Anterior Cruciate Ligament Reconstruction University Orthopaedics & Sports Medicine Presentation designed for patient education Updated 2/11.

Anterior Cruciate Anterior Cruciate Ligament Ligament

ReconstructionReconstructionUniversity Orthopaedics & Sports University Orthopaedics & Sports

MedicineMedicine

Presentation designed for patient Presentation designed for patient educationeducation

Updated 2/11

University Orthopaedics & University Orthopaedics & Sports MedicineSports Medicine

OfficesOffices

Clifton (Medical Clifton (Medical Arts Building)Arts Building)

WestchesterWestchester www.ucortho.comwww.ucortho.com 513-475-8690513-475-8690

University Orthopaedics & University Orthopaedics & Sports MedicineSports Medicine

SurgerySurgery

Holmes Hospital (Clifton)Holmes Hospital (Clifton) Outpatient Surgery CenterOutpatient Surgery Center

Mercy FairfieldMercy Fairfield MainMain Outpatient Surgery CenterOutpatient Surgery Center

Westchester Medical CenterWestchester Medical Center University Pointe Ambulatory Surgical University Pointe Ambulatory Surgical

Hospital (ASH)Hospital (ASH) University HospitalUniversity Hospital

What is the Anterior Cruciate What is the Anterior Cruciate Ligament (ACL) ?Ligament (ACL) ?

The ACL is one of The ACL is one of the 4 main the 4 main ligaments of the ligaments of the knee that keeps knee that keeps the knee stable.the knee stable.

How is the ACL injuredHow is the ACL injured

Usually injured with a Usually injured with a twisting injury to the twisting injury to the knee or a direct blow knee or a direct blow to the outside of the to the outside of the knee with a contact or knee with a contact or noncontact mechanismnoncontact mechanism

Contact injuryContact injury Example-hit by an Example-hit by an

opponentopponent Noncontact injuryNoncontact injury

Example-skiingExample-skiing

Signs and Symptoms of Signs and Symptoms of ACL tearACL tear

AcuteAcute Marked pain and popMarked pain and pop Significant knee swellingSignificant knee swelling Difficulty bearing weight on the affected Difficulty bearing weight on the affected

kneeknee ChronicChronic

The knee feels looseThe knee feels loose Feeling of “buckling”, “giving way” or Feeling of “buckling”, “giving way” or

instabilityinstability Pain and swellingPain and swelling

Signs and Symptoms of ACL Signs and Symptoms of ACL tear?tear?

May also be dependant on May also be dependant on injuries to other knee injuries to other knee structuresstructures

LigamentsLigaments Medial Collateral Ligament Medial Collateral Ligament

(MCL)(MCL) Posterior Cruciate Ligament Posterior Cruciate Ligament

(PCL)(PCL) Posterolateral CornerPosterolateral Corner

Meniscus-(cushions in the Meniscus-(cushions in the knee)knee) MedialMedial Lateral Lateral BothBoth

Articular cartilage (gliding Articular cartilage (gliding cartilage on the ends of cartilage on the ends of bones)bones)

DiagnosisDiagnosis

HistoryHistory Physical examPhysical exam X-raysX-rays usually normal but should be usually normal but should be

obtained to ensure that there is no obtained to ensure that there is no fracturefracture

MRI-excellent for evaluating not only MRI-excellent for evaluating not only the ACL but also the meniscus, the ACL but also the meniscus, articular cartilage and other knee articular cartilage and other knee ligamentsligaments

What is the acute treatment What is the acute treatment for an ACL tear?for an ACL tear?

Rest Rest Ice Ice ElevationElevation CompressionCompression Protected Weight Protected Weight

BearingBearing Brace Brace

Does everyone with a torn Does everyone with a torn ACL need surgery?ACL need surgery?

No!No! Who does not need surgery?Who does not need surgery?

Patients with very advanced arthritisPatients with very advanced arthritis Patients who do not do activities that Patients who do not do activities that

require an intact ACL?require an intact ACL? Patients who are not interested in Patients who are not interested in

committing to post-operative rehabcommitting to post-operative rehab

Who does need an ACL Who does need an ACL reconstruction?reconstruction?

