ACL Reconstruction

Anterior Cruciate Ligament Tears

The anterior cruciate ligament (ACL) is one of the major stabilizing ligaments in the knee. It is a strong rope-like structure located in the center of the knee, running from the femur to the tibia. When this ligament tears, unfortunately, it does not heal on its own, and often leads to the feeling of instability in the knee.

Causes of an ACL Injury

An ACL injury most commonly occurs during sports that involve twisting or overextending of your knee. An ACL can be injured in several ways:

  • Sudden directional change
  • Slowing down while running
  • Landing incorrectly from a jump 
  • Direct blow to the side of your knee, such as during a football tackle

Symptoms of ACL Injury

When you injure your ACL, you might hear a loud "pop" sound and may feel the knee buckle. Within a few hours after an ACL injury, your knee may swell due to bleeding from vessels within the torn ligament. You may notice that the knee feels unstable or seems to give way, especially when trying to change direction on the knee. 

Diagnosis of an ACL Injury

An ACL injury can be diagnosed with a thorough physical examination of the knee and diagnostic tests such as X-rays, MRI scans and arthroscopy. X-rays may be needed to rule out any fractures. In addition, your doctor will often perform the Lachman’s test to check if the ACL is intact. During a Lachman test, the knee with a torn ACL may show increased forward movement of the tibia, and a soft or mushy endpoint compared to a healthy knee. 

Pivot shift test is another test to assess ACL tears. During this test, if the ACL is torn, the tibia will move forward when the knee is completely straight and as the knee bends past 30° the tibia shifts back into the correct place in relation to the femur. 

What is an ACL Reconstruction?

ACL reconstruction is a commonly performed surgical procedure. With recent advances in arthroscopic surgery, it can now be performed with minimal incision and low complication rates.

The advancements in arthroscopic surgery make it easy for surgeons to view and work on knee structures through small incisions. The repair of the torn ligament can be performed at the same time as the diagnostic arthroscopy with fewer surgical risks.

The surgery can usually be performed as an outpatient procedure, which means you may be discharged to go home on the same day as the procedure.

 

Failed Anterior Cruciate Ligament (ACL) Reconstruction

Knee Joint

The knee joint is stabilized by four strong ligaments. The anterior cruciate ligament (ACL) passes diagonally in the middle of the knee, ensuring that the thigh and shin bone do not slide out of alignment during movement. ACL injury is one of the most common sports injuries of the knee joint and is generally repaired with ACL reconstruction surgery, where the torn ligament is replaced with a graft tendon. While this process is a very common and highly successful procedure, some may fail to achieve stability.

Failed ACL Reconstruction

Anterior cruciate ligament reconstruction failure may be due to the following problems:

Technical: This is the most common cause of failure and may involve incorrect drilling of a tunnel through the tibial or femoral bone for the attachment of the graft. This may cause increased stress on the graft or rubbing (impingement) of the graft on the surrounding edges of the bone. Other technical problems may include improper harvesting of the graft from the donor site, graft tensioning or inadequate graft fixation.

Biologic: This may be due to infection or graft rejection. Infection can be treated with irrigation and removal of damaged tissue of the joint as well as intravenous antibiotics. 

Traumatic: This may occur due to early return to full activity, aggressive rehabilitation, trauma or non-compliance with activity restriction during the post-operative period.

Associated ligament laxity: Laxity of the other ligaments that support the knee has to be addressed either before or during the anterior cruciate ligament reconstruction to prevent undue stress on the reconstruction, and resultant failure. 

Arthrofibrosis: Decreased post-operative range of motion of the knee called arthrofibrosis due to prolonged postoperative immobilization may be a cause for failed reconstruction. 

A revision ACL reconstruction is considered after determining the exact cause for the initial failure. Repeat surgery is performed to improve graft stability and address other comorbidities such as infection and arthrofibrosis. Various alternative techniques, fixatives, and grafts are carefully considered for the revision reconstruction to correct failures of the primary surgery. 

ACL Reconstruction Patellar Tendon

ACL Anatomy

The anterior cruciate ligament is one of the four major ligaments of the knee that connects the femur (thighbone) to the tibia (shinbone) and helps stabilize the knee joint. The anterior cruciate ligament prevents excessive forward movement of the lower leg bone (tibia) in relation to the thighbone (femur) as well as limits rotational movements of the knee. 

