Anterior cruciate ligament (ACL) surgery

The injury of the anterior cruciate ligament is one of the most common knee injuries in sport. As the lesion of the ligament changes the kinematics of the knee joint, without treatment, it could cause degenerative defects too (meniscus injuries, wear of the joint surfaces). Anterior cruciate ligament surgery replaces the torn ligament with a tendon, usually from another part of the knee.

Four ligaments are responsible for the stability of the knee joint: the medial and lateral collateral ligaments prevent the lateral displacement, the anterior and posterior cruciate ligaments block the forward-backward movement of the joint.

The anterior cruciate ligament (ACL) and the posterior cruciate ligament are located in the joint capsule, in the middle of the knee joint. Strong bands of tissues, covered with synovium. Due to the different locations of the origin and adhesion points, one of the ligaments is always tense.

The anterior cruciate ligament originates from the inner part of the extern condyle of the femur, twisting slightly around its own axis, downward in the centerline, and adhering to the medial meniscus. Its length is approximately 30 mm, with 10 mm width, and 5 mm thickness. It is heavy-duty, 1800 N force is needed to tear it.

The anterior cruciate ligament plays an important role in the knee joint:

• prevents the forward movement of the lower leg during bending
• blocks excessive dorsiflexion (hyperextension) of the knee
• inhibits the axial rotation of the knee
• acts as a secondary protection against lateral forces
• pulls back the knee to a stable position by the tension of its fibers

Anterior cruciate ligament (ACL) injuries mostly occur during sports that involve sudden stops, jumps or changes in direction. These cause the lateral displacement of the knee, with twisting at the same time, which lead to the torn of the ligament. It is common between skiers, footballers, handball and volleyball players if they foot returns to the ground at a wrong angle. Because of the different forces at the same time, these injuries are often accompanied with the lesion of the collateral ligaments or the meniscus.

When the ligament is damaged, there is usually a partial or complete tear across the tissue.

In case of an acute injury, a loud popping sound is heard at the moment of the injury. It is accompanied by severe pain, and the patient feels like his knee is out of its place and unable to continue the activity. Swelling begins within a few hours, the range of motion decrease and the patient can’t weight the limb.

In chronic ACL injury, the patient feels the knee unstable, it usually splays on rugged ground, step-up and rotational movement feels unstable. Long-standing ACL injury involves the possibility of cartilage, ligament or meniscus lesion, because the anterior cruciate ligament cannot regenerate, but slowly scarring. This scarred ligament will no longer be able to perform the function of an intact ligament, it becomes loose, wavy, and lose its stabilizing function.

If the symptoms refer to an anterior cruciate ligament injury, it is suggested to visit a specialist as soon as possible.

The traumatologist/orthopedic specialist set the anamnesis first: he inquiries about previous or existing diseases and injuries, then he asks about the circumstances of the current injury. Afterward, the specialist takes a physical examination: by touch, he checks the pressure sensitivity, localizes the pain, and check if there is swelling around the knee. A motion test is taken too, to examine the knee’s range of motion and the stability of the joint. Then he takes specific tests, which allow detecting the possible ligament injuries.

If these tests don’t help to set the diagnosis, knee arthroscopy could help to detect the problem.

Imaging diagnostic procedures can be used only to detect the potential side damages (meniscus tear, collateral ligament lesion).

Anterior cruciate ligament injury can be treated conservatively and surgically as well. After the first consultation, the orthopedist specialist advises, if conservative therapy is enough or surgery is recommended.

Besides the injury, several factors affect if conservative treatment or a surgery would be more effective treatment. The age, the build, the weight, the physical activity and the scope of activity of the patient all influence the suggested cure. In terms of a surgery, if the patient is a strong, active athlete, or doing a physical job, the knee joint would be loaded more, an ACL reconstruction is highly recommended. Nevertheless, the patient has lower weight, mostly sitting during his work, so the knee is not loaded constantly, conservative therapy might be enough.

In both cases, the aim is to restore the stability of the knee joint.

Conservative treatment is recommended, if the tear is smaller than 50% of the ligament and the patient has no sense of instability. Physiotherapy helps to reinforce the femoris muscle, to create ideal loading on the knee, and to restore the range of motion and painless move. In compliance with the therapy, the surgery can be avoided, but the chance of later cartilage damage is higher.

