What is a ligament?
A ligament is a dense connective tissue that connects bone to bone.
What ligaments are in the knee?
There are 4 major knee ligaments. All 4 connect the femur (thigh bone) to the tibia (shin bone) or fibula. These are the:
- MCL (medial collateral ligament)
- LCL (lateral collateral ligament)
- ACL (anterior cruciate ligament)
- PCL (posterior cruciate ligament)
Why is the ACL important?
The ACL stabilizes the knee. Without an ACL, the knee may be unstable and “buckle” or “give out” or “give way”, especially while playing sports involving cutting, pivoting, or twisting. This giving out could cause further damage to the cartilage surface or either meniscus in the knee.
What is the meniscus?
There are 2 menisci in the knee (one medial and one lateral). The medial meniscus is on the inner side of the knee and the lateral meniscus is on the outer side of the knee. These cartilage structures are “C”-shaped disks that function as shock-absorbers and also help stabilize the knee if the ACL is injured.
How does an ACL tear?
The most common mechanisms of injury are rapid change in direction, planting of the foot with twisting of the knee, decelerating, landing from a jump, or a direct blow to the knee.
Am I at higher risk of an ACL tear based on the sport I play?
Maybe. It depends on which sport(s) you play. There is a higher incidence of ACL tear in football, soccer, skiing, basketball, wrestling, and volleyball. This is due to the contact, cutting, twisting, and pivoting involved in these activities. There is a lower (but not zero) risk with participation in non-contact and linear sports like cross-country, track and field, and swimming.
At the time of injury, what things indicate that I tore my ACL?
Some patients feel or hear a “pop” at the time of injury. Most patients have significant swelling within the first 12 hours of injury. Most patients are unable to continue playing the sport they were playing at the time of injury. Some patients need help walking off the field after the injury because the knee feels unstable, loose, or wobbly, or is too painful.
Do I have to worry about other damage to my knee if I tear my ACL?
The most common injury with an ACL tear is a tear of the meniscus cartilage. The meniscus can tear either at the time of the injury or with recurrent episodes of instability. This is because of the increased looseness of the knee due to the ACL tear. Depending on the injury mechanism, other ligaments may be damaged at the same time of the ACL tear.
How can you tell if my ACL is torn?
While on the field, in the training room, or in the office, I will examine your knee. There are 3 special tests done to test your ACL. These are the anterior drawer, Lachman and pivot-shift tests. If there is increased laxity of the injured knee (versus the other knee), the diagnosis of ACL tear may be suspected.
How do I know for sure if my ACL is torn?
An MRI is often ordered to evaluate not only the ACL, but also the other structures in the knee, including the menisci, articular cartilage, and other ligaments.
After we know that I tore my ACL, what do we do next?
The next step is dependent upon your activity level and your goals. There are many patients that function well in daily life without an intact ACL. However, most patients that would like to continue participation in sports or activities that require any cutting or pivoting usually elect to undergo surgery.
What other options are available?
There is always the option to live with the condition. If you do not plan to return to work or a recreational sport that involves cutting, twisting, or pivoting of the knee, then you may not notice the buckling or looseness of the knee. If you plan to return to these types of activities, then I believe surgery is the best course of action.
What about stem cell treatments?
Stem cells are used in regenerative medicine to repair diseased or damaged tissues. While stem cell or PRP injections may not heal your tear on their own, there is emerging evidence that it can be used to augment and strengthen your surgical repair.
These treatments can be done during your surgery. Unfortunately, they are currently not covered by insurance. Please contact us if you would like more information or would like to include this with your surgery.
Will physical therapy (PT) help my ACL to heal?
Physical therapy is great to help strengthen the muscles in your leg and around your knee. Having strong and flexible muscles (quadriceps, hamstrings, calf) helps provide extra stability to your knee. However, once the ACL is torn, it cannot heal on its own.
If PT won’t help my ACL heal, then why do I need to go before surgery?
It is very important to have full motion in your knee before surgery, in addition to good strength and muscle control. This is important because it will help your recovery. You are also at higher risk for stiffness after surgery if you don’t have your full range-of-motion before surgery.
Because the ACL cannot heal on its own, we must use a graft to reconstruct and replace your old ACL. We drill tunnels in the femur and tibia bone to securely hold your new ACL in place. The type of fixation device that holds the graft in place depends on the type of graft used. This surgery is done under general anesthesia takes about 60-90 minutes.
What is the anesthesia like?
The surgery is almost always performed under general anesthesia. If a general anesthetic is given, then there may be an additional regional local anesthetic block for the knee.
How much time do I spend in the hospital?
You will enter the hospital in the morning, have the surgery and go home the same day. This is called outpatient surgery.
Is ice or heat helpful after surgery?
Ice is recommended instead of heat. An ice pack should be applied to the knee (not directly on the skin) for at least 20 minutes, three times a day.
The use of a cold therapy device (e.g. PolarCare) device helps decrease pain and swelling after surgery. The use of the device may or may not be covered by the particular health insurance plan you have selected. You should check with your insurance company. It is optional to use. A cold-therapy device can also be purchased for you to own. Please contact us if you have questions about this.