ACL Injuries

A tear of this ligament can make you feel as though your knees will not allow you to move or even hold you up. Anterior cruciate ligament reconstruction is surgery to reconstruct the torn ligament of your knee with a tissue graft. 

Causes of an ACL Injury

An ACL injury most commonly occurs during sports activities that involve twisting or overextending of your knee. An ACL can be injured in several ways:

  • Sudden directional change
  • Slowing down while running
  • Landing from a jump incorrectly
  • Direct blow to the side of your knee, such as during a football tackle

Symptoms of an ACL Injury

When you injure your ACL, you might hear a loud "pop" sound and may feel the knee buckle. Within a few hours after an ACL injury, your knee may swell due to bleeding within the torn ligament. You may notice that the knee feels unstable or seems to give way, especially when trying to change direction. 

Diagnosis of an ACL Injury

An ACL injury can be diagnosed with a thorough physical examination of the knee and diagnostic tests such as X-rays (to rule out fractures), MRI scans and arthroscopy. In addition, your doctor will often perform the Lachman’s test to see if the ACL is intact. During a Lachman test, the knee with a torn ACL may show increased forward movement of the tibia and a soft or mushy endpoint compared to a healthy knee. 

The pivot shift test is another test to assess ACL tears. During this test, if the ACL is torn, the tibia will move forward when the knee is completely straight and as the knee bends past 30° the tibia shifts back into correct place in relation to the femur. 

What is ACL Reconstruction Patellar Tendon Method? 

Anterior cruciate ligament (ACL) reconstruction patellar tendon is a surgical procedure that replaces the injured ACL with a patellar tendon. The goal of ACL reconstruction surgery is to tighten your knee and to restore its stability.

ACL Reconstruction Patellar Tendon Procedure 

Anterior cruciate ligament reconstruction patellar tendon is a surgical procedure to replace the torn ACL with part of the patellar tendon taken from your leg. The new ACL is harvested from the patellar tendon that connects the bottom of the kneecap (patella) to the top of the shinbone (tibia). The procedure is performed under general anesthesia. 

Your surgeon will make two small cuts about ¼ inch around your knee. An arthroscope, a tube with a small video camera on the end is inserted through one incision to see the inside of the knee joint. Along with the arthroscope, a sterile solution is pumped into the knee to expand it, providing your surgeon with a clear view of the inside of the joint. 

The torn ACL will be removed and the pathway for the new ACL is prepared. Your surgeon makes an incision over the patellar tendon and removes the middle third of the patellar tendon, along with small plugs of bone where it is attached on each end. The remaining portions of the patellar tendon on either side of the graft are sutured back after its removal. Then the incision is closed. 

The arthroscope is reinserted into the knee joint through one of the small incisions. Small holes are drilled into the upper and lower leg bones (tibia and femur) where these bones come together at the knee joint. The holes form tunnels in your bone to accept the new graft. The graft is then pulled through these holes. The new tendon is then fixed into the bone with screws to hold it in place while the ligament heals into the bone. 

The incisions are then closed with sutures and a dressing is placed.

Postoperative Care following ACL Reconstruction Patellar Tendon

Following the surgery, rehabilitation begins immediately. A physical therapist will teach you specific exercises to strengthen your leg and restore knee movement. Avoid competitive sports for 5 to 6 months to allow the new graft to get incorporated into the knee joint. 

Anterior cruciate ligament reconstruction is a very common and successful procedure. It is usually indicated in patients who desire to return to an active lifestyle, especially into sports that involve running and twisting. Anterior cruciate ligament injury is a common knee ligament injury. If you have injured your anterior cruciate ligament, surgery may be needed to regain full function of your knee.

Risks and Complications of ACL Reconstruction Patellar Tendon

The possible risks and complications associated with ACL reconstruction with the patellar tendon method include:

  • Numbness
  • Infection
  • Blood clots (deep vein thrombosis)
  • Nerve and blood vessel damage
  • Failure of the graft
  • Loosening of the graft
  • Decreased range of motion
  • Crepitus (crackling or grating feeling of the kneecap)
  • Pain in the knee
  • Recurrence of injury to the graft

 

ACL Reconstruction Procedure Hamstring Tendon

Anterior Cruciate Ligament Tears

The anterior cruciate ligament (ACL) is one of the major stabilizing ligaments in the knee. It is a strong rope-like structure located in the center of the knee running from the femur to the tibia. When this ligament tears, it does not heal on its own and often leads to the feeling of instability in the knee.

