Knee is a complex joint which plays a key role in supporting body during static & dynamic activities. Therefore, knee joint must meet major mobility as well as stability which are imitated within its structure. Anterior cruciate ligament is one of the vital structures that provide strength to the knee complex which constrains rotational stress & anterior translation kept over the knee complex. Rupture of this ligament is the most frequent knee injury occurring when it is acutely stretched & may result in serious functional impairment as a result. Those at maximum risk of injury are generally aged in between 20 to 40 years & play sports like basketball or football that needs pivoting or sudden changes in movement. Women are more prone to knee injuries, especially female athletes in comparison to men.
What is Anterior Cruciate Ligament Surgery?
Anterior cruciate ligament surgery is a procedure that involves substituting torn ligament of patients with a graft. Graft is generally taken from a tendon in another portion of knee, for example, hamstring or patella tendon of patients. But sometimes it can be an allograft which means a graft from a donor. Orthopedic surgeons will suggest various graft options for patients. ACL repair surgery is mainly carried out to make patient’s knee stable. Patients may be able to return back to playing sports after ACL surgery. However, this also depends upon other problems with knee, such as torn cartilages, arthritis or other ligament injuries.
Knee injuries can easily occur while playing sports such as football, tennis, squash, skiing & rugby. According to health reports, ACL injuries are most typical types of knee injuries, accounting for nearly 55% of all sports injuries. People can tear their ACL if lower leg or knee is stretched too much. Following factors are the most common causes of ACL injury.
- Improper landing from a jump
- Sudden stopping
- Suddenly changing direction
- Slowing down while running
- Having a direct contact or collision during football tackling
When ACL is torn, knee may become highly unstable & may completely lose its range of movement. It may become tough to perform certain movements & certain sports may become impossible to play.
When someone injures the anterior cruciate ligament, they might hear a popping sound & may feel severe pain. Typical symptoms of ACL injury can be explained as follows.
- Pain leading to discomfort while walking
- Loss of full range of motion
- Tenderness along the joint line
- Extreme swelling
Within few hours, patient’s knee will swell. If this is ignored by the patient, sometimes pain may resolve on its own. However, if they try to return to sports, the knee will possibly be unstable & can cause further damage to meniscus which is cushioning cartilage within the knee joint.
During initial physical examination, orthopedic surgeons will check knee of patients for tenderness & swelling & compare severity of injured knee to an un-injured knee. Orthopedic surgeons may move patient’s knee into a number of positions to judge range of motion & functioning of the joint. Often diagnosis of ACL injury can be made merely on the basis of physical examination, but patients may require tests to rule out other causes & to figure out sternness of injury. Evaluation tests may include the following.
- X-rays – This may be required to count out a bone fracture. X-rays however, cannot envision delicate tissues such as tendons & ligaments.
- Magnetic Resonance Imaging – MRI involves radio waves along with a magnetic field to build images of hard & gentle tissues within the patient’s body. An MRI can clearly exhibit degree of ACL injury & signs of loss to other tissues in knee.
- Ultrasound – With use of sound waves reflecting from internal structures, ultrasound may be comfortably used to check for injuries in tendons, ligaments & muscles of knee.
Techniques of surgical ACL repair may be broadly categorized into three groups.
- Primary ACL Repair
- Extra-Articular ACL Repair
- Intra-Articular ACL Repair
Primary repair is not suggested except for bony avulsions, which are normally observed in adolescents. As ACL is intra-articular, ligamentous ends are directed to synovial fluid, which does not promote ligamentous healing. Extra-articular reconstruction usually includes a tenodesis of iliotibial tract which may prevent a pivot shift. Intra-articular repair of the ACL has become a standard for treating ACL injuries.The following grafts are being used for this purpose.
- Bone-Patella-Bone Autograft – They are recently popular because they provide a considerably higher percentage of steady knees with a greater rate of return to sports.
- Hamstring Tendon Graft – This is integrated with speedy recovery & lesser knee pain.
- Allograft – This is extremely popular due to its ability, efficiency to give bony fixation & lack of patella morbidity. They are associated with certain risk of viral transmission & are best used in revision surgeries.
Preparing for Anterior Cruciate Ligament Surgery
When deciding to perform anterior cruciate ligament surgery, the orthopedic surgeon should consider the enumerated factors.
- Associated injuries
- Pre-injury activity level
- Desire to return to sports
- Abnormal laxity
- Expectations of patients from surgery
An orthopedic surgeon will explain to patients how to prepare for their ACL repair surgery.
- Physiotherapy – Usually, orthopedic surgeons will perform anterior cruciate ligament surgery after four to eight weeks of injury. Orthopedic surgeons may ask patients to do physiotherapy for a couple of weeks after knee injury. This is advised to ensure that patients can move their knee as easily as possible before undergoing surgery.
