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Anterior Cruciate Anterior Cruciate Ligament Ligament
ReconstructionReconstructionUniversity Orthopaedics & Sports University Orthopaedics & Sports
MedicineMedicine
Presentation designed for patient Presentation designed for patient educationeducation
Updated 2/11
University Orthopaedics & University Orthopaedics & Sports MedicineSports Medicine
OfficesOffices
Clifton (Medical Clifton (Medical Arts Building)Arts Building)
WestchesterWestchester www.ucortho.comwww.ucortho.com 513-475-8690513-475-8690
University Orthopaedics & University Orthopaedics & Sports MedicineSports Medicine
SurgerySurgery
Holmes Hospital (Clifton)Holmes Hospital (Clifton) Outpatient Surgery CenterOutpatient Surgery Center
Mercy FairfieldMercy Fairfield MainMain Outpatient Surgery CenterOutpatient Surgery Center
Westchester Medical CenterWestchester Medical Center University Pointe Ambulatory Surgical University Pointe Ambulatory Surgical
Hospital (ASH)Hospital (ASH) University HospitalUniversity Hospital
What is the Anterior Cruciate What is the Anterior Cruciate Ligament (ACL) ?Ligament (ACL) ?
The ACL is one of The ACL is one of the 4 main the 4 main ligaments of the ligaments of the knee that keeps knee that keeps the knee stable.the knee stable.
How is the ACL injuredHow is the ACL injured
Usually injured with a Usually injured with a twisting injury to the twisting injury to the knee or a direct blow knee or a direct blow to the outside of the to the outside of the knee with a contact or knee with a contact or noncontact mechanismnoncontact mechanism
Contact injuryContact injury Example-hit by an Example-hit by an
opponentopponent Noncontact injuryNoncontact injury
Example-skiingExample-skiing
Signs and Symptoms of Signs and Symptoms of ACL tearACL tear
AcuteAcute Marked pain and popMarked pain and pop Significant knee swellingSignificant knee swelling Difficulty bearing weight on the affected Difficulty bearing weight on the affected
kneeknee ChronicChronic
The knee feels looseThe knee feels loose Feeling of “buckling”, “giving way” or Feeling of “buckling”, “giving way” or
instabilityinstability Pain and swellingPain and swelling
Signs and Symptoms of ACL Signs and Symptoms of ACL tear?tear?
May also be dependant on May also be dependant on injuries to other knee injuries to other knee structuresstructures
LigamentsLigaments Medial Collateral Ligament Medial Collateral Ligament
(MCL)(MCL) Posterior Cruciate Ligament Posterior Cruciate Ligament
(PCL)(PCL) Posterolateral CornerPosterolateral Corner
Meniscus-(cushions in the Meniscus-(cushions in the knee)knee) MedialMedial Lateral Lateral BothBoth
Articular cartilage (gliding Articular cartilage (gliding cartilage on the ends of cartilage on the ends of bones)bones)
DiagnosisDiagnosis
HistoryHistory Physical examPhysical exam X-raysX-rays usually normal but should be usually normal but should be
obtained to ensure that there is no obtained to ensure that there is no fracturefracture
MRI-excellent for evaluating not only MRI-excellent for evaluating not only the ACL but also the meniscus, the ACL but also the meniscus, articular cartilage and other knee articular cartilage and other knee ligamentsligaments
What is the acute treatment What is the acute treatment for an ACL tear?for an ACL tear?
Rest Rest Ice Ice ElevationElevation CompressionCompression Protected Weight Protected Weight
BearingBearing Brace Brace
Does everyone with a torn Does everyone with a torn ACL need surgery?ACL need surgery?
No!No! Who does not need surgery?Who does not need surgery?
Patients with very advanced arthritisPatients with very advanced arthritis Patients who do not do activities that Patients who do not do activities that
require an intact ACL?require an intact ACL? Patients who are not interested in Patients who are not interested in
committing to post-operative rehabcommitting to post-operative rehab
Who does need an ACL Who does need an ACL reconstruction?reconstruction?
