A damaged ACL may not necessarily require surgery for a full recovery. Differences in the severity and in the type of injury will dictate the treatment, as will the degree of athletic activity that the patient wishes to pursue after treatment. ACL injuries may range from minor sprains to complete tears of the ligament. Some patients, even with quite severe injuries, may choose to not undergo surgery. However, a completely torn ACL cannot rebuild itself and surgery to reattach or reconstruct the ligament is usually recommended. Selected, less active patients may not always require this procedure.
The ACL, unable to regenerate or heal itself, is replaced with a section of the patellar tendon, located on the front of the knee.
Patients are given a complete physical examination which provides an assessment of the patient's overall health.
An examination is given of the range of movement in both the injured and uninjured knee.
Strength and walking (gait) measurements and analysis.
Knee arthrometry is utilized to measure the tightness and stability of the knee.
Immediately after surgery, as anesthesia wears off, patients will usually feel tired and slightly disoriented, though the after-effects of anesthesia can vary greatly from patient to patient.
The knee will remain tender and painful after surgery. However, the pain will tend to decrease as pain killers are administered and the knee recovers from the operation.
Immediately following surgery, it is important that the knee obtains full extension. A continuous passive motion machine (CPM) may be used after surgery to help facilitate the movement of the knee, and the patient is given instructions on extension exercises for self-exercise at home.
At the first post-operative visit to the doctor, the sutures are removed, motion is examined, and the patient is directed to a physical therapist.
Braces are recommended until the patient has good control of the knee and can easily extend the leg and do deep knee bends without difficulty.
Close examination of the knee during the following 4-6 weeks is needed to ensure that the knee is correctly healing.
Patients should avoid putting a pillow under the knee. (This will tend to bend the knee and will prevent the full straightening of the joint)
More athletic activities like jogging are usually allowed after three months, though often only in a controlled environment as on a treadmill.
Sport-specific exercises are allowed according to their intensity level and strain on the recuperating knee.
Post Operative Instructions:
Wear the brace at all times, except when bathing or showering.
Bear weight as tolerated in the brace with the knee locked in full extension.
Use crutches as needed until stability returns.
Ice the knee three times a day for 20 minutes.
Keep the wound dry until the sutures are removed. If necessary, the dressing can be removed for showering (with the knee wrapped in plastic kitchen film) after 4 days.
Unlock the brace when using the continuous passive motion (CPM) machine doing exercises, or sitting.
Use the CPM machine for up to 8 hours daily. Start at 30 degrees. Progress in 5 degree as comfort allows. Discontinue using the CPM machine when the knee can bend to 90 degrees without using the machine.
Three times a day, for 30 minutes each time, sit with a large towel role under the heel with the brace locked in full extension.
It is normal to have some discomfort and swelling, as well as some blood-tinged drainage, following ACL surgery. If this becomes severe or the patients develops a fever, calf pain, shortness of breath, or chest pain, contact a doctor immediately.
A torn ACL is usually difficult to stitch together after injury because the torn ends are frayed and difficult to manage. Most often, the torn ligament is completely replaced with
material from the patellar tendon, though the ligament can also be supplemented with synthetic material.
An arthroscope is inserted into the knee joint through a small incision in the skin. The arthroscope contains a tiny fiber optic camera and is used to project images onto a monitor which the doctor uses to view the inside of the knee. Fluid is introduced to the knee through another incision
to clear away any blood and to distend the joint.
A third incision is made to allow working instruments, such as scissors or a knife, into the joint.
As the doctor views the interior of the knee from the monitor, he is able to work the surgical instruments with
one hand while placing the arthroscope with the other hand. With scissors and a knife, the doctor removes the
central third of the patellar tendon for reconstruction, along with an attached block of bone at each end.
Using a drill guide, drill holes are placed in the tibia (lower leg bone) and femur (upper leg bone)
near the site of the original ligament attachments. The graft (replacement ligament) is then placed through
the hole and held in place with screws.
A surgically rebuilt ACL which is rehabilitated properly will allow the patient to eventually regain complete strength, stability, motion, and control of the knee.
Patients that are in good physical condition are likely to recover within 7 months and will then usually be able to perform at previous levels of intensity.
Patients that are in poorer overall condition will also be able to return to previous activity levels, though rehabilitation and physical therapy will tend to be more lengthy and involved.
In all cases, physical therapy is required to restore the muscle strength, flexibility and balance lost during the injury and to acclimate the body to the repaired ligament.
Risks during and after surgery include problems that may develop in relation to bleeding, the possibility of infection, and reactions to anesthesia.
Re-injury to the ACL is possible if physical therapy or other activities during rehabilitation are overly strenuous, causing damage to the recent tendon graft.
The patient may experience reduced mobility in the knee, even after the patient has followed physical therapy routines.
The knee may be subject to arthrofibrosis, the development of a fiber like material that the body sometimes generates in joints after injuries which can limit movement and cause stiffness.
Though the reconstructed ACL is often as strong as the original ligament, it will require a period of acclimation and will tend to remain robust if not subjected to abuse.
Non-surgical treatments are typically suitable for patients with minor sprains and pulls. These conditions may be treatable with physical therapy methods that condition and strengthen the muscles around the knee through exercise and gradual rehabilitation to compensate for the inured ACL.
Even with serious ACL injuries, patients with less active lifestyles may also be candidates for non-surgical treatments. Continued gentle use of the injured knee may allow older and moderately active patients to avoid surgical treatment.
Some patients may be suitable for either surgical or non-surgical procedures. In these cases, patients that expect to resume an athletic or an active lifestyle after treatment of their injured ACL will likely benefit more from surgery than from other, non-surgical treatments.