Most patientsMost patients Patients who perform activities requiring Patients who perform activities requiring

an intact ACL-most active patientsan intact ACL-most active patients Patients with associated knee injuriesPatients with associated knee injuries

Other ligaments, meniscus tear, gliding Other ligaments, meniscus tear, gliding cartilage injurycartilage injury

Young patients with an otherwise healthy Young patients with an otherwise healthy kneeknee No injury to meniscus or gliding cartilage No injury to meniscus or gliding cartilage

ACL dependent activitiesACL dependent activities DependentDependent

Cutting sportsCutting sports Basketball, soccer, Basketball, soccer,

football, softball, football, softball, tennis, cheerleading, tennis, cheerleading, skiing etc.skiing etc.

High end aerobicsHigh end aerobics SkateboardingSkateboarding Difficult HikingDifficult Hiking Most laboring jobsMost laboring jobs ANY ACTIVITY WHEN ANY ACTIVITY WHEN

THE KNEE BUCKLES THE KNEE BUCKLES AFTER THE INJURYAFTER THE INJURY

Not DependentNot Dependent WalkingWalking Jogging in a straight Jogging in a straight

lineline Desk jobsDesk jobs Riding a bicycleRiding a bicycle

Who needs a pre-op Who needs a pre-op brace?brace?

Patients whose Patients whose knee buckles knee buckles (gives out) with (gives out) with everyday activitieseveryday activities

What are the risks of not What are the risks of not getting your ACL fixed?getting your ACL fixed?

Every time your knee buckles you Every time your knee buckles you risk injuring other vital structures in risk injuring other vital structures in your kneeyour knee Meniscus, ligaments, gliding cartilageMeniscus, ligaments, gliding cartilage

What happens if the vital structures What happens if the vital structures are injured?are injured? Rapidly accelerated arthritisRapidly accelerated arthritis

Are there any pre-operative Are there any pre-operative requirements for ACL requirements for ACL

reconstruction?reconstruction? YesYes You should have You should have

near normal knee near normal knee range of motion.range of motion.

Sometimes patients Sometimes patients go to physical go to physical therapy pre-therapy pre-operatively to get operatively to get there motion there motion restored before restored before surgery.surgery.

What should I do before my What should I do before my surgery?surgery?

Make sure your knee does not buckleMake sure your knee does not buckle Understand your injuryUnderstand your injury Ask your surgeon any questions that Ask your surgeon any questions that

you haveyou have Understand what the expected post Understand what the expected post

operative course will be likeoperative course will be like Choose a graftChoose a graft

ACLs are not REPAIRED, but rather ACLs are not REPAIRED, but rather RECONSTRUCTED and thus require other RECONSTRUCTED and thus require other tissue for a grafttissue for a graft

Graft Choices-AutograftGraft Choices-Autograft

Autograft (your own tissue)Autograft (your own tissue) Bone-Patellar Tendon-BoneBone-Patellar Tendon-Bone

Bone plug from your knee cap, middle 1/3 of Bone plug from your knee cap, middle 1/3 of your patellar tendon and bone plug from shin your patellar tendon and bone plug from shin bonebone

Most painfulMost painful

Hamstring autograftHamstring autograft 2 hamstring tendons2 hamstring tendons Less painful than bone patellar tendon bone Less painful than bone patellar tendon bone

graftgraft Allows for a very stable kneeAllows for a very stable knee Graft of choice for patients with open growth Graft of choice for patients with open growth

platesplates

Graft Choices-AllograftGraft Choices-Allograft

Allograft (cadaver)Allograft (cadaver) Least painfulLeast painful Smallest incisionSmallest incision Recommended in patients with Recommended in patients with

significant injuries to other ligaments of significant injuries to other ligaments of the kneethe knee

Usually recommended in revision casesUsually recommended in revision cases Very, very, very small risk of disease Very, very, very small risk of disease

transmission from the donortransmission from the donor

Graft ChoicesGraft Choices

There is no convincing evidence in There is no convincing evidence in the orthopaedic literature stating the orthopaedic literature stating that one graft is any better than the that one graft is any better than the otherother

This is a personal choice and should This is a personal choice and should be discussed with your surgeon!!!!be discussed with your surgeon!!!!

