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ACL Reconstruction and ACL Repair Surgery in British Columbia and Alberta
ACL injuries can be life-altering, especially for individuals with otherwise active lifestyles. To regain knee stability and proper function after these devastating injuries, look to Ortho South to provide you with the specialized orthopaedic surgical care you need. Our private orthopaedic surgery practice has established a reputation for achieving exceptional results after ACL reconstruction and ACL repair surgery, helping patients across the country restore their mobility and function without excessive treatment delays.
Anatomy of the ACL
Entire textbooks have been written dedicated to describing the complex anatomy of the anterior cruciate ligament! At the most basic level, the anterior cruciate ligament, or simply “ACL” as it is commonly known, is a ligament in the center of the knee that connects the tibia (lower leg bone) to the femur (upper leg bone). Its job is to prevent the tibia from shifting too far forward on the femur and to help control the rotation of the knee.
The ACL is well supported by a cast of other structures in the knee that are critical to providing optimal knee function and stability. These structures include the anterolateral ligament (ALL), the medial collateral ligament (MCL), lateral collateral ligament (LCL), posterior cruciate ligament (PCL), the medial and lateral menisci, as well as the articular cartilage (“bearing surface”) of the knee.
Understanding ACL tears
ACL tears are commonly linked to athletic injuries. However, sports are not the sole culprit. ACL injuries can derive from virtually any form of abrupt movements, such as sudden pivots, stops, awkward jumps or landings, and direction changes. Other causes may include knee trauma, falls, or knee hyper-extension. Sometimes, the ACL can become “degenerative” and simply stop functioning properly over time. This is usually a chronic problem that is associated with advanced arthritis of the knee and is a very different problem than an acute ACL tear.
Classically, an acute ACL injury occurs when there is a planting/pivoting motion on the knee, and is accompanied by an audible or palpable “pop” in the knee, along with acute pain, inability to weight-bear, and significant abrupt swelling in the knee.
When the ACL is stretched beyond its elastic recoil limits, it ruptures, allowing the tibia to travel too far forward on the femur, often damaging other knee structures in the process. Commonly, there can be associated injuries to the ALL, MCL, LCL, PCL, medial and lateral meniscus, and articular cartilage of the knee. In short, almost all other important knee structures can potentially be injured at the same time the ACL ruptures!
The Importance of Recognizing an ACL Injury
The severity of an ACL tear may not be immediately apparent. In some cases, these injuries may feel like a “bad sprain”. After 4-6 weeks, much of the swelling in the knee can dissipate, and the pain tends to improve, as does the ability to walk without support or a brace. But, if there is internal damage to the meniscus or articular cartilage in the knee that is ignored, or if there is ongoing instability in the knee causing further internal damage, patients can rapidly develop irreversible arthritic changes in the knee.
It is therefore important for patients with suspected ACL injury to have a thorough assessment by an appropriately trained physician specialist to get an accurate diagnosis that identifies all damaged structures. Only then can an appropriate treatment plan be recommended.
Not all patients with an ACL injury require surgery, and a discussion with an experienced orthopaedic surgeon is usually required to determine if surgery is appropriate in each case. Contact Ortho South today to book a consultation with Dr. Anthony Costa to find out if ACL reconstruction or repair surgery is indicated for your ACL injury.
Symptoms of ACL Injuries
Usually, the first “symptom” to recognize, would be the classic injury history described above! If a patient does not relay a similar-sounding story, there is a good chance the problem is not related to the ACL.
Once the pain and swelling from an initial ACL injury have subsided, the predominant symptoms of a chronic ACL injury typically include:
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Giving way of the knee when trying to plant and pivot, or change direction quickly
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Lack of trust in the knee when attempting above
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Lack of trust or recurrent instability when running/walking on slopes or uneven ground
A feeling of “instability”, “giving way”, or “lack of trust” when simply walking on level ground/standing/sitting/lying down are not usually related to the ACL. Likewise, apart from at the time of initial injury, symptoms such as pain, locking, clicking/popping, are non-specific, and not usually directly related to an ACL problem.
Contact Ortho South today to book a consultation with Dr. Anthony Costa to find out if your knee symptoms are related to an ACL injury, and if surgical management might be appropriate in your case.
ACL Injury Treatment Options
Not all ACL injuries require surgical management. The decision to proceed with ACL surgery depends somewhat on the nature of the injury (ie what associated structures are involved), but also largely on patient factors such as activity level and functional demands. Age in itself is NOT a criterion that is particularly useful in guiding decision-making in ACL injuries.
In general, patients with ongoing instability, and functional demands that require a competent ACL, in the absence of advanced arthritis changes in the knee, will usually be candidates for ACL surgery, regardless of age. A desire to return to cutting/pivoting sports such as hockey, skiing, field sports, gymnastics, etc, would be examples of functional demands where it is appropriate to consider proceeding with ACL surgery.
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Patients with low functional demands (such as simple level ground walking and no pivoting sports), or those who have already developed arthritic changes in the knee, are probably not good candidates to consider ACL surgery. Fortunately, most of these patients will function exceptionally well without a competent ACL and have very few symptoms related to the ACL itself. Many patients even ski (blue runs mostly), and participate in other low-demand sports without an ACL! Bracing and appropriate physiotherapy are often the mainstays of successful non-operative treatment.