Most patientsMost patients Patients who perform activities requiring Patients who perform activities requiring
an intact ACL-most active patientsan intact ACL-most active patients Patients with associated knee injuriesPatients with associated knee injuries
Other ligaments, meniscus tear, gliding Other ligaments, meniscus tear, gliding cartilage injurycartilage injury
Young patients with an otherwise healthy Young patients with an otherwise healthy kneeknee No injury to meniscus or gliding cartilage No injury to meniscus or gliding cartilage
ACL dependent activitiesACL dependent activities DependentDependent
Cutting sportsCutting sports Basketball, soccer, Basketball, soccer,
football, softball, football, softball, tennis, cheerleading, tennis, cheerleading, skiing etc.skiing etc.
High end aerobicsHigh end aerobics SkateboardingSkateboarding Difficult HikingDifficult Hiking Most laboring jobsMost laboring jobs ANY ACTIVITY WHEN ANY ACTIVITY WHEN
THE KNEE BUCKLES THE KNEE BUCKLES AFTER THE INJURYAFTER THE INJURY
Not DependentNot Dependent WalkingWalking Jogging in a straight Jogging in a straight
lineline Desk jobsDesk jobs Riding a bicycleRiding a bicycle
Who needs a pre-op Who needs a pre-op brace?brace?
Patients whose Patients whose knee buckles knee buckles (gives out) with (gives out) with everyday activitieseveryday activities
What are the risks of not What are the risks of not getting your ACL fixed?getting your ACL fixed?
Every time your knee buckles you Every time your knee buckles you risk injuring other vital structures in risk injuring other vital structures in your kneeyour knee Meniscus, ligaments, gliding cartilageMeniscus, ligaments, gliding cartilage
What happens if the vital structures What happens if the vital structures are injured?are injured? Rapidly accelerated arthritisRapidly accelerated arthritis
Are there any pre-operative Are there any pre-operative requirements for ACL requirements for ACL
reconstruction?reconstruction? YesYes You should have You should have
near normal knee near normal knee range of motion.range of motion.
Sometimes patients Sometimes patients go to physical go to physical therapy pre-therapy pre-operatively to get operatively to get there motion there motion restored before restored before surgery.surgery.
What should I do before my What should I do before my surgery?surgery?
Make sure your knee does not buckleMake sure your knee does not buckle Understand your injuryUnderstand your injury Ask your surgeon any questions that Ask your surgeon any questions that
you haveyou have Understand what the expected post Understand what the expected post
operative course will be likeoperative course will be like Choose a graftChoose a graft
ACLs are not REPAIRED, but rather ACLs are not REPAIRED, but rather RECONSTRUCTED and thus require other RECONSTRUCTED and thus require other tissue for a grafttissue for a graft
Graft Choices-AutograftGraft Choices-Autograft
Autograft (your own tissue)Autograft (your own tissue) Bone-Patellar Tendon-BoneBone-Patellar Tendon-Bone
Bone plug from your knee cap, middle 1/3 of Bone plug from your knee cap, middle 1/3 of your patellar tendon and bone plug from shin your patellar tendon and bone plug from shin bonebone
Most painfulMost painful
Hamstring autograftHamstring autograft 2 hamstring tendons2 hamstring tendons Less painful than bone patellar tendon bone Less painful than bone patellar tendon bone
graftgraft Allows for a very stable kneeAllows for a very stable knee Graft of choice for patients with open growth Graft of choice for patients with open growth
platesplates
Graft Choices-AllograftGraft Choices-Allograft
Allograft (cadaver)Allograft (cadaver) Least painfulLeast painful Smallest incisionSmallest incision Recommended in patients with Recommended in patients with
significant injuries to other ligaments of significant injuries to other ligaments of the kneethe knee
Usually recommended in revision casesUsually recommended in revision cases Very, very, very small risk of disease Very, very, very small risk of disease
transmission from the donortransmission from the donor
Graft ChoicesGraft Choices
There is no convincing evidence in There is no convincing evidence in the orthopaedic literature stating the orthopaedic literature stating that one graft is any better than the that one graft is any better than the otherother
This is a personal choice and should This is a personal choice and should be discussed with your surgeon!!!!be discussed with your surgeon!!!!
