Reconstruction surgeries are of two type arthroscopic and open reconstruction depending on orthopedic surgeon’s choice and extent of injury. Time of surgery is debatable topic. Surgery immediately after injury has been associated with increased fibrous tissue leading to loss of motion (arthofibrosis) after surgery (1). According to some surgeon surgery should be delayed until swelling goes down, gain range of motion in knee and can strongly contract (flex) front of thigh muscle (quadriceps)(1). In adults age is not a factor in surgery though overall condition of body may be.
People with medical conditions may consider non surgical treatment option because surgery carries greater risk. These include use of painkillers and anti inflammatory medications and bracing for 1 to 2 weeks with ice, elevation and programmed physiotherapy. A new non surgical treatment option is Platelet rich plasma injection, in this procedure blood of the patient is taken platelets are separated by centrifuge and injected I the injured tissue to augment healing. It is useful in both acute and chronic soft tissues injuries. Choice completely depends upon patient choice and level of activity patient having after surgery (2).
Many orthopedic surgeons use arthroscopic surgery rather than open surgery for ACL injuries because:
1. It is easy to see and work on the knee structures.
2. It uses smaller incisions than open surgery.
3. It can be done at the same time as diagnostic arthroscopy (using arthroscopy to find out about the injury or damage to the knee).
4. It may have fewer risks than open surgery (3).
During arthroscopic ACL reconstruction, the surgeon makes several small incisions—usually two or three—around the knee. Sterile saline (salt) solution is pumped into the knee through one incision to expand it and to wash blood from the area. This allows the doctor to see the knee structures more clearly. The surgeon inserts an arthroscope into one of the other incisions. A camera at the end of the arthroscope transmits pictures from inside the knee to a TV monitor in the operating room.
Surgical drills are inserted through other small incisions. The surgeon drills small holes into the upper and lower leg bones where these bones come close together at the knee joint. The holes form tunnels through which the graft will be anchored. If you are using your own tissue, the surgeon will make another incision in the knee and take the graft (replacement tissue).
The graft is pulled through the tunnels that were drilled in the upper and lower leg bones. The surgeon secures the graft with hardware such as screws or staples and will close the incisions with stitches or tape. The knee is bandaged, and you are taken to the recovery room for 2 to 3 hours.3
Physical rehabilitation after ACL surgery may take several months to a year. The length of time until you can return to normal activities or sports is different for every person. It takes most people at least 6 months to return to activity after surgery (4).
ACL reconstructive surgery remains the gold standard for repairing this common knee injury. The AAOS reports that about 82 to 90 percent of ACL reconstruction surgeries yield excellent results and full knee stability.
ACL reconstruction surgery is generally safe. Complications that may arise from surgery or during rehabilitation (rehab) and recovery include following (6, 7). 0.75% (104) of the consecutive patient cohort had a wound complication recorded (5).
• Problems related to the surgery itself. These are uncommon but may include:
Numbness in the surgical scar area.
Infection in the surgical incisions. 0.25% (35) underwent a further procedure to wash out the infected knee joint (5).
Damage to structures, nerves, or blood vessels around and in the knee.
Blood clots in the leg. DVT and PTE rates were 0.30% (42) and 0.18% (25) respectively with on 90 days(5)
The usual risks of anesthesia.
There were no in-hospital deaths(5)
• Problems with the graft tendon (loosening, stretching, re-injury, or scar tissue). The screws that attach the graft to the leg bones may cause problems and require removal.
• Limited range of motion, usually at the extremes. For example, you may not be able to completely straighten or bend your leg as far as the other leg. This is uncommon, and sometimes another surgery or manipulation under anesthesia can help. Rehab attempts to restore a range of motion between 0 degrees (straight) and 130 degrees (bent or flexion). It's important to be able to get your knee straight so you can walk normally.
• Grating of the kneecap (crepitus) as it moves against the lower end of the thigh bone (femur), this may develop in people who did not have it before surgery. This may be painful and may limit your athletic performance. In rare cases, the kneecap may be fractured while the graft is being taken during surgery or from a fall onto the knee soon after surgery.
• Pain, when kneeling, at the site where the tendon graft was taken from the patellar tendon or at the site on the lower leg bone (tibia) where a hamstring or patellar tendon graft is attached.
• Repeat injury to the graft (just like the original ligament). Repeat surgery is more complicated and less successful than the first surgery. 1.36% (190) were readmitted to an orthopedic ward within 30 days (5)
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