An anterior cruciate ligament injury is the over-stretching or tearing of the anterior cruciate ligament (ACL) in the knee. A tear may be partial or complete.
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PHYSICIAN: DR. PAGNANI, DR. JONES
ACL INJURIES AND TREATMENT
Treatment of ACL tears may be operative or non-operative. In most instances during the immediate aftermath of the injury, the patient is advised to stay off the leg and elevate it, apply ice, and take medication, such as ibuprofen to reduce pain and inflammation. A course of physical therapy is prescribed to strengthen surrounding muscles, and a brace may be fitted for use during activities that would place special stress on the knee.
If you are experiencing pain in your knee, see our Questions and Answers section below and call our office at (615) 329-2520 for a consultation.
PROCEDURES: ACL RECONSTRUCTION (ALLOGRAFT)
Introduction
The anterior cruciate ligament (ACL) is one of four ligaments that are crucial to the stability of your knee. It is a strong fibrous tissue that connects the femur to the tibia. A tear of your ACL will cause your knee to become less stable and feel as though your knee is about to give out.
Incisions
Small incisions (portals) are made around the joint. The scope and surgical instruments will go into these incisions.
Visualization
The scope is inserted into the knee. Saline solution flows through a tube (cannula) and into the knee to expand the joint and to improve visualization. The image is sent to a video monitor where the surgeon can see inside the joint.
ACL Removal
A surgical instrument is inserted into the joint and the torn ACL is removed.
Graft Preparation
Allograft tissue has been previously harvested from a donor and is stored in a sterile condition. . Special tissue processing is used to clean and prepare the new ACL graft. The new graft will consist of tendon with plugs of bone attached to each end. These plugs of bone will help anchor what will become your new ACL.
Graft Insertion
Through a small incision below your kneecap, a guide wire is inserted through the tibia and femur to help accurately drill tunnels. A surgical drill is inserted over the guide wire and new tunnels in the femur and tibia are created for your new ACL Graft. The end of the graft is tied to a loop on the guide wire and the graft is pulled into place.
Securing the Graft
Screws or staples are used to secure the plugs of bone into the tunnels. Over time, the plugs of bone will incorporate into the surrounding bone.
End of Procedure
With the new ACL in position and secured, the surgical instruments are removed and the procedure is completed.
PROCEDURES: ACL RECONSTRUCTION (PATELLAR TENDON)
Introduction
The anterior cruciate ligament (ACL) is one of four ligaments that are crucial to the stability of your knee. It is a strong fibrous tissue that connects the femur to the tibia. A partial or complete tear of your ACL will cause your knee to become less stable and feel as though your knee is about to give out. There are a number of different graft options to replace your torn ACL. Your surgeon will select the option that is best for you.
Incisions
Small incisions (portals) are made around the joint. The scope and surgical instruments will go into these incisions. Another small, but longer, incision will be made below your kneecap to allow us to make the new ligament.
Visualization
The scope is inserted into the knee. Saline solution flows through a tube (cannula) and into the knee to expand the joint and to improve visualization. The image is sent to a video monitor where the surgeon can see inside the joint.
ACL Removal
A surgical instrument is inserted into the joint and the torn ACL is removed.
Graft Preparation
The central portion of the patellar tendon is removed using a scalpel and motorized tool. The ends of the tendon are attached to plugs of bone from your patella and tibia. These plugs of bone will help anchor what will become your new ACL.
Graft Insertion
A guide wire is inserted through the tibia and femur to help accurately drill tunnels. A surgical drill is inserted over the guide wire and a new tunnel in the femur and tibia is created for the new ACL Graft. The end of the graft is tied to a loop on the guide wire and the graft is pulled into place.
Securing the Graft
Screws or staples are used to secure the plugs of bone into the tunnels. Over time, the plugs of bone will incorporate into the surrounding bone.
End of Procedure
With the new ACL in position and secured, the surgical instruments are removed and the procedure is completed
ACL TEARS IN FEMALE ATHLETES
A female basketball player is five times more likely to suffer a non-contact ACL tear than a male basketball player of the same level. Further evidence comes from a survey completed by athletes who competed in the 1988 US Olympic trials. Thirteen out of 64 females suffered an ACl tear compared to only three out of 80 males.
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There are a number of anatomical and physiological differences between men and women which may account for the increased ACL tear risk that women bear. These differences biomechanically predispose women to having the knee internally rotated; thus they are more likely to find themselves in the vulnerable ACL position.
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The femoral notch width or condyle size.
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Shoe and surface interface.
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Deficiencies in training with regard to skill level, proprioception, coordination, muscular balance, and recruitment.
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Lower extremity malalignment.
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The effect of estrogen on ligament laxity
Women have a wider pelvis which leads to a greater Q angle of the femur. This means the femur angles inward from hip to knee, which leads to greater internal rotation forces of the knee joint and an internally facing patella (knee-cap). Women have less muscular development, especially in the vastus medialis oblique, which plays a crucial role in patella alignment. Women have greater knee flexibility, which may decrease joint stability. They also have a smaller intercondylar notch which impinges the ACL, thus placing it under greater tensile stress. Finally, women have increased foot pronation, which also places internal rotation forces on the knee.
The coordination of the muscular recruitment is important for knee injury prevention. Neuromuscular coordination must occur optimally for the knee joint to be safely controlled. Thus coordination drills and proprioceptive training are equally as important as muscular strength training in preventing ACL injury. Sporting movements are very rapid. Landing and cutting movements involve little knee flexion movement but require large deceleration forces. "When female athletes land, they tend to land stiffed legged with their knees coming together a little bit, versus male athletes who tend to land and bend their knees with their knee straight in front of them." He says helping athletes with this type of training is leading to an overall decrease in knee injuries.
4 Ways to Reduce ACL Injuries in Your Daughter
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Proper leg muscle strength training and core strengthening
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Proper neuromuscular (balance and speed) training
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Proper coaching on jumping and landing to avoid straight-leg landing
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Proper footwear and orthotics if necessary
QUESTIONS AND ANSWERS
1. How long does the procedure last?
The operation to reconstruct a torn ACL generally takes between 60 and 100 minutes in our hands.
2. Will I have to go under general anesthesia?
Yes. The general is also supplemented by a nerve block to help reduce pain when you wake up.
3. Will I have to stay in the hospital overnight?
No. ACL surgery is now performed on an outpatient basis.
4. What will the aftercare be?
You will be in a brace for 4-5 weeks after surgery. You can plan to be on crutches for about a week. You may remove your bandage 48 hours after surgery. After the initial bandage has been removed, you may shower.
5. How long will I be in physical therapy?
Therapy will begin 2-4 days after surgery and is generally continued for about 6 weeks after surgery. Once therapy is completed, you will have to continue strengthening exercises at a gym or health club for another 3-6 months.
6. How long will I be out of work?
You can expect to be out of work for at least 2 weeks after surgery to reconstruct the ACL. You may be out for a longer period of time if your work requires heavy lifting, working at heights, running or jumping.
7. How long until I can resume normal activities?
After an ACL reconstruction, most patients can resume normal activities (except for cutting and jumping sports) at about 6 weeks after surgery.
8. How long before I can play sports?
Jogging is usually permitted at 6 weeks after surgery. Golf is allowed at 3 months. Generally, 41/2 to 6 months are required before athletes can return to aggressive cutting sports such as football, soccer and basketball after an ACL reconstruction.
9. Are there any additional resources I can reference?
Yes! Please see the American Academy of Orthopaedic Surgeons information on ACL Injuries and Treatment:
https://orthoinfo.aaos.org/en/diseases--conditions/anterior-cruciate-ligament-acl-injuries/