The surgery is recommended, if more, than 50% of the ligament is torn and/or additional injuries (meniscus tear, collateral ligament tear) are held. During an ACL reconstruction, the torn ligament is removed and replaced with a piece of tendon from the knee, which helps to restore the stability of the knee. The ACL reconstruction can be prepared acutely (in 0-5 days after the injury), in early stage (in 2 weeks after the injury) or delayed (6 weeks after the injury).

At Medicover Hospital, the two most common procedures are prepared to reconstruct the torn anterior cruciate ligament. These techniques are using the patient’s own tendons as a replacement, which is called autograft.

The autograft can be made of the hamstring tendons or from the patellar tendon. Graft selection for ACL reconstruction is largely based on the surgeon’s experience and preference, although several patient-specific factors must be considered. Your orthopedic specialist will advise you the most suitable method. Both procedures are prepared with minimally invasive, arthroscopic surgery.

The surgery is implemented under general or regional anesthesia, while the leg is in ischemia. The specialist makes 2-3 small, 0,5 mm wide incisions next to the patella tendon,  where the arthroscope and the special tools are inserted. Next, the knee joint is filled with physiological saline, which allows the doctor to see the injuries and degenerative lesions inside the joint. First, the incidental associate injuries are treated, then the specialist replaces the ligament with the chosen method.

During the hamstring autograft technique, the specialist makes a straight incision on the inner part of the shin, close to the knee. He removes 2 hamstring tendons (semitendinosus and gracialis tendons), from what the autograft will be made of.  This autograft is pulled through two, 8-10 mm diameter isometric holes, which are prepared on the femur and the tibia, at the origin and the adhesion points of the ligament. The graft is fastened with a titanium plate to the femur, and with a cramp iron to the tibia.

At the bone-patellar-tendon-bone autograft technique, the graft is taken from the kneecap, the middle third of the tendon is used, with bone fragments removed on each end. This graft is threaded through holes, drilled in the tibia and femur, and screwed into its place.

If your doctor recommends ACL reconstruction surgery, you may need a complete physical examination before surgery to assess your health condition. At the first consultation, our orthopedic specialist will inform you about the necessary examinations and the details of the surgery.

Before the surgery, inform your orthopedic surgeon about the medications you take regularly. He or she will tell you which medicines are not recommended to take before surgery.

2 weeks before your arthroscopic ACL surgery:

• You may be told to stop taking certain kind of medicines
• Ask which medicines you should still take on the day of your surgery.
• Tell your surgeon if you have been drinking alcohol (more than 1 or 2 drinks a day).
• Quit smoking before surgery. Smoking can slow down wound -, and bone healing.
• Always let your physician know about any cold, flu, fever, herpes outbreak, or other illness you have before your surgery.

On the day of your surgery:

• Do not to drink or eat anything for 6 to 12 hours before the procedure.
• Take the prescribed medicines with water.
• Please arrive in time at Medicover Hospital.

After the operation, until the healing of the wounds and the following few weeks, use of knee brace and relief is required. The rehabilitation starts the day after the surgery, and on the 2^nd or 3^rd day, the patient can leave the hospital. Physiotherapy helps to strengthen the muscles around your knee and improve flexibility. A physiotherapist teaches the patient how to do exercises that need to be performed either with continued supervision or at home.

If no early complications occur, the stitches are removed after one week. From the day of the surgery, until complete mobility, thrombosis preventive therapy is necessary.

The technique used for the procedure is always chosen by the orthopedic specialist, taking into consideration the age, the activity of the patient and the extent of the injury. Based on researchers, patellar autograft can provide better stability, and in case of athletes, most of the patients were able to continue his sports activity on the same level.

Anterior cruciate ligament reconstruction is not enough to replace the stability of the knee joint, professional post-treatment is necessary too. It is very important to keep the rehabilitation protocol, as early or inadequate intensity exercises can lead to knee joint injuries.

On the day after the surgery, progressive physical therapy starts immediately. The therapy helps to strengthen the muscles around your knee and improve flexibility. The physiotherapist teaches the patient how to perform personalized exercises at home. 8 weeks after the operation, next to the exercises, cycling, after 12 weeks swimming is recommended.

After the surgery, the time of recovery is different for every patient. Usually, patients can return to office work 4-6 weeks after the surgery, to easy physical work after 3-4 months, to difficult physical work after 4-8 months. Active sport can be continued after 8-10 months.

The price of the arthroscopic ACL reconstruction composed of several elements. At our hospital, the listed arthroscopic ACL reconstruction cost includes the surgery and the  check-up one week after  surgery.