ACL Reconstruction Phoenix 2011 – Arthroscopic Ligament Surgery

Anterior Cruciate Ligament (ACL) Reconstruction Overview

The ACL is the main stabilizer of the knee. The ACL is frequently torn due to the location of the ligament and the external forces exerted on the ligament with activities. Treatment decisions for ACL tears are always individualized — tailored to each individual. The decision whether to offer surgery is based on the person's age, activity level, how unstable the knee is, and whether other structures in the knee have been injured. Usually surgical reconstruction is recommended to restore stability to allow people to return to desired activities and to prevent secondary damage to the menisci (cartilage cushions) and articular cartilage of the knee, hopefully avoiding premature deterioration of the knee.

All ACL reconstruction surgery is done arthroscopically and on an outpatient basis. The standard is to create the femoral tunnel using an anteromedial portal (not through the tibia tunnel – be sure your Surgeon is using this updated technique – it is critically important for proper graft placement) for more favorable graft placement and improved outcomes. Preliminary results with Double Bundle ACL surgery is encouraging. At the present time I am practicing what Dr. Freddie Fu would term the "anatomic double bundle principle," trying to reproduce more normal anatomy by using newer techniques for creating the femoral and tibial graft insertion sites. I am following the progression of surgical techniques and if future research validates two femoral and two tibial tunnels for improved outcomes I will move to this technique. I favor reconstruction using an autograft-tissue graft harvested from the patient (rather using allograft-cadaveric tissue). I believe that obtaining the graft from the patient results in a better reconstruction with superior long term results and lower ACL re injury rates. I commonly use Hamstring Autograft (semitendinosis and gracilis combined) with Endobutton CL fixation on the femur and the bio resorbing interference screw on the tibia for most other patients. In high demand athletes, typically younger than 30, without underlying patellofemoral disease a Patellar Tendon Autograft with titanium interference screw fixation is a good treatment choice. I have recently used a Quadriceps Tendon graft with good results in revision surgery in which the hamstring autograft had already been used. This may be an evolving source for a strong auto graft with minimal side effects. Two scientific studies in the last several years show a high (10 - 25 %) failure rate if allograft tissue AND aggressive rehabilitation programs are combined in patients less than 25 years of age. I will use allograft in an older patient willing to stay out of aggressive or competitive sports for a full year, thus allowing the allograft ample time to heal (even with this cautious approach there are spontaneous allograft resorptions as the cause of failure of ACL reconstruction). I will sometimes use allografts if reconstructing multiple ligaments.

Patient Health Optimization

Cigarette Smoke impairs tissue healing by a variety of mechanisms. If you are having ACL reconstruction surgery you should stop smoking 6 weeks prior to the reconstruction and not smoke for at least 2 months after ACL replacement.

• Endobutton Device
• BioScrew
• Titanium Interference Screw

Any surgical procedure has possible risks and complications. Surgeons make every effort to minimize them.

• Deep Venous Thrombosis (DVT)
• Infection
• Stiffness
• Graft ’Impingement’

Anatomy of the ACL and Mechanism of Injury

The function of the ACL is to provide stability to the knee and minimize stress across the knee joint:

• It restrains excessive forward movement of the lower leg bone (the tibia) in relation to the thigh bone (the femur).
• It limits rotational movements of the knee.

A tear to the anterior cruciate ligament (ACL) results from overstretching of this ligament within the knee:

• It's usually due to a sudden stop and twisting motion of the knee, or a force or “blow” to the front of the knee.
• The extent of the tear can be a partial or a complete tear.
• Individuals experiencing a tear to the ACL may or may not feel a pop at the time of the injury.
• It is often injured together with other structures inside the knee joint.
• After the initial injury, the knee may swell and become painful.
• Instability or a sensation the knee is “giving out” may be a major complaint following this injury.

Often, but not always, depending on a person's activity level, a torn ACL needs to be fixed. Unfortunately a simple repair by suturing the torn ligament together again is not effective. A successful repair involves completely replacing the torn ligaments, and there are a number ways that this can be done.

Hamstring ACL Graft Harvest *Warning: graphic surgical content

Femoral Nerve Block for Post Knee Surgery Pain Control *Warning: graphic surgical content