The knee is the largest joint in the human body and one of the most important joints when it comes to movement. Knee injuries can be devastating to quality of life, not only because of the impact daily life, but also because recovery from knee injuries is very difficult.
The knee if made up of the femur, or thighbone, which joins with the tibia, or lower leg bone, and is held together by various ligaments. The anterior cruciate ligament (ACL) runs from the front of the tibia to the back of the femur and prevents extreme knee rotation. However, the ACL can become torn if the person changes directions while in motion and hyperextends the knee in an unnatural way. Athletes are especially prone to ACL tears, especially those who are involved in fast-paced sports like football, soccer, basketball, and skiing.
Most ACL tears occur with some other type of damage to the knee that affects the cartilage, meniscus, or another ligament. Doctors will examine the damage to the knee and decide how best to proceed.
ACL Tear Symptoms
Most people who damaged their ACL hear a popping sound and feel their knee give out from underneath them followed by an intense pain in the knee. Any weight-bearing on the knee, like walking, will be difficult. Within a few hours the knee will swell which will make the knee hard to move. Some of the signs you may have torn your ACL and should seek immediate treatment include:
- A “popping” sound from the knee at the time of the injury.
- A feeling of the knee giving out and feeling unstable.
- Inability to return to an athletic event, if you are participating in a sport when the injury occurs.
- Difficulty bearing weight on the affected leg.
- Prominent swelling within minutes of the injury.
- Significant pain.
ACL Tear Causes
Damage to the anterior cruciate ligament is generally associated with deceleration and cutting, pivoting, sidestepping maneuvers, or awkward landings. It is believed that 70 percent of ACL injuries happen from non-contact and 30 percent occur from contact with another person or object.
ACL injuries can occur because of:
- Stopping suddenly
- Changing direction rapidly
- Landing from a jump incorrectly
- Slowing down while running
- Direct contact or collision
A physical examination can usually determine whether you have torn the ACL, especially if you experience the injury at an athletic event and a sports medicine physician is present.
Once significant swelling sets in after a few hours, diagnosing an ACL tear becomes more difficult, especially if the patient resists examination from knee pain. An orthopedist will take a full history to determine how the injury occurred, while attempting to perform a physical exam to assess the ligament.
Usually imaging tests are ordered to confirm diagnosis, such as an MRI scan to examine the soft tissues of the area. X-rays may also be performed, but those are more effective in examining dense structures such as bone. An X-ray may reveal a secondary injury, such as a fracture, which may also be present.
Some patients are advised to wait for their swelling to go down while icing the knee at regular intervals before further treatment and an accurate diagnosis can be determined. During this time, a physical therapist may be useful to help the patient work on motion, before a physician can make an easier assessment at a later date.
ACL Reconstruction Treatment
Before other treatments, patients are often advised to address the initial pain and swelling with ice, compression and elevation, as well as rehabilitation to restore strength and motion. In fact, surgery cannot be performed until excessive swelling goes down, and if surgery is performed too early while swelling is present, you risk unattractive and physically debilitating excess scar tissue formation. A brace is sometimes effective at preventing the knee from giving way in more sedentary individuals and it can help them avoid surgery, but this method isn’t usually effective for high-level athletes. Conservative methods are often ineffective at addressing knee instability, and athletes cannot return to their sports because of their knees buckling while trying to perform pivoting, jumping or cutting movements. Most athletes require surgery to be able to return to their sport.
Your doctor may choose surgery for the following reasons:
- Your ACL is completely torn or the knee is very unstable.
- Your rehab program is complete and the knee is still unstable.
- You are an athlete or have a highly physical job.
- You are willing to complete a rigorous, demanding physical therapy program.
- Chronic ACL deficiency affects your life.
- The knee is injured in multiple places, such as the cartilage or meniscus, or other ligaments and tendons.
