Anterior Cruciate Ligament

Anterior Cruciate Ligament or the ACL is an important ligament inside the knee. It is present in the middle of the knee, and pairs with another ligament called posterior cruciate ligament, or PCL. Both ligaments help in stability of the knee joint, and prevent the knee from sliding on itself, hence preventing the feeling of buckling, giving way, or falling. In the absence of either one, or both the ligaments, the knee is unstable, and the patient will have difficulty walking, but especially with running, pivoting, and cutting.

Patients who have a torn ACL usually remember an injury in which they may have fallen or got hit on the knee, with or without hearing or feeling of a pop in the knee joint. These patients have sudden onset of pain associated with swelling. They also have limping because of pain. These patients also have instability and may have episodes of buckling or giving way.

In case there is a complete ACL tear, the chances of healing without a surgery are remote. That nevertheless does not preclude conservative treatment as patients with low demands can be treated with physical therapy. If the patient has a partial tear of the ACL then, there is chance that the patient may get better just with physical therapy. If the patient does not got a stable knee even after physical therapy, then they may need ACL surgery.

ACL reconstruction, or repair surgery of the knee, is one of the major arthroscopic surgeries of the knee. It involves inspection of the joint, with repair, or reconstruction of the ACL along with treatment of any associated injury like meniscal tear. The surgery itself may take one and a half to two hours to complete. The rehabilitation process after the surgery is tedious, and involves constant supervision with a physical therapist, and a physician.

If the ACL is torn completely, and the patient is in high demand of work, or recreation, then ACL surgery is preferable to give stability to the knee. If the patient is in low demand work, or has multiple comorbidities, then patients may be treated conservatively. Patients who do not undergo ACL surgery have higher chance of getting injury to other parts of the knee, like the meniscus, and the cartilage.

After the ACL is torn, the knee becomes unstable, which is worsened by strenuous activities, like running, or pivoting, and cutting. Patients can still walk with a torn ACL, and may, or may not, require a brace to stabilize the knee.

Patients with partially torn ACL are instructed to do all of this, and, have a rehabilitation program with a physical therapist. They may take up to eight to twelve weeks to recover. Some patients may take longer periods depending on the ACL torn. Few patients may even fail rehabilitation protocol, and may have to undergo a reconstruction of ACL, later.

A torn ligament in the knee does causes instability. If only a single ligament is torn, patient is usually able to walk, though he may have some instability, and may need to use a brace, or crutches for support. If the patient has injury to multiple ligaments, or ligaments and meniscus, it may be difficult for the patient to walk without having a feeling of instability, or giving way, and may have episodes of falling.

A partial ACL tear, depending on the amount of ligament involved may heal on its own, and patient may recover by use of physical therapy. If the patient has high grade partial ACL tear, then these patients may not recover completely, and depending on the requirement of the patient, may need to undergo surgical reconstruction of the ACL.

ACL tears if present early after injury and if MRI show that they are reparable, then a trial for repair can be given to the ACL. The ligament is fixed back to the bone using some sutures and buttons to allow a natural healing process and keep the native ligament in its place. Repair leads to early recovery and owing to the retention of native ACL, gives better proprioception and hence early rehabilitation and recovery.

ACL repair, if possible, give better result than reconstruction because in ACL repair, the native ligament is kept as such and is fixed back to the bone to allow healing. In case of reconstruction, a ligament substitute is put in place, which not only takes a longer time to heal, but also takes time for ingrowth of nerves and vessels, which may also still be incomplete to give a result similar to an ACL repair.

After an ACL reconstruction, patients must be involved in a rehabilitation program with the physical therapy under direct supervision of the therapist and the treating physician. Patients must be in brace initially, which is gradually weaned off in four to eight weeks. Patient is put in rigorous physical therapy program and is also allowed to strengthen his muscles in the gym after about three months from surgery. Patients must strengthen their quadriceps as well as the hamstrings and must regain full range of motion and power before they can indulge in a sporting event. They are puts into sports rehab program. It could take six to twelve months before a professional sportsman can return to play.

A torn ACL, when treated surgically, may take up to 6 to 12 months to recover completely and allow the patient to do unrestricted activities as before the injury. In patients who do not opt to operate may have a long rehabilitation process with suboptimal results, but if the results allow the patient to live a satisfactory life in their activities of daily living as well as work and recreation, then the result is found to be okay.

The risks of ACL reconstruction arthroscopically include Medical (Anesthetic) complications like but not limited to: Allergic reactions, excessive blood loss, heart attack, stroke, kidney failure, pneumonia, bladder infections. Complications from nerve blocks such as infection or nerve damage. Complications due to surgery itself include infection, DVT, excessive swelling & bruising, joint stiffness, tingling and numbness, graft failure, damage to nerves or vessels, hardware problems, donor site problems, residual pain, reflex sympathetic dystrophy etc. Some of these conditions may require hospitalization, aspiration, injections or even surgery.

Patients are encouraged to keep their knee elevated most times for a few weeks after ACL surgery. This is to decrease the swelling as well as the pain in the knee. Once the patient’s pain has decreased and the swelling is no longer there, the patient can decrease the time of leg elevation. If the pain and swelling recur, then the patients are instructed to use ice as well as elevation and compression to decease the pain and swelling.

