Crossing between the femur and tibia within the knee is a very
important piece of tissue known as the anterior cruciate ligament,
Crossing between the femur and tibia within the knee is a very important piece of tissue known as the anterior cruciate ligament, or ACL.
Most sports players have heard that name and, doubtlessly, winced at its mention, but while ACL surgery has become more common with the popularity of rough contact sports, the surgery used to correct the problem has become increasingly sophisticated as doctors gain a better understanding of the knee’s workings.
The average patient these days will spend just a little over an hour in the operating room, and will emerge not with a giant, gaping wound running the length of his or her knee, but with delicate quarter-inch scars gracing each side of the joint and half-inch scars above and below.
The ACL helps to give the knee joint stability, which, in turn, helps to give the entire body stability since weight is distributed through the legs.
When the ligament is ruptured or torn, some patients still have the ability to walk unaided, but the majority of patients could face mounting physical pain and an increasing number of “buckling incidents,” or falls, as a result of this destabilization if they skipped ACL replacement surgery.
The sooner surgery takes place after the initial injury, the more the risk of complications, such as chronic joint pain or pre-mature arthritis, is diminished, according to Dr. Maury Harwood, a Gilroy-based orthopedic specialist in private practice.
“Usually, the ACL is torn in the middle of the ligament or it’s torn off the femur,” said Dr. Bert Tardieu, an orthopedic surgeon specializing in sports medicine and joint replacement at the Salinas-based group Precision Orthopedics. “If it has healed or made significant progress in a few weeks, we operate.”
Sports are the number one reason for ACL ruptures, said Harwood. Sports that involve a lot of cutting, pivoting and jumping can be especially dangerous, and non-contact sports like basketball and soccer join contact sports like football, rugby and lacrosse on the top-offenders list.
The good news is that many athletes who injure their ACLs will eventually regain full use of their knees and even go back to playing the same sports.
However, should the same type of accident occur, these athletes would be at no less risk of having their replacement ligament tear as well, he said.
Doctors create the small incisions around the knee in order to feed tools into the knee area, inspecting the quality of the cartilage still contained in the knee and making sure that no additional repairs will be needed before replacing the ACL, said Harwood.
Then, the doctors shave out the torn ligament and create a new one using autografts – grafts from the person’s own body, most commonly in the form of partial patellar or hamstring tendons – or allografts, which come from cadavers, said Tardieu.
Cadaver grafts are advantageous because doctors can take larger sections of muscle or tendon than they would be able to remove from a live patient, said Tardieu.
These grafts are obtained from a tissue bank, which sections, freezes and stores different pieces of donor tissue much like a blood bank. ut both autografts and allografts have their ups and downs when it comes to choice, he added.
“If you take the middle third of the patellar tendon, a piece of the tendon that goes in front of your knee and that you are actually resting on when you kneel, it requires an incision, and that’s just more injury to the knee,” said Tardieu. “If you take tendon from the hamstrings, there are fewer complications, but you are harvesting, on average, two hamstrings, and things are in the body for a reason.
“The allograft has the least amount of pain and allows you to use abundant tissue, all of which has been sterilized. The downside is a very low, but measurable risk of disease transmission, and it’s slower in incorporating to the body than your own tissue.”
Once the patient and doctor have decided on a ligament substitute, doctors put it into place and hold it there using a variety of methods, from natural stays that can be broken down and absorbed by the body to screws and other devices.
These are simply temporary fixes, designed to hold the ligament substitute in place while the body incorporates the new tissue into itself, said Tardieu.
When the surgery is complete, patients are held in a straight-leg brace for four to six weeks, and then transferred to a smaller brace, said Harwood.
The smaller brace is worn for about a month as patients also transition from using a machine to help them bend and exercise their knees to working with a physical therapist for about 12 weeks.
“ACL reconstructions are really good, really effective surgeries,” said Harwood. “I’ve seen some people 20 or 25 years down the line from ACL reconstructions and they’re really active – running, playing sports, doing triathlons.”
“The thing that makes a good versus a not so good result is usually the condition of the cartilage in the knee when you go in to operate. If that’s damaged, the healing process takes longer, and there is more likelihood of pain.”
Cartilage damage is most often caused in one of two ways: either patients hurt the cartilage along with their ACL during their injury or they injure it afterward in a series of “buckling episodes,” when their leg simply goes out from under them, according to Harwood.
After surgery, patients are subject to a number of complications, but the risk of side effects is low.
Sometimes there is post-operative bleeding, stiffness or fuzziness around the surgical site.
Rarely, some people can develop infections or blood clots, and there is always the possibility that the surgery could fail, said Harwood.
“If we do an ACL reconstruction, it’s not forever perfect,” said Harwood. “They could be skiing three years later, and tear it, but that’s also not to say that the native tissue wouldn’t have torn in the same way.”