Surgical treatment focuses on restoring the stability and function or the knee while resolving pain. Surgery does not simply repair a torn ligament, but involves constructing a new ligament, because sewing the torn ligament back together is highly prone to failure. The ACL is usually reconstructed by applying tissue grafts from the patient’s patellar or hamstring tendons or from a cadaver. Hamstring tendon auto-grafts use the patient’s own hamstring tendon, while allografts are grafts taken from cadavers and are often used for patients whose previous ACL reconstruction did not work. These different graft options all have pros and cons, which your orthopedist will discuss with you to determine the best choice.
If arthroscopic surgery is recommended, patients will be put under general anesthesia for the duration of the procedure. Arthroscopic surgery is desirable, because it minimizing soft tissue trauma. Most patients have arthroscopic ligament repair, except for the removal of graft tissue. Doctors make a small incision at the knee in arthroscopic procedure to insert a camera at the end of a tube, which is about the size of a pencil, to survey the problem. The images will display on a monitor in the operating room so the doctor can get a clear view of the patient’s anatomy, which will help him determine if there are further injuries, such as meniscus and articular cartilage injuries. Usually, these other injuries are identified and treated during the same procedure.
Doctors will first remove all the torn ACL tissue. The graft is then fed into the bone sockets. A few holes are then drilled into the thigh and shin bone, so that the new ligament graft can be attached using screws or fixation devices. These holes act as a scaffold for the ligament to grow on and provide the stabilization and support needed to return to an active lifestyle. It may take six months or longer for the graft to fully “grow into” these sockets, which is why most surgeons recommend abstaining from strenuous exercise as you heal and go through physical therapy.
Once the procedure is done, doctors will close the incisions with stitches and bandage the area. Because arthroscopy surgery is minimally invasive, the recovery time is much faster than traditional surgeries. However, it is still important to follow the instructions of your doctor for the best results.
ACL Reconstructive Surgery Risks
Like with all surgeries there are risks involved, and complications from ACL reconstructive surgery include:
- Infection has been reported in 0.2 to 0.48 percent of patients.
- Damaged nerves or blood vessels, causing bleeding or numbness at the incision site, found in 0.01 percent of patients.
- Persistent pain at the kneecap.
- Instability from rupture or stretching of the reconstructed ligament, reported to be about 2.5 – 3.4 percent risk.
- Blood clots which may be potentially life-threatening if the clot breaks off and travels to the lungs, which can cause a pulmonary embolisms or cause a stroke.
- Adverse reaction to anesthesia.
- Problems with the graft, such as loosening, stretching, re-injury or scar tissue.
- Revisional surgery required, which is much more complex than the original procedure.
- Death - mostly linked to bacterial infection from allograft tissue from improper procurement and sterilization techniques.
After you go home from surgery, you will have to watch the incision and keep it clean and dry while watching for signs of infection in the first two weeks after surgery. Change the dressings regularly according to your surgeon’s instructions.
Apart from surgery itself, physical therapy is the most important aspect of a full recovery. Before any exercise may resume, all swelling must subside, and the patient must have full range of motion in the knee. Physical therapy may also help a patient regain full strength, endurance and function. Early physical therapy is focused on fully straightening the knee and restoring control of the quadriceps muscle.
You should also continue to ice the leg after your surgery to reduce swelling and pain that may arise. You will likely use crutches to keep weight off the knee, or other mobility aids, depending on the extent of the ACL injury or other injuries present and addressed at the time of surgery.
Other aspects of physical therapy include working on a sense of balance and control of the knee through neuromuscular control. In the months of your recovery, you will wear a functional brace, but it usually is not needed once you are physically able to return to sports. Some patients may choose to continue to wear the brace after making a full recovery for a greater sense of security.
ACL surgery is complex, and we want to ensure that you feel comfortable before going into any procedure. We offer the most advanced procedures for ACL reconstruction, and our goal is to get you treated and recovered in the shortest amount of time. For more information about ACL reconstructive surgery, as well as other orthopedic services available in Los Angeles, please call our West Medical offices at (855) 690-0565.
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