rates of cartilage wear off due to recurrent instability. This is important as the cartilage wear lead to a condition called arthritis charecterized by painful restricted range of movements especially on flexing the knee more than 90 degrees. This is an irreversible change which might lead to an inability to participate in sporting activities.

Joint space reduction and wearing out of the joint is early in patients of long standing instability.

What is the complete procedure?

The ACL is a central ligament which prevents rotational force to pivot the knee. Discontinuity in these fibers leads to instability of the knee. The procedure essentially involves creating a passage in the Tibia (shin bone) and the Femur (Thigh bone) at the anatomical site of the ACL. Once these tunnels are made, the graft is passed into it and fixed using implants.

What is the new ligament made up of?

The ACL is reconstructed using variable grafts. Most commonly harvested is the Hamstring tendons called Semitendinosus and Gracilis. Patellar tendon grafts and peroneal tendons are also used as grafts in cases depending on availability and patient preference. Allografts have also been used in countries outside India for same.

Hamstrings tendon are harvested from same side and prepared to form a new ligament.

What are the implants used to fix my new ligament in the knee?

The most common method to fix the ligament is using a screw at the leg bone and a button (titanium) at the thigh bone. Different surgeons have different approach to fixation and may use screws at both ends also. The screws used can be of varied material ranging from titanium (metal) to Hydroxyl appetite (BIO composite material). Implants materials have their pros and cons. Please discuss the same with your operating surgeon for same.

What is the usual time of surgery?

The surgical procedure will take about 45 minutes to 1 hour. The usual time for attendants starts while the patient is shifted to procedure room. After shifting the patient is usually made to understand the procedure and associated complications. After the usual protocol is followed the patient is prepared for anesthesia which takes about 15 to 20 minutes. After the patient is anaesthetized, surgical preparation of the limb is done and surgery started. Post-surgery, the patient is stabilized for 10 to 15 minutes and shifted back to room when comfortable.This whole process takes about 2 hours.

When can I start walking after surgery?

The patient is made to walk with help of a knee immobilizer and a walker on next day of surgery. The first post-operative dressing is also done at the same time and drain/catheter (if any) is removed. The patient is also advised isometric knee exercises by the physiotherapist on day one along with ice packs.

When can I go home after the surgery?

A hospital stay of 2 days is usual. In the first day post-surgery the patient is made comfortable with walking and usual activities and the effect of anesthesia also wears off completely. Discharge formalities are completed within 2 hours of discharge on day 2.

How long after the surgery can I do my regular activities??

Generally it is advised to walk at day 1 with support. The patient gains up to 90 range at 2 weeks and full range by end of 3 to 4 weeks. Staircase use is advised from day two of surgery with help of walking aids.

Cycling can be started at 1 month after initial isometric exercises. These are followed by strength training exercises at 4 weeks to 3 months. Variable exercises including stretching and strengthening are important to maintain the range of movements and prevent stiffness. It is advised to start swimming by 3 months and start balance training/proprioceptive exercises at 3 months. These have to continue in addition to the exercises told earlier in the course of treatment. The patients can usually start preparing for their sports after 6 months of surgery.

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