What is a graft?
A graft is a tissue that’s used to replace or substitute for your ACL. There are two types of grafts used: Autografts and allografts. Autograft is a graft that comes from your tissue. Allograft is a graft that comes from a donated cadaver graft. The most common autografts are the patellar tendon (BTB), quadriceps tendon, and hamstring tendons.
What graft is right for me?
The type of graft selected is a personal choice that we will help you through. Typically, the bone-patellar tendon-bone (BTB) autograft is used in athletes that play contact sports such as football, hockey, or rugby. The quadriceps tendon autograft is a newer graft with excellent outcomes and less pain compared to the patellar tendon graft. Hamstring grafts are often used in certain patients, such as younger patients who are skeletally immature (meaning their growth plates are open and they are still getting taller). Allografts (donor or cadaver tissue) are used in patients who want the least painful and easiest rehabilitation and are typically used in patients over 35 years of age. The return to sport after allograft can take longer. There are many factors that help determine the best graft choice, and we will discuss these with you.
What risks are associated with allografts?
There is a less than one in one million chance that any disease transmission with the donor tissue. The grafts are universally tested for HIV, hepatitis, and many other viruses and bacteria. All grafts are provided by an accredited tissue bank (MTF). You do not need any special medications such as immunosuppressants after surgery when using an allograft.
What are the risks of surgery?
The risks are similar to the risks of any surgical procedure. There is a less than 1% risk of infection. We minimize this risk by giving you antibiotics prior to the start of surgery. There is a less than 1% risk of bleeding or nerve injury. We are very familiar with the anatomy of the nerves and blood vessels around the knee. There is a very low risk of blood clots in the leg (called deep vein thromboses and pulmonary embolus if goes to lung). In order to further reduce this risk, we recommend you take an aspirin (regular or baby strength) following surgery. There is a risk of graft re-rupture. This may occur with graft rejection (in allografts) or re-injury.
There is a risk of arthrofibrosis (stiff knee). This occurs when there is too much scar tissue that forms in your knee. Most often this can be treated with physical therapy, but there are cases when you would need a second surgery to remove scar tissue. My purpose in listing the types of complications that could possibly occur is to inform, not frighten you. While it would be preferable if we could perform surgery without any risk, this is not the case. The complications are rare (less than 1%) but regrettably, in spite of our best efforts, they do occur. I feel it is your right to know.
Will I be in a brace after surgery?
You will be in a brace for 6 weeks following surgery. This brace protects the graft until your muscles are strong enough to support your leg without buckling or giving out.
How long will I be on crutches after surgery?
You will be using crutches for two to four weeks following surgery. Your physical therapist will help determine when it is safe to discontinue the crutches.
What about pain medicine?
We will call in your pain medication prescriptions to your local pharmacy before the surgery. Please take your pain medication as directed. That means that you may take the pills every 4-6 hours as needed. Take the medicine with food in your stomach. Taking the medicine on an empty stomach can cause nausea. It can also cause constipation, so a stool softener is recommended with the pain medication.
When you need more medication, please call us or let us know at your office visit. Because of increased regulation surrounding narcotic pain, allow us 1-2 business days to complete the process before you run out of pain medication. We cannot do this after 5:00 PM, as no one will be in the office. We cannot refill narcotic medication on weekends.
How long will it be until I can shower after surgery?
Wounds should stay dry until the sutures are removed. You may shower 48-72 hours after surgery, but you must cover the incision with plastic so that it does not get wet. If it does get wet, then use a clean towel and pat-dry the wet areas. Do not submerge or soak your knee in water until 3 weeks after surgery.
When is my follow-up visit?
At 10-14 days after surgery, you will return to the office for the first visit with our Physician Assistant. We will go over your surgery further, assess your motion, and examine the incisions. The sutures I use are buried under the skin, and do not need to be removed. We will then see you again in the office to evaluate your post-operative recovery at 2 months, 4 months, 6 months, and 12 months after surgery.
When do I start physical therapy (PT)?
You want to start PT as soon as possible, ideally 2-3 days after surgery. We recommend you find a PT place that is convenient for you and schedule a PT evaluation as soon as you have a surgery date.
We will give you a prescription for physical therapy to begin the same week as your surgery. In addition, we will give you a sheet of exercises that you can do easily on your own before beginning PT.
When am I allowed to start jogging or running?
At 3 months after surgery.
When will I start sports-specific training?
At 4 to 5 months after surgery.
When will I return to competitive sports?
Typically, 9 to 12 months after surgery depending on your progress and which sport you play. The risk of re-injury is significantly reduced if we wait until 9 months after surgery for full return to sports without restrictions. Some patients will also use an ACL brace when returning to sport. We will discuss this during your follow-up visits.
What if I have more questions?
We encourage you to return to the office for a further discussion at any time. We will do our best to answer any questions by phone as well. We have a lot of information on our website, www.gomberamd.com. There are surgical animations on the website as well.
How do I schedule surgery?
Contact us at (713) 794-3457 or info@gomberamd.com