Causes of an ACL Injury

An ACL injury most commonly occurs during sports activities that involve twisting or overextending of your knee. An ACL can be injured in several ways:

  • Sudden directional change
  • Slowing down while running
  • Landing from a jump incorrectly
  • Direct blow to the side of your knee, such as during a football tackle

Symptoms of an ACL Injury

When you injure your ACL, you might hear a loud "pop" sound and may feel the knee buckle. Within a few hours after an ACL injury, your knee may swell due to bleeding within the torn ligament. You may notice that the knee feels unstable or seems to give way, especially when trying to change direction. 

Diagnosis of an ACL Injury

An ACL injury can be diagnosed with a thorough physical examination of the knee and diagnostic tests such as X-rays (to rule out fractures), MRI scans and arthroscopy. In addition, your doctor will often perform the Lachman’s test to see if the ACL is intact. During a Lachman test, the knee with a torn ACL may show increased forward movement of the tibia and a soft or mushy endpoint compared to a healthy knee. 

The pivot shift test is another test to assess ACL tears. During this test, if the ACL is torn, the tibia will move forward when the knee is completely straight and as the knee bends past 30° the tibia shifts back into correct place in relation to the femur. 

ACL Reconstruction Hamstring Tendon

The goal of ACL reconstruction surgery is to tighten your knee and restore its stability. 

Anterior cruciate ligament reconstruction hamstring method is a surgical procedure to replace the torn ACL with part of the hamstring tendon taken from your leg. 

The Hamstring is the muscle located on the back of your thigh. The procedure is performed under general anesthesia. 

Your surgeon will make two small incisions about 1/4-inch-long around your knee. An arthroscope, a tube with a small video camera on the end is inserted through one incision to view the inside of the knee joint. Along with the arthroscope, a sterile solution is pumped into the joint to expand it, enabling your surgeon to have a clear view and space to work inside the joint. 

The knee is bent at right angles and the hamstring tendons felt. A small incision is made where the hamstring tendon attaches to the tibia. The two tendons are stripped off the muscle and the graft is prepared. 

The torn ACL will be removed and the pathway for the new ACL prepared. The arthroscope is reinserted into the knee joint through one of the small incisions. Small holes are drilled into the upper and lower leg bones (tibia and femur) where these bones come together at the knee joint. The holes form tunnels in your bone to accept the new graft. The graft is pulled through these holes. The new tendon is then fixed into the bone with screws to hold it into place while the ligament heals into the bone. 

The incisions are then closed with sutures and a dressing is placed.

Postoperative care following ACL Reconstruction - Hamstring Tendon

Following the surgery, rehabilitation begins immediately. A physical therapist will teach you specific exercises to be performed to strengthen your leg and restore knee movement. Avoid competitive sports for 5 to 6 months to allow the new graft to incorporate into the knee joint. 

Risks and Complications of ACL Reconstruction – Hamstring Tendon

The possible risks and complications associated with ACL reconstruction with hamstring method include:

  • Numbness
  • Infection
  • Blood clots (deep vein thrombosis)
  • Nerve and blood vessel damage
  • Failure of the graft
  • Loosening of the graft
  • Decreased range of motion
  • Crepitus (crackling or grating feeling of the kneecap)
  • Pain in the knee
  • Repeat injury to the graft

 

 

ACL Tears

What is the ACL?

The anterior cruciate ligament (ACL) is one of the major ligaments of the knee. It is located in the middle of the knee and runs from the femur (thighbone) to the tibia (shinbone). The ACL prevents the tibia from sliding out in front of the femur. Together with the posterior cruciate ligament (PCL), it provides rotational stability to the knee.

Causes of ACL Tears

An ACL injury is a sports-related injury that occurs when the knee is forcefully twisted or hyperextended. An ACL tear usually occurs with an abrupt directional change when the foot is fixed on the ground or when the deceleration force crosses the knee. Changing direction rapidly, stopping suddenly, slowing down while running, landing from a jump incorrectly, and direct contact or collision, such as a football tackle can also cause injury to the ACL.

Symptoms of ACL Tears

When you injure your ACL, you may hear a pop sound and may feel as though the knee has given way. Within the first two hours after injury, your knee will swell and you may have a buckling sensation in the knee during twisting movements. 