This should be determined prior to This should be determined prior to the date of surgerythe date of surgery
Day Of SurgeryDay Of Surgery
NPO (nothing by mouth except meds) NPO (nothing by mouth except meds) after midnight the night beforeafter midnight the night before
Arrive to the hospital on timeArrive to the hospital on time Get pre-operative nerve blocksGet pre-operative nerve blocks
Anesthesiologist gives you sedating Anesthesiologist gives you sedating medication in your IVmedication in your IV
Then gives you shots to numb your Then gives you shots to numb your nerves so you have markedly decreased nerves so you have markedly decreased post op painpost op pain
SurgerySurgery
Examination of your knee while you are Examination of your knee while you are asleepasleep
Fix any associated injuriesFix any associated injuries
Torn meniscus Suture repair of meniscus
SurgerySurgery
Reconstruction of the ACL by drilling Reconstruction of the ACL by drilling tunnels (holes) in your femur (thigh bone) tunnels (holes) in your femur (thigh bone) and tibia (shin bone)and tibia (shin bone)
Tunnel (hole) in thigh bone for graft passage
↑
SurgerySurgery
Passing the graft across the knee and Passing the graft across the knee and using surgical devices to hold the graft in using surgical devices to hold the graft in place while it heals to the bonesplace while it heals to the bones
New ACL graft passed thru tunnels
↑
Immediately after Immediately after surgerysurgery
You will wake up with cryocuff You will wake up with cryocuff (fancy ice pack) and a brace on with (fancy ice pack) and a brace on with your knee in full extension (straight your knee in full extension (straight out)out)
If you had pre-operative nerve If you had pre-operative nerve blocks your pain should be tolerableblocks your pain should be tolerable
The recovery room nurses will also The recovery room nurses will also give you pain medicationsgive you pain medications
After surgeryAfter surgery
You can go home the same day as your You can go home the same day as your surgerysurgery
You should take your pain medications You should take your pain medications given by your surgeon no later than given by your surgeon no later than dinner time to make sure you have some dinner time to make sure you have some pain medications in your system when pain medications in your system when your block wears offyour block wears off
Your block will probably wear off Your block will probably wear off sometime in the middle of the nightsometime in the middle of the night
Your pain will decrease every day Your pain will decrease every day
Post op carePost op care
Wear your brace any time you are upWear your brace any time you are up Sleep in your braceSleep in your brace You may open your brace any time you are You may open your brace any time you are
seated or lying downseated or lying down Ice (cryocuff) as much as possibleIce (cryocuff) as much as possible Elevate your knee above your heart as Elevate your knee above your heart as
much as possiblemuch as possible You may put as much weight on your leg as You may put as much weight on your leg as
you can tolerate with your crutches you can tolerate with your crutches immediately post opimmediately post op
Post op carePost op care You can take all your dressings down except for You can take all your dressings down except for
the steri-strips (white band aid like strips) on the the steri-strips (white band aid like strips) on the third day after surgery and take a showerthird day after surgery and take a shower
DO NOT SCRUB YOUR WOUNDSDO NOT SCRUB YOUR WOUNDS DO NOT SOAK YOUR WOUNDSDO NOT SOAK YOUR WOUNDS Simply wash your thigh with soap and water and Simply wash your thigh with soap and water and
let the soap and water run offlet the soap and water run off Pat your wounds dryPat your wounds dry If your wounds are dry you may leave them open If your wounds are dry you may leave them open
to the air or put a clean dry dressing over themto the air or put a clean dry dressing over them DO NOT PUT ANY CREAMS/OINTMENTS ON DO NOT PUT ANY CREAMS/OINTMENTS ON
YOUR WOUNDS (THIS INCLUDES POLYSPORIN, YOUR WOUNDS (THIS INCLUDES POLYSPORIN, ETC.)ETC.)