This should be determined prior to This should be determined prior to the date of surgerythe date of surgery

Day Of SurgeryDay Of Surgery

NPO (nothing by mouth except meds) NPO (nothing by mouth except meds) after midnight the night beforeafter midnight the night before

Arrive to the hospital on timeArrive to the hospital on time Get pre-operative nerve blocksGet pre-operative nerve blocks

Anesthesiologist gives you sedating Anesthesiologist gives you sedating medication in your IVmedication in your IV

Then gives you shots to numb your Then gives you shots to numb your nerves so you have markedly decreased nerves so you have markedly decreased post op painpost op pain

SurgerySurgery

Examination of your knee while you are Examination of your knee while you are asleepasleep

Fix any associated injuriesFix any associated injuries

Torn meniscus Suture repair of meniscus

SurgerySurgery

Reconstruction of the ACL by drilling Reconstruction of the ACL by drilling tunnels (holes) in your femur (thigh bone) tunnels (holes) in your femur (thigh bone) and tibia (shin bone)and tibia (shin bone)

Tunnel (hole) in thigh bone for graft passage

↑

SurgerySurgery

Passing the graft across the knee and Passing the graft across the knee and using surgical devices to hold the graft in using surgical devices to hold the graft in place while it heals to the bonesplace while it heals to the bones

New ACL graft passed thru tunnels

↑

Immediately after Immediately after surgerysurgery

You will wake up with cryocuff You will wake up with cryocuff (fancy ice pack) and a brace on with (fancy ice pack) and a brace on with your knee in full extension (straight your knee in full extension (straight out)out)

If you had pre-operative nerve If you had pre-operative nerve blocks your pain should be tolerableblocks your pain should be tolerable

The recovery room nurses will also The recovery room nurses will also give you pain medicationsgive you pain medications

After surgeryAfter surgery

You can go home the same day as your You can go home the same day as your surgerysurgery

You should take your pain medications You should take your pain medications given by your surgeon no later than given by your surgeon no later than dinner time to make sure you have some dinner time to make sure you have some pain medications in your system when pain medications in your system when your block wears offyour block wears off

Your block will probably wear off Your block will probably wear off sometime in the middle of the nightsometime in the middle of the night

Your pain will decrease every day Your pain will decrease every day

Post op carePost op care

Wear your brace any time you are upWear your brace any time you are up Sleep in your braceSleep in your brace You may open your brace any time you are You may open your brace any time you are

seated or lying downseated or lying down Ice (cryocuff) as much as possibleIce (cryocuff) as much as possible Elevate your knee above your heart as Elevate your knee above your heart as

much as possiblemuch as possible You may put as much weight on your leg as You may put as much weight on your leg as

you can tolerate with your crutches you can tolerate with your crutches immediately post opimmediately post op

Post op carePost op care You can take all your dressings down except for You can take all your dressings down except for

the steri-strips (white band aid like strips) on the the steri-strips (white band aid like strips) on the third day after surgery and take a showerthird day after surgery and take a shower

DO NOT SCRUB YOUR WOUNDSDO NOT SCRUB YOUR WOUNDS DO NOT SOAK YOUR WOUNDSDO NOT SOAK YOUR WOUNDS Simply wash your thigh with soap and water and Simply wash your thigh with soap and water and

let the soap and water run offlet the soap and water run off Pat your wounds dryPat your wounds dry If your wounds are dry you may leave them open If your wounds are dry you may leave them open

to the air or put a clean dry dressing over themto the air or put a clean dry dressing over them DO NOT PUT ANY CREAMS/OINTMENTS ON DO NOT PUT ANY CREAMS/OINTMENTS ON

YOUR WOUNDS (THIS INCLUDES POLYSPORIN, YOUR WOUNDS (THIS INCLUDES POLYSPORIN, ETC.)ETC.)

