CNY Orthopedic Sports Medicine, PC: TreatmentPrint: Anterior Cruciate Ligament Tear
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Injuries and Conditions: Anterior Cruciate Ligament Tear : Anterior Cruciate Ligament Tear : Treatment Options
 

Overview
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.

Treatment options:

ACL Patellar Tendon Graft Overview
The ACL, unable to regenerate or heal itself, is replaced with a section of the patellar tendon, located on the front of the knee.

Evaluation of Patient for Surgery

  • 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.
  • Post Operative Recovery

  • 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.
  • Rehabilitation Program

    Surgical Procedure
    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.

    Long Term Expectations for Recovery

  • 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.
  • Possible Complications and Risks

  • 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.
  • Conservative Treatment of ACL Overview

  • 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.

    Rehabilitation Program

    Medication and Medical Products
    Knee: Compression SleevesKnee compression sleeves give added support, increasing stability and helping to reduce swelling in an injured knee. Patients that have light sprains may be directed to use a compression sleeve during the early stages of rehabilitation. Other patients that have ongoing knee problems or chronic conditions may be recommended to use a sleeve on a daily basis. These sleeves are less restricting than most other knee supports and can be worn under loose fitting clothing.

    Knee compression sleeves can be used to treat:

  • Light swelling.
  • Light knee strains.
  • Chronic inflammation.
  • Degenerative joint disease.


  • Knee: Support A knee support is a sleeve-like support that fits firmly around the knee. The support is used to reinforce the joint during motion and provide compression to aid healing and reduce pain and swelling. Patients suffering from knee strains or inflammation will usually be directed to use a support during daily activities.

    The thin and flexible construction of the support allows for normal movement of the knee and also allows the support to be worn under loose fitting clothing. To prevent harmful pressure to certain structures, the support applies differing compression around the knee. The sides of the joint receive intermittent pressure to help stimulate blood flow while the rear of the support fits relatively loose to prevent constriction of circulation. The kneecap is aided in positioning, but remains free of compression to allow its natural movement.

    Knee supports can be used to treat:

  • Strains
  • Sprains
  • Inflammation
  • Chondromalacia patella

  • Knee: Ligament BraceFunctional braces are designed to control abnormal motion of an unstable knee. Because ligaments help stabilize the knee, and a torn ligament leads to instability, these braces are also called Ligament Braces. The intent is to allow a previously injured athlete to compete at a higher level than they would otherwise be able to without the brace. The brace is designed to support either a newly reconstructed ligament such as the ACL, or a weakened or injured ligament, which is being treated in a conservative manner. The role of a functional brace is to increase stability to a previously injured knee.

    Type of Injuries:

  • Pre-operative ACL/PCL ruptures/injuries
  • Non-surgical ACL/PCL injuries
  • General knee instability
  • Pre/post joint replacement with ligament instability.


  • Long-Term Expectations for Recovery

  • Patients with minor injuries can expect to fully recover after a month of physical therapy.
  • Patients suffering severe injuries that have resulted in the partial tearing of the ACL will require much longer to rehabilitate, although a full recovery is still possible with intensive physical therapy. These injuries may heal over three or more months.
  • Patients that have not achieved full recovery will need to reduce their level of physical intensity to prevent re-injury to the knee. In some cases, this will mean completely abstaining from certain activities that place particular stresses on the knee.
  • Recovery is more dependent upon the condition of the joint before and after injury and how the internal structures have healed; and significantly less dependent on the number of days, weeks or months since the injury occurred.
  • Possible Complications and Risks

  • Re-injury to the joint is possible if physical therapy becomes too strenuous for the condition of the knee.
  • For injuries involving a severely sprained or damaged ACL, physical therapy may not sufficiently recondition the knee for vigorous athletic activities.
  • For injuries involving a completely torn ACL, patients that continue to have the knee "give-way" or fail to support their weight may further damage other structures in the knee.
  • Surgical Hardware Considerations

    The technology involved in the reconstruction or repair of an injured anterior cruciate ligament has significantly evolved over the last several years. Typically, a synthetic screw or anchoring device is utilized to fasten the replacement ligament to the femur. This is placed under arthroscopic control. The tibial end of the graft is usually anchored to the bone by a metal staple or screw. In addition, a screw is placed next to the graft within the tibial tunnel that has been drilled in the bone. This screw, known as a bio-absorbable interference screw, pushes the graft firmly against the inside of the bone tunnel to assist in the healing process. The screw is made of a material that gradually dissolves after the healing process is complete, and is eventually replaced by bone.


    Factors in Transplant Source
    The source of the replacement graft for an ACL reconstruction can come from different places and consist of different parts. Frequently mentioned terms are autografts and allografts.

  • An autograft comes from your body. The advantage of this type of graft is that it is readily available and is completely compatible with you, as it is already part of your body. The most frequently utilized autografts are quadrupled semitendinosus/gracilis (hamstring) tendons and bone-patellar tendon-bone. With appropriate surgical technique and rehabilitation, both of these grafts are suitable for ACL reconstruction, with equivalent success rates.
  • An allograft comes from a human cadaver. The advantage of this type of graft is that it does not require taking a piece of tissue from another of your important parts. The disadvantage is that the tissue must be carefully processed and sterilized to make it free of disease and viruses, as well as make it compatible with your body and immune system. The sterilization process can weaken or change the physical characteristics of the graft. Failure rates have been found to be higher than for autografts.
  • Synthetic grafts are not presently utilized due to unacceptable failure/infection rates.

    Although bone-patellar tendon-bone has historically been more utilized, recent studies and surgical technique innovations have resulted in the more frequent usage of quadrupled hamstring tendons. Advantages of the quadrupled hamstring tendons include a smaller surgical incinsion, a stiffer and stronger graft, and avoidance of patellofemoral problems frequently associated with bone-patellar tendon-bone grafts.

    As with all surgical procedures and options, consult your surgeon to determine which option is best for you and your knee.