Anterior Cruciate Ligament

Reconstruction

First treatment includes ice, compression, and elevation  plus a brace to protect the knee, crutches, and pain relievers. A careful physical examination, combined with x-rays and and MRI will determine the extent of the damage and whether or not other tissues such as the meniscus are torn.   

ACL reconstruction surgery is indicated for patients with unstable knees who desire to remain active.
 

When to do the ACL reconstruction surgery?
At The Stone Clinic in San Francisco, California, our guideline for ACL reconstruction surgery depends on:
a) when the patient is mentally ready to accept the ACL reconstruction surgery procedure, the associated risks, commit to the rehabilitation program and;
b) preferably when the knee has minimal swelling and a full range of motion.
 

The mental aspect of the preparedness is crucial in our approach.  We believe the mental aspect of the preparation, the surgery, the minimizing of pain, and the spirit with which the ACL surgery rehabilitation program is approached determines a how well the patient will do in recovery, and how "pleasurable" the entire experience is for the patient.  Angry, frustrated patients generally do poorly.  People not mentally-prepared often struggle with recovery.   People who do best are those that have the adopted the positive-attitude that we encourage; seeing their injury as an opportunity to use our rehabilitation-team to help them get fitter, faster, and stronger than they were before they were injured.
 

Outcome
Successful ACL reconstruction surgery tightens your knee and restores its stability.  It also helps you avoid further injury and get back to normal activity. However, ACL surgery can fail if the procedure is not done with a high degree of accuracy or the rehabilitation program is poor.

TECHNICAL DETAILS
ACL Reconstruction Surgical Video

Figure 1 - Bone-Patellar Tendon- Bone Graft

Figure 2 - MRI showing torn ACL

Figure 3 - Inserting the graft

Figure 4 – Intact ACL graft

Figure 5 - Xray of Screws (newer screws are resorbable)

Which graft material to use?

The choices include the patients own patellar tendon with bone attached at each end called Bone-Patellar Tendon-Bone (BTB) which is used about 65% of the time worldwide; hamstring tendons used about 20%, or allograft (cadaver donated tissue) used about 15% of the time (in the U.S.).  The tissues with bone attached (patellar tendon) have the advantage of the bone healing to bone in the drill holes and stronger interference fit fixation devices, which can translate into an earlier return to full activity, which is important for many athletes.  However, there is the cost of pain-and-weakness from the harvest site if the patient's own tissue is used. Hamstring tendons have the advantage of not weakening the patellar tendon, but the disadvantage of weakening the flexor tendons that bend the knee. The fixation-devices for hamstring tendons have generally been weaker than those for the bony attachments of the BTB but this is improving rapidly.  Sterilized allografts have have had equal results to autogenous tissues and higher patient satisfaction with less anterior knee pain. Newer techniques of sterilizing allografts reduces the risk of disease transmission.  Our preference is to use these sterilized allografts.  

ACL RECONSTRUCTION PROCEDURE

First, the patient is prepared for surgery in a sterile manner. Then arthroscopic portals are established to allow for visualization of the procedure and insertion points for the instruments.
 

The entire knee joint, including the ACL, PCL, meniscus, and cartilage are visualized to determine the extent of injury and confirm what was seen on MRI.  If the ACL is deemed irreparable, the surgeon will proceed with reconstruction.
 

Precise placement is necessary for a successful reconstruction.  The anatomic insertion site on the femur for the original ACL is identified, and a drill hole is initiated using a gaff to place a rear-entry guide, then drilled from outside in.  The hole is cleared out and the edges are chamfered (rounded) to avoid damage to the graft.
 

Next, the insertion site of the ACL on the tibia, on the tibial plateau, is identified, and a drill hole is initiated using a triangle-guide, again drilling from outside in.  The hole is cleared out and the edges chamfered in a similar manner.
 

The graft tissue, which usually is a bone-patellar-tendon-bone graft, is brought through the now continuous tunnel running from the femur through the knee joint and through the tibia.  The tissue is secured in place using resorbable 9x20mm screws, which bind the bone block at either end into the tunnel.
 

The knee is finally brought through a full range of motion to visualize for any impingement of the graft, and to ensure proper placement. The instruments are removed and incision sites closed, and the patient is able to return home later that day. Xrays are taken to ensure proper placement of fixation devices.  Rehab exercises start immediately at home and in our clinic the next morning.