Post opPost op
You will see your surgeon between 5-7 You will see your surgeon between 5-7 days post opdays post op
You will go directly to your first You will go directly to your first physical therapy appointment after physical therapy appointment after your office visityour office visit
You will have PT 2-3 x per week for the You will have PT 2-3 x per week for the first 6 weeksfirst 6 weeks
You can get rid of your crutches when You can get rid of your crutches when you can hold a straight leg raise for 10 you can hold a straight leg raise for 10 seconds (usually 7-14 days)seconds (usually 7-14 days)
Typical Post-Op Typical Post-Op MilestonesMilestones
Typical milestonesTypical milestones Immediately post opImmediately post op
Long brace locked in full Long brace locked in full extensionextension
Range of motion exercises Range of motion exercises and very gentle thigh and very gentle thigh exercisesexercises
PT 2-3x per week PT 2-3x per week Therapist will tell you Therapist will tell you
when safe to get off when safe to get off crutches based on thigh crutches based on thigh waking upwaking up
1 month-1 month- Shorten your post op Shorten your post op
bracebrace Therapy 2-3 x weekTherapy 2-3 x week
Typical Post-Op Typical Post-Op MilestonesMilestones
2 months2 months
- Hinged knee sleeve- Hinged knee sleeve
- begin aggressive thigh - begin aggressive thigh strengthening exercises (0-strengthening exercises (0-90°)90°)
-bike, elliptical, -bike, elliptical, stairclimber, squats, stairclimber, squats,
lungeslunges
-Many of the exercises -Many of the exercises can be done on own at a can be done on own at a gymgym
-Check in with therapist -Check in with therapist periodically for them to periodically for them to “coach” you on your “coach” you on your exercises and make sure exercises and make sure you are on the right trackyou are on the right track
Typical Post-Op Typical Post-Op MilestonesMilestones
3 months-3 months-
-OK to jog if thigh progressing -OK to jog if thigh progressing appropriatelyappropriately
4-5 months4-5 months
-begin some sport specific activities-begin some sport specific activities 6-9 months6-9 months
-return to sport/work-return to sport/work The post-op course varies between patients The post-op course varies between patients
and your course may be slightly differentand your course may be slightly different
Post-op QuestionsPost-op Questions How long will I be on crutches?How long will I be on crutches?
7-14 days-you can get off crutches when your thigh 7-14 days-you can get off crutches when your thigh wakes up and you can hold a straight leg raise for 10 wakes up and you can hold a straight leg raise for 10 secondsseconds
Your therapist will tell you when you can stop using Your therapist will tell you when you can stop using crutchescrutches
When can I go back to school?When can I go back to school? Must be off narcoticsMust be off narcotics Must be able to navigate school with brace on and Must be able to navigate school with brace on and
lockedlocked Usually between 5-7 days.Usually between 5-7 days.
When can I go back to workWhen can I go back to work Labor Job- 6 to 9 months after your knee is fully healedLabor Job- 6 to 9 months after your knee is fully healed Desk job- 7-14 days after your pain goes down and you Desk job- 7-14 days after your pain goes down and you
are off narcotic pain medsare off narcotic pain meds
Post op-QuestionsPost op-Questions
Can the post-op course be accelerated?Can the post-op course be accelerated? Not reallyNot really Cannot change biology-how fast humans Cannot change biology-how fast humans
healheal It takes several months for your new graft It takes several months for your new graft
to grow into the bone. Accelerated rehab to grow into the bone. Accelerated rehab risks stretching your graft and making it risks stretching your graft and making it too loose and non-functionaltoo loose and non-functional
Also, length of the rehab is based more on Also, length of the rehab is based more on the thigh than on the knee.the thigh than on the knee.
Post-op QuestionsPost-op Questions The thigh (quadriceps muscle) shuts down The thigh (quadriceps muscle) shuts down
(goes to sleep) after surgery and it takes time (goes to sleep) after surgery and it takes time and rehab for it to wake up?and rehab for it to wake up?
It takes 6-9 months for the quadriceps It takes 6-9 months for the quadriceps musculature to fully restore itself after musculature to fully restore itself after surgery.surgery.
Until the thigh muscle is strong again your Until the thigh muscle is strong again your knee will feel loose even though it is entirely knee will feel loose even though it is entirely stablestable
The more frequently the thigh exercises are The more frequently the thigh exercises are done the faster the thigh will be strong and the done the faster the thigh will be strong and the faster you may safely return to full activities. faster you may safely return to full activities.
Thank You Thank You
Any further questions should be Any further questions should be directed to your therapist or surgeondirected to your therapist or surgeon
513-475-8690513-475-8690
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