Patients can walk within a day after the ACL surgery with a brace. They are also asked to use crutches for support. Patient will be using a brace for four to six weeks. They may use auxiliary crutches for support, if needed.

Patients, after ACL surgery, have a brace on the knee, and may use auxiliary crutches for comfort. They may discard the crutches once they are able to ambulate without discomfort.
Is ACL surgery serious?

ACL reconstruction, or repair surgery of the knee, is one of the major arthroscopic surgeries of the knee. It involves inspection of the joint, with repair, or reconstruction of the ACL along with treatment of any associated injury like meniscal tear. The surgery itself may take one and a half to two hours to complete. The rehabilitation process after the surgery is tedious, and involves constant supervision with a physical therapist, and a physician.

Patients usually must go for six to nine months of physical therapy after an ACL reconstruction, for it to recover completely, from ACL surgery, depending on the patient’s requirement. If the patient is a sportsman, they may have to go to a sports rehabilitation program so as to recover completely, to a pre injury status.

A stretched ACL can be treated with a brace and physical therapy and may heal over time enough to provide a patient with a stable knee. If the patient does not heal completely with the brace, and physical therapy, and is still unstable enough to handle activities of daily living, or work, without limitation, then he may need to undergo ACL reconstruction surgery.

Patients are usually asked to remove their dressing after 72 hours of surgery, and can take a shower after that. Patient can dab the surgical area dry and put band aids over it.

An ACL reconstruction/repair can fail, due to multiple reasons, including wrong surgical technique, injury, fall, or twisting of the knee. ACL surgery may also fail in the presence of infection. In case of ACL repair, surgery may fail to heal the native ligament and a reconstruction may have to be done. These patients may need to undergo a revision of the ACL reconstruction, to get a stable knee.

Torn ligaments of the knee, if in place, and of low grade (partial), can heal by themselves. The lateral collateral, as the medial collateral ligaments are essentially treated conservatively with brace and physical therapy. In case of high grade ligament tear, and if the patient is not getting better with physical therapy and brace, the patient may need a surgical repair, or reconstruction of the ligament, to obtain stability.

ACL surgery is most commonly done arthroscopically, in which a camera and a light source are introduced to the knee joint through small incisions. Surgical instruments are inserted through different incision, and the ACL is examined. If the ACL is completely torn, and not repairable, then it is debrided, and cleaned.

The replacement substitute for the ACL is then harvested, either from the hamstring muscles, patellar tendon, or the quadriceps tendon, to replace the ACL. Bone tunnels are then made into lower end of femur, and upper end of tibia to pass the graft, and the graft is fixed using sutures, and either screws or buttons. Any concomitant pathology if found inside the knee is also taken care of.

The torn ACL is usually treated non-surgically and may take up to eight to twelve weeks to heal. A patient is usually treated with a brace, and physical therapy. Patient may be out of work, depending on the type of work, from two weeks to eight weeks. If the patient is in high demand job with a lot of manual work, then they may be out for a longer period.

The recovery of a combined surgery is a little longer than that of an ACL surgery. There are s slightly higher chances of complications and stiffness owing to increased surgical time and work done inside the knee. The loss of partial meniscus in cases of partial meniscectomy also plays a role in long term recovery of the knee. In cases of meniscus repair, the rehabilitation is slowed due the time needed for the healing of the meniscus.

If the ligament is in it’s place, especially near the, it’s, bony end, then they may heal with the help of bracing and physical therapy. If the ligaments are torn in mid substance then it is difficult for them to heal, because the healing between the two ends of ligaments is not optimal. The ligaments usually do not grow back, but they heal with a fibrous tissue between them.

The ACL tear is essentially caused due to injury or fall or contact sports. If a person is involved in high risk activities like contact sports, then they are advised to have strong musculature, especially in the quadriceps and the hamstrings, as this support the knee, hence preventing an ACL tear. If the patient has undergone an ACL reconstruction, or repair, surgery then they are instructed to strengthen their quadriceps as well as hamstrings before they go back into field, to prevent repeat tear of the ACL.

An ACL is usually torn due to fall, or injury, especially involving twisting of the knee, or with an indirect force; someone hitting the knee. This usually happens in a contact sport accident, but this may also happen in injuries, like automobile accidents.

Patients who undergo ACL reconstruction using their hamstring muscles can still walk and function well with their knee with rehabilitation because of other muscles substituting for those hamstring tendons as well as partial or complete regeneration of the tendons.

Surgery for ACL reconstruction is essentially an elective surgery in which the patient must discuss and understand the need for the surgery. If the patient is symptomatic enough to have inability of daily living, work and/or recreation, then it is advisable to undergo ACL reconstruction. Wearing a knee brace cannot substitute for a deficient ACL and patient will still will have restriction with regards to his activity. The knee brace may help in stabilizing the knee for certain movements, but the patients will still not be able to perform a higher level of function with that knee.

Patients with ACL injury do remember incident in which they may have injured their knee. This is usually associated with, swelling of the knee, pain along with limping. If the patient presents late, they may have symptoms of instability in which they would have knee buckling or weakness because of deficiency of the ACL. A diagnosis of ACL injury is usually made by examination followed by an MRI of the knee.