Diagnosis of ACL Tears

The diagnosis of an ACL tear is made by reviewing your symptoms and medical history and performing a physical examination of the knee. Other diagnostic tests such as X-rays, MRI scans, stress tests of the ligament and arthroscopy may also be ordered.

Treatment of ACL Tears

Treatment options include both non-surgical and surgical methods. If the overall stability of the knee is intact, your doctor may recommend non-surgical methods. Non-surgical treatment consists of rest, ice, compression and elevation (RICE protocol); all of these assists in controlling pain and swelling. Physical therapy may be recommended to improve knee motion and strength. A knee brace may be needed to help immobilize your knee.

Young athletes involved in pivoting sports will most likely require surgery to safely return to sports. The usual surgery for an ACL tear is an ACL reconstruction which tightens your knee and restores its stability. Surgery to reconstruct an ACL is performed with an arthroscope, using small incisions. During the surgery, your doctor will replace the torn ligament with a tissue graft that can be obtained from your knee (patellar tendon) or hamstring muscle. 

Following ACL reconstruction, a rehabilitation program is started to help you resume a wider range of activities.

 

 

Failed Anterior Cruciate Ligament (ACL) Reconstruction

Knee Joint

The knee joint is stabilized by four strong ligaments. The anterior cruciate ligament (ACL) passes diagonally in the middle of the knee, ensuring that the thigh and shin bone do not slide out of alignment during movement. ACL injury is one of the most common sports injuries of the knee joint and is generally repaired with ACL reconstruction surgery, where the torn ligament is replaced with a graft tendon. While this process is a very common and highly successful procedure, some may fail to achieve stability.

Failed ACL Reconstruction

Anterior cruciate ligament reconstruction failure may be due to the following problems:

Technical: This is the most common cause of failure and may involve incorrect drilling of a tunnel through the tibial or femoral bone for the attachment of the graft. This may cause increased stress on the graft or rubbing (impingement) of the graft on the surrounding edges of the bone. Other technical problems may include improper harvesting of the graft from the donor site, graft tensioning or inadequate graft fixation.

Biologic: This may be due to infection or graft rejection. Infection can be treated with irrigation and removal of damaged tissue of the joint as well as intravenous antibiotics. 

Traumatic: This may occur due to early return to full activity, aggressive rehabilitation, trauma or non-compliance with activity restriction during the post-operative period.

Associated ligament laxity: Laxity of the other ligaments that support the knee has to be addressed either before or during the anterior cruciate ligament reconstruction to prevent undue stress on the reconstruction, and resultant failure. 

Arthrofibrosis: Decreased post-operative range of motion of the knee called arthrofibrosis due to prolonged postoperative immobilization may be a cause for failed reconstruction. 

A revision ACL reconstruction is considered after determining the exact cause for the initial failure. Repeat surgery is performed to improve graft stability and address other comorbidities such as infection and arthrofibrosis. Various alternative techniques, fixatives, and grafts are carefully considered for the revision reconstruction to correct failures of the primary surgery. 

Women and ACL Injuries

Anterior Cruciate Ligament (ACL) Injuries

The anterior cruciate ligament is one of the four major ligaments of the knee that connects the femur (thigh bone) to the tibia (shin bone) and helps stabilize the knee joint. Anterior cruciate ligament (ACL) injury is one of the common injuries of the knee. An injury to the ACL commonly occurs during sports or activities that involve twisting, overextension, landing from a jump incorrectly and abrupt change in direction or speed of movements.

ACL Injuries in Women

ACL injuries are more common in women than men due to anatomical differences which include:

  • Women have a smaller ACL, a wider pelvis and an increased incidence of inward knee pointing.
  • Women have less strength in the muscles as compared to men. In addition, women use their quadriceps muscles more than men for stability and take more time to develop muscular force resulting in greater stress on the ACL.
  • Women have looser knees and a greater range of motion as compared to men. 

These factors make women more vulnerable to ACL injury by weakening the ligament.

A training and rehabilitation program can help reduce the risk of ACL injury. The program focuses on:

  • Controlling inward knee movement.
  • Emphasizing the use of the hamstring muscles for knee stability.
  • Controlling the movement of the hip and trunk and training the hip muscles to stabilize the knee.
  • Controlling knee extension.
  • Increasing muscle endurance.