Post opPost op

You will see your surgeon between 5-7 You will see your surgeon between 5-7 days post opdays post op

You will go directly to your first You will go directly to your first physical therapy appointment after physical therapy appointment after your office visityour office visit

You will have PT 2-3 x per week for the You will have PT 2-3 x per week for the first 6 weeksfirst 6 weeks

You can get rid of your crutches when You can get rid of your crutches when you can hold a straight leg raise for 10 you can hold a straight leg raise for 10 seconds (usually 7-14 days)seconds (usually 7-14 days)

Typical Post-Op Typical Post-Op MilestonesMilestones

Typical milestonesTypical milestones Immediately post opImmediately post op

Long brace locked in full Long brace locked in full extensionextension

Range of motion exercises Range of motion exercises and very gentle thigh and very gentle thigh exercisesexercises

PT 2-3x per week PT 2-3x per week Therapist will tell you Therapist will tell you

when safe to get off when safe to get off crutches based on thigh crutches based on thigh waking upwaking up

1 month-1 month- Shorten your post op Shorten your post op

bracebrace Therapy 2-3 x weekTherapy 2-3 x week

Typical Post-Op Typical Post-Op MilestonesMilestones

2 months2 months

- Hinged knee sleeve- Hinged knee sleeve

- begin aggressive thigh - begin aggressive thigh strengthening exercises (0-strengthening exercises (0-90°)90°)

-bike, elliptical, -bike, elliptical, stairclimber, squats, stairclimber, squats,

lungeslunges

-Many of the exercises -Many of the exercises can be done on own at a can be done on own at a gymgym

-Check in with therapist -Check in with therapist periodically for them to periodically for them to “coach” you on your “coach” you on your exercises and make sure exercises and make sure you are on the right trackyou are on the right track

Typical Post-Op Typical Post-Op MilestonesMilestones

3 months-3 months-

-OK to jog if thigh progressing -OK to jog if thigh progressing appropriatelyappropriately

4-5 months4-5 months

-begin some sport specific activities-begin some sport specific activities 6-9 months6-9 months

-return to sport/work-return to sport/work The post-op course varies between patients The post-op course varies between patients

and your course may be slightly differentand your course may be slightly different

Post-op QuestionsPost-op Questions How long will I be on crutches?How long will I be on crutches?

7-14 days-you can get off crutches when your thigh 7-14 days-you can get off crutches when your thigh wakes up and you can hold a straight leg raise for 10 wakes up and you can hold a straight leg raise for 10 secondsseconds

Your therapist will tell you when you can stop using Your therapist will tell you when you can stop using crutchescrutches

When can I go back to school?When can I go back to school? Must be off narcoticsMust be off narcotics Must be able to navigate school with brace on and Must be able to navigate school with brace on and

lockedlocked Usually between 5-7 days.Usually between 5-7 days.

When can I go back to workWhen can I go back to work Labor Job- 6 to 9 months after your knee is fully healedLabor Job- 6 to 9 months after your knee is fully healed Desk job- 7-14 days after your pain goes down and you Desk job- 7-14 days after your pain goes down and you

are off narcotic pain medsare off narcotic pain meds

Post op-QuestionsPost op-Questions

Can the post-op course be accelerated?Can the post-op course be accelerated? Not reallyNot really Cannot change biology-how fast humans Cannot change biology-how fast humans

healheal It takes several months for your new graft It takes several months for your new graft

to grow into the bone. Accelerated rehab to grow into the bone. Accelerated rehab risks stretching your graft and making it risks stretching your graft and making it too loose and non-functionaltoo loose and non-functional

Also, length of the rehab is based more on Also, length of the rehab is based more on the thigh than on the knee.the thigh than on the knee.

Post-op QuestionsPost-op Questions The thigh (quadriceps muscle) shuts down The thigh (quadriceps muscle) shuts down

(goes to sleep) after surgery and it takes time (goes to sleep) after surgery and it takes time and rehab for it to wake up?and rehab for it to wake up?

It takes 6-9 months for the quadriceps It takes 6-9 months for the quadriceps musculature to fully restore itself after musculature to fully restore itself after surgery.surgery.

Until the thigh muscle is strong again your Until the thigh muscle is strong again your knee will feel loose even though it is entirely knee will feel loose even though it is entirely stablestable

The more frequently the thigh exercises are The more frequently the thigh exercises are done the faster the thigh will be strong and the done the faster the thigh will be strong and the faster you may safely return to full activities. faster you may safely return to full activities.

Thank You Thank You

Any further questions should be Any further questions should be directed to your therapist or surgeondirected to your therapist or surgeon

513-475-8690513-475-8690