Contact Ortho South today to book a consultation with Dr. Anthony Costa to find out if you are a candidate for ACL surgery, or to discuss other non-operative treatment options.
Understanding ACL Surgery
A popular misconception is that the ACL is “repaired” during ACL surgery. Most commonly, however, the ACL is “reconstructed”, using tissue from another source (eg somewhere else in your knee, or from a tissue donor bank). The reason for reconstructing the ACL rather than repairing it, is because simply repairing the torn ACL does not usually work very well in the majority of cases. Imagine trying to sew crab meat together! Even if the repair can “heal”, the healed tendon might end up too long compared to the uninjured ACL due to irreversible stretching of the tissues, and may ultimately leave the knee with ongoing laxity that makes it feel unstable. While there may be some exceptions to this, chances are, if you or someone you know had an “ACL surgery”, it was probably a reconstruction, not a repair.
During an ACL reconstruction surgery, the knee will be examined while you are asleep to get a better sense of exactly how much ligament laxity there is, and which ligaments are involved. This is often called an examination under anaesthetic (EUA).
Next, a “diagnostic arthroscopy” is often carried out to confirm all intra-articular pathology suspected from the history, physical examination, and diagnostic imaging in your case. A camera is inserted into the knee through small keyhole incisions for this purpose. After confirming all pathology, a definitive surgical plan is established.
After the above, surgery is carried out to address other pathology in the knee (eg meniscus repair or meniscectomy), repair/reconstruct other ligaments, and ultimately reconstruct the ACL. If your own tissue is to be used to reconstruct the ACL, this would be harvested and prepared either before the arthroscopy, or later during the surgery.
Next, a series of tunnels or sockets are drilled in the bone of the tibia and femur, and the ACL graft is placed in these sockets, to be fixed on either end. There are many different techniques and devices used to fix the ACL tissue graft to the bone. Ultimately, the graft tissue needs to incorporate into the bone to properly stabilize the knee long term. Likewise, other injured structures need to be addressed to protect the healing ACL. Incorporation of the ACL graft into bone is an ongoing process that can take a year or more to fully occur. The graft is most vulnerable to reinjury during the first 3 months following surgery while early incorporation of the graft is occurring, but is not yet at a mature stage.
After surgery, it is therefore extremely important that you follow your surgeon’s activity recommendations, or there will likely be a higher risk of failure of the reconstructed ACL to heal, which could lead to ongoing instability and further joint degeneration. A detailed, individualized, recovery protocol will be provided by Dr. Costa to you after your surgery.
Recovery Timeline
Recovery after ACL repair or reconstruction surgery varies, and usually depends on what exactly was done during the procedure.
For most isolated ACL reconstructions, without meniscal repair or meniscectomy, most patients do not need a knee brace, and may fully weight-bear immediately after surgery. Usually, crutches are recommended for the first 6 weeks following surgery to help protect the graft from stretching out if a patient stumbles.
If a meniscal repair has been carried out, a brace is often used for the first 6 weeks to avoid flexion >90 degrees. This will help protect the meniscal repair site. Full weight bearing is usually permitted but may be restricted by your surgeon depending on the type of repair carried out and the pattern of meniscus tear. Patients are warned that the addition of a meniscal repair to an ACL procedure usually means the recovery is much harder than an isolated ACL reconstruction. Many patients with a meniscal repair report feeling like they are 6-8 weeks behind other patients with no meniscal repair.
Patients usually start formal physiotherapy about 2 weeks post-ACL reconstruction, and therapy progresses only when certain milestones are achieved. Patients are usually advised to avoid slopes or uneven grounds, working at heights, and heavy labor jobs for at least 3 months post-surgery. Return to full sports participation usually takes 10-12 months of dedicated physiotherapy and rehabilitation.
A detailed, individualized, recovery protocol will be provided by Dr. Costa to you after ACL surgery. It is important to follow this protocol closely, and not progress too quickly, or there will likely be a higher risk of failure of the reconstructed ACL, which could lead to ongoing instability in the knee, and/or lead to needing additional surgery.
Potential Risks Associated with ACL Reconstruction Surgery
Unfortunately, there are risks inherent in any surgery, and complications do occur after ACL surgery. Complications after ACL surgery may include, but are not limited to:
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Bleeding or damage to blood vessels
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Surgical site and/or knee joint infections
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Nerve injury
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Blood clots in the leg or lungs
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Stiffness in the knee
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Ongoing knee pain or instability
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Failure of the reconstructed ACL to function properly
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Failure of any meniscal repairs to heal properly
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Arthritis changes post meniscectomy
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Morbidity related to the donor tissue site (eg pain, tendon rupture, weakness)
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Requirement for additional surgery
Learn More About ACL Reconstruction Surgery
Don’t let your ACL injury hold you back from your active lifestyle, and don’t let unnecessarily long wait times for appropriate treatment lead to potentially irreversible knee damage! Contact Ortho South today to book a consultation with Dr. Costa, and to obtain an accurate diagnosis and comprehensive treatment plan for your ACL injury.