Monday, April 22, 2013

A.C.L. Reconstruction


Originally it was felt that the knee should be repaired surgically as soon as possible. Now, most orthopedic surgeons feel that the swelling should subside and the patient should work to improve range of motion with physiotherapy for 2-3 weeks. Once this is accomplished the patient can then proceed to an anterior cruciate ligament reconstruction. As stated earlier, surgery does not have to be performed on a sedentary older patient, but it is almost always recommended to a younger, active athlete that they should have anterior crucial tear repaired. With modern techniques it is performed as an outpatient – the patient is discharged from the hospital the same day. The patients will leave the hospital on crutches wearing a knee immobilizer for approximately 10 days while they are up and getting around. When the immobilizer comes off, the patient usually will use a passive motion machine that moves the knee through flexion and extension. Physical therapy is started immediately post-operatively. Treatment of a torn anterior crucial ligament in the older patient usually consists of physical therapy and exercise training as well as potentially brace-wear for some activities.

Surgical Treatment Options
There have been many options described for the surgical treatment of the anterior cruciate ligament. The most popular and currently recognized as the gold standard at this point is an operation where the middle one third of the patella tendon is used as a graft. It is virtually impossible to repair the ligament that is torn. The torn ACL is simply removed and the replaced with the patella tendon graft. Two thirds of the patella tendon is left behind and it will repair itself, not compromising the function of the knee. At each end of the patella tendon a bone block is also taken; one piece from the tibia, and the other from the patella (kneecap). These two bony blocks are inserted into holes that are drilled into the tibia and femur and held into place with screws, which provide stabilization of the ligament graft.
There are other tissues that can be used to substitute for the anterior crucial ligament. Most commonly the second choice are hamstring tendons which are weaved into a graft close to the size of the anterior crucial ligament. We have also used quadriceps tendon and allograft. An allograft is donated cadeaver tissue which is freeze dried until the time of usage upon which time it is thawed out and trimmed to size and used as an ACL substitute. The advantage of an allograft operation is that there is a smaller incision required, the rehab is shorter, and less painful. The disadvantage is that it is not quite as strong as a graft formed from the patient’s own tissue.