- Stop Smoking – Surgeon will ask patients to give up smoking because smoking escalates their risk of getting chest & wound infection, which can slow down the entire recovery process.
- Selection of Anesthesia – ACL repair surgery can be done under influence of local or general anesthesia. Local anesthetic is meant to block all pain from knee area of the patient & they will stay awake during surgery. If surgeon recommends general anesthetic, it means that the patient will be asleep during the ACL repair operation.
- Doubt Resolving Session – Orthopedic surgeons will have a chat with patients about the whole procedure of anterior cruciate ligament surgery & any pain they might have. Patients should take this time to ask any queries that they would like to be answered so that they understand what will happen during their surgical intervention. Surgeons may also ask patients to give consent for surgical procedure to move further by signing a consent form.
It can be very helpful to prepare some queries beforehand. Some of these significant questions which patients may ask doctors are listed below.
- How do I know if anterior cruciate ligament surgery will help me?
- How much does this surgery cost?
- Is there anything that I can do prior to ACL surgery so it will be more successful for me?
- Should I learn to use a walker or crutches before I undergo ACL surgery?
- Where can I get aid for quitting smoking, if I need to?
- Will I be able to get out of my bed after coming home?
- What are the possible risks or complications of ACL surgery?
- How long will it take to complete ACL surgery?
- Will I be in severe pain after this surgery? What will you do to relieve my pain?
- Do I need to quit taking any medications before ACL surgery?
- What should I do a day before my ACL surgery?
- What outcome should I expect from my ACL surgery?
Anterior cruciate ligament surgery is done as stated in the following steps.
- Incisions – During an anterior cruciate ligament surgery, orthopedic surgeons generally make two or three small incisions around the knee joint. Surgeons then pump sterile saline solution into knee through a single cut to expand it & to wash blood from that portion which eventually allows the surgeon to clearly see internal knee structures. Orthopedic surgeons then insert an arthroscope into the incision. A small camera on the other end of arthroscope transmits photos from inside of knee to a monitoring screen inside the operating room.
- Surgical Drills – These are inserted through small incisions. Orthopedic surgeons drill small holes into lower as well as upper leg bones where these bones are held together at knee joint. These holes create tunnels through which graft will be safely anchored.
- Graft – Orthopedic surgeons will create another incision in knee area & take the replacement tissue or graft. Graft taken from patellar tendon allows better recovery because the tendon remains attached to its original bone as well. If autograft comes from a hamstring, it may help the knee to appear more normal after it completely heals. Whole graft (allograft) may also be taken from a deceased donor.
- Closing Incisions – Graft is then pulled through two tunnels that were made in lower & upper leg bones. Surgeon immunes the graft with hardware such as staples or screws & will close these incisions with tape or stitches. Subsequently, knee is carefully bandaged & patients are taken to the recovery room for 4 to 5 hours following operation. Surgeons may also repair other injured parts of the knee as well during ACL surgery, such as cartilage, menisci, other ligaments or broken bones.
Healing from anterior cruciate ligament knee surgery can take up to a year or two. Patients may experience painful swelling, bruising & redness down the front of their ankle. These symptoms are temporary & should start to dissolve after about a weeks’ time. Once swelling & pain have settled, patients may be advised to do certain exercises. These exercises will help patients achieve the following results.
- Fully bending & extending knee
- Beginning to walk nicely
- Strengthening leg muscles
- Improving balance of body
Four weeks to six months after surgery, patients should gradually be able to return to normal level of activity. Patients may be able to return to playing sport within six months of time. Some patients may need to take more time intervals before feeling sure enough to play once again & athletes may need longer to return back to their original level of performance. It is very important for patients to follow guidelines given by surgeons in order to promote successful recovery.
ACL surgery is generally a safe surgical process. But, as with every other surgery, there are certain risks associated with ACL surgery as well. Some of these common complications are given below.
- Numbness within the surgical scar area
- Risks of anesthesia
- Infection in surgical incisions
- Damage to blood vessels, structures or nerves
- Blood clots
- Grating of kneecap
- Knee weakness
- Stiffness in knee
- Graft failure
- Long-term knee pain
- Limited range of motion
- Revisional surgery
Patients should ask their surgeons to explain how these risks apply to them & how can they be minimized.
Undergoing anterior cruciate ligament surgery could help in stabilizing patient’s knee, comfort the painful knee & make it work perfectly once again. After ACL surgery, patients may be capable of returning to sports, such as football, netball, basketball, rugby or skiing. Success of surgery is directly proportional to surgeon’s skill & experience as well as positive attitude of patients. ACL surgery is the best option for patients as it involves lesser pain & speedy recovery.
Medical Tourism in India for Anterior Cruciate Ligament Surgery
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